Plague - A Medical Thriller (The Plague Trilogy Book 1)

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Such a death is hardly the torture of bubonic plague, but singularly impressive for its rapidity nonetheless. I personally developed great respect for influenza as a year-old when I contracted the avian H2N2 subspecies during the Asian flu pandemic — along with most everyone else at my high school.

At the time, I was a surgical resident, confronting seriously ill patients in the intensive care unit struggling to breathe. So when a new and highly virulent subspecies of influenza, designated avian H5N1 flu, appeared in Southeast Asia in and quickly began to spread globally, I felt compelled to do something for myself and my family.

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All this begs the question: Could an influenza pandemic as bad as the one that struck in occur again? In fact, such an outbreak could be worse than the Spanish flu, even with the antiviral drugs we now have, the antibiotics that are today available for secondary infections, and the modern equipment in our intensive care units. For though medical science has learned a lot about viruses in general and influenza in particular since the World War I era, there is a long way to go.

What we do know is that viruses are highly evolutionarily developed, quintessential parasites. The problem, of course, is that the invaded entity is often killed in the process; for us humans, an attack from the influenza virus means that the cells lining our respiratory tract begin to die, as it is these cells that are selectively chosen.

The flu is primarily a respiratory disease. The fact that viruses such as influenza do their dirty work within cells is what makes treating them so much more difficult than treating bacterial diseases such as bubonic plague, which, in contrast, does most of its dirty work outside cells. In some respects the situation is akin to the difficulties of dealing with cancer in that killing infected cells can put normal cells in jeopardy, too.

Modern medicine does have some antivirals in its armamentarium, but the highly evolved, wily viruses are quick to mount resistance. What it comes down to is that the best way to deal with influenza is to prevent it. All of which brings us back to Plague , the book. And when it comes to the story line, current events are certainly lending a hand. But no matter how impressive its human-to-human transmissibility, this strain simply cannot be the influenza A subspecies for our novel.

Although this disease has killed a few people, even a few seemingly healthy people, for the most part it causes a relatively mild illness, perhaps even milder than the normal yearly flu, which also kills its share of people. But that is not the case with another flu subspecies that originally appeared in and which is now slowly spreading from Southeast Asia, particularly in its normal reservoir of aquatic birds. Luckily it has very low transmissibility — which it makes up for with knock-your-socks-off lethality. A truly scary percentage, about 60 percent, of those humans unlucky enough to have contracted the illness over the last three years have quickly died.

Is there a chance these two subspecies could hook up and help each other? This produces what is called genetic shift — in other words, transfer of entire genes or gene combinations, and hence traits. It will become key to our plot. During this activity he inhales aerosolized H1N1 and contracts the illness. Back home, still mostly asymptomatic yet massively contagious, he hand-feeds his pet duck, which is already harboring H5N1.

The avian H5N1 and the human-adapted swine H1N1 can enter pig cells simultaneously by the availability of separate pig epithelial cell receptors. And of course, this is what happens in Plague , giving the two viruses the opportunity to recombine with each other. During the millions or billions of replications of the virus inside the pigs, either the H5N1 gives its virulence to H1N1, or H1N1 gives its transmissibility to H5N1.

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Either way, a genetically shifted subspecies emerges, and the entire world faces something similar to what Europe faced in when the first Y. At that point, the story moves quickly as the deadly new agent races around the planet, thumbing its nose at all vain attempts to stop or contain it. Governments and individuals will do desperate things, some rational and others not so, like deploying the military to try to close borders or using firearms to keep possibly infected strangers at bay.

Hospitals will be overwhelmed at first and later forced to lock their doors. To avoid interpersonal contact, people will hole up in their homes, causing government offices, schools, and businesses to close. Many public officials will be forced to quarantine themselves from a diseased population and retreat to undisclosed locations, which will only fuel the public panic. Riot police in biohazard suits if there are even enough to go around will increasingly be called upon to beat back waves of sick, scared, and helpless civilians, desperate for food, water, and medicine.

Normal travel and commerce will slow to a crawl or, in some areas, stop altogether. Some island countries will fare better than continents, but it will be temporary at best. Food distribution will be interrupted, and something akin to famine will ensue in certain parts of the world.

Services of all sorts will fall off, including police protection, and marauding gangs and black-marketeers will materialize in a kind of hopeless, Darfurian Wild West. This will bring out the worst in humanity. Neighbor will turn against neighbor, fighting over newly scarce resources or simply out of fear and resentment.

