How the world’s health organizations failed to stop the Ebola disaster | Hacker News Reader

How the world’s health organizations failed to stop the Ebola disaster

washingtonpost.com

47 pointsrpm432155 comments

According to this article, it seems like a lot of health care workers are catching the disease. Even the westerners who are familiar with the transmission mechanism of the disease. Therefore, isn't possible that we are underestimating how easily the disease can spread?

It is possible but also keep in mind that they are for the most part working in horribly primitive, unsanitary conditions, lacking supplies and basic utilities.

That is the description of the whole health infrastructure of west Africa before this outbreak.

I read another article that explained how Ebola is very infectious (meaning that very few virions are needed to establish an infection), but not particularly transmissible (i.e. it's not airborne, and thus much less contagious than something like the flu or measles).

While westerners are becoming infected, I don't think it's that hard to see how the extremely poor health care facilities in West Africa would make it very difficult to follow proper protocol, even if you knew what you were doing.

Even in US settings, compliance with basic hygiene protocols may be below 50% [1]. This happens mostly in overcrowded facilities where personnel has been cut to run at or near capacity most of the time.

The most salient factor is indirect contact. Health care workers are aware that they must wash their hands after having contact with a sick patient, but it is extremely hard to remember to take similar steps after touching any surface such patient might have touched himself, even if it looks clean to the bare eye.

[1] http://prosperouswaydown.com/ebola-game-changer/

" Health care workers are aware that they must wash their hands after having contact with a sick patient"

Take that a step up - Health Care workers must wash their hands after having contact with any patient and before touching any patient (and themselves for that matter).

http://www.cdc.gov/features/handwashing/

It takes 20 seconds, and is probably one of the most effective ways of preventing the spread of various infections/diseases.

"isn't it possible that we are underestimating how easily the disease can spread?"

Yes, though the number of health care workers catching the disease in West Africa is more indicative of the total lack of basic medical supplies there, than anything else. Last that I heard, the MSF has a very low rate of transmission to medical staff because they're properly outfitted and strict about decontamination protocols.

That said, too many people are repeating the "it isn't airborne" line as if it has great significance. Ebola doesn't need to be "airborne" -- it's contagious enough, simply because it's very difficult for human beings not to come into contact with "bodily fluids", particularly when they're caring for sick people.

The fact that Ebola "isn't airborne" is comforting from the perspective that it isn't likely to spread to large numbers of people in public spaces. But even so, it's more than infectious enough to cause an epidemic.

This will be the first time humans have ever underestimated nature

The real fear is the sheer number of people getting infected. With a virus like Ebola every person infected increases the chance that Ebola will become human adapted. When you have a zoonotic virus like this spreading out of control imagine what might happen if it becomes adapted for efficient human to human transmission.

MSF seems to be effective in training people:

http://www.msf.org/article/ebola-workers-risk-tragic-reality...

(of their ~3000 staff in the region, 14 have been infected, they believe most of those infections have taken place outside of their hospitals)

The doctor in the article, who decided to check someone with potential Ebola exposure for a fever with his bare skin, was not being extremely careful.

What the MSF leave out of this article is the number of their staff that are actually treating Ebola patients. Without knowing this critical piece of information we can't really know what the transmission rate is to staff.

Sure, it isn't deeply informative. Their other releases discuss treating hundreds of confirmed cases (and a multiple of that of people admitted to their treatment centers), so I guess we can presume that there are at least a similar number of personnel dealing with that treatment (even if they are severely limiting actual patient contact, they are still dealing with a lot of waste and so on). The religious hospital in the article had 10 personnel involved in treatment and 10 of them got infected. That's enough to at least direct your attention towards what the groups are doing differently (it could well come down to limiting care based on the ability to carry it out very carefully rather than training).

As long as the doctor (A) did not have any cuts on his hand and (B) washed it immediately after checking the skin temperature, and (C) the individual was not symptomatic (No Diarrhea, No vomiting) the risk is pretty minimal. Probably more risk from being coughed on.

(Note - doctors should be washing hands continuously regardless - when I went in for a checkup in Kaiser/Mountain View a few years ago, Doctor washed his hands upon coming in the room, washed his hands after checking my heartbeat with a stethoscope, and then washed them a third time before leaving the room. This was to check someone who had no symptoms whatsoever. I asked him about it, and it was Kaiser policy - he said he washed his hands about 20 times an hour. )

So go ask that doctor how he would interact with you if he believed there was a chance that you had an infectious disease with a high mortality rate. Or if he was in a room that didn't even have a sink.

