The Hot Zone: The Terrifying True Story of the Origins of the Ebola Virus

Medical staff at Nairobi Hospital try unsuccessfully to save Monet. A young doctor, Dr. Shem Musoke, examines Monet with a laryngoscope, and is hit in the face with vomit. Musoke continues to treat him, attempting a blood transfusion, but Monet’s veins break apart under the needle, and the needle punctures do not clot. Monet dies the next morning. An autopsy finds his liver and kidneys destroyed and parts of his liver liquefied, as well as widespread clotting and hemorrhages.

Nine days later, on January 24, 1980, Dr. Musoke gets a backache and notices that his eyes are turning red. Taking a clue from the discolored eyes, a colleague orders exploratory surgery for a liver abscess or gallstones, and during the surgery, Musoke’s colleagues have difficulty stopping his bleeding. After the surgery, Musoke continues to deteriorate and enters kidney failure. A second physician, Dr. David Silverstein, takes over, and, suspecting an unusual virus, sends some blood samples to the National Institute of Virology in Sandringham, South Africa, and to the Centers for Disease Control in Atlanta, Georgia, USA.

Dr. Silverstein receives news that the South African laboratory found Marburg virus in Dr. Musoke’s blood. Silverstein looks up Marburg in a medical textbook and learns that the virus takes its name from a city in Germany, where a 1967 outbreak infected workers at a vaccine plant that used African green monkeys imported from Uganda. Marburg is a filovirus, named for its thread-like appearance under a microscope, whereas many other viruses are ball-shaped. The only other two viruses in this family are Ebola Zaire and Ebola Sudan. Of them, Marburg is the mildest, killing one in four victims, whereas Ebola Zaire kills nine in 10.

Here, Preston takes a detour through the history of the study of the Marburg outbreak and the subsequent investigation. The virus infected 31 people, seven of whom died. The first infected one of the monkeys’ caretakers, and then spread from person to person through laboratory accident, corpse-handling, and sexual intercourse. A subsequent World Health Organization investigation was unable to pin down the exact location in which the sick monkeys were trapped and did not even interview the British veterinarian who signed their export certificates. Reaching the veterinarian by phone, Preston learns some new details, including that the monkey exporter was releasing sick monkeys on an island in Lake Victoria instead of destroying them, and was later trapping monkeys from the plague island to fill out shipments. The veterinarian also shares unconfirmed rumors of a Marburg-like virus impacting wild monkeys and human villages near Mount Elgon in the early 1960s.

Preston also notes that the shores of Lake Victoria are recognized as one of the first epicenters of the AIDS epidemic. The export of primates from Uganda for medical research in industrialized countries was a new and growing business around this time in the 1960s. Preston points out that the concentration of monkeys of various species in densely packed, unsanitary conditions and in close contact with human workers was novel and dangerous: “a perfect setup for an outbreak of a virus that could jump species” (59).

Returning to Dr. Shem Musoke’s story, Preston shares that he made a slow but complete recovery from his encounter with the Marburg virus and is today one of the leading physicians at the Nairobi Hospital.

Preston introduces Major Nancy Jaax, a US Army veterinarian working on an Ebola research project. Preston describes her as a small but strong woman and an avid practitioner of martial arts. The story opens in September 1983, as Major Jaax accidentally cuts her hand while preparing dinner for her family at their home in suburban Maryland.

Major Jaax goes to work at the United States Army Medical Research Institute of Infectious Diseases (USAMRIID), colloquially known as the Institute. Her task for the day is to work with her immediate supervisor, Lieutenant Colonel Tony Johnson, to dissect a monkey that has crashed from Ebola. The monkey is part of a research project in which Johnson injected healthy monkeys with the Ebola virus and treated them with a drug to see if it would help them survive. It did not. The chapter follows Jaax as she dons her surgical scrubs and the pressurized blue space suit that will keep her safe in the Level 4 area where the Ebola virus is contained.

