Ebola; send in the army!

by Maria on October 2, 2014

When I was sixteen and seventeen I did my 5th Year of secondary school twice. Amidst grinds, tears and two to three hours of Honours Maths homework each night, I just could not make it past Christmas and still understand what was going on. (The obvious and practical response; take Ordinary Level Maths instead and accept that a career in Medicine was out, just didn’t seem to present itself.) For two years I hungrily repeated the exercises in the small part of the curriculum I understood, and threw myself with increasing desperation and diminishing returns at the rest. The last chapter I remember mastering was called something like ‘Sequences, Series and the Binomial Theorem’.

Happily, understanding – at least a little – the concept of geometric progressions has turned out to be one of the most useful and widely applicable bits of Maths I could have picked up. It crops up everywhere; understanding the spread and gravity of DDOS attacks, why mouse infestations need to be hit early, why skimming stones on water is so hard, and how a young woman settling for less money than a man at the beginning of her career may still be paying for it when she’s middle-aged.

The definition of a geometric series or progression is ‘whenever a term of a sequence is a constant multiple of the preceding term’. When that multiple is greater than one, the numbers will get very big, very fast. If, for example, the multiple is two, you’ve got ‘exponential growth’, a mathematical term of art that’s often used inaccurately elsewhere to describe rapid but not geometric increases. Real exponential growth tends to sound pretty grim when the term is correctly applied in epidemiology.

At dinner the other night, I learnt that the rate of increase of cases of Ebola in certain African countries has been modeled as a geometric progression for weeks, if not months.* Since at least August, the number of new Ebola infections has started to double every month. Common sense dictates that the more people infected, the more people who will be infected. Mathematics predicts chillingly just how bad it will be. The battle to stop the spread of this disease reaching the threshold where it is now running like wildfire has already been lost.

How did it get so bad, so fast? We already know the answer – failed states with no capacity to look after their people at the best of times fell totally apart in a crisis. Over the past two years, the Liberian government disbursed about 5% of the aid it received from the EU that should have gone into building a decent health system. People who might or might not be infected resisted government attempts to round them up and put them in hospitals that more accurately resembled enforced quarantine zones with little or no treatment.

In Sierra Leone, where the UK cut its direct aid budget by 20% two years ago, reported Ebola cases are doubling every three weeks. NGOs there believe a far greater number of people are dying of the disease unreported and at home. There are just over three hundred hospital beds for Ebola in the country. It is a complete disaster and as our mathematics tell us, it will only get worse.

Something must be done, but what? A donors’ conference is happening in London today, where developed countries will pledge more money, divvy up responsibilities, and try to figure out how to channel emergency assistance through or past state channels.

Already, soldiers from the US, UK and France are in affected countries – numerically dwarfing the build-up in Syria / Iraq. (Parse that, for a moment. See where the biggest actual threat seems to be.) The US military is focused on Liberia, the UK on Sierra Leone, and France on Guinea.

And these are not small numbers of troops. The Americans have sent the bones of a brigade to Liberia, where they are building multiple 100-bed military hospitals. The UK is aiming to build a 700-bed hospital in Sierra Leone. The military is used to building instant infrastructure in impossible environments, but will it be enough?

The new Sierra Leone hospital will need hire and train for the special conditions about 7000 personnel, most of them nurses. Where will they come from? A mix of local and international, probably, but that’s a lot harder to put together than it sounds.

What about the soldiers themselves? It sounds very prime-ministerial to ‘send in the army’ to fill and deploy sandbags against the UK’s seasonal floods, to save the day when G4S has cocked up tending Olympics security lines, to be on six-hour standby when Hackney and Peckham are engulfed in riots. But the boots on the ground belong to real people, with real families.

A practicality; UK soldiers deploying abroad usually insure their lives and incomes under private sector schemes like Pax. (Because no, an army pension is not typically enough for a surviving family to live on, and yes, your average critical and life insurer doesn’t cover deployment to war zones.) Pax doesn’t cover Ebola and it’s not likely to either. It’s one thing deploying somewhere terrible when your family will be looked after in case of the worst, quite another when you’ve just voided your income protection along with your fatigues, and the people you love will be kicked off the patch six months after your ugly and lingering death.

Another practicality; it’s all very well to fly the odd Ebola-stricken aid worker back to the UK to be treated – though it presents a stark and nasty calculus of the respective values of African and European/American lives. But how will that work if we’re sending a dozen or two dozen sick and infections soldiers back every month to the UK’s precious few medical isolation units? As to the dead, the flower-lined streets and heroes’ laments of Royal Wooton Bassett will be a dim memory for those felled by a revolting disease spread partly through contaminated corpses.

Scale matters. A lot. It changes not just the scope but the type of problem we’re dealing with, and the proliferation of problems around that. An exponentially growing problem is a problem that metastasizes out of recognition every few months.

  • Of course if you spread out the time factor long enough, I suppose any steady increase can appear exponential. But then we’re into rate of change over time and oh dear that’s calculus which I sort of understood to begin with and then quickly fell away.

{ 107 comments }

1

Guano 10.02.14 at 11:11 am

Failed and failing states – a common factor in Ebola and terrorism. Yet so little is done to address this issue and so much is done (like invading Iraq and destabilising Libya and Syria) that exacerbates the problem.

2

J Thomas 10.02.14 at 11:24 am

Failed and failing states – a common factor in Ebola and terrorism. Yet so little is done to address this issue and so much is done (like invading Iraq and destabilising Libya and Syria) that exacerbates the problem.

I want to point out that while in some ways it might seem like a good thing if it accidentally happened that Ebola spread to the failed states of the middle east — that this would make things better for Israel — in reality it would make things much worse.

For various reasons it would be far better — for Israel and everybody else — if that did not happen.

3

Marc 10.02.14 at 11:55 am

The infection rate for aid workers can be controlled – they may need to wear expensive hazmat suits in the heat, but so be it. The carnage among African health care workers is a function of a complete lack of basic things like latex gloves for them, and much of the remaining toll is tied to funeral rites for highly contagious bodies.

It’ll cost a fortune, but count me as doubting that we’ll see many – if any – soldiers infected with Ebola.

4

ZM 10.02.14 at 12:11 pm

Some projections have said 1.4 million people could be affected with Ebola by January. It is very scary that this has got so big and is out of control – it must be absolutely terrifying for people in affected countries. Donations can be made through here http://www.un.org/ebolaresponse/donate.shtml

There was a conference at uni the last few days, with various sorts of talks on innovation, sustainability, and resilience. One was on disaster management , with some interesting speakers . One problem is that about 2% of funds are spent beforehand on preventive activities and 98% on emergencies and their aftermaths (not to mention the figure for indirect costs). More needs to be spent beforehand on preparedness and prevention.

Someone from US Homeland security I think it was spoke of his experience with Hurricane Katrina – a big issue he said was that there was not good trusting relationships between groups during that emergency which lead to difficulties in communication and coordination. He said one lesson was that (since disasters have been on the increase with globalisation, increasing connections and complexity and climate change and environmental problems since the 1970s [this might have been from another panelist’s slide]) it is very important to build trustworthy relationships in preparation before disasters happen, get ready to communicate with different groups eg multilingual, elderly, disabled and poor who will likely bear the brunt of the disaster, – and tell the survivors properly what they need to know and not do political massaging of communication.

The other thing the man from the US said was that he was in Haiti too – and you have to be ready for old fashioned communications – so walkie-talkies, printed out flyers, – you can’t rely on technology everywhere. And that going beyond media to communicate was important – find trusted figures in affected communities because people are more likely to believe the information then.

They also mentioned data and processing of data would be important in disaster management and decision making , talking about something called cognitive computing and scenario testing to see potential consequences*.

Also that people who do sums for costs for projects should now be including the likelihood of disasters in their costs and also the savings that would be achieved/losses that could be avoided by spending on preventative measures.

* another panel talked of new high level computers where 1 hour = 3000 years on a desktop – but you would need a nuclear reactor to run them so we will not like to have them here in Australia as this would increase our risks of disaster

5

Barry 10.02.14 at 12:19 pm

Marc, aid workers are presumably better trained on anti-infection procedures than soldiers. They are probably better-equipped, as well – deploying thousands of soldiers on top of thousands of aid workers will probably strain supplies.

6

Dan 10.02.14 at 12:29 pm

As Marc hints, the lack of protective clothing is one of the really outrageous things here

For months now, medical workers have been complaining about a lack of protective clothing. This is a rare case where international aid could have been an uncomplicated good thing. The cost of sending in hazmat suits is surely minuscule compared to that of sending in soldiers, and much less likely to have unexpected side-effects.

And somehow, it didn’t happen, at least not for a very long time. I can’t figure out why — surely somebody, somewhere must have had the authority to do a cost-benefit analysis and write a cheque?

7

Ronan(rf) 10.02.14 at 12:31 pm

My impression was that there isnt a significant risk to the soldiers going as they wont be in direct contact with patients (just building clinics etc) ?

8

harry b 10.02.14 at 12:37 pm

Ok, I feel guilty about doing this, and hope that if you think it will derail things you’ll just delete this, Maria, but…. what on earth does the concept of geometric progressions have to do with why skimming stones on the water is so hard? (I ask because it is the one thing I do extremely well that my children think is cool — the younger girl seems to have inherited the capability, whereas the other two just throw stones in the water and watch them splash, disappointed).

9

Mike Huben 10.02.14 at 1:15 pm

Ebola is looking scarier and scarier to me. I worry that the epidemic is spreading far too fast for our responses in Africa. When it spreads to China and India, it might kill more people than the world has ever seen die in other epidemics. At the current doubling rate, the world’s entire population could be infected within two years.

The US (and the world) is unprepared: our medical supply system is not ready to produce the vast quantities of isolation supplies let alone the basic supplies of intravenous saline and nutrition needed to support these patients. We don’t even have the supplies for dealing with contaminated materials and bodies. We don’t have these supplies in the quantities needed for Africa in the next few months.

I think we should be on a wartime footing here to direct production to likely future needs.

