googlead166c37c697d4d3.html Glenn Ashton Author Blog: Ebola: Will a US city have to be quarantined if it spreads?


Friday, October 31, 2014

Ebola: Will a US city have to be quarantined if it spreads?

USA problems in coping
Today we saw an ebola nurse defy the order of the Governor of her state to remain in quarantine, after she returned from ebola-stricken Africa. Kaci Hickox took to the streets to indicate her opposition, by riding her bicycle.

And Governor Paul LePage of Maine was not amused:

Kaci Hickox took her campaign against an Ebola quarantine out for a spin on Thursday.
The Maine nurse, openly defying an order to stay home after she treated patients in West Africa, sped off on a bike ride on a sunny morning with her boyfriend, Ted Wilbur. She returned after about an hour.

“I hope that we can continue negotiations and work this out amicably,” Hickox told reporters. “There is no legal action against me, so I’m free to go on a bike ride in my hometown.”

Authorities in Maine are pursuing a court order to enforce the quarantine through Nov. 10. Hickox says she is completely healthy and free of symptoms, and that the quarantine is unnecessary and unconstitutional.

Several hours after the bike outing, Gov. Paul LePage said that efforts to negotiate with Hickox had failed. Citing confidentiality laws, he did not specify his next steps. But his office pledged in a statement: “The governor will exercise the full extent of his authority allowable by law.”

In an interview with NBC affiliate WSCH, LePage suggested it was all right for Hickox to leave home, as long as she doesn’t touch anyone or go into a public establishment. He said a police cruiser outside the home was there for Hickox’s protection.

“Her behavior is really riling a lot of people up,” he said.

He said he hoped for legal clarification later in the day on enforcing restrictions on her movement. The governor said he was looking out for the 1.3 million people of Maine.

“I don’t want her within three feet of anyone,” he said.

Kaci Hickox’s stance throws into high relief a topic that right now concerns not only the President, but the Governors and Legislatures of several States. There is no vaccine for ebola, and the lethal disease (it has a very high mortality rate for those infected) has caused thousands of deaths in several countries of Africa.

Ebola nurse Kaci Hickox
The Problem: How to contain the Infector Pool

The countries in Africa grappling with this deadly scourge have been unable to date to solve this problem. Because ebola is spread by contact with an infected person during the infection period, it is very easy for those tending the sick to fall victim. So far, ebola has not been spread through the air, but only by bodily contact with fluids of the sick persons.

Preventing such contact is the primary goal of all efforts to prevent ebola spreading. This means putting infected people into containment structures that limit their contact with others, and making sure that all medical and other personnel wear appropriate biohazard clothing. Intense training in the removal of such clothing is also needed.

But what if there are not enough containment structures, and not enough protective clothing?

What then?

The simple answer is that ebola will spread, unless none of the sick are attended to.

Ebola container
Even if all helpers moved away from the sick, ebola will spread of infected people move into fresh populations.

This brings us back to the steps being taken by Governor LePage and by others, to require that any person who has – or might have – come into contact with a person infected with ebola, whether in Africa or in the US, be placed in physical quarantine for the incubation period of some 21 days.
Quarantine in the USA: Is it legal?

There is some doubt whether it is. Some Governors have said that they will insist on mandatory quarantine of persons at risk, regardless of legality, in order to protect the citizens of their states.

But what if ebola – or a similar, highly contagious and very lethal disease – should spread inside the USA? Would the US be prepared for this, on a massive scale? Would any developed country?

A US President might consider the spreading of such a highly contagious disease to be a national state of emergency, but even then there is some question whether compulsory quarantine of persons or of areas (or cities) would be legal.
An Example of a National State of Emergency caused by a contagious disease:

I was curious about how the US might react if this happened, and in my thriller, Silent Lips, this theme was developed.

Silent Lips can be described using the dedication in my novel:

During one of my visits to the city I was walking in Central Park when the thought struck me: What if something happened and this huge, bustling, energetic city was forced to shut its borders, to keep people inside and stop people entering? That thought stayed with me for several visits until one day I sat down, pen in hand, and sketched out the story of Silent Lips.
 It is a story of New York struck by a mysterious disease which forces the President to blockade the city. Nothing can leave; nothing can enter.

