USA Dot Com is a blog covering politics and government from a conservative Christian perspective. Verne Strickland is a 50-year veteran of investigative journalism. This blog offers a take-no-prisoners style with a modicum of biting satire. Verne and his wife of 55 years, Durrene, live in Wilmington, NC.
Kaci Hickox has gotten a lot of mileage out of her emotion-packed description of her ordeal with screening and monitoring of individuals entering or returning to this country from Ebola stricken West Africa, her criticism of forced quarantine and the claim of civil rights violations.
It might be more mileage than she originally intended.
In her article for The Dallas News, Hickox claimed that she worked with Doctors Without Borders caring for Ebola stricken individuals in West Africa.
In actuality, Hickox had ties with the Centers for Disease Control by virtue of being an official CDC Epidemic Intelligence Service (EIS) officer.
According to the Daily Caller, Hickox was listed as an “active” EIS officer as recently as July 18, 2014, per the CDC’s own documents.
Hickox retained attorney Norman Siegel to file a lawsuit on her behalf alleging civil rights violations due to the mandatory quarantine issued by the state of New Jersey because of the possibility Hickox could be infected with Ebola.
In an interesting coincidence, Siegel happened to be an official guest at the White House State Dinner on February 11, 2014, accompanying none other than Ms. Rachel Robinson, the widow of Jackie Robinson.
Siegel, in another coincidence, partnered with none other than race-baiter supreme Al Sharpton in opposition to the New York state proposal to implement a DNA database of felons.
Naturally, the White House, aka Barack Hussein (Ebola) Obama, criticized the state of New Jersey in quarantining Hickox while the CDC was developing guidelines for the states to follow in dealing with health care workers returning from Ebola stricken West African nations.
It has been no secret that Ebola-Obama opposes any type of quarantine and the parrots at the CDC, Dr. Tom Frieden and Steven Fauci, mimic his rhetoric.
However, the Department of Defense commander of US Army Africa, Maj. Gen. Darryl Williams, has implemented mandatory quarantine for himself and 10 other soldiers upon returning to an Italian Army base after building treatment facilities in Ebola ravaged West Africa.
It appears that Maj. Gen. Williams understands much more about public health safety, personal responsibility and duty than anyone at the CDC or Ms. Hickox – individuals who are supposed to be trained healthcare professionals.
Ms. Hickox would do well to remember that she practices her profession under her resident state nurse practice act.
Since it has been disclosed she resides in Maine, Ms. Hickox has to follow the laws of the state of Maine when functioning as a nurse.
According to the State of Maine Nurse Practice Act, disciplinary action, up to suspension and revocation of the license of the licensee, can be taken when the license holder engages in
“(E) Incompetence in the practice for which the licensee is licensed."
A licensee is considered incompetent in the practice if the licensee has:
(1) engaged in conduct that evidences a lack of ability or fitness to discharge the duty owed by the licensee to a client or patient or general public; ….”
Since Ms. Hickox was unwilling to discharge her duty to follow the State of New Jersey public health mandate of a quarantine in their state under the guidelines the state was allowed to implement by virtue of abdication of the federal government, she exhibited a level of incompetence to fulfill her duty to the general public.
The State of Maine Nurse Practice Act states that disciplinary action may be taken against a licensee who engages in “unprofessional conduct.”
According to the law, “a licensee is considered to have engaged in unprofessional conduct if the licensee violates a standard of professional behavior that has been established in the practice for which the license is issued.”
In the case of Ms. Hickox, the standard of professional behavior would be to follow the state’s mandate of quarantine according to their guidelines and at their designated facility in order to “do no harm” to the general public.
The standard of professional behavior is to exercise personal responsibility to insist that public health safety come before oneself and follow the World Health Organization (WHO) 42 day incubation period for Ebola with a quarantine.
Instead, Ms. Hickox complained about the treatment of health care workers in a news outlet almost demanding preferential treatment for health care workers.
The Maine Nurse Practice Act also allows disciplinary action for “engaging in false, misleading or deceptive advertising.”
Ms. Hickox failed to disclose her association with the CDC, instead promoting first and foremost her work with Doctors Without Borders.
By engaging in this “deception,” one could assume Ms. Hickox was a willing participant in a plan to undermine the guidelines for screening, monitoring and quarantining of individuals, mostly health care workers, returning from caring for Ebola stricken individuals in West Africa.
Also, Ms. Hickox has basically hired an attorney to file a lawsuit for violation of civil rights concerning a quarantine issued to ensure public health safety, since three health care professionals have refused to exercise personal responsibility based on current medical knowledge regarding Ebola and endangered the general public with infection.
Ms. Hickox intentionally hid her association and employment with the CDC in order to “tow the company line” against sound medical intervention.
Basically, she mislead the public by failing to fully disclose her close association and employment with the CDC, which would account for her ranting and “special treatment.”
This “nurse” needs to have multiple complaints filed against her with the State of Maine Board of Nursing for violation of the State Nurse Practice Act should it be found she is licensed to practice in that state.
Since Ms. Hickox indicated she graduated from the University of Texas Arlington, a search of the State of Texas Board of Nursing produced a result for a Kaci Lynne Hickox, who resides in Grapevine, Texas, according to the Nursing Board record.
This license holder has a compact license meaning the license holder may practice in multiple states using the license issued by the State of Texas.
However, the license holder is responsible for following the Nurse Practice Act in all states in which the license is valid and the state of residence.
The Texas Board of Nursing has similar rules allowing for disciplinary action as Maine for similar offenses.
The “ranting” Hickox reportedly returned home to Maine for her quarantine after the White House became involved.
Anyone may file a complaint against a nurse for violation of the Nurse Practice Act.
Normally, the complaints are filed by colleagues, other nurses or physicians.
However, with the actions of Ms. Hickox out in the open, the general public has every reason to question this nurses’ ability to follow any nurse practice act which indicates that the professional registered nurse has a duty to public health safety.
Maybe Ms. Hickox should have thought all of this through before opening her mouth and engaging in making herself a media spectacle.
It’s possible that Ms. Hickox was willing to sacrifice her career in exchange for fame, millions of dollars or both in order to undermine the public health safety at the behest of the CDC.
Should that be the case, Ms. Hickox should be ashamed to call herself a professional nurse.
If anyone would like to lodge a complaint against Ms. Hickox for unprofessional conduct and violations of standard professional conduct, the address for both Texas and Maine Nursing Boards are listed below.
Washington
/
Dave Boucher, The Tennessean October 31, 2014
The two sides have raised more than $5 million this year and spent most of it since Oct. 1.
NASHVILLE, Tenn. — More than $4 million in advertising for and against an abortion measure has flooded airwaves and mailboxes in Tennessee since the start of October, with opponents outstripping supporters by nearly a 3-1 ratio.
Both
campaigns have combined to raise more than $5 million this year, and
they've spent most of it since Oct. 1. Much of the funding to defeat the
proposed constitutional amendment comes from out-of-state donors, an
indication of the national implications for the outcome of the election
Tuesday.
The amendment gives state lawmakers more authority to
create restrictions on abortion clinics. Supporters say it allows for
greater oversight to protect the health of women. Opponents say it's a
guise to limit a woman's right to a safe abortion.