Obama will have to scale up efforts again in the next month or two. This is going to be far more deadly than anything in Iraq.

We are also going about this without the support of local populations, which will likely make us very ineffective. Why would any poor person want to go to a western-style hospital to be isolated from family? At the very least, we should be providing the patient and the family with cellphones for keeping in contact.

We should be conspicuously employing recovered patients at locally high wages, if not to care for current patients then for outreach to help bring people in for treatment and for communicating with their families. We need to attract people to treatment: they already have huge, frightening incentives for denial.

We are also going to see discouragement of physical contact of all sorts: hugs, kisses, hand shaking, fist bumping, you name it.

10

Mike Huben 10.02.14 at 1:19 pm

“At the current doubling rate, the world’s entire population could be infected within two years.”

By this, I don’t mean all will, just how fast the exponential increase is happening at this point of the sigmoid curve.

11

Lynne 10.02.14 at 1:32 pm

I agree that it would have been great if Hazmat suits had been sent in early. It is beyond frustrating that international aid to governments isn’t always used for the good of the populace, but Hazmat suits probably would have been used where they were needed.

I have been struck by two things about this outbreak. One is the profound, almost unimaginable ignorance of some of the affected population so that they deny the disease exists, or blame the government or aid workers for it. The other is—whatever happened to the idea of quarantining the sick? This seems not to be thought of any more. There’s a folk song about the British town of Eame (I think it was) during the Black Death, which quarantined itself rather than infect anyone else. This outbreak could probably have been limited if villages had quarantined themselves.

International aid workers can’t force villages to quarantine themselves (sick people run away into the jungle, even crossing borders!), and removing villagers to hospitals is very hard on families and not great for the sick people either, though at least they can be kept hydrated so their immune systems have a chance to fight off the disease and it is less likely they will infect anyone else. But it is a poor second cousin to an early quarantine. I have seldom been so dismayed by the scale of a disaster.

I watched a documentary recently in which UN workers, in outreach to villages, had to forego their protective suits or the people would run from them. Even then sometimes the entire village hid. It comes back again and again to a lack of education. It is beyond sad. I’ve never been so glad I donate to Medecins san frontiere.

12

Ronan(rf) 10.02.14 at 1:33 pm

@9 – pretty much every health care expert Ive heard speak about it has said there is virtually no threat of an outbreak in any country with a functioning health service. I’d assume that includes India and China, who have the capacity to isolate people bringing the virus into the country and deal with any limited outbreak they might trigger.
Even the CDC ‘s worst case projection was 1.4 million infected (which wouldnt reach “more people (killed) than the world has ever seen die in other epidemics”) More realistic models see the infection rate as being much lower:

http://virologydownunder.blogspot.com.au/2014/09/updating-model-of-modern-ebola-epidemic.html

This is a tragedy for people in West Africa, too speculate beyond that that we’re facing an unprecedented global epidemic is hyperbolic.

13

Lynne 10.02.14 at 1:36 pm

I should add that during the SARS outbreak in Toronto people were quarantined in their homes. So sometimes quarantine is used, though often not early enough to contain a disease, it seems.

14

Ronan(rf) 10.02.14 at 1:40 pm

“One is the profound, almost unimaginable ignorance of some of the affected population so that they deny the disease exists, or blame the government or aid workers for it. “

It’s understandable as well, though, in the context of a recent history of civil war, where authority figures *can’t* be trusted a lot of the time, and where there’s little, meaningful positive state intervention in their lifes (or attempts to educate them on the specifics of the outbreak) When you’re dealing with the psychological after effects of war, poverty and then this happens, I can see the logic behind attributing it to nefarious actors.

15

Omega Centauri 10.02.14 at 1:55 pm

To second Ronan, I read Nigeria thinks they’ve stamped out the infection there. It doesn’t require first world medical facilities to get this under control. Also, I have the impression that the people in the affected areas are getting rapidly educated on what they need to do -nothing concentrates the mind like imminent catastrophe.

Of course even countries with highly advanced care, will suffer occasional clusters, just like the potential one in Dallas, which is all over the news. So the personal risk isn’t zero for the ninety percent of the worlds population that lives in areas with sufficiently advanced anti-epidemic controls, but it can be contained to very low levels. My concern is about those areas that for whatever reason -usually being a war zone, can’t really create effective control. We could have islands of infection seeding clusters elsewhere for years to come.

But, promising treatments and even vaccines are on the way, but they won’t be ready in time for the early part of the outbreak.

Hopefully once this is over, the world will have learned that is needs to be prepared for the next time.

16

Roy 10.02.14 at 2:19 pm

As an American I have always been shocked at how shabbily the UK treats its soldiers, and always has for that matter.

17

MPAVictoria 10.02.14 at 2:20 pm

There is always money for bombs how come there isn’t money for this? Drives me crazy.

18

Bruce Wilder 10.02.14 at 2:41 pm

Hospitals have been an important nexus for transmission, accelerating the epidemic. Ordinary people may not have the maths, but they notice things like that. “Failed state” means a loss of legitimacy for elites and their feeble, palsied institutions. We should not blame the victims for the loss of trust.

I worry that we in the developed world, victims ourselves of increasingly predatory elites, are failing to recognize the bottom dropping out in a lot of disparate places at once as being due to common causes. It is too easy to look at Syria and see Islamic radicalism as cause, instead of symptom; too easy to see Cold War motifs in Ukraine; too easy to not see Central America at all; too easy to see the crises of Thailand, say, as peculiarly exotic in their details.

Africa is markedly poorer than some other places. After decades of civil war, Liberia is one of the most chaotic and dysfunctional places on earth. Deadly pandemics are never purely a matter of the biology of some viral or bacterial pathogen; they are not diseases of individual bodies alone; they are symptoms of a disease of political economy.

What I get from the math is not fear that Ebola may engulf the world, but that Ebola like a fire in a drought-ravaged forest has been left to burn itself out, and now the fire has grown large enough to attract attention and response, but the drought, not so much.

19

James Wimberley 10.02.14 at 2:52 pm

Marc #3: Latex gloves cost $11 a 100 on Amazon, presumably half that if you are buying in serious bulk. Mass distribution to the African populations at risk – a box a household – would be cheap.

20

Maria 10.02.14 at 3:08 pm

harry b; well there are 2 probs with skimming. First is technique and second is – probably wrongly – assuming the skims follow a xeno’s paradox patern.

21

Trader Joe 10.02.14 at 3:13 pm

@19
It’s a fact that gloves cost pennies per unit and are cheap and highly effective in reducing the spread of not just ebola, but plenty of other more common bacterial or virological infections. The difficulty is 1) in the distribution and 2) in the use.

A team of foreign doctors in haz mat suits handing out rubber gloves and saying this will fix it doesn’t sound believable even if we know it to be true. The populace trusts nothing that the government does and there is an active element of belief that the doctors are on the side of the government and trying to kill the patients. The fact that the survival rate is low even in perfect circumstances does nothing to dispel the fear.

The warning signs of potential infection are likewise very benign, not dissimilar to a common cold. If you wake up with a sore throat the initial response is not to assume you have ebola. Maybe now, after much education, some portion of the literate population – the portion that doesn’t fear the hospitals, governments and foreign doctors in haz mat suits – might wake up with a sore throat and understand they have a problem, but even then their first instinct would not be to check themselves into an understaffed, undersupplied hospital where most people die, the quite natural reaction (IMO) is to stay home, and hope you might be a lucky one that rides it out. Pallet loads of rubber gloves won’t change that calculus.

Cost was never the problem. Distribution of services and gaining the confidence of the afflicted is the problem. The army building quantine hospitals might help, but the issue is more human nature and has been seen in other epidemics – people naturally fear them and self protect – they don’t respond in ways that facilitate good public policy.

22

Maria 10.02.14 at 3:22 pm

I agree with what a lot of people on this thread have pointed out; the link between effectively failed states – and therefore shambolic public health systems – and the spread of Ebola is pretty causal and likely (we hope) to put a natural limit on this disease becoming a global pandemic.

But Ronan @14 and Bruce point out something very useful that illustrates one side of how this works; how the experience of living in a failed (or just a bit crap) state dramatically colours people’s attitudes towards the state, and in ways that count in a situation like this. I’ve been kicking myself for months for not keeping the reference to an eye-opening piece of research published earlier this year on the topic. If I remember rightly, it was something like ‘90% of the time when people who live in the Kibera slums of Nairobi (or similar) come into contact with an agent of the state, it’s some form of intimidation and/or a policeman asking for a bribe’. The state is absolutely not your friend, in many places, and in a way your average western libertarian would go pale thinking about.

To Lynn’s question about why quarantine isn’t working / being tried – it has been, very much, but people a) completely distrust the state, b) do not want to be locked in somewhere with diseased people and no medical care because the staff have all run away, and c) believe ALL SORTS of crazy about the disease and whether it exists or if it’s a plot of the CIA / opposing tribe / the state itself.

23

Maria 10.02.14 at 3:26 pm

Or what Trader Joe says.

The point is – and without reducing this to a behavioural economics 101 cod analysis – individuals acting in perfectly understandable and even sensible ways are making the situation a lot worse for everyone.

24

Z 10.02.14 at 3:30 pm

what on earth does the concept of geometric progressions have to do with why skimming stones on the water is so hard?

In first approximation, the kinetic energy is multiplied by a fix number (smaller than 1) at each rebound and so the kinetic energy follows a geometric progression and rapidly passes under the minimal threshold. In fact, however, in all likelihood the limiting factor in skimming stone is rather the angular velocity (the initial spin) which stabilizes the pebble rather than kinetic energy and the variation of kinetic energy is more realistically modeled as quadratic rather than geometric. So we’d rather go back to discussing the Ebola epidemic.

25

Maria 10.02.14 at 3:55 pm

Thank you, Z….!

26

Enda H 10.02.14 at 4:31 pm

Rumour has it that O.D. Morris, of “Text and Tests” fame, is actually named Maurice O’Donnell.