The CDC model http://stacks.cdc.gov/view/cdc/24900 assumes that a sick person in a hospital or containment unit spreads the disease to 0.02 people per day (vs. 0.3 people per day "in the wild") if you have enough Ebola patients in the hospital for a long enough period of time you are going to see a lot of medical personnel infected. For example if this epidemic lasts another 6-12 months in West Africa (which is the CDC's current estimate) some hospitals or containment facilities may operate for 100-300 days with personnel exposed to new sets of Ebola patients every five to ten days.

I am surprised that there has not been more written about recruiting survivors to work in the facilities (on the theory the they are much more likely to be immune to re-infection at least on many basic cleaning and patient care tasks (not inserting IV's or doing complex procedures).

Edit/Update Medscape did a detailed write-up on Ebola at http://emedicine.medscape.com/article/216288-overview and includes this note on recovery time, which may explain why even those who survive may take months to recover:

In those patients who do recover, recovery often requires months, and delays may be expected before full resumption of normal activities. Weight gain and return of strength are slow. Ebola virus continues to be present for many weeks after resolution of the clinical illness.

Very interesting modelling work here by the CDC. The transmission rate has been estimated using the following three assumptions:

(i) No additional imports of infection.

(ii) Patients maintain the pattern of either going to a hospital early in infectious period, or at home or in a community setting such that there is a reduced risk of disease transmission (includes safe burial when needed).

(iii) Maintenance of effective isolation and barriers-to-infection at hospitals and at home or in a community setting such that there is a reduced risk of disease transmission (includes safe burial when needed).

Both (ii) and (iii) are already wrong so I don’t know how much faith we can put in the modelling accuracy.

You can put faith in the modeling accuracy, while at the same time noting that given the current conditions, it does not have great predictive ability.

The modelling is actually really good and almost perfectly matches what has actually happened. The problem is they are expecting that things are about to change to fit the three assumptions. If we model the situation using the current conditions on the ground then things look a lot less rosy.

Donation pages for Médecins Sans Frontières:

http://www.msf.org.uk/make-a-donation

https://donate.doctorswithoutborders.org/

MSF are a great organisation - very efficient and clear-headed in what they do - ~"ok, here's how much money we spend, how do we help the most people?"

And in the past they have even said ~"actually, for disaster x, we cannot efficiently help any more people, please stop donating money" - not many charities would be that honest.

If you want to donate your money, MSF will likely do the most good with it.

Sometimes I worry that the epidemics (or potential epidemics, rather) will continue until eventually our incompetence in large-scale organization overtakes all of the 20th century innovations in medicine.

I read through the comments here, and read through the article, and I guess it's hard for people who mostly deal with first-world problems to wrap their minds around what it's like to live in a much poorer place. "West Africa was ill-equipped for an Ebola disaster because civil war and chronic poverty had undermined local health systems and there were few doctors and nurses. Health workers in the region had never experienced an Ebola outbreak and didn't know what they were seeing in those first critical months." Yes. The ebola virus had previously appeared in other parts of Africa, and previous outbreaks have always fizzled out. There are so many urgent health problems in west Africa that at first ebola didn't look like it needed an all-hands-on-deck response.

One part of that "there were few doctors and nurses" in west Africa has to do with the brain drain. People with medical training in west Africa are well positioned to emigrate to other countries. In the six years of my late dad's life when he was completely paralyzed from the neck down, one of the long-term care facilities where he stayed for quite a while was staffed mostly by Liberian immigrants, with various job classifications. The Liberian immigrant community here in Minnesota (and the Tibetan immigrant community, and several other groups of immigrants) is mostly employed in hospital and nursing home work, with the more skilled immigrants of course making MUCH better incomes than they could in their home countries. Our gain is another country's loss in the short term. (Eventually, interchange of people through immigration helps both the sending and receiving countries, because ideas and trade ties flow both ways, but those networks take time to build up, and freedom and stability in the developing country to have best effect.)

The stark differences between life in a barely developing country and life in a developed country are hard for people to imagine if they haven't experienced them. Not many participants here on Hacker News have first-hand experience with this.

What I want to know is why anyone think this outbreak is going to be brought under controls anytime soon. Looking at the size of the outbreak and with with the R0 well over 2 since August there is nothing that makes me think it is not going to hit the predicted 1.5 million infections by January. Then what?

I think we will see an infected person make it out of West Africa at a rate of one per month to one per week. We have one case in Dallas and a case earlier this summer in Nigeria. Both were contained but as the number of infected people goes up in West Africa the pressure to leave is going to be greater.