The
organization Vote No on One Tennessee spent $3.4 million from Oct. 1 to
Oct. 25 in an effort to defeat the Amendment 1, according to campaign
finance disclosures.
"There's a large interest nationally in
making a statement that here in the South, it's not OK for politicians
to strip away personal, private medical decisions," said Steven
Hershkowitz, a spokesman for the Vote No campaign.
The
leading organization advocating for the amendment —Yes on 1 — spent
more than $1 million in October, almost entirely on campaign
advertising. It was thanks in part to raising $670,000 in the first
three weeks of the month.
But it couldn't match the nearly $2.1
million raised from Oct. 1 to Oct. 25 by the Vote No campaign. The
influx of money helped the organization spend almost $3.8 million since
the start of the year. More than $3 million went toward advertising or
campaign media since the start of October.
Planned Parenthood
drove the bulk of the fundraising for the Vote No camp in October. The
Seattle chapter donated $750,000, while three chapters in California
combined to donate $500,000. Two Florida chapters contributed $101,000,
while Planned Parenthood of Middle and East Tennessee chipped in
$50,000.
The American Civil Liberties Union also donated $100,000 to the Vote No campaign.
Pharmaceutical
tycoon and conservative political supporter John Gregory donated
$150,000 to the Yes on 1 campaign, leading all independent donors in
October. The organization also shifted over the last $150,000 it had
raised when it first started advocating for the amendment as a nonprofit
organization.
The
vast majority of the most recent contributions supporting the amendment
came from Tennessee donors, mainly from churches or anti-abortion
rights organizations, noted campaign finance director Jason Albin.
"Our
strength is in our grass roots, and that is where we feel we're going
to win this amendment on Tuesday," Albin said. "Those are actually the
people on the ground and voting."
A Middle Tennessee State
University poll released this week said 39 percent of respondents
supported the amendment, 32 percent opposed it, and 15 percent were
still undecided. That led the poll organizers to deem the results "too
close to call."
Many in my generation fly the American flag. I hope it's not a dying tradition, although there are signs that is may be.
I'm 77, and the flag has always been a part of American life for me. Its history is dear to me. It flew over Fort McHenry, inspiring Francis Scott Key to write our National Anthem-- "The Star Spangled Banner." It was raised by our U.S. Marines over Mt. Suribachi during the desperate war in the Pacific. It was posted on the Moon in America's conquest of space.
And, for generations, it has flown in the yards of millions of American homes, where patriots wanted to thank those who fought for our freedoms, and saw the flag as a symbol of pride in the Greatest Nation. I fit into the latter category. And though I never fought for my country in battle, I somehow feel close to those who have -- giving the last full measure of devotion. At our home in Wilmington, North Carolina, as soon as we moved to our current address, we raised the American flag we had brought from our home downtown. We didn't feel that we had really moved in until it flew from a pole on the front of the garage.We hung the flag at a 45-degree angle, which is how we like to display it. It waves jauntily in the beach breeze we feel here, and almost seems alive. Each morning from my home office window, I am cheered to see it. Its colors are bright and pure. To me it is our America, under God.But from time to time, the flag is buffeted by higher winds, and by rain. The torrents and turbulence cause its folds to become snarled around the pole, where it seems unable to free itself. As soon as possible, I go out, reach up with my cane, and pull it down. Its sparkling stars and stripes, now unsnarled, fall gracefully, displaying their full beauty. I feel a palpable sense of relief when it waves free again. And I began to think -- this is the experience of the America that our flag represents. It waves smartly in a fair breeze, even snapping briskly when the wind pipes up. But it is not always this way. As trouble brews around the globe, and America's enemies seek to attack and destroy our nation, the flag, soaked by storm and torrent, may become wrapped and snarled around the pole from which it is suspended. It has not fallen, and will not -- but it requires attention -- defense, if you will and the tender hand of one who cares for it -- to fly again in its full glory. We Americans are called now to note what besets Old Glory and come quickly to her aid. Freeing the Flag is our God-Given Privilege and Duty. We must never fail her.
Civitas Poll Shows Tillis Has Slight Edge over Hagan
The
newest Civitas Poll showed state House Speaker Thom Tillis, a
Republican, with a slight edge over Democratic Sen. Kay Hagan in voters’
views of the U.S. Senate candidates.
When we asked 600 North Carolina registered voters who they’d vote
for if the election were today, 40 percent picked Tillis, 39 percent
Hagan and 5 percent Libertarian Sean Haugh. Fourteen percent were
undecided. Asked about their choices without Haugh, Tillis again led
Hagan by 1 point, 42 to 41, with 15 percent undecided.
“This is the first time since June that our polls showed Tillis in
the lead,” Civitas President Francis De Luca said. “The Nov. 4 outcome
will depend on whether the Democrats’ vaunted ground game can turn out
their base, especially those who voted only in the 2012 presidential
year but are less likely to say they are certain to vote this year.”
More data from the poll will be released at our next poll lunch on
Thursday, Oct. 30, at the Raleigh Marriott Crabtree Valley. To sign up,
click here.
The poll questioned 600 registered voters, of whom 25 percent were
“cell phone only” users and were contacted via cell phone. The survey
was taken Oct. 15-18, and had a margin of error of plus/minus 4 percent.
Text of questions*:
If the election for U.S. Senate were being held today, for whom would
you vote between … Thom Tillis, the Republican, Kay Hagan, the
Democrat, or Sean Haugh, the Libertarian? 5/14 6/14 7/14 9/14 10/14 39% 36% 39% 40% 40% Total Tillis, the Republican 36% 42% 41% 41% 39% Total Hagan, the Democrat 8% 9% 7% 4% 5% Total Haugh, the Libertarian 15% 12% 12% 14% 14% Total Lean/ Undecided
10% 9% 7% 7% 9% HARD UNDECIDED
1% — — 1% — OTHER (Specify)
1% — 1% 1% 1% REFUSED
And now suppose only two candidates were running for U.S. Senate. For
whom would you vote between: Thom Tillis, the Republican, or Kay Hagan,
the Democrat? 5/14 6/14 7/14 9/14 10/14 46% 43% 45% 42% 42% Total Tillis 41% 47% 43% 43% 41% Total Hagan 12% 9% 10% 14% 15% Total Lean/ Undecided
37% 36% 39% 35% 37% Definitely Tillis
10% 8% 6% 7% 5% Probably Tillis
1% 2% 2% 1% 2% Lean Tillis
9% 5% 5% 6% 10% Undecided
2% 1% 3% 7% 3% Lean Hagan
10% 8% 7% 5% 4% Probably Hagan
31% 39% 36% 38% 36% Definitely Hagan
– 1% 2% 2% 2% Refused
*Totals may not add up to 100 due to rounding.
Crosstabs here. About the poll: This poll of 600 registered voters
in North Carolina was conducted Oct. 15-18, 2014 by National Research,
Inc. of Holmdel, NJ. All respondents were part of a fully representative
sample of registered general election voters in North Carolina.