Old prejudices will rise to the surface, as minority groups — be they Jews, black Africans, Shiites, Hispanics, gays, or others — are blamed for bringing the plague into healthy communities. Long-simmering tensions between old rivals — Pakistanis and Indians, for example, or Iraqis and Iranians — will break out into new wars.

Fanaticism, especially apocalyptic strains of the major religions, will reign. Plague will be a worldwide infectious holocaust.

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The astute reader, however, will by now recognize that there is a slight problem with this story: the ending. A good cautionary novel, like any novel, only needs three things: a good beginning to pull in the reader, a good middle to keep the reader interested, and finally a good ending.

And for a cautionary novel, a good ending is one that, after the readers have been scared to death by the beginning and middle, reassures them that they are not about to be victimized by a similar calamity — provided, of course, that certain appropriate steps are taken. There is certainly not going to be a Hollywood-style conclusion like the sudden appearance of a handsome couple that had been secretly toiling away in an isolated laboratory studying viruses and developing a cure while the rest of the world partied on in a false sense of security.

There will be no Dustin Hoffman swooping in to save the day, as he did in the movie adaptation of my novel Outbreak. Perhaps the answer is to make Plague as long as War and Peace so that the reader will welcome any ending. Such complacency can be dangerous, and that is the case with influenza A. Mucus streamed from their noses. Their lungs became clotted and collapsed. Their intestines turned the consistency of gumbo.

As one animal after another died, the keepers of the monkey house were first puzzled, then terrified as they realized that they had on their hands the first North American outbreak of African Ebola virus. To make matters worse, the strain of Ebola in the monkey house appeared to be different than most. African Ebola passes from one victim to another through direct contact with blood or bodily fluids. But Ebola Reston, as it became known, appeared to be airborne, moving from one monkey to another as if it were the flu. The gravity of this situation cannot be exaggerated.

By the time the U. Army and the Centers for Disease Control were notified, several workers in the monkey house in Reston had already clearly been exposed to the infected monkeys. They had also gone home to their families and eaten in restaurants and ridden on buses, which meant that the virus, if it was truly was airborne, might have spread throughout the Washington area.

Acting under strict secrecy, so as not to cause public alarm, the Army moved in and sealed off the monkey house, incinerating every animal inside. Then they braced for a possible human epidemic. It never came. By some genetic fluke, the same mutation that rendered Ebola Reston airborne apparently also left it harmless to humans. If this plot sounds familiar, it should. Such is the lingering impact of Crichton's novel, and of fiction upon fact, that in both The Hot Zone and The Coming Plague scientists are quoted as using the book's title to refer to the hypothetical virus capable of wiping out humanity.

In Crichton's book, the American military sends up a secret satellite that disrupts the delicate ecosystem of a strange and hostile place outer space and comes back down with a microbe that kills everyone it touches the Andromeda Strain. A team of crack scientists put on space suits and seal off the town invaded by Andromeda. The microbe, they soon realize, is airborne and threatens the United States. Just as it is clear that it has escaped, however, the microbe mutates and in its new form ends up harmless to humans. But the parallels go beyond plot. Both books, Crichton's work of fiction and Preston's work of non-fiction, have the same cinematic breathlessness, the same quick cutting between scenes, the same hushed melodramatic endings to paragraphs, the same heroic depictions of scientists.

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But there are conventions of fear in modern American culture, and there is no denying The Hot Zone is written, in style and substance, in self-conscious imitation of a sci-fi thriller. This is one of the things that makes the book so exciting. It is also what makes the book occasionally dishonest.

Preston's book begins, for example, in a place called Kitum Cave at the base of Mount Elgon on the Kenyan-Ugandan border, a huge volcanic cavern that for centuries has served as a gathering place for the wildlife of the rainforest. In the book's climactic scene, he actually dons a plastic biohazard suit and visits the cave himself, gingerly making his way along the cavern's walls.

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In medieval times, the plague was thought to originate in miasma, or a marshy putrescense, and Kitum Cave is Preston's miasma, a dark hole deep in the rainforest that gives Ebola an appropriately sinister provenance. It is a marvelous image. Just what it has to do with the story, beyond the adding of atmosphere, is a little unclear. Two of the three known outbreaks of Ebola took place hundreds of miles away from Kitum in Zaire, and the third outbreak was centered in the grasslands of southern Sudan, which suggests that there may be no special relationship between Ebola and the rainforest at all.

Preston also follows the conventions of the genre in his over-the-top descriptions of the men who hunt down and probe the mysteries of Ebola.