On July 20 Patrick Sawyer entered Nigeria in an infected state and infected at least 20 people, 8 of whom died. See http://www.washingtonpost.com/news/to-your-health/wp/2014/09...

On Sept 20 Thomas Duncan arrived in Dallas, and was subsequently diagnosed with Ebola. At least 15 people are at high risk for contracting the disease and another 100 had some risk of exposure.

If you take two cases in two months it's not an unreasonable estimate that at least one person a month will escape the quarantine protocols. The protocols are likely to get better but the number of infected people trying to leave is likely to be substantially higher in each month going forward for at least three to six months. If the numbers hit the upper end the current CDC estimate (1.5 million infected) then it's likely the "escape rate" will be much higher, hence an estimate of one per week.

>Both were contained but as the number of infected people goes up in West Africa the pressure to leave is going to be greater.

It sure is. The problem is there are already 10,000s of people in Liberia and surrounding countries that are infected right now. How are the surrounding country going to keep out the ten to hundreds of thousands of people fleeing if the case numbers reach 1.5 million since the borders between these countries are completely porous? We need to get really serious about controlling this outbreak (full scale mobilisation) and not just hope everything is going to turn out OK.

Right now the protocols aren't nearly strong enough, hopefully we will close air travel for anybody who has been in west africa, which should prevent people from escaping.

Right now the excuse is that they can't infect anybody while one the flights, but that is not really the concern - the concern is that they end up infecting others after they land.

" hopefully we will close air travel for anybody who has been in west africa" - CDC advises against this. It does more harm than good, and makes it difficult for supplies, and medical staff to travel in/out of the area. Also, once you put in travel restrictions, you enter an adversarial rather than cooperative phase, and people start to fight you, rather than work with you.

http://www.politico.com/story/2014/10/ebola-us-border-111581...

What I don't understand, is why don't we enhance screening for anyone who has travelled recently in West Africa? I get pulled into secondary every time I note I've visited a "Farm" - you would think the impact on the system wouldn't be that great to just ask a few questions (and take a temperature) of people who've visited ebola impacted regions.

I read the story and they don't get the problem - the problem isn't saving people in Africa, but making sure the disease doesn't spread via people who travel on airplanes.

Speaking from a US centric view, the only way to protect America is to control the disease at it's source. If you prevent air travel, you make it difficult, if not possible to control the disease.

By putting on travel restrictions, you will lose control of the disease and jeopardize the United States.

So, in effect, if you wanted to spread the disease and put the United States in grave danger, you would put travel restrictions in place.

I would say/hope closing air travel is not necessary - what is necessary is strict quarantine procedures for anyone who travels via an infected country.

The problem with both of these approaches, however, is that if that is the response of the international community, then countries will avoid reporting Ebola cases until it is unavoidable. Perhaps they already are doing this.

Containment is unlikely to work all that well when Ebola reaches millions of victims, imho. The panic that will be happening at that moment will also ensure that every one of hundreds of millions of people living in Africa (or any other seriously infected continent) will be doing their best to figure out a way to get out. Many inevitably will.

It might burn itself out, which is as bad as it sounds - it will kill so many people there will be no one left to infect.

There will probably be mandatory quarantine as well, and everyone inside the zone will either die or become immune.

Or we might figure out how to manufacture the 2 or 3 known cures in great enough quantity.

Or a vaccine - seems to me this should not be a huge challenge to develop a vaccine for because (unlike HIV) people become immune after exposure, which is half the battle already.

A vaccine is defiantly the way to go, but do we have the infrastructure (or will) to produce a vaccine in the quantities required? The progress towards a vaccine seems to be rather lackadaisical given the scale of the problem.

I bet we will see things speeding up as we get more "patient zero" episodes in developed countries, putting pressure on Western governments who will, in turn, pressure the pharmaceutical industry.

I'd go out on a limb and say that this would have happened already, if it weren't for the fact that the "avian flu" fiasco / profiteering is still very fresh in people's minds.

The problem is you can’t just click your fingers and suddenly have a new vaccine on demand. We have yet to have even stage 1 testing of any candidate vaccine for Ebola. Once we have a vaccine we need to produce millions of doses and then distribute it in countries with no functioning health infrastructure. And we need to get all this done in a couple of months!

There is already a functional system for distributing basic vaccines across the world, reaching 80% of babies.

It would not be difficult to distribute the vaccine, and we don't have to get everyone - we just have to get the viral rate below 1.

