Richard Preston on legacy of The Hot Zone and the future of Ebola outbreaks

Tonight, the National Geographic Channel will begin airing its six-part adaptation of Richard Preston’s book, The Hot Zone, which covered the first outbreaks of Ebola in Africa, and an outbreak in a Reston, Virginia laboratory in 1989 that required the US Army to clean up.

The book was an immediate and frightening hit with the public, bringing Ebola to the forefront of the public’s attention. National Geographic’s adaptation of the book comes a quarter-century after it was first published, and unfortunately it’s very timely. The virus has been back in the news in recent years: A massive outbreak in West Africa killed more than 10,000 people between 2013 and 2015, and another ongoing outbreak in the Democratic Republic of the Congo has killed more than a thousand people since it began last year.

We spoke with Preston about the legacy of The Hot Zone, what we’ve learned since then, and what we likely face in the future.

The interview has been edited for clarity and length.

I’d like to start off with thinking back on The Hot Zone when it was originally published. Can you just walk me through a bit about where the book originally came from and what sparked your interest in Ebola in the first place?

The book originated when I was between articles in The New Yorker magazine and I was just hunting around for a topic for an article, not a book. I stumbled across the whole idea of these emerging viruses. These are wild, natural viruses that are coming out of the ecosystems of the Earth and invading human beings, and we have essentially zero immunity to them, so there is this potential for a massive pandemic that seems to come out of nowhere.

I start poking around and I heard about this outbreak of the Ebola virus in a group of monkeys near Washington DC, and that the Army had sent space-suited teams of soldiers in to deal with them. It was just an inherently dramatic story.

When the book was first published in 1994, what was the general public awareness of not just Ebola, but these infectious diseases? Do you think that was the dramatic nature of the viruses that made it a success, or that it was the aftermath of the 1980s and the AIDs epidemic?

I think two things were going on. First, there was the Stephen King-element — that it was it was filled with suspense. It was really horrifying and scary, and the descriptions of people dying of Ebola were vivid, and they hit home because the whole story makes you feel like “wow Ebola could wind up right here among us.”

The other thing was that there was a huge shift of consciousness happening in the scientific community about the nature of emerging viruses. There was a dawning realization that HIV was the tip of the iceberg. It wasn’t an isolated event at all. It was part of a pattern of emergences of unknown viruses extremely deadly to humans that we’re making what are called cross-species jumps out of wild creatures into the human species.

Our numbers have increased vastly over the past hundred and fifty years, what we represent is a vast, rapidly enlarging host that has zero immunity to these emerging viruses. We represent an incredible opportunity to a virus like Ebola.

That reminds me of a book by David Quammen, Spillover: Animal Infections and the Next Human Pandemic, which talks a lot about the transfer of these viruses from animal populations to humans.

That’s right, and the other interesting thing is that nature is highly reactive. Nature is simple, and it’s not just that we’re coming into contact with these reservoirs, but the reservoirs are coming into contact with us, and they’re changing and they’re reacting to the human presence.

Just to give you an example: in West Africa there is a hot agent called Lassa. It looks a whole lot like Ebola, except that it also invades the brain, and it cycles naturally in a certain species of rat. As the forests of West Africa have been cut down for agriculture, these rats have exploded in numbers and they’ve also increased their geographic range. The Lassa virus is living in a larger and larger rat population and it’s also now getting more and more opportunities to jump into humans.

The Hot Zone contains vivid descriptions of bleeding and vomiting bright red blood. I’ve seen some researchers complain that it planted an overly dramatic image of Ebola in the public’s eye. Have you had pushback from researchers in the field?

In his book, Quammen criticized The Hot Zone for exactly that: for laying on the gore blood too thick. I think that if I could do it all over again, there are certain sentences that I would tone down, particularly at the very beginning of the book with Charles Monet on the airplane, and I would be doing that just simply to make it more clinically accurate, because clinical accuracy always makes things more scary anyway.

One thing I think that was a little bit misinterpreted was that the major source of hemorrhage with Ebola is intestinal. During the first outbreak in 1976, people were projectile-vomiting, but the other massive source of bleeding where people really did bleed out was through the intestines, so the blood is black in color. I think I don’t think that I did a good job explaining that the blood that’s coming out of a person’s intestines is not bright red like paint — it’s just black and tarry, but there’s a lot of it.

