Bug Zappers
Virus Ground Zero: Stalking the Killer Viruses with the Centers for Disease Control, by Ed Regis, New York: Pocket Books, 244 pages, $23.00
The 1995 movie Outbreak, in which a cute monkey carries a nasty virus from Zaire to California, opens with a quote from the geneticist Joshua Lederberg: "The single biggest threat to man's continued dominance on the planet is the virus." Early in the film we learn that the "Motaba virus" causes a form of hemorrhagic fever that "kills in two or three days," and "the mortality rate is 100 percent." After a small California town hit by the microbe is quarantined, the general played by Donald Sutherland says, "If that bug gets out of there, 260 million Americans will be dead or dying." The general played by Morgan Freeman raises the stakes even higher: "The fate of the nation, perhaps of the world, is in our hands."
As it happened, the movie opened a couple of months before a highly publicized outbreak of hemorrhagic fever in Kikwit, Zaire. The real-life outbreak, which science writer Ed Regis chronicles in his fast-paced and absorbing new book, Virus Ground Zero, also inspired apocalyptic warnings. Early press reports cited "fears that it may be the deadly Ebola virus, an incurable 'doomsday disease,' " and quoted a Zairian doctor who said, "The situation could get totally out of control." A World Health Organization official told the San Francisco Chronicle, "If it is Ebola, this is the big one–this is what we're always thinking about when we talk about serious, dangerous disease threats."
The public had been primed to expect "the big one" by books like Laurie Garrett's The Coming Plague and Richard Preston's The Hot Zone, both published in 1994. "In a sense, the earth is mounting an immune response against the human species," Preston wrote. "Perhaps the biosphere does not 'like' the idea of five billion humans….The earth is attempting to rid itself of an infection by the human parasite." Preston called AIDS "the revenge of the rain forest" and warned, "It is only the first act of revenge." Outbreak, in which the first person to be infected picks up the disease while helping to build a road through the jungle, flirts with a similar idea. The local witch doctor, explains a physician, "believes that the gods were awakened from their sleep by the men cutting down the trees where no man should be, and the gods got angry. This is their punishment."
Regis has little patience with this sort of nonsense. "The 'revenge of the rain forest' doctrine was in fact a return to a prescientific, animistic conception of nature," he writes. "[I]t was a throwback to the days when the gods were portrayed as stomping about in heaven and hurling thunderbolts down from the sky. The only difference was that these days they were slinging viruses." The notion also helped fill a void left by the end of the Cold War: "All at once viruses had replaced the A-bomb as the object of the apocalyptic vision." Noting that "Ebola kills 88 percent of its victims," a participant in an Internet discussion group called it "the mightiest threat mankind has yet faced."
But in the end, Ebola killed less than one-tenth of 1 percent of Kikwit's population–300 people out of half a million, in a crowded city with poor medical care and abysmal sanitary conditions. And as Regis shows, it was stopped through utterly prosaic methods. A physician with the U.S. Centers for Disease Control and Prevention describes the first order of business when he and his colleagues arrived at Kikwit General Hospital, the main locus of transmission for Ebola: "We just went in, cleaned the floor, removed the needles, removed the cadavers, put them in body bags, did the cleaning." Wearing protective clothing, they cleared out and carefully disposed of the vomit, urine, excrement, dirty needles, and dead bodies, liberally applying bleach solution to everything. They instituted basic sanitary procedures, including the wearing of gloves and face masks. Thus was the "doomsday disease" conquered.
"The fact of the matter was that Ebola hemorrhagic fever, along with Marburg and Lassa, were diseases of poverty and bad hospitals," writes Regis. "Although they thrived momentarily when they erupted in such environments, those same viruses were stopped cold every time they turned up in well-equipped medical institutions….Common and ordinary items such as rubber gloves, plastic gowns, and face masks could halt an epidemic. A killer virus itself could be killed by a liberal application of household bleach. [T]hose items, mundane and boring as they were, had been the very things that had terminated the Ebola outbreak in Kikwit." He quotes a South African physician who dealt with an earlier outbreak of the disease: "Ebola is of absolutely no danger to the world at large. It is a dangerous virus, but it's relatively rare and quite easily contained….The media is scaring the world out of its wits, and movies like Outbreak are doing people a great disservice."
What about "erring on the side of caution"? Dustin Hoffman's character in Outbreak, a virus specialist at the U.S. Army Medical Research Institute of Infectious Diseases, is portrayed as heroic because he always assumes the worst, and sometimes he's right. But as Regis's account of the 1976 swine flu fiasco makes clear, such pessimism has its costs. Based on a single ambiguous case, the Ford administration ordered a crash vaccination program that killed 58 people through side effects before it was aborted. The program saved no one, since the epidemic never materialized: "The swine flu virus had disappeared from the United States before the vaccination campaign began."
