Ebola and Borders

Published on October 10th, 2014

In 1995, Richard Preston’s “The Hot Zone” was published. The New York Times No. 1 Bestseller chronicles some of the lethal “hot viruses” that have emerged out of Africa, including Ebola which was first identified in 1976.

Preston’s writing on the viruses was vivid, compelling, riveting and horrifying – the story “stuck” with me since reading the book when it was first printed. In the opening chapter, Preston tells the story of a Frenchman who becomes infected in Africa with one of the deadly viruses:

… on the third day after his headache started, he became nauseated, spiked a fever, and began to vomit. His vomiting grew intense and turned into dry heaves. At the same time, he became strangely passive. His face lost all appearance of life and set itself into an expressionless mask, with the eyeballs fixed, paralytic, and staring. The eyelids were slightly droopy, which gave him a peculiar appearance, as if his eyes were popping out of his head and half closed at the same time. The eyeballs themselves seemed almost frozen in their sockets, and they turned bright red. The skin of his face turned yellowish, with a brilliant starlike red speckles. He began to look like a zombie. His appearance frightened the temporary housekeeper.


The doctors at the hospital examined Monet, and could not come up with any explanation for what had happened to his eyes or his face or his mind. Thinking that he might have some kind of bacterial infection, they gave him injections of antibiotics, but the antibiotics had no effect on his illness.

The doctors thought he should go to Nairobi Hospital, which is the best private hospital in East Africa. The telephone system hardly worked, and it did not seem worth the effort to call any doctors to tell them that he was coming. He could still walk, and he seemed able to travel by himself. He had money; he understood he had to get to Nairobi. They put him in a taxi to the airport, and he boarded a Kenya Airways flight.

A hot virus from the rain forest lives within a twenty-four hour plane flight from every city on earth. All of the earth’s cities are connected by a web of airline routes. The web is a network. Once a virus hits the net, it can shoot anywhere in a day – Paris, Tokyo, New York, Los Angeles, wherever planes fly. Charles Monet and the life form inside him had entered the net.

Then on the airplane:

He is holding an airsickness bag over his mouth. He coughs a deep cough and regurgitates something into the bag. The bag swells up. Perhaps he glances around, and then you see that his lips are smeared with something slippery and red, mixed with black specks, as if he has been chewing coffee grounds. His eyes are the color of rubies, and his face is an expressionless mass of bruises. The red spots, which a few days before had started out as starlike speckles, have expanded and merged into huge, spontaneous purple shadows: his whole head is turning black-and-blue. The muscles of his face droop. The connective tissue in his face is dissolving, and his face appears to hang from the underlying bone, as if the face is detaching itself from the skull. He opens his mouth and gasps into the bag, and the vomiting goes on endlessly. It will not stop, and he keeps bringing up liquid, long after his stomach should have been empty. The airsickness bag fills up to the brim with a substance know as the vomito negro, or the black vomit. The black vomit is not really black; it is a speckled liquid of two colors, black and red, a stew of tarry granules mixed with fresh red arterial blood. It is hemorrhage, and it smells like a slaughterhouse. The black vomit is loaded with virus. It is highly infective, lethally hot, a liquid that would scare the daylights out of a military biohazard specialist. The smell of the vomito negro fills the passenger cabin. The airsickness bag is brimming with black vomit, so Monet closes the bag and rolls up the top. The bag is bulging and softening, threatening to leak, and he hands it to a flight attendant.

When a hot virus multiplies in a host, it can saturate the body with virus particles, from the brain to the skin. The military experts then say that the virus has undergone ‘extreme amplification.’ This is not something like the common cold. By the time an extreme amplification peaks out, an eyedropper of the victim’s blood may contain a hundred million particles. In other words, the host is possessed by a life form that is attempting to convert the host into itself. The transformation is not entirely successful, however, and the end result is a great deal of liquefying flesh mixed with virus, a kind of biological accident. Extreme amplification has occurred in Monet, and the sign of it is the black vomit.

Ultimately, the Frenchman bleeds out and dies.

Suited-up staff at the Doctors Without Borders center in Monrovia, the capital city of Liberia, respond to the Ebola outbreak.

While this writing may sound like science fiction, “The Hot Zone” is indeed nonfiction. Death by one of these African viruses, including Ebola, Marburg and other viral hemorrhagic fevers, is a modern day visitation that recalls the Black Plague.

Perhaps not surprisingly then, the media (at least what coverage I’ve seen during the last six months) hasn’t given the public gory details about Ebola; leave it at the images of fully suited up medical workers in West Africa to convey the level of seriousness.

The current Ebola outbreak began in March this year in Guinea, followed by cases in neighboring Liberia and Sierra Leone, and then Nigeria. As I write this post, there were more than 7,100 cases and 3,300 deaths from Ebola. There are five strains of Ebola, and the strain in this outbreak is the worst, according to Dr. Gavin Macgregor-Skinner, infectious disease specialist.

The 2014 Ebola Outbreak – By the Numbers Source: CDC

Probable, Suspected
Confirmed Cases


Mar 30



Apr 30



May 27



Jun 24



Jul 31


Aug 28



Oct 2



I’ve followed this story since March, and my continuing sense has been that needed response has been slow and insufficient, or consistently a day late and a dollar short. June reports of doctors being overwhelmed did not seem to produce a stepped-up response, nor did statements from Doctors Without Borders when it told the United Nations in September that world leaders were failing to address the worst Ebola epidemic ever.

