"The Hot Zone" and the mythos of Ebola

The Hot Zone was first released in 1994, the year I graduated high school. Like many readers, that book and Laurie Garrett's The Coming Plague* really sparked my interest in infectious diseases. In some sense, I have those books to thank (or blame?) for my career.

But I'm still going to criticize The Hot Zone, because as a mature infectious disease epidemiologist and a science communicator in the midst of the biggest Ebola outbreak in history, The Hot Zone is now one of the banes of my existence. A recent article noted that the book is back on the bestseller list, going as high as #7 on the New York Times list recently, and #23 on Amazon. It's sold over 3.5 million copies, and it's reported as "a terrifying true story." Many people have gotten almost all of their Ebola education from just The Hot Zone (as they've told me over, and over, and over in the comments to this blog and other sites).

Here's why The Hot Zone is infuriating to so many of us in epidemiology and  infectious diseases.

First--the description of symptoms.Preston himself admits that these were exaggerated. Over and over, he uses words like "dissolving," "liquefy," "bleeding out" to describe patient pathology. (If I had been playing a drinking game while reading and did a shot every time Preston uses "liquefy" in the book, I'd be dead right now).

Of a Marburg patient, pseudonymously named Charles Monet, he describes him as

"...holding an airsickness bag over his mouth. He coughs a deep cough and regurgitates something into the bag. The bag swells up....you see that his lips are smeared with something slippery and red, mixed with black specks, as if he has been chewing coffee grounds. His eyes are the color of rubies, and his face is an expressionless mask of bruises. The red spots...have expanded and merged into huge, spontaneous purple shadows; his whole head is turning black-and-blue...The connective tissue of his face is dissolving, and his face appears to hang from the underlying bone, as if the face is detaching itself from the skull...The airsickness bag fills up to the brim with a substance known as the vomito negro, or black vomit. The black vomit is not really black; it is a speckled liquid of two colors, black and red, a stew of tarry granules mixed with fresh red arterial blood. It is hemorrhage, and smells like a slaughterhouse....It is highly infective, lethally hot, a liquid that would scare the daylights out of a military biohazard specialist...The airsickness bag is brimming with black vomit, so Monet closes the bag and rolls up the top. The bag is bulging and softening, threatening to leak, and he hands it to a flight attendant.

"...the body is partly transformed into virus particles...The transformation is not entirely successful, however, and the end result is a great deal of liquefying flesh mixed with virus...The intestinal muscles are beginning to die, and the intestines are starting to go slack...His personality is being wiped away by brain damage...He is becoming an automaton. Tiny spots in his brain are liquefying...Monet has been transformed into a human virus bomb.

"...The human virus bomb explodes...The victim has "crashed and bled out."...He becomes dizzy and utterly weak, and his spine goes limp and nerveless and he loses all sense of balance....He leans over, head on his knees, and brings up an incredible quantity of blood from his stomach and spills it onto the floor with a gasping groan. He loses consciousness and pitches forward onto the floor. The only sound is a choking in his throat as he continues to vomit while unconscious. Then comes a sound like a bedsheet being torn in half, which is the sound of his bowels opening and venting blood from the anus. The blood is mixed with intestinal lining. He has sloughed his gut. The linings of his intestines have come off and are being expelled along with huge amounts of blood. Monet has crashed and is bleeding out."

And later, at autopsy:

"His liver...was yellow, and parts of it had liquefied--it looked like the liver of a three-day-old cadaver. It was as if Monet had become a corpse before his death...Everything had gone wrong inside this man, absolutely everything, any one of which could have been fatal: the clotting, the massive hemorrhages, the liver turned into pudding, the intestines full of blood."

And I didn't even get to what Preston says about Ebola and testicles. Or pregnant women. Seriously, there's pages upon pages upon pages of this stuff.

Throughout the book, Preston presents these types of symptoms as typical of Ebola. Not "in worst case, this is what Ebola could do," but simply, "here's what happens to you when you get Ebola." It's even beyond a worst case scenario, as he notes in part: "In the original 'Hot Zone,' I have a description of a nurse weeping tears of blood. That almost certainly didn’t happen."

Compare that to just about any blog post by actual workers with Médecins Sans Frontières, healthcare workers on the front lines of this and many previous Ebola outbreaks. Stories are scary enough when the reality of the virus is exposed, and with it the dual affliction of poverty and the terrible health system conditions of affected countries. I interviewed MSF's Armand Sprecher a few years back during a different Ebola outbreak, and he noted this about symptoms--quite different from the picture Preston paints:

The patients mostly look sick and weak. If there is blood, it is not a lot, usually in the vomit or diarrhea, occasionally from the gums or nose.