What is this disease? Where did it come from? Who made it? Can it be stopped?
 Inside the quarantined city, I thought of men and women fighting to find the answer to the mysterious sickness that raged in the streets and hotels and homes, while still more men and women came from all over the world to the city to help it fight for its survival. This is the story of the people inside the city, its sky blackened by the fires of its funeral pyres, and of those outside who watch with anguish the mounting crisis.
            The crisis immediately creates problems for the US President:

People inside and outside New York race against time to save the city from a genetically engineered virus created by mistake.
 With a quarantine of the city enforced by the Army, doctors in the ParkLab set up in Central Park try everything they can think of to cure people, and the U.S. President makes the most agonizing decision any president has ever made.
Why would quarantine of a US city be considered?

            Simple: if it appeared that the disease might spread. This was faced in Silent Lips:

One such unit had started tracking the outbreak in New York as soon as the second case had been admitted to hospital. 
 This unit believed that the disease was a brand new one. 

They weren't sure, the civilians said, but McGroarty noticed that General Grant seemed to have bought their conclusions; he did not look like the kind of man who bought crap easily. 

The group also believed that the disease was growing at a rapid rate; according to their calculations it was due to start a phase of exponential growth within the next day or two, and the thing could go out of control unless it was checked, or cured.

Or contained.

Everybody had nodded when the last option had been mentioned;  McGroarty didn't need to have it spelled out which option the seven gentlemen around the table thought was most feasible.

The President appointed a disease czar – similar to President Obama’s appointment of his own Ebola Czar – to coordinate the response to the disease, only in Silent Lips the disease is spreading inside New York City. The investigation team reports to the President:

The team's recommendation was terse, and strongly worded: the city of New York had to be quarantined. 
 All indications were that the disease was spreading so fast that it could break out of the city and travel elsewhere.

He remembered the discussion, and the expression used by one of the experts. We have to erect firebreaks and turn the disease back on itself, let it burn itself out, consume itself. 

You mean wait until all the trees are burnt, he had commented wryly, and the answer had come: Yes.

Until all the people die, he had pressed, and again the answer: Yes, if necessary.

The decision to quarantine a large American city:

Given the virulence of ebola, the lack of vaccines for it, and the response of the various Governors and States to the limited threat now posed by those returning from tending the sick in Africa, it is not too difficult to envisage a situation arising today that is very similar to the one described in my thriller, Silent Lips: a President of the United States decides not to allow a disease that originates in that country, to be exported:

The wrong people at the wrong place at the wrong time. 
 The net had been cast and they had been caught.     

The airports were the first to be closed because they were the gateways for the staggering traffic in bodies and cargo out of the city: more than forty percent of the country's overseas traffic and close on sixty percent of the total exports from America. 

The President of the United States of America had decided: he would not allow the disease to be exported.

A major role would have to be played by the US military forces, in enforcing the quarantine of the big city, and in keeping order inside the quarantine boundaries:

The air trembled above Base Three, the largest of the three staging bases located just outside Zone 5's boundaries. Airplanes of all sorts swooped down to land in the base, with the majority being huge transports carrying troops and supplies.  Gradually stocks were built up until whole acres of land were covered by row upon row of boxes and cans and trucks. An infrastructure the size of an average medium sized city was assembled.
 People, too, were processed in Base Three.

Civilians flew in and disembarked before being driven by truck into the city; they never came back nor did the trucks in which they travelled.

Soldiers also came, in their thousands. Platoons marched off the huge transports to the makeshift barracks that covered so much of Base Three; then they marched to the trucking depots and boarded them for the one way trip into the city. As the troops filed aboard the trucks they dropped their wills and government sponsored insurance policies into the 44 gallon oil drums converted for the purpose.

Treatment of those who died:

Until a cure was found, thousands could die from such a virulent disease, and this would mean finding the fastest way to get rid of the bodies, so as to lessen the risk of infecting others:

Burton reflected on this once more. How could they disinfect the  city? Disinfestation usually meant the destruction of small animals such as rodents, present on the person or clothing of the people or in their physical environment.

How did one disinfestate a whole city? Destroy the carriers... But the carriers were people in New York. So it must be impossible...

Hospitals were overflowing with the dead and dying, and military units were now making periodic sweeps of homes, block by block, to locate the dead and take them away for disposal.

There were no longer any burials. Bodies were cremated.

The temporary cremating ovens in the grounds of Central Park had been tripled in size in the past twenty-four hours, to cope with the people who died in the Parklab.

In various places throughout the city, several huge centers had been established to burn the bodies of the dead; daily convoys of military trucks trundled through the city's neighborhoods, guarded by troops, ferrying bodies to the new crematoria.