27

TM 10.02.14 at 4:35 pm

Technical quibble:

“The definition of a geometric series or progression is ‘whenever a term of a sequence is a constant multiple of the preceding term’. When that multiple is greater than one, the numbers will get very big, very fast. If, for example, the multiple is two, you’ll get what we often lazily mislabel ‘exponential growth’.”

It’s not a mislabel, that is exactly the definition of exponential growth. You get exponential growth for any multiple greater than one (and exponential decay for any multiple between zero and one).

http://www.slideshare.net/amenning/growth-in-a-finite-world-sustainability-and-the-exponential-function

28

L.M. Dorsey 10.02.14 at 4:37 pm

“Avoid irritation more than exposure to the sun. Adieu. How do you English say, eh? Good-bye. Ah! Good-bye. Adieu. In the tropics one must before everything keep calm.’ . . . He lifted a warning forefinger. . . . ‘Du calme, du calme. Adieu.'”

Right. Soldiers plunging around in an epidemic. What could go wrong?

29

Maria 10.02.14 at 4:42 pm

TM – thanks and sorry, I was fixing some poor drafting and managed to mess up the edit, and missed it when I published. What I was trying to get at is how often the term ‘exponential growth’ is chucked around elsewhere when really we just mean ‘high rates of growth’. I’ll try and fix that.

30

cassander 10.02.14 at 6:33 pm

>Failed and failing states – a common factor in Ebola and terrorism. Yet so little is done to address this issue and so much is done (like invading Iraq and destabilising Libya and Syria) that exacerbates the problem.

you can say a lot of things about the iraq war, but to call the biggest, in dollar terms, nation building program in history not doing much about the problem is just silly. And to compare it to libya, where the western coalition merely bombed the shit out of the place until Gaddafi fell (or syria, where that looks like it will be the plan going forward), is simply sticking your head in the sand. Agree with it or not, the Iraq was an attempt to deal with a failed state, and one an administration bet its entire presidency on at least twice. the bush administration had many faults, lack of effort was not one of them.

31

Rich Puchalsky 10.02.14 at 6:45 pm

“Agree with it or not, the Iraq was an attempt to deal with a failed state”

It was a failed state after we bombed it and invaded it and killed the dictator who ran it. It wasn’t a failed state before that: it was a dictatorial one.

32

Plume 10.02.14 at 6:50 pm

Cassander @30,

There was very little actual “nation building” in Iraq after the invasion. The massive dollars spent went to things like that godawful embassy compound, which cost more than a billion dollars and will likely be abandoned some day in the not so distant future. They also went toward training Iraqi soldiers who recently proved they didn’t much care to put that training to use. And it went to making sure the oil flowed for capitalist vultures.

All in all, the invasion of Iraq was easily one of the worst decisions ever made by an American administration, and virtually no prediction from that administration came true, even remotely. From “it will pay for itself” to “it will be a cakewalk” and “we will be welcomed as liberators” . . . . nothing went as planned — other than wracking up major profits for those vultures and assorted private contractors like Halliburton. That Cheney wasn’t thrown in jail for the obvious conflicts of interest alone is a sure sign that we have separate justice systems for the rich, middle and poor. There were plenty of other reason to throw Bush and Cheney in jail, obviously.

Effort? Give them credit for their effort? Why? It resulted in a million dead civilians, 4 million exiled, 5,000 dead Americans, just for starters.

33

Ronan(rf) 10.02.14 at 6:53 pm

Yeah, Rich is right. Iraq wasnt really a failed state in 2003.
Also, more than being the biggest ‘nation building program in history’, the Iraq War should be more plausibly seen (if you want to use that frame) as a grandiose attempt of radical social transformation with little to no thought put into how to achieve it. (Going completly against conventional wisdom on how to build state capacity, develop democratic political institutions or maintain order etc.)
Admittedly that was corrected over the years, although in a half assed way in the end.

Although I do agree with the idea that the problem is less one of a lack of ‘commitment’, than the fact that the problem of failed states is very difficult to resolve.

34

Bruce Wilder 10.02.14 at 6:57 pm

Ronan(rf): Admittedly that was corrected over the years . . .

It was?!? When? How corrected?

35

Bruce Wilder 10.02.14 at 7:03 pm

cassander: you can say a lot of things about the iraq war, but to call the biggest, in dollar terms, nation building program in history not doing much about the problem is just silly.

Right-wing tools and fools steal billions and waste the rest, and in your demented mind, it’s the biggest nation building program in history, not the biggest rip-off and screw-up.

It’s would be the farcical, fun-house mirror version of conservativism never fails, it is only failed, if it wasn’t so emblematic of how conservatism always fails, as corruption and predation.

36

Bruce Wilder 10.02.14 at 7:04 pm

Plume @ 32

Give them full credit for what the bastards achieved.

37

Plume 10.02.14 at 7:11 pm

Bruce,

Yes, they should be held accountable. If my comment suggested otherwise, it was poorly worded.

. . . .

Cassander,

I forgot to mention. One of the reasons why the “reconstruction” efforts were so costly? They kept losing billions of taxpayer dollars. We don’t even know how many billions were lost, all told, but it’s at least 10 billion. Lost on purpose, most likely, so more would flow there.

38

Suzanne 10.02.14 at 7:18 pm

Adding to what Maria says @ 22: When the affected governments finally did wake up to what was happening (initially and to some extent understandably, the authorities thought they were dealing with cholera, not Ebola), in their wish to emphasize the gravity of the situation they terrified people by informing them that Ebola has a 90% mortality rate – not exactly untrue, but an exaggeration (the odds can go down to 50/50 with treatment). Many of their auditors concluded there was little point in seeking help from people they didn’t necessarily trust anyway. Best to die at home with family.

39

cassander 10.02.14 at 7:45 pm

@rich

>It was a failed state after we bombed it and invaded it and killed the dictator who ran it. It wasn’t a failed state before that: it was a dictatorial one.

A state can be both dictatorial and failing. large chunks of the country were not under central government control, and 10s of thousands were dying every year because saddam prefered to play games with sanctions and build palaces rather than feed his people. Iraq was definitely doing worse in 2003 than libya was in 2011.

@plume

>All in all, the invasion of Iraq was easily one of the worst decisions ever made by an American administration, and virtually no prediction from that administration came true, even remotely.

That does not mean it was not a profound attempt to transform a failed state, unlike Libya or, probably, syria.

>That Cheney wasn’t thrown in jail for the obvious conflicts of interest alone is a sure sign that we have separate justice systems for the rich, middle and poor.

First, cheney divested himself of all his haliburton stock before becoming VP, so he had no financial interest. But I’ve long given up trying to correct you on facts, we’ve established that they don’t matter to you once you’ve made up your mind. High political officials not being held accountable for their actions are evidence that it is political power that shield you from prosecution, not wealth. But we can put that aside too, let’s say cheney stole a fuckton of money and laughed all the way to the bank, what on earth does that have to do with whether or not iraq was an effort to transform iraqi society? Are you claiming that cheney mind controlled the rest of the administration to go along with his evil plan to bilk the tax payers? Surely, there were easier ways to do that than launching the largest nation building project in history.

>I forgot to mention. One of the reasons why the “reconstruction” efforts were so costly? They kept losing billions of taxpayer dollars.

ah, so you mean the reconstruction efforts were like a typical large government program in their slipshod accounting, liberality with tax payer dollars, and massive waste? I agree entirely. I fail to see, however, what that has to do with my contention that a massive effort was made to transform iraqi society.

Are you starting to notice a theme, here? Stop moving the goalposts and stop attacking points I never made.

@bruce

>Right-wing tools and fools steal billions and waste the rest, and in your demented mind, it’s the biggest nation building program in history, not the biggest rip-off and screw-up.

Why can’t it be both?

>It’s would be the farcical, fun-house mirror version of conservativism never fails, it is only failed,

I’m not at all sure how you got aggressive wilsonian internationalism confused with conservatism, but that’s definitely whole other debate. I’m much more interested in what it was I said that you interpreted as me saying iraq was a success, or how the success or failure of the iraq adventure has any bearing on whether or not that adventure represented an attempt to transform iraqi society.

40

Bruce Wilder 10.02.14 at 7:51 pm

Actually, Cheney had a retirement plan in place that channelled quite a large chunk of change from Halliburton profits into his own pocket.

41

cassander 10.02.14 at 8:00 pm

@bruce

>Actually, Cheney had a retirement plan in place that channelled quite a large chunk of change from Halliburton profits into his own pocket.

Do you have any evidence of this? Not that cheney had a retirement plan, mind you, but that this plan meant he directly profited from anything other than halliburton’s continued existence? And should I assume by your focus on this trivial point that you’ve conceded everywhere else?

42

Maria 10.02.14 at 8:02 pm

Well that is quite the epic thread derail.

Bruce, Cassander, Plume and Rich – enough already about US politics and Iraq. If you don’t mind, we’re discussing another topic, here, and one that is overdue some attention.

43

Bruce Wilder 10.02.14 at 8:05 pm

cassander: I’m much more interested in . . . how the success or failure of the iraq adventure has any bearing on whether or not that adventure represented an attempt to transform iraqi society.

I suppose my declared intention to prepare a gourmet soup for my dinner guests, followed by me pissing in the serving dish and setting it on the table, could be counted a culinary failure despite my declared best intentions, and the quality of my efforts need not be taken into account.

44

Maria 10.02.14 at 8:12 pm

Seriously. Enough about Iraq or I’m going to start putting you guys in moderation.

(Benefit of doubt Bruce, that your comment crossed with mine.)

45

TM 10.02.14 at 8:19 pm

I guess the fact is most of us know little about Ebola, Liberia and Sierra Leone. Thanks for trying to raise awareness…

46

MPAVictoria 10.02.14 at 8:22 pm

“I guess the fact is most of us know little about Ebola, Liberia and Sierra Leone. Thanks for trying to raise awareness…”

Plus 1!