The clinical picture of Ebola that people take away from The Hot Zone just isn't accurate, and with 3.5 million copies sold, is certainly driving some (much? most?) of the fear about this virus.

Second, airborne Ebola. Though this trope is often traced back to "Outbreak," Preston clearly suggests that both Zaire Ebolavirus and Reston Ebolavirus can be airborne. What he never discusses nor clarifies is that the "evidence" for this potential airborne spread is really thin, and not even indicative of animal-to-animal or animal-to-person transmission.

Rather, it's much more likely that if airborne spread was involved, it was aerosols generated by husbandry (such as spraying while cleaning cages), rather than ones which would have been generated by infected primate lungs (a necessary step for primate-to-primate transmission via a respiratory route). Indeed, this is the paper that Nancy Jaax et al. published on the findings Preston talks to Jaax about, 13 years after the fact (the experiment is marked as 1986 in The Hot Zone), and noting that transmission due to husbandry practices could not be completely ruled out. It's unclear also that the Reston strain moved through the primate facility via air, rather than via spread due to caretakers, equipment, or husbandry. Nevertheless,  it's frequently cited as fact and without any qualification that Reston is an airborne type of Ebola.

Instead, here is what Preston says about it:

"If a healthy person were placed on the other side of a room from a person who was sick with AIDS, the AIDS virus would not be able to drift across the room through the air and infect the healthy person. But Ebola had drifted across a room. It had moved quickly, decisively, and by an unknown route. Most likely the control monkeys inhaled it into their lungs. 'It got there somehow,' Nancy Jaax would say to me as she told me the story some years later. 'Monkeys spit and throw stuff. An when the caretakers wash the cages down with water hoses, that can create an aerosol of droplets. It probably traveled through the air in aerosolized secretions. That was when I knew that Ebola can travel through the air.'"

He then comes back to "airborne Ebola" several times, based in part on this idea.

But here's the thing. Just about any virus or bacterium could be aerosolized this way--via high pressure washing of cages, for example. If it can bind to lung cells and replicate there, as we already know Ebola can, it can cause an active infection.

But that's not the same as saying "Ebola can drift across the room" from one sick person to a healthy person and cause an active infection, as Preston tries to parallel with HIV in the above paragraph. Even in Jaax's experiment and others like it, there's zero evidence that primates are expelling Ebola from their lungs in a high enough concentration to actively infect someone else. And that is the key to effective airborne transmission. Think of anthrax--if it's released into the air, we can inhale it into our lungs. It can replicate and cause a deadly pneumonia. But anthrax isn't spread person-to-person because we don't exhale the bacteria--we're dead ends when we breathe it in. This is what happens with primates as well who are experimentally infected with Ebola in a respiratory route, but Preston implies the opposite.

Third, if it wasn't for points one and two, The Hot Zone really could be read as a "damn, Ebola really isn't that dangerous or contagious so I have little to worry about" narrative. Preston describes many "near misses"--people who were exposed to huge amounts of "lethally hot" Ebola-laden body fluids, but never get sick--but doesn't really bother to expose them as such. All 35 or so people on the little commuter plane Monet flies on between his plantation in western Kenya and Nairobi, deathly ill, vomiting his coffee grounds and dripping nasal blood into the airsickness bag he handed to a flight attendant--none of them come down with the disease.

The single secondary infection Monet causes is in a physician at the hospital where he's treated, after his bowels "ripped open" like a bedsheet. That physician, Shem Musoke, not only swept out Monet's mouth until "his hands became greasy with black curd" but also was "showered" with black vomit, striking him in the eyes and mouth. Monet's blood covered Musoke's "hands, wrists, and forearms," because "he was not wearing rubber gloves." Musoke developed Marburg virus disease, but survived--one of the few secondary cases of infection described in the book.

Another "close call" was that of Nurse Mayinga N. She had been caring for one of the Ebola-infected nuns at Ngaliema Hospital in Kinshasa during the 1976 outbreak in Zaire, the first detected entry of Zaire Ebolavirus into the human population. Beginning to feel ill herself, she ditched her job and disappeared into the city for two days. She took a taxi to a different, larger, hospital in the city, but was sent away with a malaria shot. She's examined at a third hospital and sent away. Finally she returns to Ngaliema hospital and is admitted, but by that time, had caused a panic. Preston says:

"When the story reached the offices of the World Health Organization in Geneva, the place went into full-scale alert...Nurse Mayinga seemed to be a vector for an explosive chain of lethal transmission in a crowded third-world city with a population of two million people. Officials at WHO began to fear that Nurse Mayinga would become the vector for a world-wide plague. European governments contemplated blocking flights from Kinshasa. The fact that one infected person had wandered around the city for two days when she should have been isolated in a hospital room began to look like a species-threatening event."