So that’s part one. Part two of all this is that these use explosions of blood in The Hot Zone, led, I think they led people to the common idea that Ebola really isn’t that dangerous, because it’s too hot and too deadly, that it “burns itself out” when it gets into humans, and that it’s stable — it doesn’t evolve when it gets into people. The West African outbreak gave the lie to all those misperceptions.

Do you think there’s a racial component do this?

Yes. There was were accusations that that books like The Hot Zone — not just The Hot Zone, but others as well — portrayed Africans as being the victims and the white people were coming to Africa, and they were kind of taking charge and saving the Africans. That these viruses all come from Africa, and they’re a danger to the developed world. I don’t think those are valid criticisms of The Hot Zone or of other books like that. They may be valid criticisms of media, of film and television depictions.

I’ve got a new book just about to come out, Crisis in the Red Zone: The Story of the Deadliest Ebola Outbreak in History, and of the Outbreaks to Come. It’s the successor to The Hot Zone, and I tackle all these issues. The main protagonists are African scientists, doctors and nurses, and I detail their lives and their experiences.

So there was the outbreak in West Africa and the ongoing one in the Congo. Looking at these outbreaks, what have we learned that we didn’t know in 1994, when the book first came out? We have vaccines and treatment protocols, but it doesn’t seem like it’s going anywhere.

That’s the paradox isn’t it? That we have a good good vaccine, but Ebola isn’t going away. We know a lot more about Ebola and viruses than we did in the 1990s. One thing that’s come along is something called deep sequencing; genome sequencing where we we go deep into the nature of the virus by genome sequencing the particles in detail in a large number. A virus like Ebola is not really a thing — it’s actually a swarm and the swarm of particles is vast in numbers. When 400 people are infected with Ebola, that’s a population or a swarm of particles that amounts to about 1 quintillion particles of Ebola.

Each particle is an individual life-form that is doing its best to replicate and survive and it’s competing against all the others for survival in the environment of the human body, and when the particles replicate, they mutate. You could think of a school of fish, with many different kinds of fish in it. Some of the fish have sharper teeth and can swim faster in those fish eventually take over the school. This is what happened with Ebola in West Africa, and when you think about Ebola virus, you need to think of a cloud of vast cloud of particles that is moving through time and constantly changing.

So with that in mind, what lessons do we have before us that we have to keep in mind as we move forward?

I think we have learned lessons from the recent Ebola outbreaks including the one in Congo, and one of the lessons is that it really pays to do the research, and we now have what looks like at least one good antibody drug that seems to be effective against Ebola. We also have a vaccine which is definitely effective. It turns out that antibody drugs can be designed pretty quickly. While we don’t yet have any kind of surge capacity to produce large amounts of those drug for a new virus, we do have the technology to do it.

Ebola kind of woke everybody up to the possibility that somebody can show up at a hospital in Dallas with a Level 4 Virus, and as good as our medical system is, people were absolutely helpless. They had no idea what they were dealing with, whereas moderately well-trained African medical professionals would never have made the kinds of mistakes that the American medical system did.

It seems like that is borne out of experience. What occurs to me is that in a lot of ways, vaccines are just one tool in the toolbox: things like a functioning hospital system, education, and hygiene are just as important to solving a problem.

You just put your finger right on it. It’s the weakness of the medical system and the public health system and in many lesser-developed countries. Countries where they have real economic problems and just don’t have the resources that a country like the United States has. In my experience writing about this is that the African medical professionals were unbelievably professional in what they did. They were under-equipped with the tools and backup to really fight a level 4 virus, and they went in there and they fought it anyway with extraordinary acts of heroism and self-sacrifice, but they shouldn’t have had to do that. They should have had more backing from the developed world.

In order for the human species to protect itself, we have to recognize that that the health of an individual in West Africa is important for our health too, and that what West Africa or what the lesser-developed world needs is is a much better functioning medical system. A little bit of money goes a long way in an African healthcare setting, and the United States would do itself a big favor if it were to channel more resources into basically helping those African medical personnel create create better a medical infrastructure.

The other thing that’s just incredibly important is public health education. It’s as much of a problem in the United States as it is in eastern Congo. To give you an example: in eastern Congo, a lot of people believe that Ebola isn’t real, that it’s a plot by the government to do bad things to people. This exact same thing is happening in the United States with the measles vaccine: there are people who don’t believe in measles. They don’t believe in the seriousness of measles as a disease, and they don’t believe anything they’re told by the government about the effectiveness of measles vaccine. They are as much you know in a dreamland of unreality as African people who deny the existence of Ebola.