In the final analysis, however, the implication that there is a decision to be made (seek medical care or not) or a ‘spreader’ to be found is merely a cognitive convention that has been imposed on the PPE-bereft care nexus by western philosophy.

Eugene T. Richardson and many others, in The Ebola suspect’s dilemma[1] 

[Hi everybody, this is Fred. You might be wondering what epidemic I’m talking about, and what that quote means. Frankly, I don’t have a crystal ball; I don’t know what the next epidemic will be. We’ll discuss the quote later.

Of course the last really scary epidemic was Ebola; there are multiple varieties of that, and one or another of them could break out at any time. But there are other possibilities as well: hemorrhagic fevers that have yet to imitate Ebola’s success; Zika, a virus spread through common varieties of the mosquito, that horribly damages the unborn; or things we don’t know about, hiding in the nooks and crannies of the planet. Nature is tenacious, and evolution is one of her weapons. When silly humans poke into areas they don’t normally invade, the local flora and fauna adapt, and their parasites do as well. Then, perhaps a new epidemic!

I don’t know what the next epidemic will be, but definitely there will be one. There always is.

So if there’s another plague coming, how do we prepare for it without a crystal ball? Well, the other option, I guess, is to look to the past to see what it tells us about the future. Learn from experience?

So let’s talk about how and why Ebola spread so rapidly the last time it broke out. It just so happens that the Washington Post recently put out an article on that very subject.[2] It seems that, according to the Post report, Ebola was spread mostly by a few people who just wouldn’t go to the hospital. “If super spreading had been completely controlled, almost two-thirds of the infections might have been prevented, scientists said.”[3] So problem solved! Just confine the people who have Ebola and you confine the disease!]

Ebola

Let’s back up for a minute. If you followed the outbreak of two years ago – I did – you were told at the time that there was no known cure for Ebola; only “palliative” care, if any, could be provided at local hospitals; the disease was spread by personal contact with Ebola victims; and that fatality rates were ranging from 53 to 64%[4]. So let’s say that you lived in one of the infected areas, and you developed symptoms. You had fever, vomiting, muscle pain and headache. Those are signs of Ebola for sure; but they’re also symptoms of malaria, and that also was prevalent in your area.[5] So which did you have?

Governments and doctors knew that the best way to contain Ebola was to isolate the people who had it. The problem was there was no easy way to tell Ebola from malaria, until Ebola more fully presented itself. So why not err on the side of caution? Gather together everybody who might have Ebola and treat them as a group?  

The problem was that Ebola was very contagious; it spread mostly by personal contact with people who are infected; and it was difficult even for health care workers to avoid getting it in a hospital setting.  So if you took someone who had malaria and put him [or her] in with Ebola patients, the malaria sufferer could get Ebola as well. Also, two years ago there was no known cure for Ebola. The best the so-called treatment centers could do was offer “palliative” care, i.e., infusions of fluids, etc., to help sustain the patient until his or her immune system deployed against the disease. I don’t have any statistics, but my impression is that palliative treatment was more effective than expected, but wasn’t available everywhere.

This is not to criticize the brave people who fought Ebola in West Africa. They did the best they could with what they had, and the epidemic was contained. But even so why didn’t everybody cooperate with authorities in the crisis? Well, because there were major incentives to do the opposite.

This is the point of The Ebola suspect’s dilemma, the article we quote at the beginning of this piece. The argument is simple. Two years ago in West Africa:

  • If you had malaria, you had a 0.2% chance of dying from it at home, and no chance of dying from Ebola Virus Disease;
  • If you had undiagnosed malaria and you went to an Ebola Treatment Unit, you had a 16.1 % chance of catching Ebola and dying from it.[6]
  • If you had undiagnosed Ebola and stayed home you had a 70.8% chance of dying from it.
  • If you had Ebola and were treated at an Ebola Treatment Unit, you had a 64.3% chance of dying from Ebola.[7]

So think about it. What’s the rational thing to do? If a patient knows he [or she] has malaria, and not Ebola, he/she would be stupid to go to an Ebola Treatment Unit, even if the Government wanted that. There’s too high a risk that the patient will get and perish from Ebola, and malaria is not that hard to treat at home and survive.

In our example the patient doesn’t know his illness. Nobody, with or without Ebola has very good luck at the ETUs. If they don’t have Ebola they may catch it; and if they do have it, the ETUs aren’t very good at curing people. Why don’t they just rationalize; tell themselves they have malaria and stay away from the ETU?