Jaax enters the Level 4 containment area and assists Johnson in removing the dead monkey from the cage and dissecting it. They use blunt instruments to avoid the danger of cutting their own protective equipment or aerosolizing virus particles through the use of a bone saw. After they remove the monkey’s brain, Johnson notices a tear in Jaax’s outermost glove. Removing it, she washes the bloody hand and arm of her suit in disinfectant, but then notices that her hand feels cold. There is a crack in her suit. Alarmed, Jaax exits the Level 4 area and enters the decontamination shower. She imagines the sequence of events that might follow: She will be put in the “Slammer,” an isolation hospital ward within the Institute, where she will break with Ebola and then die, to be taken to the Submarine, a nearby Level 4 biocontainment morgue.

After the seven-minute shower, Jaax removes her suit and finds her scrubs and the latex glove also wet with monkey blood. This is the last layer of protection between her cut palm and the Ebola-infected blood. She rinses the glove and removes it, finding the only blood inside is her own. When she fills it with water under the tap, the glove holds. She has had a near miss with Ebola.

Two weeks after this incident, something else of note occurs in the Ebola experiment. The two control monkeys, who were not injected with Ebola blood and did not have direct contact with the sick monkeys, also sicken and die: “That is when I knew that Ebola can travel through the air,” Jaax concludes (97).

Preston introduces Mr. Yu G., the first known victim of a July 1976 outbreak in southern Sudan. The route of Yu G.’s infection remains a mystery, but he worked in a cotton factory and infected several neighboring workers. When the illness reached the hospital in the nearby town of Maridi, infections skyrocketed until the medical staff panicked and ran off, effectively shutting down the hospital, where the reuse of needles had been furthering the spread of the virus. Shortly after the hospital closure, the outbreak subsided. Preston speculates that this outbreak may have died out rather than spreading to other towns and major cities in part because “It was exceedingly hot” (101)—meaning that it killed its hosts so quickly that it ultimately limited the spread.

Two months later and 500 miles west in the Bumba Zone of northern Zaire, another outbreak occurs in early September. A mission hospital where nuns reused the same unsterilized needles on hundreds of patients each day is the epicenter of the outbreak. Ebola Zaire is even more lethal than Ebola Sudan, killing nine in 10 victims. The first nun to sicken is Sister ME. Her colleagues fly with her to the city of Kinshasa, seeking treatment in the private Ngaliema Hospital. After her death, the entire hospital room is stained with blood, including the walls.

The nun who arrived with Sister ME then sickens too, along with the young Nurse Mayinga N., one of the staff who cared for her. Afraid or in denial about what her symptoms mean, Nurse Mayinga leaves the hospital and goes into the city, hoping to organize her permits to travel to Europe, where a college scholarship is ready for her. The reader already knows, however, that she will die of Ebola and her name will be given to the Mayinga Strain of the virus isolated from her blood. Mayinga waits in lines at the foreign ministry on October 12, and then seeks care in the Mama Yemo hospital, the largest and most overcrowded in Kinshasa. Doctors there want to quarantine her for malaria, but there is no room, so she takes a taxi to University hospital, where doctors can find little wrong with her. Finally, she returns to the Ngaliema Hospital for treatment.

Rumors that a sick nurse had wandered around Kinshasa for two days spark alarm in diplomatic circles and at the World Health Organization. The President of Zaire (now the Democratic Republic of the Congo) uses the army to quarantine the hospital and seal the Bumba Zone—the center of the outbreak, but 600 miles northeast of Kinshasa—with roadblocks. Riverboat captains were already refusing to stop for people along the Congo River for the length of the Bumba Zone, effectively isolating it. Soon all radio contact, too, is lost.

