Ebola; send in the army!

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.

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.

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.

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) ?

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.

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.

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.

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.

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

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.

@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.

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

“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.

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.

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.

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.

@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.

@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?

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.

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

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.

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.

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.

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

“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.”

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.

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.

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.

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).

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.

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

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

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.

#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.

also relatedly

http://africanarguments.org/2014/08/20/ebola-what-west-africa-could-learn-from-uganda/

“…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.

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.

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.

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.

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?

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.

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.

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.

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?

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.

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.

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.

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

This is hilarious:

http://www.dailykos.com/story/2014/10/07/1334865/-Stephen-Colbert-destroys-Fox-News-for-pushing-extreme-ebola-conspiracy-theories