There is a reason to do the other thing, but it’s altruistic, not practical. If Ebola is everywhere, and spreading rapidly, perhaps citizens with undiagnosed illness ought to isolate themselves from the community. Perhaps it’s better to check into an ETU, even a dangerous one, rather than risk spreading a virulent disease. I’m not sure how many folks accepted this notion in West Africa, but altruism was on display during the Ebola crisis. Think of the health care workers, for example, who worked the front lines of the epidemic and died on the job. No doubt there were lots of other people like that who we didn’t hear about.

Nevertheless, getting back to our authors and their quote, it’s not clear they accept altruism as socially useful. Is it simply a concept left over from “western philosophy,” and therefore to be discarded? Or are they saying we should avoid the need for self-sacrifice by doing more advanced planning? Or are they saying both things?

I would agree with the second point, but not the first. Health crises tend to expand from one place to others. It’s better to prepare now rather than wait for the crisis to come to us. And what about altruism? Well, sometimes we just have to do things for the greater good. Self-sacrifice is not immoral.

Vaccines

Since we’re talking about planning and looking to past experience to guide the future, let’s consider Ebola vaccines. There the news is pretty good. Currently there are at least 8 of them in clinical trials[8], with one granted Breakthrough Therapy Status by the FDA and PRIME status by the European Medicines Agency. Research is continuing to extend the immune response generated by all research approaches. The most recent information suggests that all of them should continue for now. “[I]t would be unwise to rely on a single vaccine candidate, and it is reassuring that the assessment of other potential vaccine strategies is ongoing.”[9]

So perhaps competent research, world-wide, really is a way to tackle potential epidemics. Did you expect me to say something else?

[1] See The Lancet, Comment, Richardson, et al., The Ebola Suspect’s Dilemma (March, 2017), available at http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30041-4/fulltext?elsca1=etoc (Cited hereafter as Dilemma at __).

[2] See The Washington Post, Sun, ‘Super spreaders’ were driving cause of 2014 Ebola epidemic, study finds (February 14, 2017) at p. A2.

[3] See Dilemma at e254.

[4] See, e.g., CDC, Morbidity and Mortality Weekly Report,  Ebola Viral Disease Outbreak — West Africa, 2014 (June 27, 2014), available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6325a4.htm “On March 21, 2014, the Guinea Ministry of Health reported the outbreak of an illness characterized by fever, severe diarrhea, vomiting, and a high case-fatality rate (59%) among 49 persons (1). Specimens from 15 of 20 persons tested at Institute Pasteur in Lyon, France, were positive for an Ebola virus by polymerase chain reaction (2). Viral sequencing identified Ebola virus (species Zaïre ebolavirus), one of five viruses in the genus Ebolavirus, as the cause (2). Cases of Ebola viral disease (EVD) were initially reported in three southeastern districts (Gueckedou, Macenta, and Kissidougou) of Guinea and in the capital city of Conakry. By March 30, cases had been reported in Foya district in neighboring Liberia (1), and in May, the first cases identified in Sierra Leone were reported. As of June 18, the outbreak was the largest EVD outbreak ever documented, with a combined total of 528 cases (including laboratory-confirmed, probable, and suspected cases) and 337 deaths (case-fatality rate = 64%) reported in the three countries. The largest previous outbreak occurred in Uganda during 2000–2001, when 425 cases were reported with 224 deaths (case-fatality rate = 53%) (3). The current outbreak also represents the first outbreak of EVD in West Africa (a single case caused by Taï Forest virus was reported in Côte d’Ivoire in 1994 [3]) and marks the first time that Ebola virus transmission has been reported in a capital city.”

[5] See Dilemma at e254. “West Africa is the region with the world’s highest incidence of malaria.”

[6] Id. As the authors explain, that’s about a 25% chance of catching Ebola, adjusted by a 64.3% mortality rate. A disease caught at a hospital is called “nosocomial.” Write that down for future reference. No doubt you and I will need to know the word at some point.

[7] Id.

[8] See The Lancet, Comment, Snape, Persistence of immune responses induced by Ebola virus vaccines (March 2017)

http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30039-6/fulltext?elsca1=etoc  (Cited hereafter as Immune Response at __).

[9] See Immune Response at p. e239.

 

 

 

 

 

 

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