47

Omega Centauri 10.02.14 at 8:31 pm

My 2cents worth on Iraq, you are all right. We did try to rebuild it, but in a highly foolish way. Then it was too late to fix the bad plan because enough Iraqis were by thendetermined to sabotage any attempt to rebuild. From then on aid was being poured into a block-hole. The analogy is a good one as black holes are sloppy eaters, and various parties enriched themselves on the slop.

Iraq might be relevant. Is the state/medical service good enough to fend off ebola? What about in the IS controlled territory? Contested territory in Syria/Iraq that is being fought over? I’m pretty much satisfied than any reasonably functional state can fight off this epidemic.But that doesn’t include the whole of the planet’s human population.

48

Maria 10.02.14 at 8:47 pm

Oh FFS.

Omega Centauri – really? Relevant? I’m not even going there.

Everyone who wants to talk about America’s failed / exemplary rebuilding of Iraq can go and get themselves a room. Elsewhere.

Yes, TM and MPAVictoria – it’s not like we are over-run with threads about Ebola. I’ve personally learnt a lot on this one from people with something to add to our fairly paltry knowledge of the topic (e.g. Suzanne @ 38, almost lost amidst the dick-waving on Iraq.), or useful questions, or suggestions for potentially helpful places to send money. Let’s have more of that, please.

Anyone who tries my patience at this stage is looking at a temporary ban.

49

clew 10.02.14 at 8:50 pm

I hope this *one* piece of good news from the Ebola epidemic also spreads geometrically:

http://www.cnn.com/2014/09/25/health/ebola-fatu-family/

I don’t know how quickly one can teach IV administration, remotely, but I’m sure the world could ship a whole lot of trash bags if it wanted to.

50

clew 10.02.14 at 8:53 pm

I can’t imagine how the US would react to a widespread pandemic. Badly, I think. All y’all well stocked with pantry food, just in case? Maybe some for the neighbors? Oatmeal, canned pumpkin, peanut butter, dried milk is the cheap version of what my household can roll into pantry meals year-round, and they’re digestible without long heating, and not a terrible diet. Canned beans and tomatoes, too.

And a lot of trash bags!

51

Maria 10.02.14 at 8:59 pm

Cassander, you are BANNED from any further commenting on this thread.

Other derailers, take note.

52

Plume 10.02.14 at 9:32 pm

Maria,

The picture you paint, especially because of the geometric progression, already sounds quite nearly hopeless. It’s a classic “no good answers” situation. Part of me thinks that sending in the soldiers is a very good idea, but then you make the (correct) point that the soldiers, too, can spread the disease — and their lives obviously matter as much as the rest of us. And it’s not as if the so-called “developed world” has invested enough in medical infrastructure, much less the developing countries. So those soldiers are coming “home” to what?

And there are other factors which make this all the more dangerous. I’m in my 50s, and I can’t remember a time in America in which government was held in less esteem, or trusted less. And the whole notion of “experts” has been under attack for some time now. How many people actually believe this is a serious problem?

This all has the makings of one ginormous clusterf***.

Do you have any proposals for what to do?

53

maidhc 10.02.14 at 9:43 pm

The last time the Western world had a widespread pandemic was the flu outbreak of 1919, which of course came on the heels of WWI. The US was badly hit, although the US didn’t suffer particularly from WWI, not like some parts of Europe. But returning soldiers would have contributed to the spread of the disease.

54

Lynne 10.02.14 at 9:52 pm

Maria, Medecins sans frontieres predicted the extent of the epidemic well before WHO did. They seem to be stretched thin at this point, but they do good work (speaking of good places to donate.) Mind you, this scale of problem surely demands more help than private charities can muster.

55

Dan 10.02.14 at 10:40 pm

MSF seem to have been the only international organisation really getting to grips with this. It’s embarrassing how long they’ve been screaming for help. here’s a press release from June:

MSF is currently the only aid organisation treating people affected by the virus, which can kill up to 90 percent of those infected. Since the outbreak began in March, MSF has treated some 470 patients, 215 of them confirmed cases, in specialised centres set up in the region. However, MSF is having difficulty responding to the large number of new cases and locations.

“We have reached our limits,” says Janssens. “Despite the human resources and equipment deployed by MSF in the three affected countries, we are no longer able to send teams to the new outbreak sites.”

http://www.msf.org/article/ebola-west-africa-epidemic-requires-massive-deployment-resources

56

derrida derider 10.03.14 at 12:12 am

Roy @16 –
Yes, its quite amazing how national traditions persist – the UK one of considering their soldiers “the very scum of the earth” (Wellington’s phrase) and treating them accordingly is literally centuries old. Kipling and Orwell both made similar observations as yours. And its not simple antimilitarism either – the Royal Navy was always revered.

57

MPAVictoria 10.03.14 at 12:57 am

“I went into a public-‘ouse to get a pint o’ beer,
The publican ‘e up an’ sez, “We serve no red-coats here.”
The girls be’ind the bar they laughed an’ giggled fit to die,
I outs into the street again an’ to myself sez I:
O it’s Tommy this, an’ Tommy that, an’ “Tommy, go away”;
But it’s “Thank you, Mister Atkins”, when the band begins to play,
The band begins to play, my boys, the band begins to play,
O it’s “Thank you, Mister Atkins”, when the band begins to play.”

58

Glen Tomkins 10.03.14 at 1:02 am

Well, the big problem with blaming this outbreak getting out of control on failed states, as that the previous dozen or so outbreaks occurred in Central African states that are probably lower on the failure scale, and those outbreaks all petered out at a “mere” few hundred victims.

One or more factors are different for this outbreak, and occurrence in a failed state doesn’t seem to be one of those factors, because the earlier outbreaks occurred in states just as failed.

59

Ronan(rf) 10.03.14 at 1:19 am

Well what are the other factors ? Perhaps that it’s occuring in more urbanised areas, rather than less accessible (and so less chance of spreading ) rural areas in Central Africa? A cut in funding for international health aid ? A history of local knowledge in Central Africa (even if not institutionalised in a national health service) among health care providers on how to deal with it (which isnt available in West Africa) ?
A ‘weak state’ with little legitimacy does seem to be *an important* factor though (I don’t think anyone said *only*) in making the virus fatal on a large scale and diffcult to manage.

60

Glen Tomkins 10.03.14 at 2:17 am

As for the confidence that Ebola won’t spread in the US or Europe, well, it’s probably not a misplaced confidence. But that failure of Ebola to spread in the US (where I practice, I can’t speak for how medicine works or fails to work in Europe) won’t be because we are so great at contact tracing and all the basics of understanding and controlling outbreaks. We’ve let all that atrophy for decades, and those capabilities can’t be restored overnight.

If we contain this thing in the US, it will be because, unlike in Liberia, say, we can identify which patients with fever to worry about with one very simple discriminator. “Have you been in Liberia, Sierra Leone or Guinea during the last 4 weeks?” You take it from there if you get a “yes” response. That simple filter is not available in Liberia, where every single one of their patients has been in Liberia within the past four weeks, so they have to worry about doing contact tracing on everyone with fever.

What happened in Dallas is not reassuring that the US can manage even this much simpler task. Mr. Duncan came to the ER of a US tertiary care center with high fever, and volunteered that he had recently returned from Liberia, which was presumably the reason he was concerned at his high fever. He was then turned away to expose over a hundred people in the community to the Ebola he has subsequently been proven to have as the cause of his high fever. If we can’t manage at this pre-K level of public health, then we start having people infected within the US, andwe lose that simple filter, and then we’re into geometric progression territory.

Now, obviously, starting today, in the aftermath of this disastrous failure, people who show up in US ERs with high fever are going to start being asked a travel history. The problem is that we’ve raised generations of providers in the US who have no idea what to do with positive answers to travel hx questions.

I saw a patient just last week in my practice, which is at a (formerly) free clinic in Northern Virginia. This gentleman, who arrived in this country 16 years ago from his native Honduras, where TB is high prevalence, had never been tested for latent TB, or asked about such testing, since his arrival in this country up until I saw him for the first time. This lack of curiosity occurred in the face of hospital admission for a surgery on his hand a few years ago, and even persisted through the recent hospitalization I was seeing him for, a hospitalization for fever and productive cough, which, curiously enough, is exactly how re-activation TB presents itself. My patient got better on the antibiotics these medical experts (he was seen by a Pulmonologist!) gave him for the bacterial pneumonia they presumed (his bacterial cultures never grew anything) was causing his symptoms, but TB will partly respond to almost all of the usual suspect anti-bacterials. Bottom line, this group of highly skilled US medical professionals may very well have created a public health disaster (if the TB testing I have ordered comes back positive) by letting someone with active TB cough up an ICU for several days, then go back to the community to keep spreading his partially treated TB. Oh, and the partial treatment might have made it drug-resistant.

This isn’t an isolated case in my practice, which is why I tend to think that what happened in Dallas wasn’t a fluke either (flukes, by the way, are something I found infesting the bladder of one of my patients last year). These providers weren’t stupid or lazy, they simply don’t have the habit of asking where their patients are from , and how recently they’re from there. I have that habit because I see people who don’t have insurance, and in my community, that’s people from places where they still get flukes and TB and malaria and hemorrhagic fevers like Ebola. You can’t acquire my habit overnight, and probably not ever if you’re under the gun to be as “efficient” at treating paying customers, as this ER in Dallas, or my hospital with the TB nosagnosia. My habit requires knowing what to do with the many possible answers to, “Where are you from?”

So, sure, here in the US we’ll probably be saved from Ebola because discriminating it from other febrile illnesses is probably not going to get beyond the shooting fish in a barrel stage in the US. But I’m not at all confident that we could handle anything even a little bit more challenging. It’s not lack of resources, it’s not lack of knowledge. It’s bad habits, the central one being the lack of attention to the full spectrum of diseases that even the uninsured in the US is prone to, as opposed to only paying attention to problems that the insured are likely to have. We’ve decided not to notice the medical problems that some of us who are from Liberia, or Honduras, might have, in the overall refusal to provide everyone in the US medical care.