How many secondary cases were the result of Mayinga N's wanderings? That possibly "species-threatening" event? Preston again devotes several paragraphs to Mayinga's gruesome illness and death, and notes that 37 people were identified as contacts of hers during her time wandering Kinshasa. He tells us they were quarantined "for a couple of weeks."

The fact that exactly zero people were infected because of Mayinga's time in Kinshasa merits half a paragraph, and not dramatic or memorable. "She had shared a bottle of soda pop with someone, and not even that person became ill. The crisis passed." <--Yes, that is a direct quote and the end of the chapter on Mayinga. Contrast that to Preston's language above.

Finally, beyond the science and the fear-mongering about Ebola, beyond everything and everyone in the story "liquefying" and "dissolving" and "bleeding out," reading this book again as an adult, as a woman in a science career with a partner and kids, I was also left annoyed at the portrayal of the scientists. All of the major characters except one, Nancy Jaax, are men of course, ranging in age from late 20s to 50s-60sish. Understandable since this is in a mostly-male military institution and in a BLS4 setting to boot, but the one Preston focuses on for much of the narrative is Jaax.

While Preston may have been trying to portray Jaax as the having-it-all, tough-as-nails woman scientist, the fact that she's the only one with any kind of home life is telling--mostly because he devotes more paragraphs to how she neglects both her children and her dying father than any success she has in her life outside of work. She is told early on by one of her colonels that "This work is not for a married female. You are either going to neglect your work or neglect your family." This thought comes up repeatedly for Jaax, and in the end, while she was accepted and even honored by her colleagues and bosses, we hear over and over again how her children are left on their own to microwave meals and tend to their homework. How they desperately wait up for her to get home after work, often eventually falling asleep in her bed before she arrives. How she tells her father, dying of cancer back in Kansas and both knowing he only has a few hours to days to live, good-bye and "I'll see you at Christmas" over the phone. How she barely arrives on time for his funeral after he passes.

We hear one paragraph about how another colleague, Thomas Geisbert, had a crumbling marriage with two small children, and how he left the children at his parents' house for a weekend. Other than that, the personal lives of any other characters are practically absent, save for Jerry Jaax, Nancy's husband. Even with him, much of the character development revolves around his fears of his wife working in a BSL4 lab.

The Hot Zone, for me, is unfortunately one of those books that you read as a young person and think is amazing, only to revisit years later and see it as much more shallow and contrived, the characters one-dimensional and the plot predictable. The problem is that The Hot Zone is not just a young adult novel--it's still presented and defended as an absolutely true story, especially by huge Preston fans who seem to populate comment threads everywhere. And now it looks like there will be a sequel. At least it should be good for a drinking game.


*I'll note that The Coming Plague is much more measured when it comes to Ebola--the two were grouped together because temporally, they were released close together, not because they display the same type of hype regarding the virus.


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Thanks for going through these problems in detail. I had read the book 15 years ago or so, and your guess is correct: I am still carrying those misleading images in my head. They are extremely unhelpful as the US decides how to respond to this rather minor public health challenge.

By Don Monroe (not verified) on 20 Oct 2014 #permalink

Thanks for writing this. I haven't read that book since like '95 when I was 15. So it's been nearly 20 years, I may actually even still have it on my shelf. I barely remember it other than that it scared the shit out of me. For a long time The Hot Zone and the movie Outbreak were responsible for my entire understanding of what Ebola was.

By Chris Berez (not verified) on 20 Oct 2014 #permalink

Agree with you on all of this. However there is an important issue the book brings to light you did not mention-what if the "authorities" don't agree on how to handle an outbreak? In the book the Army and the CDC did not agree-things ended before it really mattered. But's not clear how that would work.

They actually worked it out fairly well per the book. I don't know how things really went down, of course, but it seems reasonable that the CDC would handle human cases (as they are now if called in by local public health or otherwise assigned). USAMRIID typically wouldn't really have jurisdiction but this was an odd case since they found the virus and it was in their backyard. There are definitely turf wars but if they get out of hand upper-level people can get them under control. I didn't discuss that here because it's not one of the main points people 1) even remember or 2) get drastically wrong in the current Ebolamania.

Back in the mid-1990s, when the Kikwit outbreak was still going, a participant in one of the bionet chat groups coined the term "Ebola Preston": that is, a meme that spreads like wildfire that consists largely of spectacularly overblown hype.