Twenty-five percent of the respondents were cell phone-only users. For
purposes of this study, voters interviewed had to have voted in at least
one of the past two general elections (2010, 2012) or be newly
registered to vote since November 7, 2012.The confidence interval
associated with a sample of this size is such that: 95 percent of the
time, results from 600 interviews (registered voters) will be within
+-4% of the “True Values.”
Civitas conducts the only regular live-caller polling of North
Carolina voters. For more information on Civitas polling, see
http://www.nccivitas.org/category/poll/.
While nearly inseparable on the
campaign trail, Susan Tillis often found herself addressing crowd’s on
Thom’s behalf while he was busy in Raleigh. Susan Tillis has been a key fixture in her husband’s campaign for the U.S. Senate.
HUNTERSVILLE, N.C. -- When Susan Tillis stepped away from her role as
broker-in-charge of Allen Tate Realtors’ Lake Norman office in June of
last year, she wasn’t sure what to expect.
Her husband, North Carolina
Speaker of the House Thom Tillis, had just announced he was seeking the
Republican nomination for the U.S. Senate seat held by Democrat Kay
Hagan. Susan Tillis knew she’d be involved in her husband’s campaign,
but this race would be far different than his three State House races.
“When this all started, I didn’t know what my role would be,” Susan
Tillis said by phone Monday afternoon as she and her husband drove from a
campaign stop in Winston-Salem to another in Lumberton before heading
back to Raleigh.
It didn’t take long for her role to crystalize, though. With Thom
Tillis overseeing a busy legislative session, he often was unavailable
when groups across the state asked him to come and speak. Susan Tillis
soon became the Speaker’s speaker.
“Now Thom jokes about it,” she said. “He says, ‘When people used to call, they wanted me. Now they just ask for Susan.’”
It’s a role Susan Tillis has embraced.
“I don’t know that I’ve been to every single county in the state,” she said, “but it’s close.”
In what is projected to be the most expensive non-presidential race
in U.S. history, the demands on the Tillises have, at times, been
overwhelming. Tillis says she and her husband get to spend about one
night a week at their Huntersville home. If he wins on Nov. 4, they may
be spending even less time there.
‘Most vilified candidate’
But, in what also is being called the nation’s most negative
political race ever, being busy has unintended advantages. While the
rest of us are deluged with television attack ads aimed at both
candidates, the Tillises rarely have time to sit in front of a
television.
That doesn’t mean Susan Tillis doesn’t know what others are saying about her husband, of course.
“Thom is the most vilified candidate,” she said.
But she also realizes that such attention means her husband is a
legitimate threat to take the Senate seat from Hagan, who beat GOP
incumbent Elizabeth Dole in 2008.
“When you know the man Thom is, it doesn’t bother me,” Tillis said of
the attack ads from the Hagan campaign and national political action
committees that have pumped tens of millions of dollars into advertising
for the North Carolina race (as have pro-Tillis groups attacking
Hagan). “I just keep doing my job.”
She added that the most recent legislative session, which was at
times combative and sparked weekly protests at (and sometimes inside)
the State House building, actually helped steel the Tillises for what
was to come in the Senate race.
“In some ways, we’ve been ready for the onslaught,” she said. “It
hasn’t been easy for some of our friends, though. It’s probably harder
for them to watch (the attack ads). We’ll be glad when they’re not
airing because people are sick of them.”
That doesn’t mean every political spouse can dismiss mudslinging so
easily, and Tillis has some advice for those who are more sensitive to
the attacks.
“Don’t read the newspaper and don’t read social media if it upsets you because it takes you out of your game,” she said.
Bueller? Bueller?
On the campaign trail for her husband, Susan Tillis has had the
chance to meet some of the most-influential political and media figures.
The most interesting?
“I’d have to say Ben Stein,” she said of the
actor/comedian/economist/commentator, with whom she and her husband
shared a private dinner. “He’s very smart. I was impressed with his
thought process and the way he engaged with us.”
And, she said, with the sneakers he wore with his suit and tie.
“I was hoping he wouldn’t ask me a question,” Tillis admitted.
Political spouses take on their own roles. Susan Tillis sees hers as humanizing her husband.
“I try to share a side of Thom they don’t see on television,” she said.
And what is her husband’s other side? “He’s very funny,” she said. “And he’d much rather be in shorts and a T-shirt. He’d much rather be riding his mountain bike.”
But Susan Tillis also is quick to note that while she chose to be
deeply involved in her husband’s campaign, that kind of arrangement
might not work for everyone.
“I would never, ever want a (political) spouse to feel like they have
to follow a particular path,” she said. “I just felt like it was my
duty and my job to do this.”
Preview on this breaking story by Verne Strickland usa dot com: 10/28/14 8:31 pm
Spectacular explosion of NASA rocket at launch tonight. This is the fine print. The real story is that the rocket is Russian-made, and many serious problems have happened in previous launches.
But see this statement from AOL story of the failed Russian engine tonight at Wallop's Island launch site in Virginia:
"A radio operator advised all staffers on the launch to remain at their
work stations, according to audio of the launch on NASA TV. Later
instructions strangely included the scrubbing of all launch notes and
observations."
VS: This extraordinarily unusual -- almost unprecedented in such NASA operations. Until further explanation, a cover-up might be suspected, in view of the use of a Russian-designed rocket engine.
This is part of the story which unfolded tonight -- sanitized just as the "scrubbing" of all launch notes and observations.
A
rocket built for NASA by a private contractor exploded shortly after
lifting off Tuesday night from the space agency's Wallops Flight
Facility in Virginia.
The unmanned Antares rocket was carrying about 5,000 pounds of supplies
to the International Space Station (ISS). It was built by a Orbital
Sciences Corporation (OSC) and launched in collaboration with the space
agency.
Problems became apparent only 6 seconds into the 6:22 p.m. launch when
the rocket stopped climbing, started falling and two radio operators
shouted over each other.
Stunned silence accompanied the rocket's stunning fall back to Earth and spectacular explosion when it hit the ground.
"A radio operator advised all staffers on the launch to remain at their
work stations, according to audio of the launch on NASA TV. Later
instructions strangely included the scrubbing of all launch notes and
observations."
A statement issued to CNN shortly after the accident said "there was no
apparent loss of life," but significant damage to property and vehicles.
The privately-built rocket's mission was meant to provide supplies to
astronauts on the ISS, and observers online immediately wondered what
the ramifications to the ISS were. About 1,360 pounds of food were
included in the supplies.
Also included in the payload were 1,602 pounds of science experiments,
1,404 pounds of vehicle hardware, 273 pounds of flight equipment, 145
pounds of spacewalk equipment, about 82 pounds of computers and 15
pounds of flight procedures manuals, according to NASA.
The space agency's launch commander said "classified crypto equipment"
was also included in the payload, but no further information was
provided.
The ISS cannot be used for military or spy purposes.
Antares was seen by NASA as the first step towards the future of space
travel and exploration when a nearly $2 billion contract was awarded by the space agency to OSC.
The company called the incident a "vehicle anomaly" in an official statement.
"It is far too early to know the details of what happened," said Mr.
Frank Culbertson, Orbital's Executive Vice President and General Manager
of its Advanced Programs Group.