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They are blunt, passionate and iconoclastic: loners driven by a fierce desire to know the truth. Peters," he writes of one,. He inspired great loyalty in his staff, and he made enemies easily and deliberately, when it suited him He was required by Army regulations to show up for work at eight o'clock in the morning, but he usually drifted in around ten o'clock.

He disliked wearing a uniform. Usually he wore faded blue jeans with a flaming Hawaiian shirt On another occasion, our breathless correspondent catches up with the co-discoverer of Ebola, Karl Johnson, "a lean, bearded man, with a soft voice that one had to listen for in the wind" the Sam Waterston role. He is fly-fishing on the Bighorn River in Montana, where Preston poses the overwhelming question:. Certainly it hasn't happened yet.

I'm not worried. More likely it would be a virus that reduces us by 90 percent. A look of mysterious amusement crossed his face. One wonders, reading this passage, just who is manipulating whom. Is Johnson slyly putting one over on the naive journalist about just how nonchalantly he views the "thinning" of the species? Or is Preston complicit in all of this, and trying to scare the bejesus out of his readers? Either way, it would have been nice if Preston had shown even a trace of skepticism about the pronouncements of his lean, grizzled hero. The people who worry about epidemics, after all, are people inclined to think in apocalyptic terms.

They spend all their time looking at or thinking about things that kill people and then trying to talk non-medical people into what often seems like an overreaction. The best of them, like those who shut down the San Francisco bath houses in the early s, can accurately see the possibility of disaster with only the scantest of evidence.

But it is important to realize that the alarmism that makes them good at their job also makes them rather unreliable on matters such as the future of the human race. I remember once having lunch with a well-known epidemiologist, a man who had cut his teeth investigating outbreaks of food poisoning. We were supposed to be talking about the aids epidemic.

But in the course of our meal he became increasingly distracted, staring worriedly over my shoulder. Only at the end of our lunch did I figure out why. Behind me was the restaurant's salad bar, and behind that a large picture window. For a full hour he had been fixated on the sun creeping slowly along the restaurant floor, menacingly making its way toward the potato salad.

Still, it would be a mistake to dismiss The Hot Zone as frivolous. This is more than merely a thriller. What makes the book so interesting, and helps to account for its extraordinary popularity, is the manner in which Preston manages to turn the story of Ebola into an ecological parable. This is not only a medical warning, it is also an environmental warning. In Preston's hands, epidemiology leads directly to a kind of Luddism. For the new killer viruses of the African rainforest, he believes, represent nature's response to humanity's environmental crimes.

This is an argument that rose to prominence with the emergence of aids. HIV, the theory goes, probably lived for millennia in the jungles of Africa, peacefully co-existing with its natural animal host. From time to time, it may have jumped into humans, making a brief run, say, through a jungle village, but it stayed in the rainforest.

Then came the massive environmental upheaval of the s. Truck routes were built into the continental interior. The Ugandan-Tanzanian war, which took place at the center of where monkey-borne HIV is thought to reside, uprooted entire populations. Cities began to spill over into what had been virgin territory, bringing with them new patterns of sexual behavior and prostitution.

The effect was to give HIV a clear route out of the jungle. And what happened with aids, Preston says, is what is now happening with Ebola, and may soon happen again with something infinitely nastier than either of them. Laurie Garrett takes this argument one step further. In The Coming Plague , her page opus, she is not concerned just with rainforest viruses.

She maintains that toxic shock syndrome, Legionnaires' disease, the rise of antibiotic-resistant infections, Lassa fever, Hantaan virus and virtually every other microbial outbreak of the past twenty years are all linked by the same pattern of environmental irresponsibility. In the world of microbes,. The human race seems equally complacent about blazing a path into a rainforest with bulldozers and arson or using an antibiotic "scorched earth" policy to chase unwanted microbes across the duodenum.

This idea clearly has its roots in the environmentalism of the s. Then we were told that destroying the rainforest would irreparably alter our climate. Now we are told that it will destroy our health. This revision, however, is not trivial. If the environmentalist warnings failed to ignite mass fear or mass politics, it was because they were so abstract. For how long could a series of speculative scientific projections about long-term trends toward warmer weather of all the terrifying fates!

But the new virus paranoia puts the old global warming paranoia to shame. This is not a prediction. It is a judgment. We have wronged nature and it will exact its revenge. The emergence of aids, Ebola and any number of other rainforest agents appears to be a natural consequence of the ruin of the tropical biosphere.