In a speech to the UN, the head of Doctors Without Borders said, “Leaders are failing to come to grips with this transnational threat. The WHO announcement on August 8 that the epidemic constituted a ‘public health emergency of international concern’ has not led to decisive action, and states have essentially joined a global coalition of inaction.”

And not until mid-September did President Obama commit 3,000 military personnel to set up a command center in Liberia.

Maybe not enough people have read “The Hot Zone.”

Even talking among friends about the Ebola outbreak, I’ve received a lot of pushback that I am over-reacting, particularly after I suggested that two American health workers infected with Ebola should be treated in Africa rather than flown back to America and treated at Emory (a third aid worker now has been flown back to Atlanta and is being treated). Among the feedback: People should be more worried about the flu and getting a flu shot … Fancy charts on how one person with mumps or measles can infect more people than one person with Ebola … I shouldn’t panic … We have superior medical systems … I should have confidence in the Western system … You’re just armchair quarterbacking our medical professionals.

Well, our Western system definitely dropped the ball at the end of September in Dallas. The initial level of incompetence in the first identified case of Ebola in the U.S. (that is, a patient with the disease that was not intentionally brought into the country under medical supervision) was very troubling. Given the amount of attention that this Ebola outbreak has received and the availability of CDC guidelines, that a patient displaying symptoms, who reportedly self-identified as coming from a country in Africa that is experiencing an Ebola outbreak, would be sent home with antibiotics can only leave one with mouth agape, going “What?!!”

If we’re not adequately prepared to appropriately handle one case, how might we deal with 10 or 100 Ebola cases? (Just consider the waste that must be properly disposed of – in the two Emory cases, up to 40 bags a day at the peak.) Certainly, this may not happen – and hopefully it doesn’t. But as I write this, news is breaking of a freelance NBC cameraman working in Liberia who now has Ebola and is being flown back to the United States for treatment in Nebraska. An aid worker also was treated for Ebola in Nebraska.

The Dallas apartment where the first Ebola patient in the U.S. stayed is decontaminated. Source: New York Times

So whether it’s this crisis or another medical crisis, are we prepared?

Another troubling aspect to consider in the Texas case is whether or not this patient, who is reported to have assisted an Ebola patient in Liberia, was truthful in the “self-reporting” process before flying. According to Liberian officials, Thomas Eric Duncan said he had not come into contact with Ebola while in Liberia. So, this all goes to the reliability of protocols for air travel in this Ebola outbreak. Perhaps Duncan was truthful, but this case does raise the question: if there were the opportunity to travel to the U.S., would desperate people fly here for better health care if they thought they might have contracted this virus (or another equally lethal disease)? Besides the potential danger of spreading illness, there is the question of who picks up the tab for the medical costs of sick foreigners.

The Liberian’s visa had recently just come through for the U.S. (An estimated 13,500 people from Guinea, Liberia and Sierra Leone, the epicenter of this outbreak, have visas to visit the U.S.) So, this is yet another very troubling aspect. Why in the middle of the worst Ebola outbreak to date is the U.S. issuing visas to any of the outbreak countries for nonessential travel? Why not put a moratorium for nonessential travel until the outbreak has burned out? Apparently, 10,000 people travel out of West Africa daily. Does that make sense six months into an Ebola outbreak, as more cases are occurring? Should travel be limited to health care professionals, military, media and any other essential personnel to battle this disease?

Our seemingly lax approach to dealing with this outbreak seems to be our standard for dealing with any border-related issue. Whether it’s a potentially deadly disease or our everyday, now commonplace illegal border crossings, we continue to act as though borders don’t matter. Until we live in a world become Utopia, the borders of countries should serve to protect the citizens of sovereign nations from a variety of threats, including diseases that can be stopped, criminals and terrorists.

In the event just one U.S. citizen contracts Ebola in the U.S. as a result of poor border controls, then our government has failed at one of its most basic responsibilities – protecting its population.

If there’s a positive to the initial botched handling of the first Ebola case in the U.S., it may be that folks in government got a kick in the butt. Media were genuinely outraged at the failure. More individuals started voicing their concern about poor travel protocols in the U.S. From several first-hand reports of passengers, there are (as of this writing) no Ebola protocols currently in place to screen passengers who originated their travel in West Africa once they land in the U.S.

After the initial fiasco (how many times did we hear Andersen Cooper and other CNN reporters talk about the infected sheets still on the bed in the apartment where Duncan was staying when he arrived in Texas?), the medical community and government officials seem to have stepped up their game – a bit. On October 5, there was a report that the U.S. government was considering new airport screening procedures – again, a little late to the party.

Then on October 6, it was reported that President Obama and his administration were working on protocols to screen airplane passengers for Ebola and to better prepare the medical community. (After months of inaction, I doubt these October governmental discussions would have occurred if not for the Fourth Estate.)

Still, the longer the international community waits to apply the maximum resources to contain this disease within the borders of the impacted countries in West Africa, the more opportunity the virus has to evolve into something that is more easily spread. Shutting down nonessential travel from these countries until the outbreak has died out is overdue.

I’m no Alan Krumwiede (Jude Law’s character in “Contagion”), but it’s well past time to put better border enforcement into action.

Look for an upcoming article on this topic from Richard Preston in The New Yorker.

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