Some bodies were being burnt even before identification, if there were any delays. They were simply photographed and there were queues of people lined up before police precincts to check the books in search of missing friends or relatives.

The search for a cure:

A frantic search for a cure would be launched. In Silent Lips, suspicion fastens on the activities of a deceased young doctor, and the President’s Czar visits his makeshift laboratory to find out if there any clues as to how the disease started:

He pulled from his briefcase the large scale map of the city and looked again at the initial survey results of the spread of the disease. The map tracked the victims. They had assumed there might be a carrier or carriers and wanted to find his or their location.

But what if the location of the victims was a clue to the location of the maker of the bug, assuming it was made by someone and not a naturally occurring mutant? John Raymond's small laboratory was right in the centre of the initial area, in Zero Area.

Did it start here?

He leant back in the chair, teetering its legs. John Raymond had been here where it started.  

Had he carried it to the other areas? 

He rocked the chair back and forth, his eyes on the cages: there were several smaller ones next to three large ones. Burton noted idly that they were all empty. Probably rabbits or hamsters, he thought, looking at the little tuft of fur caught in the corner of the wires of one of the cages.

He plucked it out and rubbed it in his fingers: it was silky. He tried to brush it off and it clung to his fingers.

There were droppings on the floor of the cages. He scooped some into envelopes and numbered them, starting with the cage on the left as number one. 

Perhaps we made the Bug, he thought.

Perhaps it was a fortuitous mixture of viruses and one of the myriad chemicals in the city.

The debate about limits:

Very soon, the difficult issue would surface: what could be done to find a cure, given the high rate of infection, and of death? Would normal limits and protocols that apply to new cures and vaccines, be followed? They would be among the first casualties, I believe:

"We have tried all the conventional ways," Marshall began. "Now we will try everything we can think of. And I mean everything. Mix up the treatments. Speed them up. Push conventional methods to their extremes. Try everything. I know that will not sit well with many of you, but we do not have the time."
 Marshall raised his grey face and stared steadily at the team.

"I do not know what the cost will be in human lives. I do know there will be deaths as a result of our attempts. You must not worry about this. It is not your responsibility but mine." He closed his eyes briefly. "I do not want your effectiveness to be reduced by concern. Leave that to me. Any questions?"

"Colonel," Levine raised his hand, "surely there must be limits..." 


His reply was sharp.

"There are no limits." Raising his voice, he said commandingly: "I set the limits here, and I have just taken them off. There are no limits any more, doctor. None whatsoever. We do not have the time." 

There was anger in his voice. "Remember that the cure will save thousands more than will die here."

He reached for a pile of documents stacked in front of him.

"I have prepared the criteria you will apply in selecting subjects for treatment. As far as possible we will stick to these types of subjects. If it requires any modification then I will do so when that need manifests itself."

He handed out copies of a slim document stamped Top Secret: Not to be taken out of this room.

Inside the besieged city, disorder would break out, and the police and army would have to take steps to restore as much calm as was possible:

Down below, the police were moving in, the front row firing the snub teargas guns and stopping to reload while the second row stepped past them and fired.
 Fire stop reload; fire stop reload.

They worked their way steadily down the street, through the crushed mannequins the halftrack had ridden over. The teargas bullets thumped into the crowd, the wax containers splitting open and the white powder spreading for ten yards from each burst. White covered individuals crawled on the pavement or curled in agony, retching.

Strict steps might have to be taken to enforce the quarantine zone, both by keeping those inside the city inside, and those outside from trying to come inside to rescue their loved ones trapped in the city:

Miles from the building, the choppers came in low out of the early morning light, spreading out in a V with the lead chopper a little ahead of the other four, spotting the signs the sappers had erected the day before, and guiding the mine sowers between them. This was their third sortie since noon yesterday; another three trips and they would finish the work in their sector. The route hugged the outskirts of Zone Five, winding along the banks of rivers and next to boundary roads. In places it ran between coils of barbed wire, but in other places the ground was bare.
 The pilot jinked the stick slightly, edging the nose up to keep at the same altitude as the flock behind him, watching the small anti personnel mines spray behind the choppers. They bounced and tumbled on the soil, spinning in flashes of glinting light in the early sun.

The shiny ones were for warning purposes, designed to alert people to the presence of mines, but the really deadly ones were the sand colored ones that lay flat and hidden in the dusty fields, and the green and grey ones that fell into the grass. Contact mines were mixed with proximity mines. 