"We will conduct a thorough investigation immediately to determine the
cause of this failure and what steps can be taken to avoid a repeat of
this incident," he continued. "As soon as we understand the cause we
will begin the necessary work to return to flight to support our
customers and the nation's space program."
Experts who spoke to CNN believe there may have been a self-destruction
of the rocket after it's first launch stage failed. It is not clear if
that would have been a manual or automated process, if the rocket did
self-destruct.
The launch was originally scheduled for Monday evening but scrubbed because a boat was in the area off Wallops Island.
Another privately-built rocket, from SpaceX, is scheduled to launch from Cape Canaveral no earlier than December.
This is a developing story, more information will come as it is made available.
Tom Kennedy 31 minutes ago
"Later instructions strangely included the scrubbing of all launch notes and observations" WHAT?!?!?! FlagShareReply+4rate up
Verne Strickland: Watch this story closely. This is the first step in commercial space travel in cooperation with NASA -- with an exploding Russian-designed rocket.
There are signs of U.S. Government cover-up -- possibly to spare Russian embarrassment. USA DOT COM has already gathered archival information about Russian rocket failures. Watch this site for more.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, circa 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
21 Days
An expert in biological warfare warns against complacency in public measures against Ebola.
Steven Hatfill (center) with aeromedical isolation team
at Fort Detrick, Maryland, ca 1998 (Hatfill)
“I want to be pleasant through this whole thing,” California
Representative Darrell Issa said on Friday, unpleasantly, to a panel of
medical experts at a congressional oversight-committee hearing.
“But,” he continued, scolding from his perch, “we have the head of
CDC—supposed to be the expert—and he’s made statements that simply
aren’t true.”
During the tense four-hour session, the subcommittee challenged
almost every element of the United States’ response to its domestic
Ebola cases so far. Most pointedly, chairman Issa criticized the Centers
for Disease Control and Prevention’s messages to the public.
“Doctor,” Issa said, turning slightly to address Assistant Secretary
of the Department of Health and Human Services Nicole Lurie, “You can get Ebola sitting next to someone on a bus if they, in fact, throw up on you, can’t you? That’s reasonable?”
Lurie responded deliberately, after a brief pause, “The way you get Ebola is by exposure to bodily fluids, yes.”
“Okay. So. When the head of the CDC says you can’t get it from
somebody on the bus next to you, that’s just not true,” Issa concluded.
“When the head of the CDC says we know what we’re doing, but, in fact,
healthcare professionals wearing what they thought was appropriate
protective material get [Ebola], that means he’s wrong. When the head of
the CDC goes on television and says sometimes less protection is
better, and then has to reverse the protocol so that we no longer have
nurses who have their necks exposed, that was just wrong, wasn’t it?”
“Those nurses were not protected,” Deborah Burger, a co-president of National Nurses United, responded.
Even since they were revised (“tightened”)
last week, the CDC’s official guidelines for how to safely care for a
person with Ebola are hazy with regard to what protective equipment must
be used. It has become difficult to distinguish science from politics
in the word that has gone out to the public in the wake of the domestic
Ebola cases. Democratic messaging tends to be supportive of CDC handling
and quelling of outbreak anxieties: If you have not had intimate
contact with a person who is severely ill, you have no cause for
concern. The quintessential Republican message, meanwhile, is one of
mishandling and incompetence: Readily transmissible, even “airborne”
Ebola virus is a legitimate concern. And, with that, obviously, comes
fear. But it is not only Republican politicians who are baldly
criticizing the American response to the outbreak and inconsistent
public messaging.
This week I received a "monograph" for review from an unlikely,
politically removed scientist. It was plainly titled "Summary of Ebola
Virus Disease," and written in exhaustive scientific detail. The author
was Steven Hatfill.
If the name rings a bell—I don’t want to dwell on this, but it's
germane to the context of his perspective I'm sharing here—it’s because
he was very publicly, very falsely accused of killing several people
with anthrax in 2001.
Hatfill is rightly
wary of the media that overwhelmingly convicted him in the court of
public opinion, driving him to despair before his acquittal and much
less-publicized redemption. But not as wary as he is of his knowledge
and perspective on the Ebola outbreak going unheard. His 11,000-word
textbook-like research review made several points that are contrary to
the mainstream public messaging about Ebola transmission. As he wrote in
an accompanying lay explanation: “The initial response to the outbreak
of Ebola in the United States has been badly designed, and poorly and
incompetently implemented. In their effort to minimize public concern or
even panic, the leading health authorities of the United States have
made far over-reaching statements and assumptions that are not fully
supported by the existing scientific literature.”
For one objection, Hatfill wants it known that, while it must be
emphasized that airborne droplet and particle transmission between
humans has not been evident in this outbreak, aerosol droplet
transmission of Ebola virus has been shown in animal studies. “It is
therefore irresponsible for government health officials to emphatically
state that aerosol transmission does not occur,” he writes. He also
believes the argument against a national quarantine is “inexcusable in
light of the size of the current West African epidemic.”
Hatfill’s concerns are backed by some compelling evidence and the
clout of a long, storied career. It was actually his unique expertise in
biomedical warfare—his extensive experience studying the world’s
deadliest infectious agents—that led to his implication in the 2001 U.S.
anthrax attacks. His training was in military special operations and
tropical pathology, and after serving as an overwinter physician in
Antarctica, he obtained master’s degrees in microbial genetics, medical
biochemistry, and hematological pathology, including postdoctoral
fellowships at Oxford University, the National Institutes of Health, and
the National Research Council, in addition to over 15 years of clinical
work in Africa.
In the wake of 9/11, Attorney General John Ashcroft made a rare move
in publicly naming Hatfill as a “person of interest” in the
investigation that desperately demanded a lead. Five people were dead
and 17 sickened by anthrax sent via U.S. mail during an unprecedented
crisis of confidence in domestic security. As writer David Freed
recounted the story in our magazine
in 2010, it was the only time an attorney general ever gave a person
that designation during an active criminal investigation. The FBI
trailed Hatfill everywhere he went for more than a year. Members of the
media widely condemned him. Nicholas Kristof of The New York Times
even implored the FBI to dig deeper on Hatfill in 2002, making
outlandish accusations: “Have you examined whether [Hatfill] has
connections to the biggest anthrax outbreak among humans ever recorded,
the one that sickened more than 10,000 black farmers in Zimbabwe in
1978–80?”
The Kristofian character assassination of Hatfill stretched so far as
to note that while Hatfill was “a true-blue American with close ties to
the U.S. Defense Department, the C.I.A., and the American biodefense
program”—in 2000, Hatfill was certified by the United Nations as a
biological-weapons inspector for a commission in Iraq—”on the other
hand, he was once caught with a girlfriend in a biohazard ‘hot suite’ at
Fort Detrick, surrounded only by blushing germs.”
That was only vaguely true. In the midst of this condemnation,
Hatfill became depressed, sinking into reclusive alcohol abuse. Brooding
until his day in court, he took solace in studying microbiology and
sculpting the lawsuits that would eventually earn him $5.8 million from
the Department of Justice in addition to undisclosed settlements from
media outlets. (The New York Times paid nothing, on the defense
that Hatfill was a public figure and thus fairly subject to unfair
accusations, but Kristof did recant artfully, six years later:
“The job of the news media is supposed to be to afflict the comfortable
and comfort the afflicted. Instead, I managed to afflict the
afflicted.”)
