Abstract
Inside the Hot Zone: A Soldier on the Front Lines of Biological Warfare by Mark G. Kortepeter. Lincoln, NE: Potomac Books; 2020. 336 pages. Reviewed by Amesh A. Adalja, MD
When it comes to biodefense and biosecurity, the late 1990s to the present have been a tumultuous time, marked by event after event. Deliberate anthrax attacks, explosive Ebola outbreaks, and threats of smallpox use are just a few examples of what biosecurity professionals have had to contend with. Over the years, several books that delve into these issues have appeared. However, this latest one, Mark Kortepeter's Inside the Hot Zone: A Soldier on the Front Lines of Biological Warfare, is one that stands out for several reasons.
The book is the memoir of a military physician who witnessed and participated in many of the seminal events that have occurred in the past 20-plus years in the field. Kortepeter is a military infectious disease physician whose career trajectory eventually led to his appointment as deputy commander of the US Army Medical Research Institute of Infectious Diseases (USAMRIID). To those familiar with the field, USAMRIID is arguably the premier facility of its kind in the world and, as Kortepeter puts it, the nation's “biohazard 911” center. As such, his book reflects the uniquely informed views of someone in the thick of the government's response to infectious disease threats.
Illustrating the high-stakes decision making characteristic of Kortepeter's role, he begins his book with an anecdote about a needlestick injury suffered by a USAMRIID scientist that landed her in the “slammer”—the now-defunct and infamous biocontainment unit at USAMRIID. The rest of the book concretizes the high stakes of biosecurity.
Surveying Kortepeter's career in medicine and the military, there does not appear to be an area in biosecurity in the past quarter century with which he was not involved in some capacity. He is one of the rare—but vital—experts who is able to straddle both operational and policy roles. For example, he was tasked with vaccinating soldiers against biothreat agents under harrowing physical (and bureaucratic) circumstances during Operation Iraqi Freedom, while also being part of the original group that helped define the various categories of threat agents.
The book is divided into 23 relatively short chapters that are vignette-like, but each embodies the underlying theme of the crucial nature of the infectious disease mission to which Dr. Kortepeter remains committed. Each chapter uses some activity that Kortepeter was tasked with to add more data to the multifaceted view of biosecurity issues that the reader is immersed in by reading the book.
One enjoyable and important highlight from the book includes an innovative way to describe category A biowarfare agents as chess pieces, based on their capacities—for example, King smallpox and pawn botulinum toxin. I found this analogy very illuminating. For example, botulinum, despite being 15,000 times more potent than the VX nerve agent, is labeled a pawn, reflecting its limitations: It is not transmitted person-to-person and has limited dissemination capacity (“it can attack only one space away”). Tularemia (the rook) merits a higher classification, given its long-range reach, which may explain why US biological weapons expert William Patrick considered it his “favorite.”
Another anecdote Kortepeter recounts is the botulism scare at the George W. Bush White House, which has been recounted in several memoirs. Kortepeter's account demonstrates how the threat was seen to be genuine, as evidenced by the large amounts of antitoxin he had to mobilize.
Knowing Kortepeter's role at USAMRIID and the outcome of the Federal Bureau of Investigation's (FBI) Amerithrax investigation, I eagerly looked forward to reading his perspective on the events and the aftermath of having a USAMRIID scientist (Bruce Ivins) identified by the FBI as the culprit. To me, this was one of the most fascinating parts of the book. Rather than taking a definitive side, Kortepeter even-handedly discusses the evidence amassed by the FBI, including some of its scientific shortcomings and tendentious nature. Interspersed are quotes from USAMRIID scientists familiar with Ivins, anthrax, and USAMRIID procedures. What results is a very thought-provoking treatment of arguably the most important biosecurity event in the nation's history.
Kortepeter discusses the resultant morale problem and stigmatization that ensued in the aftermath of the Amerithrax attack and the FBI's naming of USAMRIID as a source. He talks about the new heightened scrutiny that resulted in halts in scientific work, the need for extensive inventory management improvements, and the public relations challenges. Throughout this section—and indeed throughout the book—Kortepeter is an admirably fierce and loyal defender of USAMRIID and its value, which he likens to a crown jewel, the nexus for response to infectious disease emergencies, and a vital national security resource.
After leaving USAMRIID, Kortepeter continued his work in biodefense as the associate dean at the Uniformed Services University for Health Sciences (USUHS) and as the biosecurity consultant to the army surgeon general. It was in that capacity, during the 2014 West African Ebola outbreak, that Kortepeter used his expertise from USAMRIID and “the slammer” to argue presciently for a system of care for high-consequence infectious diseases such as Ebola. As the events in Dallas proved, he was correct in identifying this need, and his ideas now form the basis for the current system in place in this country. He has been instrumental in implementing this system through the National Ebola Training and Education Center (NETEC) and at the University of Nebraska.
I highly recommend the book, especially to those wanting a first-person account of what it was and is like being on the leading edge of biosecurity. Biosecurity is a fairly new field, and this book provides a thorough overview of it for those interested in the field. It is also of value to those with in-depth knowledge of biosecurity, as it provides a relevant context for many of the events in the past decades that have shaped the field.