It’s not lack of resources that’s going to get us, it’s going to be their maldistribution. Big surprise.

61

Glen Tomkins 10.03.14 at 3:17 am

59,

The possible differences fall into two categories:
1) the virus has changed, and is more easily transmitted
2) host factors are different, more conducive to spread.

People more versed on what’s happening on the ground in Africa are better placed to answer if 1) is tenable. So far, they aren’t saying Ebola has changed. But even these clinicians may not have enough information to go on. As you point out, the earlier outbreaks tended to happen out in the bush, and patients never made it to the urban areas of these countries. Many of these outbreaks centered around bush clinics, and few if any of the clinicians involved survived to pass on what they might have learned. Even those that did survive were treating docs who had their hands more than full trying to treat cases, without the resources to do contact tracing, which is where we could find out about transmission rates, and how these vary with different types of contact with cases. It’s not clear how well this contact tracing is being done in this current outbreak, so we really don’t have either end of the equation available for such comparisons.

Host factors, 2), would include individual susceptibility. It’s possible that populations out in the bush in Central Africa have had genes that create ease of transmission of Ebola deleted. The likelihood of that would have to be judged from similar information as for 1), proven, at a later stage, by genomic analysis of the different populations.

It’s also true that 2) encompasses social and political factors, how society responds to the outbreak. The idea you present, that the earlier outbreaks burnt out after relatively few deaths because the infected could not make it out of the bush to the cities, seems a plausible mechanism, that might explain at least some of the difference. (But the effect is the 180deg from what is being talked about. You would have to say that these Central African countries either don’t have much medical care in their urban centers that Ebola-infected people would flee towards, or they’re so undeveloped that the patients couldn’t make it to the capitol, or the capitol is a politically scary place, more socially dangerous than Ebola is medically dangerous). But insofar as that mechanism is at work, it puts us in a dilemma. Try to keep the disease out in the bush, and never learn about its natural history, or let it into the urban areas where there are some resources to learn its epidemiology, but you pay for that knowledge with thousands of deaths, and run the risk that such knowledge won’t allow us to get it under control even after thousands have died to let us learn about its epidemiology and natural history. A more reasonable way to put this is that a country like Liberia is not so failed, not so supine, as to lack urban areas that sick people would go to for help, or a govt that people are not convinced is more dangerous than Ebola, but not developed enough to be able to provide that help, and not thuggish enough to try to keep people out in the bush to die abandoned to their fates. It’s possible that really failed states actually do better against Ebola. I hasten to add that that hardly recommends them as a model for imitation. Some motto for, say, the govt of the DRC, “Scarier than Ebola!”. It’s possible that that contributes to Liberia’s Ebola problem, it’s govt is not scarier than Ebola. It’s not really trusted, but not really hated and feared either.

We have no real choice but to help make these states less failed, whatever the role half-measures and half-way states may have in encouraging one sort of disaster or another. These are less than the big disaster of rule by out and out thugs. And we don’t have any real choice about providing medical aid. I am absolutely not confident that “medical experts” know what they’re talking about when they assure you that it can’t spread in the US. It is absolutely not an act of selfless charity to help understand and control this disease. It threatens us all. We’re all in the same boat.

62

Meredith 10.03.14 at 5:41 am

Re Glen Thomkins’ comments. The Dallas case seems to have involved some kind of failure of communication among the medical staff.
The next time you (any of us) are asked (what seem to you) the same questions by a series of medical personnel, after you’ve already filled out a form where you thought you’d already answered those questions: be patient, keep answering. Communication among medical staff is imperfect at best (and always will be, no matter how many ways we try to improve it). And different medical staff may think to ask slightly different questions or ask them in a different way, or you might mention something on the third inquisition you hadn’t thought to mention earlier, and then, bingo. Crucial information is revealed.

Meanwhile, I think people should calm down a bit. Be alert, even alarmed, but let’s not panic.

63

dsquared 10.03.14 at 7:19 am

And its not simple antimilitarism either

You’re right, it isn’t simple anti-militarism. It has a lot to do with the fact that for a lot of its history in the crucial period during which British popular culture started to form and homogenise, the Army was mainly used as an instrument of overseas aggression and domestic repression (and strike-breaking). I once suggested to the curators of the Imperial War Museum that they could put a whole exhibition together called “Peterloo To Tonypandy – the British Army In Action Against Unarmed Demonstrators”. Britain doesn’t have a military police or carabinieri, so the hostility that those types of units tend to attract in Europe ends up with the army itself.

None of which has much to do with the modern post-war Army, or why it’s often so badly equipped (that is, I think, more easily explained by the fairly obviously dysfunctional relationship between the Ministry of Defence and the arms industry), but it is a major point that both Orwell and Kipling seemed to miss; the British public of their time had pretty good reasons for disliking the presence of soldiers which had nothing to do with cowardice or complacency.

64

Maria 10.03.14 at 7:39 am

I moan about specific cuts and not-thought-through policies towards the UK military, but on the whole I think the country still has a healthier and more robust relationship with them than many countries do.

Historic roots for a healthy level of ‘you’ll be fine’ include suppressing local dissent as dsquared points out, and also distrust to risk politically and also unwillingness to fund a fulltime standing army, going back before Cromwell. Which seems quite reasonable, in the circumstances (Alan Mallinson’s History of the British Army is quite good on the historic distrust by crown and parliament of a standing army.)

65

Maria 10.03.14 at 7:41 am

Though the ‘all soldiers are heroes’ and ‘how dare the people do x/y/z while we’re fighting for their FREEDOMS’ memes are starting to creep in, this side of the pond. Ugh.

66

Maria 10.03.14 at 7:53 am

Plume, I did worry that doing stuff in this post like putting a sentence like “The battle to stop the spread of this disease reaching the threshold where it is now running like wildfire has already been lost” just above the fold and focusing on how sending in the army is not straightforward would make it seem the situation is hopeless. What I actually think is too late is containing the thing before it hit the geometric scaling button. That moment is past.

But – and anyone else in this thread knows at least as much as I do about this – what I think we can helpfully do at this stage is be clear about what we’re doing and why. (and the ‘we’ is pretty much us in the countries sending money and soldiers.)

We’re not doing this to prevent it becoming a global pandemic, because ultimately the chances of that are slim – unless the disease morphs and becomes airborne. (Another vector you don’t hear so much about is semen, and for 3 months after a survivor recovers – that’s going to have some different public health impacts, more akin to the fighting Aids ones.)

But AFAICT we’re doing this for humanitarian reasons on the ground – the most noble of impulses – and also to stop these crumbling and kleptocratic states becoming entirely failed ones; i.e. for regional geopolitical reasons.

Just staying clear-minded about those objectives will help (since you ask what I think we should do), because it will keep the focus and resourcing fairly sharp and also prevent horrible spillover policies and longer term public sentiment effects arising from encouraging widespread fear of central and west Africans carrying a horrible disease.

67

dsquared 10.03.14 at 7:54 am

unwillingness to fund a fulltime standing army, going back before Cromwell

always interesting that people who otherwise revere the Founding Fathers manage to miss this bit; lots of them were very very opposed to it. Kind of like people who presume to know Jesus Christ’s views on homosexuality (never said a word about it) while conspicuously avoiding any knowledge of his views on divorce (iirc, very much opposed to it and not shy about saying so).

68

Maria 10.03.14 at 8:04 am

Glen @58, I think the failed state thing becomes a factor – well, practically a vector – not when a new disease is at the bush clinic level of sporadic outbreaks, but if/when it gets to the cities. That seems to be the point at which an infectious disease accelerates because of the large and close populations, and also the point at which a functioning state *might* be able to arrest it.

Just a guess, though. Thanks so much for your insight on actually treating patients.

(Ronan may well be right that I’m / we’re focusing too much on state legitimacy and capacity, but I think it’s worth teasing out the many ways this may become a critical factor when a disease like Ebola comes along.)

69

dsquared 10.03.14 at 8:26 am

just a technical note; epidemiological models do tend to have exponential growth in them (because it’s the only way that diseases can grow at all – each sufferer infects X>1 new sufferers). But they tend to also incorporate an impeding factor (people who get the disease and recover are immune, people are treated, etc), which also grows exponentially. So they tend to have logistic or similar curves to them – they look like they’re heading to the sky (or “infecting the whole population of the world in two months”) in the early stages but the forecasts flatten out pretty quickly once the growth rate has slowed down.

70

John Quiggin 10.03.14 at 8:27 am

Maybe the more relevant notion is state capacity. The UK wasn’t a failed state in the 1840s and its political leaders weren’t monsters, but they still let a million people starve to death because they couldn’t overcome the barriers to action.

71

Alex 10.03.14 at 8:33 am

Meanwhile, completely unmentioned, Nigeria has successfully dealt with the epidemic:

http://www.nytimes.com/2014/10/01/health/ebola-outbreak-in-nigeria-appears-to-be-over.html

72

Alex 10.03.14 at 8:34 am

69: I was hoping someone would make this point.

73

dsquared 10.03.14 at 8:45 am

I seem to remember that some gifted young consultant managed to adapt an epidemiological model to forecast the takeup of a mobile phone network …

74

Niall McAuley 10.03.14 at 8:47 am

Alex writes : Meanwhile, completely unmentioned

Ahem.

75

ZM 10.03.14 at 9:23 am

dsquared,
“I once suggested to the curators of the Imperial War Museum that they could put a whole exhibition together called “Peterloo To Tonypandy – the British Army In Action Against Unarmed Demonstrators”.”

This is a bit off topic, but in Australia there has been some discussion that the war museum and town rsl halls and monuments etc should have something to commemorate the frontier wars of colonialism here. This has been discussed for decades now – an old article I read about it suggested we need something like a Vietnam commemorative monument in the US which I gather is black stone polished to a mirror with names of the dead. But the discussion has been reawakened through the recent publication of a book on the frontier wars Australia’s Forgotten War and also our potential upcoming constitutional referendum on acknowledging indigenous people as the traditional owners in the constitution (some indigenous people are suspicious of this though thinking it might be the government trying to hoodwink them out of getting a treaty)

On Ebola, there was an article on the ABC about a man living in Tasmania who has already lost 8 family members to Ebola how is organising with a disaster reliefs organisation to send donated medical supplies back to Sierra Leone – but no airplane company will donate space in their aircraft to get the supplies there quickly – so he has only found someone to donate space on a boat which will be far slower. This is very selfish of all the airline companies flying between Africa and Australia who should assist in this time.