One of the oddest things about the whole ordeal was that Hatfill
knows relatively little about anthrax. Even though he was touted as an
international expert with unique access and knowledge to the bacterium,
he has always been primarily a student of deadly viruses. What he does
know, at a depth that can rival any scientist’s knowledge, is Ebola.
* * *
Dr. Hatfill is currently an independent researcher with a state-of-the-art boat
(in construction) on which he will conduct his own trials. He is an
adjunct assistant professor at George Washington University School of
Medicine, chair of the Asymmetrical Biodiversity Studies and Observation
Group in Malaysia, and medical director of a London-based company with
extensive contracts in the Middle East and Africa called EFP Tacmed,
which operates a remote jungle-training facility to test new equipment
in high-biodiversity areas. He is also a fellow of the Explorers Club
and a board member of the Arizona-based nonprofit Doctors for Disaster
Preparedness [Update 10/27/14: This is a controversial organization.] He has a handshake that could crack a walnut.
In the late 1990s, Hatfill finished a term at the National Institutes
of Health, and began working with the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Maryland.
USAMRIID researches vaccines, treatments, and disease pathologies,
primarily to protect military service members from biological threats.
(The agency boasts, on its website, “world-class expertise in the
generation of biological aerosols for testing candidate vaccines and
therapeutics.”) Its laboratories have specialized capabilities to
research and treat the most dangerous infectious agents conceivable.
There
was one other Ebola outbreak in the United States, for which the
country was well prepared. It happened in 1990, when a shipment of
macaque monkeys from the Philippines fell ill in the laboratories of
Hazelton Research Products in Reston, Virginia. The company sent tissue
samples from the animals to nearby Fort Detrick, where tests showed
antibodies to Ebola virus. The macaques were evacuated to Fort Detrick
by its highly trained Aeromedical Isolation Team. There they were
euthanized and studied. No humans there contracted the virus, despite
handling the extremely contagious tissue.
The Fort Detrick team was very experienced, and very practiced. The
rapid response unit had worldwide airlift capability designed to safely
evacuate and manage contagious patients under high-level containment.
They knew exactly how to handle the infected macaques. In their work
with primates, they had the capacity to pick up a patient overseas, put
them in a mobile isolator, fly them to Maryland, and put them into the
treatment facility designed for exactly this kind of outbreak. Everyone
wore space suits, so it didn't matter the amount of virus that the
patients were shedding into the environment. The suits were filled with
air by a fan, inflated like balloons, so that if by some chance there
was a tear in the suit, nothing could be sucked in to expose the person.
When doctors left the isolation unit, they went through an air lock
into an anteroom, where they spread their arms and were sprayed down
with a glutaraldehyde-based disinfectant. The colorless liquid killed
every known life form. While in that room, Hatfill recalled, those
people were the cleanest things on the planet. When they came out, the
suits were cut away from them and incinerated on site. Patient transport isolator (U.S. Department of Defense)Now infected materials have to be transported by a medical-waste company. That facility at Fort Detrick was the quintessential Biosafety Level 4
(BSL-4) containment lab. But it was shuttered in 2010, a casualty of
what Hatfill understands to be imprudent budgetary cuts. The World
Health Organization classifies the Ebola virus in the highest-risk
category of infectious pathogens, Risk Group 4, denoting that infected
people should be handled with BSL-4 precautions. But since its outbreak
in the United States, Ebola guidelines from the CDC have treated the
virus under the much less stringent BSL-3.
For that reason Hatfill is both incredulous and seriously concerned.
He believes, of course, that there is no good in panic, and that this
outbreak will “burn itself out” despite yet-inappropriate handling and
public messaging. But healthcare workers will contract this virus who
needn’t, as more than a hundred in West Africa and two in the U.S. have.
The world has to learn from this Ebola outbreak, because it will happen
again on a bigger scale, and possibly with a more deadly virus, for
which the United States is not properly prepared.
* * *
Pathologists at Fort Detrick concluded that the Reston outbreak was a unique strain of Ebola, which they called, aptly, Reston ebolavirus.
There are currently five known species of Ebola virus: Zaire,
Bundibugyo, Sudan, Taï Forest, and Reston. The ongoing west-African
outbreak is of the Zaire species. Ebola is an RNA virus: seven proteins
organized around a strand of nucleic acid. They exist squarely at the
border of the definition of life. When the virus breaks into a human
cell, the RNA directs production of a small army of
seven-protein-plus-one-nucleic-acid entities.
An average of 12.7 days after exposure to Ebola virus, sudden-onset flu-like
symptoms take the person. The symptoms are described as
“nonspecific”—doctor-speak for saying that they could be due to tons of
different things. (“I don’t know what this is.”) Those symptoms often
include fever, headaches, nausea, diarrhea, sore throat, joint pain,
chest pain, hiccups, shortness of breath, and difficulty swallowing.
For 4.1 percent of patients, based on mathematical modeling, the
period between exposure and onset of the first symptoms is longer than
21 days. Around 13 percent of infected people in the current outbreak
did not have a documented fever, according to a New England Journal of Medicinereport
last month. As Hatfill noted in his manuscript, researchers studying an
outbreak in Uganda in late 2000 reported that "the commonest symptom …
was fever, but this occurred in only 85 percent of the cases.” Another
study of that outbreak found fever in only 88 percent. A study of the
1995 outbreak in the Democratic Republic of Congo found fever in 93
percent of the 84 people who died.
On the second or third days of symptoms, about half of patients
develop a skin rash on their face and chest. That coincides with a
generalized inflammatory response to the virus in the person’s blood.
The blood pressure drops dangerously low. As the virus continues to
replicate, the person’s immune system goes further into overdrive. Some
of the immune cells receive false signals from the virus that tell them
to kill themselves. And so they do. As in AIDS, a person’s white blood
cells are destroyed, and the immune system bottoms out. Then, for some,
comes the bleeding.
Because the body’s inflammatory response is in overdrive, little
blood clots start forming everywhere, blocking tiny capillaries that
feed vital organs. The overuse of that clotting material is doubly bad,
in that the remaining blood no longer clots normally. Five to seven days
after the first symptoms, people begin bleeding from their eyes,
throat, and bowels. Without any supportive care, most people are dead
from widespread organ failure in another two to three days.
Ebola is the prototype of an emerging infectious disease in that it
is, importantly, a zoonotic virus (transmitted from animals to people).
This is the route of introduction of the world’s most virulent new
pathogens. During the past 30 years, to Hatfill’s knowledge, 41 new
infectious organisms or strains have crossed from animal hosts into
humans. The period between 2010 and 2014 alone saw the advent of the
MERS Coronavirus, the Bas-Congo Rhabdovirus (which causes a hemorrhagic
fever, similar to Ebola), ongoing Monkeypox outbreaks, and a rash of
Ebola in the Democratic Republic of Congo, in addition to the ongoing
West African Ebola outbreak.