The emerging viruses are surfacing from ecologically damaged parts of the earth In a sense, the earth is mounting an immune response against the human species. It is beginning to react to the human parasite, the flooding infection of people, the dead spots of concrete all over the planet, the cancerous rot-outs in Europe, Japan and the United States, thick with replicating primates, the colonies enlarging and spreading and threatening to shock the biosphere with mass extinctions.

Nature has interesting ways of balancing itself. The rainforest has its own defenses. The earth's immune system, so to speak, has recognized the presence of the human species and is starting to kick back in. The earth is attempting to rid itself of an infection by the human parasite. Perhaps aids is the first step in a natural process of clearance.

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There is a very peculiar collection of ideas here. The ideology expressed is not at all like the one in The Hot Zone 's fictional predecessors from the cold war. They shared Preston's preoccupation with mankind's extinction, but without this self-loathing. Crichton's book delivered only a straightforward warning that America has enemies even in the farthest of places outer space and the smallest of sizes sub-microscopic. And in Panic in the Streets the plague is carried into the United States by an illegal alien. The evil isn't American, it's someone else's. But Preston's notion of plague isn't really biblical either.

True, it has a hoary punitive dimension: the idea of disease as a punishment for wickedness. And so does Outbreak , in which the killer virus comes into this country as a result of a Pentagon biological warfare experiment gone awry. This is a punishment. God promised Noah after the great flood that he will never again "destroy every living creature," and created the rainbow to attest to the promise. And so plague was not apocalypse. Plagues in medieval times were "visitations. And aids is "the gay plague" to the Christian right precisely because it seems so selective: it singles out those guilty of the sins of homosexual promiscuity and drug use.

Today's imagined plague is something entirely new. We are in the grip of a terrifying super-virus of our own creation, a mutant hybrid of cold war apocalyptics, biblical moralism and environmental fire and brimstone. Is it any wonder that grown men are running around comparing mankind to chickens? What should we make of all this? Is nature really about to teach humanity a lesson? The answer depends in large part on whether you are an optimist or a pessimist, and on the magnitude of your faith in the power of medical science to respond quickly to new problems.

But it should be said, first of all, that nature has been striking back against the ceaseless explorations and expansions of human beings, against the "human parasite," for as long as men have roamed the earth. In Plagues and Peoples , which appeared in , William McNeill pointed out that the full development of central and southern China was probably delayed for five or six centuries by the "disease barrier" that the Yangtze River and the warmer climate of the south created.

The effort to explore and to civilize the New World probably brought syphilis back to Europe, where it raged as the aids of its time throughout the sixteenth century; and typhus came to Europe at the end of the fifteenth century when Spanish soldiers picked up the infection fighting in Cyprus.

That HIV and its kin should have been loosed from the rainforest by the environmental disruptions of the past twenty years, in other words, is hardly unprecedented. When it comes to "remodeling" natural environments, McNeill writes, man has been very good at dealing with what can be seen and can be manipulated. But there are things that cannot be seen and cannot be manipulated, and. As a result the ravages of disease among crops, herds and peoples played a significant part in human affairs throughout historic time.

McNeill's point, however, is that while man's efforts to "remodel" his environment are sometimes a source of new disease, they are seldom a source of serious epidemic disease. Quite the opposite. As humans and new microorganisms interact, they begin to accommodate each other. Human populations slowly build up resistance to circulating infections. What were once virulent infections, such as syphilis, become attenuated. Over time, diseases of adults, such as measles and chicken pox, become limited to children, whose immune systems are still naive.

McNeill remarks that it was during the mid-fifteenth century that the population of Europe began to expand steadily, even though "it was during these decades that the oceanic discoveries took place, and European sailors had the opportunity to import new infections into their homelands from the ports of all the earth. This, says McNeill, is the paradox of infection: "The more diseased a community, the less destructive its epidemics become. Not the conquerors, the ones who were despoiling a virgin environment.

It was the conquered, the American Indians, the peoples living on a secluded and pristine continent, who were all but wiped out by the sudden arrival of smallpox. This does not mean, of course, that we should not worry about the effects of man's continuing assault on nature. But it does mean that there is nothing inherently terrifying about the fact that the West is now being exposed to new microbes from equatorial Africa.

We are ultimately safer in a world where new viruses and bacteria are in constant circulation, and where human populations can encounter and build defenses against them. Unlocking the viruses of the rainforest is part of the way we tame nature, not the way nature tames us. One can go further. Sometimes disrupting the environment is the way we get rid of disease. In England in the seventeenth century, for example, farmers began disrupting nature by raising livestock on a large scale for the first time. What happened? Malaria-carrying mosquitoes, which used to feed on people, switched to cattle.