76

Belle Waring 10.03.14 at 2:56 pm

Singapore has an active campaign to fight against persistent dengue fever infections, which kill maybe 30 people a year? In a city of 4.5 million but sicken many more. There’s giant ads on the sides of buses, a five-step mozzie wipe-out drill one is meant to do every Sunday, and public notices of clusters of infection. I have received two $100 mosquito-breeding tickets in my 14 years here, pots tuned over behind the house by the drain with water in the inner rim, in one case, and potted plant that had grown roots to clog the drain of its dish in the other. The mosquito police can come in your house anytime and check the water in your flowers! And during the SARS outbreak they closed schools, which they also do periodically when there are big outbreaks of foot and mouth (the girls and I have had it twice, it’s not awful. We pretend to be sheep who need to be burned in a sad pile.) They were taking the girls’ temperature at school every morning for quite a while and turning away all children with fevers. The Singapore government is all up in your business. They send you letters when your kid misses vaccinations. Along some axes of life this intrusiveness would be unwelcome, but here I tend to feel like, carry on, warn me about a nearby cluster of dengue fever! I think it is the anti-Liberia of public trust/buy-in on health interventions.

I am not redirecting the thread anywhere unhelpful, but I think the U.S.’s peculiar and intimate political relations with Liberia are worth noting as we diagnose the state as having totally failed.

77

J Thomas 10.03.14 at 3:34 pm

#58

One or more factors are different for this outbreak, and occurrence in a failed state doesn’t seem to be one of those factors, because the earlier outbreaks occurred in states just as failed.

I don’t know yet that any factors are different. Or maybe it’s homeopathic factors that are different. If you repeatedly roll the dice eventually you get snake eyes.

For whatever reason, this time it didn’t fizzle after it did every previous time. Maybe something is different.

Could it be on purpose? I can’t think why. Somebody who didn’t care about africa and thought it mostly wouldn’t get out of africa, could have done it for a distraction. They were getting uncomfortable world attention and wanted their issues to be less visible by comparison. Russia/Ukraine? China/Hongkong? Israel/Arabs? I can’t really see it. It’s too out of proportion, and anybody would see that it’s something that’s easier to start than to stop. Russia and China really don’t need to be upstaged. Israel isn’t doing that much, and they’ve never seemed to think that way. They lied to Eisenhower/Kennedy about getting nukes, and then they never used them. They’ve never used their bioweapons on any large scale, or their nerve gas. They don’t make big gambles to solve future problems, they make minor attempts at maintenance while problems build up and then make some sort of spasmodic response. It just doesn’t fit. Not for anybody important. Some sort of private ecowarriors? I guess it’s vaguely possible. Who else would think they benefit?

If there are humans who actively promoted it, I guess they got away with it and there isn’t much to do about that now unless some sort of evidence randomly shows up.

Developed nations can probably handle one small outbreak each. Find the people who’ve been exposed, treat the ones who are infected, release the others when they show they’re not infected, soon it’s over. We could handle a second small outbreak if it waits until long enough after the first. We could handle a mass quarantine at great expense, maybe.

I could have done it at my previous home. We had a stream just off our property, in the flood zone. So if the tapwater stopped working, I could carry buckets there. I had four gallons of chlorox stored which would go a long way toward decontaminating a lot of water. I had pasta and lentils plus wheat etc and vitamin pills and a few canned goods, enough for a few months if nobody took them from us. Enough salt and sugar for hundreds of gallons of rehydration fluid, plus rice and barley to make rice water etc. Charcoal was the limiting factor, I only had enough charcoal for maybe five hundred gallons of water. My zip stove could burn any wood scraps, though, and there was a small forest with down wood behind us, plus scrap lumber and furniture.

But now I’m 150 yards from the nearest running water. If the power and water and sewage went out, it would be hard. Plus there’s a higher population density here. Everybody would use their backyards for their toilets, some of them would bury it and some not, and the water would be even more polluted. So walk to the water, scoop up a couple buckets, add the chlorox right then, carry it home, and maybe get infected with something before you get the whole way.

A whole lot better if they can keep the waterworks going. Without that, it looks grim.

But it very likely won’t get that far. There’s a chance to catch each outbreak while it’s small, provided there are only a few of them and they happen far enough apart.

78

Ronan(rf) 10.03.14 at 4:21 pm

Glen @61 – that’s pretty interesting, and convincing; although I dont think it neccesarily negates the claim that ‘state failure’ (as shorthand, and for whatever definition of failure) plays a major part in allowing Ebola to develop and limiting the ability to contain it. Afaict a lot of the problems that lead to it’s spread – little access to clean water, overcrowding, semi functioning health services, corrupt officials etc – are common across the countries (Uganda, DRC, Sierra Leone, Liberia, Guinea) where there have been outbreaks in the past (even if the level of ‘state failure’ in each isnt comparable and those that had the worst outbreaks are at the better end of the spectrum)
But a lot of your points, which I hadn’t really considered, are pretty interesting.

79

Ronan(rf) 10.03.14 at 4:46 pm

80

Glen Tomkins 10.03.14 at 4:52 pm

Maria @68,

At this point in Liberia, we’re beyond the stage at which any govt, no matter how well-organized, resourced and respected by its citizens, could contain Ebola. If we had the same level of penetration in the US, scaled up for differences in population and geographic areas of the two countries, we absolutely would not be able to do the contact tracing of every suspected case that needs to be done to halt spread. Every patient who presented in every clinic or ER in the country with fever, would have to either have alternate causes of that fever proven (Something that absolutely does not happen at all often with fever in this country. If you’ve gotten an antibiotic in the US in the past generation, I would lose money hand over fist if I took even bets that there was a definitive diagnosis.) , or have quarantine and contact tracing started.

This is why I find the failure in Dallas so dismaying. We can’t even manage when it’s easy, when the only patients with fever who need a program are the very manageable few who have been in the three West African countries within the past 4 weeks.

Even the US couldn’t do the program needed, if it were needed for everyone with fever, as it now is in Liberia. Even if resources were theoretically available, getting the country to agree to divert them to such a massive project wouldn’t happen without, as Senator Vandenberg put it ref Communism, scaring the hell out of the American people. That never ends well. An American people that had had the hell scared out of it in respect to a deadly contagious disease would predictably act badly. The quarantine and contact tracing would be done in a way that would insure that many victims of Ebola would not cooperate (people with fever would stop seeking medical attention that would carry with it unwanted govt attention), which would only serve to further sow panic, and make the program even more harsh and more irrational.

The point at which Liberia lost control, or reasonable hope of restoring control, however successful as a state, was probably the point at which Ebola reached urban areas. That’s the point at which you lose a narrow geographic filter such as we have now in the US, and have to start worrying about everyone with fever.

Ebola made that leap from the bush to cities in the three West African countries the first time they had an outbreak, but failed to make that jump out of the bush and into urban areas during over a dozen prior Central African outbreaks. Something is different, it’s not reasonable to explain this disparity as a chance occurrence. My point is that I can’t see the difference as due to failed govt, except perhaps in the opposite direction, that in the DCR whole villages or whole clinics out in the bush can be destroyed by Ebola before anyone notices or cares, while in Liberia people with Ebola go to a city to seek help. The difference in outbreaks isn’t at all necessarily due to differences in govt, as there are many other possibilities, and what we don’t know about Ebola far exceeds what we do know.

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Layman 10.03.14 at 5:00 pm

“…except perhaps in the opposite direction, that in the DCR whole villages or whole clinics out in the bush can be destroyed by Ebola before anyone notices or cares…”

I’m just a layman, but this is the explanation I have always heard as to why Ebola didn’t result in widespread outbreaks – that it was isolated by geography and the absence of transportation / freedom of movement, and killed its victims in isolated groups before they could carry it elsewhere. Break down those barriers, and you have a big problem.

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Glen Tomkins 10.03.14 at 5:12 pm

77,

“Developed nations can probably handle one small outbreak each. Find the people who’ve been exposed, treat the ones who are infected, release the others when they show they’re not infected, soon it’s over.”

That’s the problem in Liberia right now, finding the people who’ve been exposed.

In the US right now it’s simple. You ask everyone with an otherwise unexplained febrile illness whether or not they’ve been to the three West African countries involved. With the very few who say “yes”, you take it from there, everybody else is not a potential problem.

They no longer have such a restrictive geographical filter in the three affected countries. They would have to assume that everyone who develops fever had been exposed, and keep with that assumption until the clinical course of the febrile illness disproved it. They would have to assume during this interval that all contacts of these people with fever had been exposed.

And they wouldn’t even be able to find everyone who is developing fever unless everyone with fever presented for medical attention. Not only is it the case that most people in these countries do not routinely present for medical attention every time they develop fever (that’s even true in the US, even among the insured), if we reach a point where presenting for medical attention for fever means you were going to be put in some camp with a bunch of other people who might have Ebola, even a lot of people who normally would go see a doctor for fever will stop doing that.

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Glen Tomkins 10.03.14 at 5:40 pm

81,

Without disagreeing with anything you say, and without implying that you mean anything malign in your statement of this theory (after all, you’re just expressing, perhaps a bit more succinctly, the same theory I mentioned), I think it’s important to not mention this theory without taking it all the way to it logical conclusion. It is a theory that has some potentially malign implications.

It is possible that, had the baseline lack of transportation, lack of good govt and lack of healthcare in these countries been augmented by a more systematically ruthless program of neglect and forced isolation, perhaps Ebola would have been confined to the bush for longer. Perhaps we wouldn’t have the present outbreak in urban areas.