The
risk for human infection by these viruses depends, initially, on
human-animal interactions. Chiroptera bats are an important example of a
reservoir for severe RNA viruses that can cross species barriers to
infect humans. Bats in the sub-order that include the now-notorious
fruit bats have been implicated in RNA-virus outbreaks among the most
lethal infectious diseases on the planet: Ebola, Marburg, Hendra, Hipah,
SARS, MERS, and the Australian lyssaviruses. Those interactions are
driven by the expanding human population (which has doubled worldwide in
the past three decades). They are also driven by animal-habitat
fragmentation, losses in biodiversity, and war.
Many of the deadly emerging RNA viruses arise, as Hatfill makes clear
in his work, from “biodiversity hotspots”—regions that house at least
1,500 species of vascular plants and have lost at least 70 percent of
their vegetation. There are somewhere between 25 and 34 biodiversity
hotspots globally, which house more than half of the world's plant and
non-fish animal species, as well as more than a billion of the world’s
poorest people. These regions also involve more than 90 percent of
recent armed conflicts. War refugees hunt for meat and build remote
encampments, increasing the pressure on local resources and interfering
with wildlife, increasingly drawing human populations into the line of
fire between RNA viruses with their animal reservoirs. And so it is
there that Hatfill believes efforts to manage inevitable future
outbreaks must focus.
What follows is a condensed transcript of our conversation last week
in Washington, D.C. It’s still long, but I decided to err on the side of
including information. His message is, again, not intended to panic,
but to provoke nuanced evaluation of the scientific evidence around
Ebola transmission, and whether or not we are truly prepared for the
inevitable viral outbreaks of the future.
* * *
Steven Hatfill: For the last at least 30 years,
scientists have been very, very worried about emerging infectious
diseases. And we've been seeing outbreaks of things we'd never seen
before at an alarming frequency over the last few years. Right now we're
looking at about five agents, several of which we've never seen before.
The Bas-Congo virus
is a rabies-type virus transmitted by bats through their droppings, we
assume. It's a hemorrhagic fever; it kills you in two to three days from
the start of symptoms. This is Ebola on wheels. [Ed: There have been only three known cases.] Hatfill (right) in BSL-4 encapsulating suit (Hatfill)There
is also the MERS virus outbreak in the Middle East. And Coronavirus,
we'd never seen before, came in from the camels imported into the UAE
and Saudi Arabia. The outbreaks of monkeypox in Kasai Oriental Province,
that's ongoing. An Ebola outbreak right now in Democratic Republic of
the Congo. We've got a Chikungunya epidemic in Puerto Rico, outbreaks in
Florida, a secondary case that indicates the mosquitoes are
transmitting it. And dengue. It's in the albopictus mosquito, the Asian tigers, and we assume it's going to move north in Florida. James Hamblin : And population density is the driving factor of these new infectious-disease outbreaks? Hatfill: For dengue and chikungunya, yeah. People
that have been trapping bats and other animals in these high
biodiversity areas are finding viral sequences, and we don't know what
they're from. This is not in the GenBank
database. So there are things lurking out there we don't have a clue
about. How do you get a rabies virus that causes hemorrhagic fever?
Well, going back through the literature, there's a fish virus that can
cause hemorrhagic septicemia. The frequency that these things are
happening is very disturbing. Just remember, our population's doubled in
27 years. So you encroach on animal habitats, or you fragment those
animal habitats, you disrupt the ecology, the normal food sources.
At the moment, it's the fruit bats. And their range extends way past
Africa, the ones that are transmitting this. We found Ebola Zaire
antibodies in bats in Bangladesh, and as far over as Borneo, although
that paper needs some reassessment. [Ed:There is evidence
that filoviruses (Ebola among them) may be harbored across a larger
geographic range than some previously assumed. Contested evidence of
Ebola Zaire has been reported in orangutans in Borneo.]
So that's a huge swath of land down into northern Australia, India, and
over. So the more these habitats become fragmented, and the bats move
closer to humans—the fruit bats, especially. You cut down their forest,
you build orchards, where are they going to go? To the orchards. And
these bats are carrying everything from the Hendra virus in Australia,
that unusual outbreak in the mid-90s, to the Nipah virus in Malaysia.
And we're going to put 4,000 troops in the middle of this habitat. Are
you going to tell the bats not to poop on the soldiers? Hamblin: I could tell them, but I don't think they'd listen. Hatfill: No, I don't either. So it's a problem. Hamblin: I wanted to ask about your work at Fort
Detrick. Excellent conditions for research, with lots of years that we
had there to develop a treatment or vaccine, but we don't have one. Hatfill: We went down a wrong path. ... But again,
funding is intermittent. And with the sequestration, we're not even
training Navy SEALS in combat-casualty care anymore. You had this whole
unit that was ready for some type of emerging disease, whether it was
Ebola or whatever, completely unknown. And they practiced. The Walter
Reed people would come up and put on the space suit. I know because I
was a patient once, a simulated patient. And they fly you in the
isolator. And the isolator hooks up to the outside of the building and
seals. And then they drag you inside the BSL-4 treatment area. So, I
mean, you couldn’t do better than that. It's an Andromeda strain. And
then it's gone. Hamblin: Totally gone? Hatfill: Yeah. You could change the airflow around
Fort Detrick and bring it back, but you still wouldn’t immediately have
the experienced people who have rehearsed protocol for years. Intubation
[placing a breathing tube down a dying patient’s throat] is difficult
enough. You ever tried to do it in a space suit? Hamblin: No. Hatfill: So you practice these things. And develop a
sense of calm. You don't take a nurse that's just come out of ICU
training and then say, "Yeah, you go in there." You'd be crapping
yourself. You need very experienced people that are used to it, and you
need appropriate guidelines. We've taken a BSL-4 disease, and we're
treating it in BSL-3 conditions. Because they did it in Africa. Well,
outside is a much different story than inside. Outside, these viruses,
if they do get airborne, they don't last long. They're subjected to
oxidation by the oxygen in the air. Osmotic stress from the ambient
humidity in the air and ultraviolet light. Plus they're open-air
hospitals, so [the viruses] blow away. That's different than in an
enclosed room.
So when I heard Anthony Fauci [director of the National Institute of
Allergy and Infectious Diseases] say, yeah, one glove is sufficient, I
just lost my mind. Hamblin: There were claims, I'm not sure the origin
of them, after the first Dallas nurse contracted Ebola, that it was
maybe because she wore too much protective gear. I didn’t understand
what that meant. Hatfill: That's just complete nonsense. Look how they dress in
Africa, and look at the first CDC guidelines. There's no comparison.
You wear hoods. You wear masks and hoods over them. You wear goggles.
You're getting sprayed when you come out and you're walking through a
little kiddie pool filled with bleach. So the outside of your suit is
being decontaminated before you try to take it off. Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.? Hatfill: [Thomas Frieden, CDC director] has become a
political animal, in my opinion. And when you're dealing with this type
of agent with no cure, no real vaccine, you must always err on the side
of caution. They ignored a lot of published data. We've known for years
now that the skin is a site of viral replication. The Langerhans cells,
the antigen-presenting cells in the skin, are major targets for Ebola.
The strains we know of.