In addition to debunking microbe-of- the-moment alarmism, Regis offers a lively, engaging, and often amusing account of how disease controllers do their job: tracing (and breaking) lines of transmission, identifying pathogens, looking for their source, developing countermeasures. He pops back and forth in time a lot, which is occasionally confusing (and makes the absence of an index all the more irritating) but generally helps to keep things interesting. We learn not only about the Ebola outbreak in Kikwit but also about the eradication of smallpox, the solution to the mystery of Legionnaires' disease, and other fascinating episodes in epidemiology.
In telling these stories, Regis also tells the story of the CDC, which in many ways has been a victim of its own success. Because Americans no longer live in fear of once common scourges such as malaria, polio, measles, and tuberculosis (to say nothing of smallpox and bubonic plague), occasional outbreaks of infectious diseases get a lot of attention. And because scientists have learned to identify a bewildering variety of previously unrecognized pathogens–hantavirus, Legionella pneumophila, the Rocky Mountain spotted fever Rickettsia–it sometimes seems as if dangerous diseases are cropping up everywhere. "The irony was that the CDC's increasing successes identifying pathogens were looked upon as ominous and threatening, as foreshadowing uncontrolled outbreaks of 'new' and 'emerging' diseases," writes Regis. "The more successful the CDC became, in other words, the more diseased the world looked."
In reality, however, the CDC's new assignments simply did not compare to the plagues of the past. Even AIDS, though incurable, could generally be avoided by eschewing certain activities; contrary to the impression created by the CDC itself, it never threatened to sweep through the general population. Once the infectious disease business seemed to be winding down, it was only natural that the CDC would seek new missions, moving from diseases to injuries, from germs to risky behavior. It became "the ultimate self-amplifying federal bureaucracy. After all, who could object to any institutional excess, any expenditure or innovative new program, so long as it was done in the name of 'health'? And so the place was always building itself up, expanding, and heading off in important new directions."
By the late 1970s, the CDC was taking an interest in smoking, drug addiction, car accidents, unwanted pregnancy, social disorders, emotional stress–even violence. "Whatever else could be said about it," notes Regis, "violence was a product of human free choice, not something that was transmitted to you unknowingly or against your will, like a virus. You did not wake up in the morning and find yourself suddenly in the grip of a violence infection."
But such quibbles did not stand in the way of the CDC's empire building. By 1994, Regis reports, "the CDC's main business, the control of infectious diseases, was just one of dozens of jobs that the CDC had taken on, just another of its many and diffuse assignments. At that point, indeed, the National Center for Infectious Diseases…was receiving only about 10 percent of the CDC's overall budget." Traditional public health specialists–including Dr. C.J. Peters, head of the CDC's Special Pathogens Branch, who is featured prominently in Virus Ground Zero–have expressed discomfort with the agency's ever-expanding agenda, which they think detracts from its central function. Regis notes that, contrary to expectations, infectious disease mortality in the United States rose between 1980 and 1992, a period when the CDC was spreading itself thin by taking on projects far afield from its original mandate.
Virus Ground Zero suggests another problem with the CDC's undisciplined ambitions: The attitude and temperament needed to fight infectious diseases may not be appropriate for other causes of morbidity and mortality. "By and large," Regis says, "physicians gravitated toward public health because they regarded traditional one-on-one medicine as boring, pointless, or both." They liked the fact that "the focus was on herd health,' which meant concentrating on groups of people rather than individuals; the objective was prevention, immunization, making whole populations healthy." This collective approach may work fine for tuberculosis or Ebola, but it tends to run roughshod over individual rights when it's applied to voluntarily assumed risks.
Dr. Joanna Buffington, head of the CDC's Epidemic Intelligence Service, is one of those physicians who prefers to deal with populations rather than people. As Regis tells it, she joined the CDC because she was sick of her family practice. "She hated it," he writes. "She hated the patients who wouldn't take care of themselves, the smokers who came in with their fourth bout of pneumonia but who wouldn't quit smoking, the plump and portly jumbo types who wouldn't cut down on their eating, wouldn't exercise." She tells Regis, "I started to resent these people. And then I'd think, 'Wait a minute, a doctor is not supposed to feel like that. I'm supposed to be compassionate and caring.' But I was getting angry at these people!"
It's a good thing that people like Buffington turn their anger against deadly microbes. But I worry about putting them in charge of achieving "a smoke-free society" or halting the "epidemic of obesity." Recalcitrant smokers and portly jumbo types should worry too.