This system was not set up from scratch in a couple of months. I think you are underestimating the difficult of distributing a vaccine we don't have in west Africa once the case numbers there reaches into the millions.

There was a good point made in a nother piece that ebola is highly infectious, but not so much readily contagious. Its worth considering the subtle distintion to appreciate how difficult it is to deal with. It spreads somewhat rapidly nonetheless because of the problems that trace amounts of contaminats cause. Not because the cantaminants themselves are necessarily widespred or pervasive in the environment.

http://www.washingtonpost.com/news/to-your-health/wp/2014/10...

http://atoday.org/adventist-mission-doctor-speaks-ebola-cris...

This doc claims the "health organizations" and aid helped cause of the epidemic. Weird diseases happen so often in that part of the world the west africans know how to deal with it. They quarantine an outbreak village and have the surrounding villages drop off food until the infections burn out. But recently everybody got so excited for the foreign goodies that materialize when you say "ebola," traditional quarantine procedure went out the window.

You read other stuff from that website, like this http://atoday.org/god-create-evolution.html or that http://atoday.org/wilson-ii-president-adventist-general-conf..., and suddenly you are unsure if you are dealing with trolls or kooks.

Maybe, but it's hard to argue logically against the notion that strict quarantine would be effective, if brutal way of containing the outbreak. Building large central makeshift treatment centers only encourages sick people to travel and infect new populations.

strict quarantine would be effective, if brutal way of containing the outbreak

With a lengthy incubation time, and in an area that's just emerging from several decades of civil war quarantine isn't going to happen. The best hope is that there will soon be a vaccine, preferably before the plague reaches Calcutta, Karachi, Jakarta or Johannesburg. It's not unrealistic, the virus mutates only slowly, and India did get on top of smallpox; there is historical precedent for this approach to work.

Quarantine has never been successful during wartime. The Attic plague happened in the middle of a war.

But was that indeed the case that the local healthcare systems were implementing and successfully enforcing quarantines in previous situations?

Also, It's not the western cultural mindset to let it "burn out" when they could go in and "save" each person...

So people with a different set of beliefs from your own are "trolls and kooks". Man I get tired of seeing this kind intolerance, lack of respect, call it what you will.

Regardless of your feelings about the rest of the site, I do not think the doctor's points are in any way invalidated if you actually read what he has to say, as some others here have already pointed out.

So people with a different set of beliefs from your own are "trolls and kooks".

Yes, if the beliefs are different enough in ways that the person cannot possibly justify.

Good. Intelligent and educated people should be actively intolerant of religion, superstition and ignorance. No respect should be offered to irrational, unfounded, faith-based beliefs.

Couple of points: ( If there are any downvotes, please provide reasons for downvote, Thanks.)

1. I understand this is an article about the impact of Ebola virus. But why does the article highlighted the religious beliefs of the doctors/persons involved? If we remove that religious aspect from the article, how the integrity/message of this article's content will be impacted? I think, there is subtle religious propaganda in the article which is unnecessary to convey the virus, its impact and required global effective response.

2. Effectiveness of Govt. organizations (excluding armed forces who are trained) in majority of nations, especially in developing countries is doubtful.Organizations like WHO, UN, World bank, IMF also have similar characteristics on effectiveness, unfortunately but with no other alternatives.

3. I am not sure about testing arrangements at US airports. Since US hosts people from majority of nations who may have travel plans to other nations, i.e. some sort of hub, virus can reach other nations quickly, if US authorities fail to respond properly. Hope arrangements are made to test people who are coming into US. My guess is, testing doctors/nurses, checking customs/security officials ...etc i.e. all employees at the interfaces i.e. shipping ports, airports need to be wearing spacesuit sort of dresses as mentioned in the article so that they themselves won't be infected and become carriers of virus. This applies to all other countries including in Europe, China ...etc. Is it happening?

4. What about the effectiveness of other forms of medicine like Homeopathy/Ayurveda ...etc on this virus? I think we need to have alternative options of medicines/treatments, given the danger and magnitude of the problem to humanity ...etc.

You might be downvoted because your suggestions are a little overboard at this point, in particular, "Hope arrangements are made to test people who are coming into US. My guess is, testing doctors/nurses, checking customs/security officials ...etc i.e. all employees at the interfaces i.e. shipping ports, airports need to be wearing spacesuit sort of dresses as mentioned in the article so that they themselves won't be infected and become carriers of virus."