But sooner or later, under even the harshest and most inhumane response to people who live in the bush, Ebola would have eventually made it to the cities, and put us all in the stew we now find ourselves in. Those decades between when we recognized this disease that formerly stayed in the bush, and our present dilemma in which it is spreading to places we actually seem to care about, were a grace period that we might have used much more profitably — in our own purely selfish interest — understanding this disease. We largely threw away that opportunity, and now have to play catch up. We’ld be in the same stew, maybe even worse, had Ebola made its jump later because we had been even more ruthlessly neglectful of the bush than we actually were.

Common sense and common decency are rarely in conflict. This Ebola outbreak isn’t one of those rare counterexamples — a point that bears emphasizing when we discuss theories that might seem to put our self-interest at odds with the interests of others.

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JanieM 10.03.14 at 6:13 pm

Mostly just a note to say how much I appreciate the contributions of Glen Tomkins to CT comment threads. Also, of course, Belle, and particularly the point in her comment above about the US and Liberia.

Question for Glen: does Nigeria offer any reason to be a little more hopeful than we might otherwise be about containing Ebola here?

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TM 10.03.14 at 6:54 pm

60: “This gentleman, who arrived in this country 16 years ago from his native Honduras, where TB is high prevalence, had never been tested for latent TB, or asked about such testing, since his arrival in this country up until I saw him for the first time.”

This is interesting because anybody applying for a Green Card does get screened for TB (even required to vaccinate for chicken pox). It always struck me as pointless to be that strict with a small subset of people living in the US. Would make much more sense to identify the high risk population and concentrate on them regardless of visa status.

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TM 10.03.14 at 7:05 pm

[67 totally off-topic but Jesus’ opposition to divorce has been inferred (by the Catholic Church mainly) from one single reported statement and that can plausibly be interpreted as concern for the rights of the wife (who would simply have been kicked out) rather than blanket opposition to divorce. A much better example would of course have been his views about the rich.]

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Layman 10.03.14 at 7:33 pm

83,

Thanks for your tactful response. I concur with your response, and didn’t mean to imply either that things were fine so long as Ebola was killing people in remote, far-off lands, and we should endeavor to keep it so; or that it would not inevitably get beyond that.

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Lynne 10.03.14 at 8:36 pm

About the case in Texas, my morning newspaper reports that the family the Ebola patient was staying with are not staying in their apartment willingly, so an guard has been posted. Sounds like it’s a woman, her son and two nephews. Food is being sent to the apartment but she says, “Who wants to be locked up?”

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bianca steele 10.03.14 at 8:41 pm

I want to second JanieM, and though I don’t want to clutter up Maria’s comment section with chat, I would like to ask Glen if this means he’s finished his Ph.D. program?

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Glen Tomkins 10.03.14 at 9:08 pm

TM #83,

I used to assume that was true, that if you came into the country via the documented path, with a green card, that meant you had had a negative PPD, or positive and been treated for latent TB.

But lately I find people with green cards who have no memory of a PPD (it’s pretty memorable, as it involves getting a bit of PPD injected under the skin, then coming back in 2-3 days for a reading). I test these people, and I find some of them to be positive, even if they have no exposure hx since leaving their home country.

Perhaps the screening now just involves answering some questions. Maybe they stopped using the PPD to screen as more countries started using BCG, which tends to give false positive PPDs. Perhaps someone did an efficiency study and determined it wasn’t cost-effective to bother.

One problem I have with all this talk of failed states in West or Central Africa, is that we have a pretty well-developed failed state right here in North America, and I’m not talking about Mexico or Canada.

I tried to get on with the Army field hospital I was sure the US govt would be sending to New Orleans to deal with Katrina. I had only just retired, and figured they would be happy to take on volunteers to fill the requirements. I discovered to my horror that the US govt wasn’t sending in any filed hospitals. My next step was to call MSF, to see if I could get on with them, but their representative informed me, rather too snootily I thought, that their organization only helped in areas where national govts had failed, so they had no plans either to send in help. I told the MSF person about the US Army’s lack of orders to go in, and whether that might not be pretty good evidence of failed state status, but I only got a chuckle.

The joke seems less and less funny as the years go by.

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Glen Tomkins 10.03.14 at 9:14 pm

bianca steele @89.

I am deeply hurt that you mistake me for a Putterer in the History of Denmark. I am actually a Minor Deity. But my undergraduate degree was in Classical Languages, so perhaps I still write like a PhD candidate, and the mistake is understandable.

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Glen Tomkins 10.03.14 at 9:34 pm

Janie M,

There could be a lot of reasons Nigeria succeeded in containing what were apparently at least two penetrations.

But if we just consider the medical response, Nigeria has something going for it that we lack in the US, for all our material advantages. Medical professionals there undoubtedly do not systematically ignore contagious diseases that are exotic here in the US, and tend to affect only the uninsured.

That hospital in Dallas delegated the travel hx to a triage nurse. The MD on the case either failed to read what the nurse had written, or was simply so caught up in the same arrogant disdain for travel histories attested to by the fact that they get delegated to nurses, that he didn’t read what the nurse had written. All of our wealth, and all of our resources are not going to be able to compensate for that kind of stupidity. If Nigeria has not been able to afford such arrogance, and so doesn’t have provider’s that stupid, they are well ahead of us in this game.

But to get back to what medical factors that might have made Nigeria succeed where Liberia hasn’t — even if a country doesn’t have a lot of resources available to do a lot of contact tracing and a lot of isolation, as long as providers have a good filter that allows them to narrow down the patients they have to worry about as having Ebola, they can do the needed tracing and isolation. Nigeria, like the US, only has to worry about people with fever who have been in the three affected countries in the last four weeks. Only some of those are actually of concern (those with sick contacts, say). Get it down to a small enough number, and even a country without a lot of resources can succeed.

However small the number though, a country that makes willful, stupid mistakes, like not providing care to everyone when it can well afford that, is not going to do well. If that hospital in Dallas had been used to treating all kinds of people, not just people with insurance, its providers would not have found the concept of the travel history so exotic. No country however wealthy can afford the luxury of stupidity.

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bianca steele 10.03.14 at 9:40 pm

Glen, I thought you mentioned you were doing graduate work (in evidence-based medicine?), and I thought I remembered you mentioning that it was a Ph.D. program. Guess not.

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Glen Tomkins 10.03.14 at 9:57 pm

Is there an imposter out there, stealing the great good name of Glen Tomkins?

Actually, I did get an MPH (Master of Public Health) a while back, which does involve studying epidemiology and biostatistics, which is the Evidence-Based Medicine emphasis, and perhaps I mentioned that in some earlier thread. Rather shocking, really, that they let you become a Minor Deity without understanding the epidemiology and biostatistics that are behind the treatment evidence, but hey, what could go wrong with MDs not studying epidemiology?

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Val 10.03.14 at 10:13 pm

Have browsed through this thread – haven’t read it all – but as someone who works in public health but not this field, I’m interested to know whether anyone has discussed the issue that death rates for diseases of concern in epidemics don’t tend to be as high in wealthier, better nourished societies.

Has anyone discussed this – can’t see it in the thread browsing through? I’m very interested in this , but don’t have the specialist expertise needed to predict how it would work in the case of Ebola. I know a lot about differential patterns of disease and mortality within my own country, and the way in which this is associated with income and the social determinants of health, and a little bit about this is regard to eg Aids in Africa, but not enough to express an opinion re Ebola.

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Barb Roseman 10.04.14 at 1:34 am

Joining in a bit late, but I too have read some articles that I’m kicking myself for not bookmarking at the time. One was a very well written piece by an aid worker who was just returning from having been in either Seirra Leone or Liberia back in August, I believe. He wrote movingly about why families might be less than enthusiastic about sending their loved ones to care centers, to, as he put it, suffer alone with the thought that they were facing almost certain death. He said that he had such fears himself should he be found feverish while transiting Schipol or some other airport and whisked into a high-security quarantine far from his family and friends.

Additionally, I’ve read a few interviews with Peter Piot and others who say they believe the changed factor in these outbreaks is twofold: Firstly, the populations of the countries involved are impinging more on the “bush” than those of earlier outbreaks causing greater contact with potentially infected animal hosts; and secondly that there is no such thing as an outlying village these days. With buses, taxis, and other easy transportation from village to city and back again, there is no way that a remote outbreak of Ebola or some of the other less frequently seen diseases will remain remote. One of the consequences of improved infrastructure is improved contact from city to country, and that necessarily involves new vectors of contagion.

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shah8 10.04.14 at 3:42 am

I have been doing a lot of musing about Ebola.

1) Cultivating failed states tend to be a strategy of postcolonialism. There are, of course, attendent dysfunction. One reason people in Liberia did not believe that Ebola was real, besides the fact that it’s usually way off in Central Africa, was that people had the credible belief that the state was crying wolf so international actors would give them money, when then the comprador bourgeoisie siphons off most of. The dysfunctional side effects is more serious now, as the state has literally no means of compelling conduct besides young men with guns, and in Liberia’s case, has now been more or less demobilized because various barracks have suffered from Ebola losses. The soldiers sent by the US and UK probably has to do with preserving at the very least, the fiction of the state beyond the next two to three weeks more than particularly real aid work.

2) I have the pretty strong suspicion that the lack of control over Ebola is not quite so much to do being in more population dense areas. Guinea almost did manage to control the outbreak at the small stage. I think the actual issue, as far as the utility of contact tracing is concerned, was that Ebola has gotten into the heroin culture that’s been present in W Africa. Liberia especially, but W Africa, because the states are so puny, tend to serve as a major transhipping area for trafficking people and drugs into Europe, which has led to a current severe local problem with heroin addiction. Needle-sharing, as with AIDS was how Ebola spread in one previous outbreak in DRC. Most of these fires today, rather than start big in the coastal cities, tend to spark at smaller towns where major roads join. Heroin isn’t really lifting the total, but adds to the difficulty of finding all of the victims.