Meanwhile, samples of Sister ME’s blood are flown to Belgium and England, and scientists at America’s Centers for Disease Control (CDC) scramble to obtain their own sample. When the blood arrives, however, the tubes have cracked in shipment, leaving the black, rotted blood loose inside the box. Wearing rubber gloves and using a cotton ball, a virologist is able to dab up enough of the blood to add it to a flask of monkey cells, where the then-unknown virus begins to replicate. On October 13, her colleague Frederick A. Murphy attempts to photograph the virus with an electron microscope. He immediately believes he is looking at the Marburg virus, and he stands up in alarm and bleaches the laboratory where he prepared the slide. The next day, however, tests reveal that the virus is not Marburg. Dr. Karl Johnson, the leader of the CDC’s Special Pathogens Branch, names the organism Ebola, after the Ebola River—a tributary of the Congo that passes through the outbreak’s center.

The World Health Organization (WHO) dispatches teams to Kinshasa and Bumba to try and stop the outbreak and learn more about the pathogen. As it pushes into the Bumba Zone by Land Rover, the WHO team finds roadblocks outside each village: The elders have sealed their communities to outsiders to prevent the spread of the illness, as they had done for smallpox epidemics for centuries. Reaching the mission hospital, the team finds three surviving nuns and a priest. The survivors have cleaned up all but the bloody obstetric ward where dying mothers had aborted Ebola-infected fetuses. It is clear to the WHO team both that the epidemic has already begun to subside and that the hospital had been the source of many of the infections. The team later makes contact with nearby villages, where they find Ebola victims dying in isolated huts at the edges of villages, which are then burned down.

At the Ngaliema Hospital in Kinshasa, Nurse Mayinga is cared for by Dr. Margaretha Isaäcson, who first wears a military gas mask, but then decides to accept the possibility of her own death and treat Mayinga face to face. Isaäcson tries to reassure her, gives her ice cubes to suck, treats her with Valium, and gives her three blood transfusions to replace the blood she loses in a slow and endless hemorrhagic nosebleed. After Nurse Mayinga dies, the hospital staff is still afraid to clean her room and those of the dead nuns. Believing herself already doomed, Isaäcson washes the rooms. The World Health Organization organizes a hospital ship and waits for the virus to burn through the city, but against all odds, it does not happen. No one caught the virus from Nurse Mayinga.

Preston introduces a civilian biohazard expert, Eugene Johnson, who works for USAMRIID. In September 1987, he goes to the Dulles airport near Washington, DC, and receives a medical sample from a colleague arriving from Kenya. The sample is from a 10-year-old Danish boy, referred to as “Peter Cardinal,” who died in Nairobi hospital the day before from an unknown virus. The child had been in Kenya visiting his family, who lived near Lake Victoria. When he became ill, doctors in Mombasa initially diagnosed malaria, but his mother insisted he be flown to Nairobi, where he was treated by Dr. Daniel Silverstein, who had cared for Dr. Musoke during his Marburg illness. Cardinal had arrived in Nairobi feverish but alert, but he continued to decline. Eventually, his body swelled up as he bled into the space between his skin and muscle tissue, and his pupils dilated, indicating brain death.

Working at the CDC, Eugene Johnson confirms Dr. Silverstein’s suspicion that Cardinal had the Marburg virus and asks Dr. Peter Tukei, a colleague in Kenya, to interview Cardinal’s parents and learn where he had traveled and what he had been doing before he fell ill. Dr. Tukei learns that, like Charles Monet, Cardinal visited Kitum Cave on Mount Elgon.

Eugene Johnson travels to Kenya and retraces Peter Cardinal’s steps. In spring of 1988, he persuades the Army to sponsor a major expedition to Kitum Cave. The expedition includes 35 team members who use full biohazard gear to collect samples of animals and insects inside the cave. It also stations caged monkeys and guinea pigs in the cave in the hopes they might become infected with the Marburg virus and illuminate the infection pathway. Dissecting these animals at the end of the mission, the team finds no signs of infection; nor is it found in any of the captured organisms. The expedition is a failure, but Johnson takes the biohazard gear home to Fort Detrick and puts it in storage.