And since cattle aren't an hospitable host for the malarial plasmodium, the disease, which had been endemic in Britain for centuries, retreated from the British Isles for good. Or consider Russia in the eighteenth century, when the natural ecosystem of the countryside began to be disrupted by the aggressive expansion of agriculture into areas that had previously been wilderness.

The plowing of fallow land destroyed the natural habitat of the rats that carried the bubonic plague. Thus freed of plague, which had been a persistent problem in Russia long after the disease left the rest of Europe, the Russian population grew from The point is that the relationship between environment and disease is a complicated one.

There are diseases that are caused by environmental disruption, diseases that are eliminated by environmental disruption and diseases whose rise has nothing to do with environmental disruption. The current plague paranoia is an obsession with the first category. Thus Garrett is very convincing when she talks about how the new cities of the Third World--overpopulated, vastly underserved by medical care, troubled by appalling sanitary conditions--are breeding grounds for new infections.

But this is not an accurate diagnosis of all new diseases. Garrett, for example, writes a long and intelligent chapter on the worrying rise of new bacterial strains that are resistant to the antibiotics that once cured them easily. But what does this have to do with mankind's environmental responsibility? Antibiotic resistance is the result of shoddy infection control procedures in hospitals, well-meaning but ill-advised overprescription of certain drugs by physicians and the fact that the pharmaceutical industry got cocky in the late s and stopped developing new classes of antibiotics.

We could preserve every acre of rainforest the world over, clean up every river and stop every war, and we would still have a raging antibiotic resistance problem. Even in cases where environmental disruptions do seem to have played a role in the emergence of disease, it is not the overwhelming factor that Preston and Garrett imply.

HIV may have been loosed from the jungle by the upheaval in Africa during the s. Still, absent epidemic levels of unsafe promiscuous sex and intravenous needle use in the West, the virus would have gone nowhere. The critical factor with aids, and with an awful lot of the diseases that we face, is what we do to ourselves and each other, not what we do to our environment. But these are, to some extent, side issues. There is no question that for whatever reason, as a result of what man does to himself or what he does to his environment, the threat of infectious disease is on the rise in the world right now.

The re-emergence of tuberculosis and untreatable strains of malaria, for example, are worrisome trends. Should we be scared? Well, yes and no. In his brilliant study, Evolution of Infectious Disease , Paul Ewald describes how the chaos at the end of the First World War directly contributed to the rise of an unusually vicious strain of influenza. The result was the influenza pandemic of , which left 20 million people dead. This could happen again. But whether or not some new virus could emerge that could wipe us all out is an entirely different matter.

It is simply very difficult to imagine where such a super-virus would come from or what it would look like. Let's start with Ebola. Preston argues that Ebola, under the right conditions, could obliterate a significant chunk of humanity. Yet that never happened For reasons that are not clear, the outbreak subsided. But this is simply not true. The reason for the abatement of the outbreak is entirely clear.

Ebola kills its victims too quickly. It is one of the fundamental rules of infectious diseases, which Preston no more than hints at, that the deadlier they are to the people they infect, the less dangerous they are to everyone else. Ebola kills within two weeks, and during those two weeks it is not as if its victims are walking around meeting and infecting hundreds of unsuspecting others the way someone with a cold does. After only a brief incubation period, they are at home or in the hospital, immediately, obviously and unambiguously sick, with limited contact with the outside world.

How much chance, then, do they have to pass on their disease? This is why Ebola causes outbreaks, not epidemics. It cannot sustain itself. Ironically, the outbreak in Zaire that has so clearly boosted the visibility and the sales of The Hot Zone is also the event that most emphatically demonstrates the book's dishonesty on this point. Here was a crowded, filthy slum, crammed with , people under the worst sanitary conditions: an ideal breeding ground, in short, for an epidemic.

And how far did Ebola get?

Plague - A Medical Thriller (The Plague Trilogy Book 1) Plague - A Medical Thriller (The Plague Trilogy Book 1)
Plague - A Medical Thriller (The Plague Trilogy Book 1) Plague - A Medical Thriller (The Plague Trilogy Book 1)
Plague - A Medical Thriller (The Plague Trilogy Book 1) Plague - A Medical Thriller (The Plague Trilogy Book 1)
Plague - A Medical Thriller (The Plague Trilogy Book 1) Plague - A Medical Thriller (The Plague Trilogy Book 1)
Plague - A Medical Thriller (The Plague Trilogy Book 1) Plague - A Medical Thriller (The Plague Trilogy Book 1)

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