By Ed Rybicki (not verified) on 21 Oct 2014 #permalink

Really good Tara. I have a similar relationship to the book, in that at first I thought it was amazing, and I now find it depressingly overblown and unhelpful.

keep up the good work

By Bill Hanage (not verified) on 21 Oct 2014 #permalink

I think you're being a little unfair. Even as an adult (and professional female), I thought the Preston book was an entertaining and informative read. My takeaway (based the very facts you mention), was that Ebola is difficult to catch and clearly not airborne. Perhaps you'd find the book less vexing if you had a higher opinion of the reading public.

More generally, I'm a little baffled by all the concern about Ebola hysteria. Apart from a lot of chatter on twitter and calls to limit the air travel of people out of the hot zone (not entirely unreasonable), I see none of the hysteria that the media seems to be so worried about. Ebola, even if it doesn't cause people to liquify, is a highly lethal disease that needs to be taken seriously. I'm glad the public is paying attention.

Everything you said is very true about the virus. What you failed to mention was the term, "microbreaks:. Virus' attempt to make a permanent break into species to find another host to "take up shop" in as the book states. Each attempt/break can, and has, been different. You are speaking as if 1976, 1983, 1986 is the same as today. In fact it isnt; the virus today has mutated and we do not know nearly as much as we believe. What I garnered out of this article is what I already figured: we do not know as much as we are led to believe about this virus; the virus has always and will always burn out on its own without a single bureaucratic agency stopping a damn thing.

Also, each and every time an outbreak ended from ebola it was not because of some human hero, but because the virus seemingly , "disappeared" into the bush. My concern is not with the virus as much as it has to do with how we cope with it. My fear is not the virus but oir incompetence and arrogance as a species at times. I also have read the book and what alarmed me more than anything was how the cdc and military did nothing to avert crisis: seemingly, somehow, the virus burned out on its own. If it ever found a macrobreak into society and did not burn out, all deals are off. The ones who truly understand this virus know this and is why it is paramount that we stop it in africa.

As for the virus being airborne.. I also have read the book and she only assumed that the cleaner of the cages was how the monkeys became infected, but that is only an assumption. Also, johnson and jax both infected monkeys with airborne zaire and wrote an entire scientific peer reviewed study and surmised thst the virus is capable of surviving longer in a colder and drier climate in air and on objects; that the humid and hot climate of africa was not its best place to thrive.

Does that mean we are doomed? No, far from. It only means what they wrotwww and found through scientific experimentation and that the virus survives better in drier cooler conditions, I.e. a lab or winter.

Tara, you mention The Coming Plague in passing, and I hope you are not painting my book with the "Hot Zone" brush. I actually covered the Reston outbreak as it happened and have another issue: How he treats Dr. Joe McCormick. Joe was part of the team in the 1976 Yambuku Ebola outbreak, for CDC, so as soon as USAMRIID said there were possible human cases in Reston Joe was sent up to check it out. He almost immediately determined it was flu in the people, ruled out danger for people and noted Hemorrhagic B virus was also in the animal population, possibly the bigger threat. In order to maintain a long suspenseful read Preston had to destroy Joe & make him seem incompetent and irrelevant -- otherwise the book is done somewhere around Chapter 2. It was a nasty thing to do to Joe, and inaccurate.

By Laurie Garrett (not verified) on 21 Oct 2014 #permalink

Laurie, no not at all. I'll edit in a note in about that but TCP was simply temporally in that same time frame. I don't think that's been a driver of the "Fearbola" like the Hot Zone has.

I did leave out the whole issue of CDC/USAMRIID political inter-fighting that he describes. There also was a scene where he simply describes a "Belgian doctor" (Piot?) greasing some wheels during the 1976 outbreak that seemed a bit odd as well, but I'm way more familiar with the epi & microbiology than all of the personalities involved. As such, I don't have as much background to be able to comment on inaccuracies there. Thanks for adding that perspective.

Sean, here in Northeast Ohio, public health has fielded literally thousands of calls about Ebola since Amber Vinson traveled here. Thousands of dollars (tens of thousands?) have been spent on "cleaning up" schools and airports far from where Vinson or any direct contacts were. I myself spent hours discussing just how Ebola can be transmitted, how long it can live on surfaces, etc., because there is so much misinformation out there and people are scared. It's great you're not seeing it wherever you are, but that certainly is not the state everywhere. Also, while writing about this outbreak, you have no idea how many comments I get that are simply instructions to "read Hot Zone" and that will show me that "Ebola is airborne," or whatever similar claim they're making, despite the fact that I know the papers published by Jaax and others--and those papers are much more measured in the scientific literature than their HZ descriptions. Others clearly are taking away a different message than you are.