What that means is, you're shedding virus from the skin to the point where Bob Swanepoel
[a professor of medical virology at University of Pretoria] and some
people actually found you could come up, take a swab, just a cotton swab
off the skin, and diagnose [Ebola] with a non-PCR method, something
like immunohistochemistry, and get a positive result from a live virus. Hamblin: So you’re saying there is at least some evidence that a person could brush up against someone and contract Ebola virus? Hatfill: People have touched the bed of a patient
and caught this, after the patient died and was removed. They brushed up
against the bed and caught it. [Ed:Such a bed would need to be grossly contaminated, according to the vast majority of evidence.] Hamblin: You write that as few as 10 Ebola virus
particles could cause human infection, though that number needs more
research. Everyone is sticking very hard to the message that unless
you've come in contact with the bodily fluid— Hatfill: Here's the problem. You don't want to panic
everyone. And [the CDC leaders] were at a loss that their [preventive]
procedures didn't work and this happened and the leadership were
shocked. You don't want to panic people, but people aren't stupid. You
see people wearing semi-space suits taking these patients into
hospitals, and everyone's telling you there's no aerosol transmission.
In the classical outbreaks of Ebola, there has been no evidence of
aerosol transmission. That nurse and lab technician who handled the
blood from the first guy, Duncan, I'm sure his blood went to the lab and
he had a full blood count at his first admission. Well, Coulter counters
[machines used to perform blood tests] are notorious for making little
aerosols. And the fact that nobody in the laboratory came down with it
is, yay. So we haven't seen aerosol transmission, classically, in all
these smaller outbreaks for the last 30 years. And it's assumed that it
wasn't transmitted aerosol. But that doesn't mean that it can't be under
conditions. And we really don't know the amount of viral shedding. C.J.
Peters [distinguished chair in tropical and emerging virology at the
University of Texas Medical Branch] and other people have found live
virus in saliva, tears, and nasal secretions.
So to say it's not aerosol transmitted is irresponsible. People
aren't stupid. Look at Ebola Reston. When that broke out, a lot of
people were thinking this was aerosol-transmitted because several people
seroconverted [showed evidence of Ebola exposure in their blood]. But
not one of them got sick. We found in Fort Detrick the Reston strain
doesn't attack the lining of your blood vessels, and your own immune
system just hoofs it. Hamblin: But it was some evidence of a possible aerosolized mode of transmission? [Ed: More on the specifics of droplet transmission here.] Hatfill: It was suggestive. Late experiments took some Landrace strain pigs—the cute little Green Acres
ones—and infected them nasally. They put the infected pigs in with some
uninfected pigs, and they all contracted it. In pigs, it gives them a
very severe respiratory disease.
Then they took Ebola Zaire, and they mixed nasal secretions of uninfected pigs and primates together, and the primates got it. Now, none of the primates passed it between them.
So we're talking about viral shedding, and the question is, how much
virus is being secreted from what sites, what fluids? There are a lot of
unknowns. Most particularly, when does viral shedding start? Hamblin: And what we're hearing most commonly is that it's around when a person develops a fever. Hatfill: Well, 12.5 percent of patients don't run a fever. In that New England Journal of Medicine study,
where they just looked at several thousand of these cases in West
Africa, the lead author of the paper is adamant. He says, I sat there, I
monitored this patient's temperature myself until they died and they
never ran a fever. Well, generating a fever is a fairly complex
mechanism in your body. Neutrophils and cytokines are involved. One of
the things a virus does is it inhibits neutrophil activation. Ebola's
outer glycoprotein can secrete a truncated version of it. You've seen
the planes come over and shoot out the flares so the missile can't get
them. That's what Ebola's doing. It's shooting out these little
truncated bits of glycoprotein as flares. It's masking itself.
Indirectly, its inhibiting neutrophil activation, and what they release
tell us to run a fever. Hamblin: So the neutrophils attack that flare. Hatfill: They're getting confused by it. Hamblin: And the immune system says, it's not a big deal, everything's okay. Hatfill: And they're not releasing pyrogens. This is
our best guess. We need to get it in the lab and have a better look at
it. And it's not just the West African outbreak. The other outbreaks
have reported the same thing fairly consistently. So to use this as a
screening measure rather than quarantine measures becomes problematic. Hamblin: Is there any other better screening measure that could be considered? Hatfill: We have rapid PCR tests. Texas had them,
but they're not allowed to use them because the FDA never certified it.
We have a classified set of Department of Defense primers for PCR that
work great. Hamblin: So any hospital cannot handle patients with
Ebola. What do we do with the people who have it? What should be done
with the future cases in the U.S.? Hatfill: The CDC put out inadequate guidelines, and
now they have to admit it. So everybody's backtracking. The generation
before me classified Ebola as BSL-4. That's safe. We've been working
with it for years. Hamblin: Don’t we have facilities that can handle BSL-4 infectious disease? Hatfill: We only have a handful, and they're not
geared up for patients. Now, USAMRIID could change it back over quickly,
but the most they could handle would be one or two patients. But
instead of [investing in] that, we went out and built all new research
centers. We've wasted 120 billion dollars over the last 20 years.
Nothing to show for it. We can't even handle one patient with Ebola.
Chikungunya is Swahili for “walks bent over.” It attacks the synovial
membranes in your joints. It's agonizing. In fact, you're afraid you
won't die. But most people get through it. It was, a hundred years ago, a
fairly benign disease. There was a lot of travel between India and
Durban in South Africa. Commerce, personnel, people, immigrants, back
and forth. And the population density ramped up. It’s an RNA virus—you
won't find an RNA virus that has more than about 10 genes or so, because
any more than that it's made so many mistakes as it's replicated its
genome, it's nonfunctional. So it doesn't get propagated. Some time over
the last 100 years, one of these strains had a single mutation that
enabled it to replicate to a higher titer inside the mosquito, and now
that's the dominant form, which means these patients are getting a
higher dose of virus. As with any infectious disease agent, the bigger
dose you're exposed to, the quicker and more severe are going to be your
symptoms. Hamblin: You write about the role of conflict and war in viral outbreaks. Hatfill: Eighty percent of the conflicts fought
since 1953 have been in stressed high-biodiversity areas. This is asking
for trouble. … You put your troops in there and wonder why they get
Korean hemorrhagic fever in Korea. I don't know where those fruit bats
have gone. They're migrating at the moment. This is why there are these
periodic outbreaks here and there. Hamblin: The idea of a travel ban has been so controversial. Hatfill: Not to other countries. Hamblin: To the U.S. it has. Hatfill: When the SARS epidemic happened, Singapore
came very close to being wiped out. People don't realize this. And over
there, if you chew gum or spit on the street, they cane you. Singapore
had this under control overnight, and all their contact tracings were
confined to their house, to the point where they would phone you every
hour and you'd better answer the phone or the cops came by to arrest
you. And they stopped it. You saw in the U.S. the journalist went out
for pizza, this nurse went on a plane. Are you out of your mind? Though
in a way this is good, because it shows aerosol and skin shedding in
early infection is not occurring.
The cops went in to check Duncan's apartment without any personal
protective equipment. His family members didn't come down with it.