All were lethal.

The whole boundary of Zone Five, except for the checkpoints allowing traffic to enter, was being sown with the mines. The no man's land separating Zones Three, Four and Five had already been sown.        

The President would have to rely on those who governed the state and city affected by the quarantine, to help maintain order. In Silent Lips, this is done by the Governor of New York:

The crowd was on its feet now, cheering the old fighter.
 "One of our great Presidents went to a city that was in danger from another kind of enemy and told them: Ich bien ein Berliner! Now I say to you, I am proud to stand here and tell you and the world that I am a New Yorker!"

The singing had started in the corner of the hall and was spreading.

"If the only thing I can do in this terrible, terrible time is to wait this side of the wall and if necessary lay down my life for my fellow citizens, then I say: Take me! Take me! Take me!" 

He grabbed the microphone in both hands and joined in the song, starting at the beginning, his powerful voice roaring out Oh! Say can you see in the dawn's early light ...   and the crowd stood and sang with him, the pride they had shining in their eyes.

This, they were saying, as their massed voice rang through the huge hall and out to the nation through the television cameras, this is our moment. Tomorrow, in the cold light of the dawn, we will live with our fears again, but now we are marching with that wild, crazy, proud old man.

Now we are living our commitment to that wild, crazy, proud country of ours.

Again, if a cure is not found soon, what would happen to the limits on the rush to find one? Inside the ParkLab set up in Central Park, one of the researchers who voluntarily entered the city to work with others to find a cure, finds himself dragged into doing things that he never ever thought he would have to do:

He turned back to face her. 
 They were still doing it, pumping the solution into patients who were still dying from it, but how would she understand that they were desperate; that they had to keep on in case there was some faint hope that a slightly different strength of cyanate solution or some slight change in the atmospheric pressure in the tanks in which some patients were suspended might be the key to a cure?

They would keep on and on, until this whole mad insanity had come to an end.

He would agree with each experiment, and with the next and the next in an endless succession, because he knew of no other way.

"We have not been successful," he said, taking her arm and guiding her to the door. 

The Frenchman looked at her, his tired eyes compassionate.

The buck stops with the President:

Inevitably, the President would have to do something to save the rest of the country, and other countries as well. In Silent Lips, President Stanton visits the source of his inspiration in so many difficult moments as president – the spot in the Gettysburg cemetery where Lincoln had stood, delivering the famous Address. He bends down beside one of the simple small white blocks of marble, inscribed with a number because the dead soldier’s name was not known when he was buried there:

Gettysburg grave markers
The President caressed the cold stone one last time and rose, walking slowly down the path, watching the sudden flashes of brief light of the fireflies between the white stones.
 Sudden yellow firefly flashes at his feet, on the ground. He thought of the strength he found most telling in Lincoln: his uncanny foresight. Before that harsh, bitter tragedy had ended, long before the killing had halted, he was looking forward to the peace to come, reaching out to shape the peace even before the battle was over. 

Now, he, too, like Lincoln, would have to look forward, beyond the killing of Americans by Americans, beyond what had to be done, to shape the future.

He stood in front of the memorial to New York State, staring at the column; then he knelt in front of it and pressed his face against the cold step. New York had suffered then, in that war of Americans against Americans; she had lost men, young men, in those bloody battles.

Should she sacrifice now?

Tom Watts watched the slumped figure of the President in front of the memorial and a cold shudder shook his body in the hot night.
Holy shit.
The man was going to do it.

An Amazon Review of Silent Lips:

This is what one reader thought about the novel:

Reading Silent Lips by Glenn Ashton is like getting on a train heading up a long mountain. The suspense builds and builds until you reach the top and then swoops down into a very surprising ending. The level of detail involved in describing the battle against a plague-like virus attacking New York City is amazing and it feels like you are there in the laboratories and treatment rooms as well as in the highest offices in the land.
Beware that this book can keep you up well past your bedtime. The complexity almost demands a consistent dedication to finishing the book. Then you want to start over to make sure you understand the underlying science, but it's not really a necessity that you do, as it is just a very fine read.
It is definitely an amazing first book and I look forward to other books by this author.

If you would like to buy Silent Lips, a printed copy is yours from Amazon’s Createspace, for around $13, and an ebook from Kindle, for only 99 cents, at my Amazon author site.

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