"Me," there is no evidence of mutation in this outbreak that is in excess of previous outbreaks. *Every* human transmission and introduction of the virus into the population will be with a slightly different virus--a "mutant" from previous ones we've seen. But we don't see any differences in this one that appears to make it more transmissible or virulent. You are also mistaken about prior outbreaks. They have been contained, by and large, via large and tedious field investigations involving lots of isolation of patients and contact tracing of those who were infected or exposed. See the recent work in Nigeria, involving hundreds of contacts and thousands of home visits. Sounds like that involved lots of human heroes to me.

I started reading it and immediately thought it was fiction, couldn't be an accurate description of how any disease actually worked, and tossed it aside as overwrought drivel.

It seems my assessment was mostly right.

By Brian Evans (not verified) on 21 Oct 2014 #permalink

Richard Preston also wrote a novel about bioterrorism ("The Cobra Event"). It's certainly a gripping story, but I have no expertise to evaluate the medical aspect of it.

Rereading it for the first time since it came out, I noticed all the references to an Iraqi biowarfare program, mobile weapons labs, etc. To be fair, at the time RP wrote this (pre-2002) lots of people believed the stories about biological weapons research in Iraq.

I spent some time with Google looking for any remarks by RP following the Iraq war, to see what he had to say about the striking absence of all the biowar infrastructure he thought would be there. But nobody seems to have asked him about it, or if they did I can't find any record of it.

Apologies if this is somewhat tangential to the topic, but I think it's another example of RP being less than scrupulous in his writing.

Please be direct, is The Hot Zone: A Terrifying True Story fiction or an instance of Truthiness? I read it shortly after it came out and realized I had been working in and out of hat area (block away) at the time of the case. The book scared the hell out of me. The symptoms of Marburg/Ebola reminded me of blood agents as they were described in Military Nuclear Chemical and Biologic Weapons classes. If the transmission is so difficult how did it get passed in Dallas when it appears that the only unprotected skin was the neck area? I find it hard to believe that nurses in this case were careless. If it is as difficult to transmit as you seem to propose then the 95% coverage (face/eyes/nose/mouth shields) should have been pretty effective.

By Anhout Zwingley (not verified) on 21 Oct 2014 #permalink

"If it is as difficult to transmit as you seem to propose then the 95% coverage (face/eyes/nose/mouth shields) should have been pretty effective."

It is speculated that the transmission occurred when they were removing the protective clothing. Dr. Smith actually mentions that on her appearance in this podcast:

Also in our local paper this morning, there was a photo and small article about aid responders training that focused on shedding safety gear:

My comment with links went into moderation. The possible transmission may have occurred when they removed their safety gear.

^Yes. Actually at the blog I linked earlier (http://haicontroversies.blogspot.com/), it's run by experts in hospital infection control and they discuss extensively how tough it is to "don and doff" protective gear correctly. If the hospital didn't give them careful training--which seems like they probably didn't given the other issues that have surfaced--they could have contaminated themselves upon removal, when most people "feel safe."

While I agree the book can be seen as exaggerated, it brought an awareness to Ebola that would never have existed otherwise.

While your claim of misplaced paranoia may be true, there has been little evidence of that paranoia actually being put into effect other than on internet comment sections. People (outside of communities with someone who has been quarantined) aren't cancelling flights en masse, or stopping all interaction with others and locking themselves in their homes. This paranoia is on the same level as political paranoia, that Obama is actually in league with China or North Korea or al Qaeda. It is a bunch of people talking.

I doubt your quality of life is at all impacted by Preston's overblown description of the disease. You're not going to lose your job. People probably aren't mobbing your home for safety or threatening you to not come back until this blown over for fear of you getting contaminated and spreading it to all of them. I could be wrong, in which case I am sorry for the assumption. But I doubt it, otherwise the trigger happy news feeds would pick up on it.

Let's not discredit what Preston set out to do, tell a gripping story based somewhat in reality. The reality base makes it scary but exciting (like the sensation of hearing a ghost in your home after you see a horror movie - gets you all freaked out but statistically, the amount of people with an apparition floating around in there is null). Ebola is always a remote risk in the world and he probably never had any intention of inciting panic since how likely was an Ebola outbreak in the US. He wanted to tell a good story and sell a lot of copies and that's what he did. He didn't claim to be giving medical advice or crisis management tips on how to handle it.