Again, this is like, whew. Kinda dodged a bullet there. Hamblin: When you talk about aerosol potential, you mean in respiratory droplets? Hatfill: That's what is normally referred to. Here's
the thing. The antigen-presenting cells in the body are major targets
for Ebola, and we find these everywhere. Our throat, the Waldemeyer’s
ring, is full of antigen-presenting cells. Its job is to check
everything coming into my airway and my mouth, show it to its buddies,
and determine, "Should I be alarmed?" "No, no." Or, "Oh, no, we're going
to make an immune response." Bronchial-associated lymphoid tissue,
skin-associated lymphoid tissue, gut-associated lymphoid tissue: All
these portals to the outside world are protected by these sentries. The
virus likes to attack the sentries and replicate in them to [a] high
concentration.
So physiologically, biomedically, yes, it looks like it's possible.
Epidemiologically when we look at it, we don't appear to see it. But
don't get up and say, "Cannot occur." That's nonsense. And people aren't
stupid. They see everyone running around in Tyvex and positive-pressure
respirators, and they're going, what they heck is going on here? Don't
dumb it down. Tell people: The animal data shows this can happen, [and]
we're looking for it. We haven't seen any indications at this time.
The other thing Singapore did was put in the thermal scanners
[at airports] immediately, like the next day. They're commercially
available. It's so unobtrusive you can't even tell, but, oh, yeah, there
it is over there. And you can see your thermal image. We waited to the
last minute to do it. Why? You have you err on the side of caution,
especially when you have 317 million people in close proximity and a
very good infrastructure. You can be from here to there in 6 hours. You
can be from the Congo to JFK in 24. Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa. Hatfill: You know, I went for a Department of
Defense interview years ago. They wanted a scientist down at the
Pentagon that could invent stuff that would support presidential policy.
... They just wanted a spokesperson that could kind of come up with a
plausible explanation to explain a higher-up directive. And I think this
is the same thing. Hamblin: I'm wondering what is driving— Hatfill: There are no cases in Kenya. Hamblin: And they have a travel ban? Hatfill: Yes.
Sanjay Gupta, who is a neurosurgeon, did probably the best
demonstration I've seen on why the CDC protocol failed. He dressed up in
the recommended protective equipment and they put chocolate syrup on
his hands. As an experienced neurosurgeon, how many times he's donned
and doffed this gear? He took off his gear, and, yep, there were
chocolate splashes all over his skin. There's a reason we use
front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon
can't do it, what do you think a poor gal just out of ICU training is
going to do?
The nurse that got infected knows she's in there with an Ebola
patient, and God bless her for volunteering to do this. It's a very,
very brave thing to do. But it's not just issuing a guideline. You have
to practice implementing it. And the whole hospital has to practice. You
can't come up with it at the last minute. Hamblin: Do you think this outbreak will— Hatfill: It'll burn itself out. Nigeria's already got control over theirs. Why? They follow the rules. Hamblin: Is it going to be a wakeup call for the U.S.? Hatfill: If it isn't, then we're doomed. Dr.
Hamblin, there are worse things out there. Again, we're finding viral
sequences, and we don't know what these are from. There are other things
out there. Hamblin: How do we get the government to invest? Hatfill: We spent 120 billion on this, on emerging
disease and bioterrorism, what have we got to show for it? Machines that
the FDA hasn't licensed for rapid diagnosis. Hamblin: I don't understand where the money you mention is going. Hatfill: It disappeared. It just disappeared. Hamblin: I don't know what that means. Hatfill: We have nothing to show for it. … Mother Nature is not happy with us at the moment. Hamblin: So this is a tip-of-the-iceberg situation, this outbreak? Hatfill: Here's a very good example. In 1993, 1994
somewhere I think in that timeframe, we almost lost every lion in the
Serengeti. The Distemper virus jumped from the wild African dogs into
the great cats and it slaughtered them. They had no immunity. And they
had to go in and vaccinate wild lions. Hamblin: They did that with darts? Hatfill: I forget how they did it. Hamblin: They could tranquilize them. Hatfill: I heard rumors of infected meat. I don't
know how that would work. But 80, 90 percent of the population crashed.
Mother Nature tends to do that. We're not there yet. But when's our next
doubling time for population? Hamblin: It's not long. I know the over-65 population in the U.S. is doubling in the next 25 years. Hatfill: With poor immune systems because they're
older, susceptible to all sorts of stuff. And now China's moving
everybody into high-density urban areas. They built these huge cities,
million person cities, and there's nobody in there. And they're going to
relocate their rural population. Why? Because it stimulates consumer
spending and provides jobs. This is their grand plan. Well this is where
all the flu viruses mix and come from. God knows what that will
generate. This is a serious problem. It's not something that can be
ignored any longer. Hamblin: You said not many hospitals can handle a case. I saw the number six thrown around. Do you think it's that low? Hatfill: Depends on how much they practice. And if
it's not mandated, hospital administrators aren't going to do it.
They're stressed as it is. Hamblin: It's a tough investment to justify until a threat is imminent. Hatfill: Exactly. You want me to do what? Practice
what? You know, that's going to cost the hospital. So I mean, this is
for-profit medicine in this country, unfortunately. Hamblin: Speaking of the for-profit: Pharmaceutical
companies, they're not going to factor into development of vaccines and
treatments of emerging infections diseases. Hatfill: Well no, because the majority of [Ebola]
patients don't have any money. These are businesses. Fair on them, it's a
business, right?... Do we have enough Tyvek suits?
This was a thing that was brought up yesterday evening during a meeting.
Dupont can make these things, we can crank them out and we can double
our capacity, but if the epidemic ends we've just outlaid millions to
ramp up capacity. Who's going to pay us? Because we're not going to do
it on our own, we're a business.
… So there are positive signs here, and it's not the sky is falling,
but dammit, animal data is pretty convincing that this is a possibility.
Don't tell people it's not. Be honest with them. "Yes, we've had some
animal studies, it's shown this, but I have to reaffirm we have not seen
this to date."
* * *
Though Hatfill preferred that I not mention geographic specifics, he
is consulting to African countries on Ebola containment and prevention.
Shortly after our conversation, he left the U.S. to answer the calls for
policy help from long-standing contacts established over his 15-plus
years of work in Africa.
His advice to the CDC, though no one has asked him for it, centers on
the fact that as new antiviral treatments are developed, the need for
rapid medical response units will become paramount. These treatments
have to be administered quickly, but they could stem outbreaks before
they become significant. Medical response units would need to be able to
enter remote areas for on-site diagnosis and administration of
antiviral medication. They would need isolation transportation and BSL-4
treatment facilities in the United States. Because outbreaks like this
one will happen again, and they are best addressed by focusing
containment and treatment efforts at the source of the outbreak.
With the right military crew properly equipped, he said, smiling at
the thought, "They'd love doing it. I guarantee it. Hell, I'd like to be
on one. It depends if we're going to take this as a wake-up call or
not."
James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.
Flag Share Reply +4 rate up
Verne Strickland: Watch this story closely. This is the first step in commercial space travel in cooperation with NASA -- with an exploding Russian-designed rocket.
There are signs of U.S. Government cover-up -- possibly to spare Russian embarrassment.
USA DOT COM has already gathered archival information about Russian rocket failures. Watch this site for more.