The Risk/Reward of spending money on hazmat gear for every screener who has to work secondary (presumably you are suggesting that we would only screen people who had just come from an ebola active area) is pretty weak.

I agree that I am suggesting screening of only those, who are coming from Ebola active area. As this article mentions, incubation period to see symptoms by other humans is between one week to three weeks after infection. But tests may catch before. Since we are living in globalized world, where people move across borders, I am worried about people carrying virus unknowingly. Many parts of Asia are very dense and it may be overnight catastrophe if this happens. So authorities at the hubs of human activity (US/Europe/China/Japan ...etc) need to be more vigilant than normal humans outside.

Please note that "prevention is better than care". Thanks.

Edit: small grammar change.

Vigilant, yes. But full hazmat gear to screen asymptomatic individuals is going overboard.

Liberia has a government. It receives vast amounts of foreign aid. So when the article says: "West Africa was ill-equipped for an Ebola disaster because civil war and chronic poverty had undermined local health systems and there were few doctors and nurses", this is missing the point.

Corruption undermined the health systems, and much more besides.

Those responsible for this disaster are the Liberian officials who collect a minimum of $449 million annually from overseas donors, but somehow can't seem to manage their nation with it. (But their personal bank accounts are probably very healthy.)

There have been previous outbreaks of Ebola in the region, so no one is unfamiliar with it. With a growing and expanding population, it was not a case of 'if', but 'when'; there is no excuse. When this is all over, a number of individuals - from Liberian government and donor nations - should be prosecuted for corruption, negligence, and possibly even crimes against humanity.

Liberia population: ~4m

Budget you declare: $449m

UK population: 63m

Budget of the NHS: £109b = $174b

People employed by NHS: 1.35m people

To match the NHS, Liberia would need $11b, almost 25 times the amount of aid it's receiving. Hell, that's 5 times the GDP of Liberia at the moment. It would also need to train 85,000 medical professionals (doctors and nurses mostly) - all that in a country that's just emerging out of war (basically 20 years of civil war ending 9 years ago), has low education levels (60% literacy - 4 in 10 people you meet can't read and write), zero infrastructure, etc.

Let's not forget that the NHS has been receiving that sort of funding for many decades - today's infrastructure builds on yesterday's infrastructure, etc.

I put it to you that the NHS would be brought to its knees by 3000 Ebola cases to deal with. If we ever let it get that bad in the UK, the only way we're getting out of that is through a complete country shutdown (if that's even possible in our supermarket-driven world - people would starve; starving people tend to do stupid things to get food).

Blame corruption all you want (though ironically, Liberia had elections that were widely regarded as fair, and that resulted in electing a highly qualified, female president, in 2005), but I think in Liberia's case it is totally fair to say that with or without corruption this country is extremely ill-equipped to deal with an Ebola epidemic.

Links:

https://en.wikipedia.org/wiki/Liberia

http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.asp...

No, this is about basic readiness for a number of contagions that are endemic to the region, which should be prominent on a list of healthcare priorities.

Nine years is a considerable time to be able to fix many of the problems you mention. After all those billions of dollars in aid, where is the infrastructure? Education? Compare to post WWII Japan or Korea...

And a comparison to the NHS behemoth - a model of mismanagement, waste, and inefficiency - is not a good one.

Ebola isn't endemic to Liberia and on health outcomes for money spent per head, the NHS is considered to be one of the most efficient health care systems in the world, according to the people who actually measure these things rather than just spouting off stuff they think might be true.

The people who measure these things would probably disagree with you. A small, random, selection:

https://www.openrightsgroup.org/blog/2007/system-failure-pri...

http://www.thesundaytimes.co.uk/sto/news/uk_news/Health/arti...

http://www.bbc.co.uk/news/health-12338984

One computer system overspend, the opinion of Jeremy Hunt, and a report saying half a percent of the budget could be saved by being more careful when buying stuff like office supplies.

I note that none of those things is a comparison of NHS with other health systems.

These are though:

http://www.telegraph.co.uk/health/healthnews/8877412/NHS-amo...

http://www.washingtonpost.com/news/to-your-health/wp/2014/06...

http://www.bbc.co.uk/news/10375877

http://eprints.lse.ac.uk/42050/1/How_the_NHS_measures_up_to_...

http://shr.sagepub.com/content/2/7/60.abstract

The worst recent estimate I could find was Bloomberg, who had the UK as 10th out of 51 countries studied, with the US coming in at 41st.

http://www.bloomberg.com/visual-data/best-and-worst/most-eff...

Reply on news.ycombinator.com