It is no different than any news we receive nowadays which is often sensationalized.

According to your post, it seems you are more negatively impacted by the public's perception than by the threat of the actual disease. If it's really affecting your health, stop reading internet blogs and the comment section.

Problem solved.

Steve, I don't think we know that regarding your first claim. We can't go back and re-run history. And you are also incorrect about what is happening with regard to Ebola paranoia. Check out all these examples journalist Tara Haelle provides--http://www.politico.com/magazine/story/2014/10/how-the-media-stoked-ebo…

You're correct that my quality of life is not personally impacted. But, this *has* come to my school and place of employment. Fellow employees are dealing with their own sick relative, and with being in isolation, and with all of the stigma that comes along with that. Students who are from West Africa--or are even obviously "foreign" but may be from Kenya or other countries in Africa--are being viewed with suspiscion and are feeling the discrimination (even more than usual). Because is not impacting me personally, should I ignore that? You are being incredibly dismissive of this and defending not only the sensationalistic news culture, but also authors like Preston who benefit from this. That's your choice but I prefer to fight against exactly that mentality.

I support your right to fight but paranoia is often rooted in sound logic that's pushed too far.

Perhaps Ebola isn't as contagious as the news would lead us to believe but isn't it better to stay away from the cliff entirely rather than just be extra careful while playing on the ledge? This paranoia has pushed politicians to start acting, implementing screening at airports and respond more aggressively (finally issuing protocols) to try to prevent it from even entering the country. If people were calm as a winter lamb, there's a good chance they'd still be sitting on their hands debating how much resources to throw at this possible threat, perhaps letting hospitals continue fumbling their own way through how to respond to this new agent.

Agreed that it's unfortunate that some people are discriminated against, but this discrimination could also prevent another infected person from getting into the country. Thus revealing my bias, err on the side of safety, even at the risk of inconvenience or offense. If you ask the family of one of these infected nurses if they wish airport discrimination-screening had stopped Duncan from bringing it into the country, thereby leading to their relative's infection, even at the expense of inconveniencing thousands of people, I'm willing to bet they'd sign up for that in a liquified heartbeat.

With a kill rate as high as Ebola has, people are understandably afraid. Even if it isn't airborne like some have claimed it to be, what if someone sneezes and then grabs a handrail or hands over their money to the cash register worker? Chance of infection right there. The so-called paranoia arises from the fact that these people are walking around, interacting with pyramids of other people before they're finally isolated. And while I use the nurses' families in defense of my point above, I'll throw the first under the bus now.

When a trained nurse, who presumably understands the value of safety and health precaution, has been caring for an Ebola-infected patient for several weeks and then comes down with a fever and nausea herself, one would think that the nurse would logically play it safe and not fly, even though she wore a protective suit. But she flew anyway. The CDC employees even cleared her. What inconsiderate flaming idiot would think it was at all appropriate to allow that? Even with a protective suit on her all the time, with a 70% kill rate, normal people would assume she would play it safe and take one for the team by staying home, JUST IN CASE. Normal people would assume that government agency employees would play it safe and tell her to stay home when she calls up to ask for permission to travel. But she flew. They even let her fly.

Management failure is so grossly evident that normal people start freaking out at how the system failed, at how easily this thing is traveling through airports and around the country. If a trained nurse is not wise enough to play it extra-safe and can slip through controls, airborne or not, Ebola could end up in your city within a 4 hour flight.

I think a little paranoia is justified in this case.

What would you have suggested be done to curb the threat before people started freaking out? What do you suggest be done now, after the freak out has started?

I recognize I am negating my first claim that the paranoia is only manifesting itself on internet boards, as your politico article refutes. I guess my overall point is, even if it's happening outside of comment boards, I can't completely say it's unwarranted.

Now where did I put that gas mask and pitchfork?

Steve - There are healthy people locking themselves in their own homes for fear of Ebola, and there are people on the internet yammering to prosecute victims and their families; someone threatened to burn down the house of a recently returned missionary who is healthy but self-quarantining, with him and his family inside. Others are spewing even on TV - don't even consider talk radio - that Obama is deliberately importing Ebola-infected Kenyan Mooslim terrorists to kill good white people, etc.; you can imagine how the smaller-brained members of the audience react to that.

The nurses who cared for Duncan - not for "several" weeks - were told that they were not at real risk and only needed to self-monitor out of an abundance of caution. We now know that was wrong, but when Vinson went to Ohio, she did not know that, as Pham had not yet gotten sick. The CDC told her it was okay to fly, both ways. That was an error, but Vinson wasn't "selfish" or "inconsiderate" as so many are claiming; she asked if she should urgently return to Dallas after Pham was diagnosed, she asked if she should go to a hospital when she had a tiny fever, and the CDC "expert" repeatedly said no. This isn't directed at you, Steve, but given the nature of much of the ultra-right response to Ebola, I cannot help doubting that there would be so much howling against her if she were lily-white.