3) Control of most of these exotic disease generally comes down to common sense. It’s not a matter of how advanced your society or health care infrastructure is, but how well those resources are aligned. Diseases that tend to thrive, thrived on social pathology, like AIDS and homophobia. So talking about how Nigeria could do it, so can we is missing the point. Hanoi moved rapidly and effectively to control SARS in their hospitals. It wasn’t really anything genius-like. They did what they were supposed to do, recognized something was FUBAR, that it spreads in hospitals, and decide to isolate strange diseases and close hospitals to new patients. That wasn’t what Canadians did in Toronto, because that would mean big losses in an economically rationalized ecology. Because Canadians were slow to do some of the basic things–instead going for more data and doing heroic health care (which made things slower and worse, respectively), they had a much worse experience with SARS as they infected a large number of patients who visited the emergency rooms. So understand that all institutions follow their incentives, regardless of sound practice, and some of those incentives are rooted in less than transparent social forces.

4) Leading on from three….Forget about drugs and vaccines. We have therapies now for AIDS, but not always available for people who need them, and after hundreds of thousands of people are dead. Doing some mock raid on the FDA about their purported relunctance to approve drugs was not productive at all. Being less of a puritan asshole who got those condoms out, talked to gay communities like they’re normal folks, got those needle programs out for the addicts? Save more lives and created far more wellbeing than AZT. Or any of the actually reasonably effective stuff.

5) Strongly suspicious that there are more cases outside of the three main epidemic countries at this point. At any rate, it’s inevitable. But if it’s inevitable, what does it mean, when Ivory Coast, Mali, Senegal, etc have to isolate themselves, and deal with new sparks of disease for any real length of time?

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B.I. 10.04.14 at 8:03 am

A main source of the early spread was the failure of Occam’s Razor to apply in this situation. The initial outbreak was diagnosed by doctors, including MSF, as a cholera epidemic. Without hemorrhaging, which only occurs in a minority of cases, the clinical presentation is almost identical (fever and hiccups can be easily overlooked, particularly in a clinic with few diagnostic tools), and cholera’s mortality rate without treatment can top 60%. Cholera is endemic at the initial outbreak site, and there had been a few serious outbreaks not long before the initial cases. Given the information available at the time, it was an extremely sensible diagnosis, but unfortunately very tragic and with terrible consequences. But anyways, “western medicine” played just as much a role in facilitating the early spread as “folk medicine” did.

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TM 10.05.14 at 2:01 am

Glen 90, TB screening is definitely required for Green Card applicants (http://www.uscis.gov/archive/archive-news/questions-and-answers-2009-update-tuberculosis-screening-required-adjustment-status-0) but other groups of people, obviously including US citizens, are never subject to that screening. From a public health perspective, it seems pointless.

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Glen Tomkins 10.05.14 at 3:55 am

TM,

Well, some of the people I see came over with a refugee status, or because they were in danger in their country (Iraq of Afghanistan) for someone in their family working for the US. I think that circumstance covers the ones I’ve seen who didn’t get the testing. Same rules for them?

If they test positive, what happens?

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Glen Tomkins 10.05.14 at 4:30 am

TM,

I went over the provisions of the site you linked to, and it seems that, at least theoretically, everybody is supposed to be screened, but they are let in if they only have latent TB. Well, to be more precise, they’re let in if they test positive on a PPD or Quantiferon, and the “Civil Surgeon” certifies that they don’t have active TB.

Either even this isn’t actually enforced universally, or some of my patients just don’t remember the test, or the “Civil Surgeon” (someone they hire?), gives them the written form of the TB test, so to speak.

When I was a drill corporal quite some time ago, at a time when the Army was desperate for recruits, we would sometimes get folks in to start their basic training who, because they were from someplace way out in the styx where the Army couldn’t afford to maintain an entrance station, had their entrance physical done by a local hire doctor rather than the govt employee doctor at an entrance station. We had one young man make it all the way to the first day of PT (calisthenics) before the fact that he had a below-the-knee amputation became evident. Boots hid it, but dressing out for PT in running shoes, and his socks drooped mournfully down around the foot prosthesis, no way to hide that. Another one made it to basic rifle marksmanship, but was stopped by his inability to sight down the M16 with his right, firing, eye, because that eye was made of glass, as he cheerfully demonstrated for me by pulling it out of the socket to show to me. We tried to rescue his enlistment (he was otherwise a solid prospect, and the US Army was pretty desperate in those days) by seeing if we could get him to fire as a leftie. But that plan was shot down by the fact that he was legally blind in his left eye.

Both of these gentlemen had physical exam forms filled out and signed by MDs, including the bits where vision in both eyes and the presence of all four limbs were attested to. One of them admitted to never having seen the MD in question, but both of them evidently had what can be considered the written version of the physical exam.

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Meredith 10.05.14 at 6:11 am

If they test positive, what happens?

Some ten years ago, I was involved in getting a colleague (who had come to the US some ten years earlier) a green card. All made easy by a Boston law firm that told me what to do. So, my lovely and bright and wonderful colleague, from a healthy and prosperous middle class world in Greece, had to take a few steps herself, including (for the first time, after years in the US on student and other visas) some medical tests. Turned out, she might have/carry (I don’t pretend to understand details here) some form of TB. (Tyne tests I know a little about: they can indicate harmless exposure. Probably, she’d just been exposed — I understand that much.) Anyway, for the sake of green card acquisition, a doctor gave her an antibiotic regimen. Of which, at my very dinner table, she announced her abandonment. To hell with limits on wine, on yogurt — hell, I am Greek! a healthy Greek, at that (as she was). I didn’t know how to respond. Well, maybe you are a health risk to the rest of us? Maybe stopping antibiotics midstream is a problem in itself?
An anecdote about the inevitable complications of regulating. (She is now a US citizen with wonderful citizen children, all healthy and doing well, as is she and everyone who is fortunate to meet her.)

All of which is to say: I don’t know much at all about epidemiology, but over-regulation and undue fear don’t stop spread of disease. It all makes life very complicated, which it was already, after all.

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Glen Tomkins 10.05.14 at 6:39 am

Half-measures are never a good idea.

Presumably your friend had latent TB. She had been exposed, and some of the TB organisms were (probably) living on, dormant and walled-off by her immune system, in her lungs. As long as the TB remains latent, it would not at all affect her health, she would feel just fine. And it would not be a contagion threat to others as long as it remains latent.

We recommend treating while latent, once it’s found on the tine test (or PPD or TST), because there is a small chance every year that it will reactivate. At that point it would be a threat to your friend’s health, and that of people around her, especially young children. The other reason to treat while latent, and not adopt a strategy of treating only if it becomes active, gambling on it never becoming active and therefore never requiring any treatment, is that treating it while latent only requires one medication, while active TB is now treated with four different medications, greatly increasing the risk of side effects.

It doesn’t sound like all this was explained to your friend before treatment was initiated, or she would have made her choice not to be treated for latent TB before running any risk of side effects from even just one medication. Just on general principles, for reasons this case makes clear, it’s always best to discuss these things fully, so that the patient understands the rationale and really agrees with the treatment. This is especially true for treating latent TB because the course is 6-9 months long (“doctor’s orders”, even if the phrase carries any weight at all with a patient, loses steam as a motivator after a few weeks), the patients feel in perfect health, and, perhaps most importantly, the partial treatment of having your patient quit halfway runs the risk of creating resistance without killing off the latent TB. Let’s hope your friend never goes active, or she may require 5 or 6 medications to get the TB under control.

And yes, for the govt to have a requirement to test for TB, and then not require any action for a positives — treating latent TB — and then not enforcing a requirement if there is one (the regulation TM links to doesn’t seem to require treatment, but perhaps the doctor your friend was seeing was following the medical recommendation for what should be done for latent TB, not a govt requirement), is another half-measure that will predictably cause harm rather than good.

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Meredith 10.05.14 at 10:52 pm

Thanks, Glen. As ever, you are very clear and to-the-point helpful. (I like to think it’s your Classics training! But I know better, from watching my son develop as a medical student and now first-year resident/intern: it’s the medical education and experience.)

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Voluptuous Hypothesis 10.06.14 at 12:30 am

I am sure that the spread of Ebola will be stopped just as quickly and effectively as the spread of AIDS was.

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Dan Hardie 10.06.14 at 4:36 pm

‘Pax doesn’t cover Ebola and it’s not likely to either. It’s one thing deploying somewhere terrible when your family will be looked after in case of the worst, quite another when you’ve just voided your income protection along with your fatigues, and the people you love will be kicked off the patch six months after your ugly and lingering death.’

I’m pretty sure that you are wrong on this, and I’m certainly going to check my Pax policy very quickly to make sure. When I took Pax out, it was on the understanding that it covered me for death on operations regardless of cause- which needs to be the case, since a high proportion of operational casualties are always DNBI (Disease and Non-Battle Injury). If this isn’t true, then it needs to be fixed soonest, and I will be on the phone to some MPs.

‘Another practicality; it’s all very well to fly the odd Ebola-stricken aid worker back to the UK to be treated – though it presents a stark and nasty calculus of the respective values of African and European/American lives. But how will that work if we’re sending a dozen or two dozen sick and infections soldiers back every month to the UK’s precious few medical isolation units? ‘

Frankly, the tri-service Medical Command and the NHS need to have contingency plans in case for this already, and if they don’t then senior people need to be fired. Even if we don’t send troops and/or civilian professionals to zones of disease outbreak, this is something that the emergency services, the NHS and the Forces need to be ready for. Again, it would be a good idea for someone in Parliament to ask the relevant Cabinet Ministers what plans are in place, whether they have been stress-tested by exercises, and if the contingency stores are already bought and in place.

More widely, on the theme of your post: if you’re looking for an organisation to build long-term civilian institutions, then you’re quite right that the British Army is not the right choice. (Not that you needed me to tell you that.) But if you want an organisation to put emergency measure in place, rapidly, in a logistically problematic and dangerous region, then the Army is certainly one organisation that should be considered, and in some circumstances it may be the best.

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TM 10.07.14 at 6:42 pm

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