I don't think someone sneezing and touching a handrail is a big issue, since the virus in humans is not primarily produced in the respiratory system nor in sweat, certainly not in large quantities before the person is symptomatic. It's clear from Dallas that if you have to care for a patient who is being violently ill, aerosol or skin-as-fomite transmission is a huge risk. However, it's equally clear that just being near a person who is starting to get sick is not, since none of Duncan's family - who were in the apartment with him when he was first sick, then were caged inside with all their "dangerous, contaminated" personal possessions for four days afterwards - became ill.

There is a small minority of nutcases in almost any issue you could mention. There is probably a small minority of creepers hiding outside of Justin Bieber's house hoping he is the second coming. But the small minority doesn't represent the great majority and in this case, I would say the great majority are not burning houses down but are legitimately scared and worried and upset at how this has been handled. Just as the majority are upset that Bieber gets any news coverage ever.

As opposed to your ultra-right comment, I consider myself right-winged and I have no idea what skin color either nurse is, nor what their names are, that anyone cares about their skin color (you or them) makes me think this is an attempt to turn the situation into political fuel against the opposite side. I couldn't care less if Mitt Romney was in charge or Obama, male or female, black or white, rich or poor; crap went down that shouldn't have and I'm upset over it as it could lead to me and my family being put at risk when this should have been nipped in the bud before it even got within 100 miles of the coastline, or 10 miles of any major airport.

The virus is not produced int he respiratory system, but it is carried in saliva, which becomes airborne or much more mobile when someone sneezes. Heck, when you sneeze, your salivary drops can travel hundreds of yards on the wind.

Is ebola transmittable by saliva? If so, then paranoia is justified because hot dang, people's saliva is everywhere. If not, then I and everyone else can settle down and worry a little less next time we have to take change from a cashier or grab the airport door handle.

The virus is quickly inactivated in saliva. Spit is not an issue.

I was a uni student when I first read 'The Hot Zone' whilst browsing at a local bookshop - it caused me to miss my bus at least a couple of times. (Yes, I eventually bought my own copy - money was an issue then.. now too come to think of it!)

I very vividly recall reading the paragraphs on "Monet" and what the Marburg virus apparently did to him -and nurse Mayinga and others.

Hellishly powerful and memorable stuff. Quite a meme if not a virus.

Many, um, yikes decades later, well, I am just going to say thanks for you writing this.

By Astrostevo (not verified) on 23 Oct 2014 #permalink

Well then, slap that on a news site headline and we can put this baby to bed.

Thanks for the info.

EBOV has been isolated from saliva, and the CDC website says that it's a potential route of transmission. It might not be the most efficient route, but I don't think current data really can be interpreted as categorically as you suggest here.

Hi Tara,

I'm not going to belabor the argument that we should be preparing for the worst. Instead, I wanted your opinion on a different topic.

In Dallas, a nurse who had been caring for Duncan flew multiple times on commercial airlines. Another nurse went ahead and booked a vacation on a cruise line. Now we're learning that in New York Dr. Spencer did not self-quarantine himself after caring for ebola victims in Africa, but instead decided it was fine to ride in taxi cabs, take the subway, and go bowling.

Clearly this is one of the most exasperating aspects of the ebola outbreak in the United States; specifically, there seems to be a cavalier disregard for the deadliness of the disease by the same people who are supposed to be on the front lines containing the disease.

What is your opinion on this?


By TJ Harvey (not verified) on 24 Oct 2014 #permalink

Another nurse went ahead and booked a vacation on a cruise line. Now we’re learning that in New York Dr. Spencer did not self-quarantine himself after caring for ebola victims in Africa, but instead decided it was fine to ride in taxi cabs, take the subway, and go bowling.

That's because it was fine.

It was just dandy for the doctor, to be sure. But it was not so fine for the people who later road in his cab, or for the mother or father who later put on his rented bowling shoes, all of whom are now wondering whether they are going to live or die.

It's good to see that the politicians in New York finally got some common sense and imposed mandatory quarantines:


By TJ harvey (not verified) on 24 Oct 2014 #permalink

Not common sense at all. It's going to put more of us in danger by belaboring the outbreak in Africa. We're freaking out here over something that is actually tough to transmit (bowling shoes, really?) while we're now actively discouraging people from helping to fight it. Political pandering of the worst kind.

There seem to be folks here like you, Tara Smith, who out of some sense of guilt over "discrimination" or "colonialism" or some other such thing keep telling us all how we have to be "fair" to the Africans. And we have to avoid any semblance of "discrimination." You said the same thing in your new POLITICO article, and some folks in this discussion thread are saying the same thing.

"Fairness" and "discrimination" aren't medical terms, they aren't biological terms, and they aren't epidemiological terms.

They're political terms.

I don't see any compelling reason to do anything that would put the public health of the American people at risk just to be fair or nice or non-discriminatory with other people. America's public health should not take a back seat to international public relations.

If America's health care officials aren't concerned first and foremost with public health in America as opposed to public health in Africa or anywhere else, they're not doing their jobs and they should be fired.

If we can institute a visa ban and keep Ebola out of this country, I don't care if the whole world calls us racist, colonialist, imperialist, blah-blah-blah. All that stuff isn't worth a single innocent American life.

It has nothing to do with being "fair." It has everything to do with maintaining relationships and trust with citizens of the affected countries. We need their help to get this under control, and if they see US policy as basically shutting them in and slamming the door, why in the world would they trust us? And if we can't get it controlled over there, you can be sure we'll keep seeing cases over here, no matter what type of ban might be put in place. It *is* a public health matter and if you truly believe that we need to protect "innocent American life," then you do that by putting everything we have into containing the outbreak in the affected countries.

It’s good to see that the politicians in New York finally got some common sense and imposed mandatory quarantines

So we're all cool about the same – and then some – for other diseases with a higher effective reproduction number, right? No, that wouldn't work. It seems as though you have some comparative analysis between R and CFR in mind, but I'll be jiggered if I can find the inflection point, legally speaking.

Hey, (Na) sinz54, two things:

1) Thanks for bringing in the science-free, racist FOX News perspective to this thread. Now we all know what bullcrap to expect to see from our right-wing rellies with Facebook accounts.

2) If Ebola came from France, would you still favor a travel ban?

By Phoenix Woman (not verified) on 29 Oct 2014 #permalink

This really is very basic, everyone. For those of you who have spent anytime studying networks, you know that the communicative power of a network is proportional to the square of the number of people connected to the network. Ergo, by imposing travel bans you reduce the number of people in the network and thus degrade its communicative power (i.e., its rate of transmission). This is Science 101, folks, and is not open to dispute.

I agree that our ability to combat ebola worldwide depends on trust between nations. But the suggestion that foreign governments will no longer trust us if we merely prevent common citizens from flying into our country is really a stretch, especially in light of everything we have done to help these afflicted countries.

There seems to be a persistent, unspoken meme that Americans should be willing to sacrifice their safety and dare I say - peace of mind - so that less fortunate Africans can gain access to our health care system. This type of view is terribly disloyal to our fellow citizens. Even worse, the current policies that arise from this unspoken view also run counter to any notions of sound science.


By TJ Harvey (not verified) on 30 Oct 2014 #permalink

Actually TJ, it is open to dispute because you're assuming no net gain of cases from the one lost to travel. I don't buy that, and neither do the people on the ground in West Africa. (Or Bill Foege, for example: http://www.humanosphere.org/basics/2014/10/op-ed-bill-foege-make-ebola-…). Conspiracy theories are gaining ground even here in the US (see Natural News & his post on Kaci Hickox--I refuse to link it)--so why shouldn't they believe them at ground zero?

If Americans want peace of mind, simple way to have it--eliminate the outbreak where it is occurring. Period.

My last response to your post disappeared from your site, so I will attempt to re-post the gist of my message.

The network at issue is the global community, and by removing a certain group of people from that community the communicative power of that network diminishes. This is mathematical truism that is not altered by the fact that a quarantined person might infect others in quarantine.

I would also point out that the people on the ground ARE quarantining people, which has always been the default protocol for ebola. I think this speaks volumes about Mr. Foege's theories about limiting travel.

Maintaining credibility in times like this is very important. Nothing is served by espousing conspiracy theories. However, nothing is gained by painting so rosy picture of the risks that the public loses faith in our institutions. This is precisely what is happening now.


By TJ Harvey (not verified) on 31 Oct 2014 #permalink

Why is it that Ebola and Anthrax dead end with humans? In the case of Ebola, does this mean that the reservoir transmits to humans and we can only spread it among ourselves, and cannot transmit back to susceptible species? I guess I am wondering if transmission only works one way (bats give it to humans, why can't humans infect susceptible bats?).