How Nigeria Stopped Ebola
businessinsider.com
businessinsider.com
1) The health workers who treated the index patient were a major factor in preventing the spread of Ebola to the rest of the city. This is because the index patient initially lied he had been in contact with an Ebola patient, the Liberian Ambassador tried to pressurize the hospital into releasing the patient to attend a conference in another state. The doctors treating him refused and 2 of them died after contacting the virus.
2) A group of volunteers set up a website [1] to pass across information to the public. Their aim was to stop the spread of false information, reduce panic and help socialize government message about Ebola. Stars of the Nigerian film industry (AKA Nollywood) also helped in the media campaign.
The group/government working on this really did their part.
2) The person referred to in the article was one of the nurses who attended to the index patient. After it was confirmed that the index patient had Ebola, all those who came into contact with him (including the medical personnel who treated him) were isolated. One of them (the nurse in the article)'broke off' and went to another city. When the Government found out, they brought her back to Lagos in a 'special vehicle'. Some of the other medical personnel (who were in isolation) later tested positive for the virus and some of them died.
Contact Tracing works when you have one guy that you know has it -- and you fan out like wildfire to catch all the people exposed. It'll probably work for the one U.S. case.
It does not work when you have tens of thousands of people infected, like we do in other African countries. People who are dying at home. People who have been in contact with who-knows-whom.
So we're entering a new phase of Ebola: places where the disease is everywhere and we have no contact tracing, and places that can catch one or two cases as they appear. Nigera is currently in the latter camp. I hope they stay there.
This is why scientists think the U.S. and other more advanced countries will do better: we'll be able to stomp on new cases, track the contacts down, and catch the secondaries.
This will continue to work -- until it doesn't. That is, if the disease can be contained elsewhere, a low volume of cross-border transmission should be manageable. If, however, it continues to spread to unknown places, and grows in immeasurable ways? Then at some point the trickle of cases overloads any healthcare system.
Like with scotch tape?
Our non-existent southern border is a further problem, mitigated to a degree by the extra time it takes to travel that way. Not to mention that if we're concerned, Mexico should be bat shit scared of Ebola breaking out in its various slums; they have little more chance of containing it in them than these three West African nations.
A little bit of research into what everyone used to when we had widespread, often endemic incurable diseases running rampant, will show that we have solutions to Ebola.
(I think it is likely pragmatic to at least encourage people to not travel, for instance, I don't see why the nurse flew to Ohio in the first place, but I don't understand how the Liberia, Sierra Leone, Guinea->Mexican slum is a useful idea to focus on)
But then I realized it might take only one index case to start another hell on earth like we see in the three current epidemic nations.
So then you e.g. wonder about indirect vectors. Suppose, for example, those guys who pressure washed Duncan's vomit etc. outside his apartment without using any PPE, even had their water bottles too close, were directed to do it quickly, before a few days of heat and UV almost certainly killed the Ebola in it. And then one takes a visit back home.
Or look at this 2nd nurse, who felt compelled to travel to Cleveland to continue organizing her wedding. Suppose that was south of the border instead (essentially no further by air, right?).
Concepts like requiring "a lot" are potentially lethal when the real metric is "it only takes one". Not that Mexico's medical system is non-existent or hopeless by any means, I'd assume it would take another goof for it to get into an area where containment was impractical to impossible.
My general point is that as long as we (the world at large, but the US has a special responsibility to our neighbors) allow unconstrained export of Ebola from its current epidemic nations, bad things are certain to happen. Look at the current Dallas nightmare. Surely, we hope, we'll do better next time. But other nations will also screw up their first cases, and plenty have less margin.
When stakes this high ... well, here's a quick list of the big 3rd World regions and populations, in billions:
Africa: 1.111
Latin America: 0.558
Southeast Asia: 0.618
South Asia: 1.591
Total for above: 3.378
PRC: 1.350
While it's hardly inevitable, especially if we can soon develop a safe, easily manufactured and distributed vaccine, what are we going to say to our children if we let 1 billion or more people die because we're now too [fill in the blank] to implement old fashioned quarantines.
I guess a middle step would be to throw a bunch of resources at making a better voluntary quarantine available to people traveling out of the affected regions (not just the self quarantine like failed with the NBC crew, set up some facilities for it).
edit: Also, unless something has again gone horribly wrong, they should be rinsing whatever disinfectant off the sidewalks, not anything directly (and it is clear enough that bleach is effective in denaturing Ebola, so obtaining effective disinfectant isn't an issue).
How do you reconcile that with my above "[we] allow unconstrained export of Ebola from its current epidemic nations"?
According to Congresscritter Ed Royce, the US Embassies in the three afflicted nations are receiving 100 applications for visas every day. He doesn't say how many on average are getting them, there is of course some screening, but as Duncan shows an asymptotic carrier who doesn't declare close contact with an Ebola patient (for whatever reason, no need to go into the weeds there) can get through. An incubation period of as many as 21 days is a serious problem.
This current US outbreak has, so far, a R nought of 2 (1 patient infected 2), and I don't expect other hospitals including the 4 specialist ones to necessary do a whole lot better when an unheralded patient arrives at their ER. (You're know we're finally serious about it when ERs station someone in isolation gear in outside to triage patients.)
Unlike sending a known Ebola patient to one of those 4, as we've done 4 times, with 2 cases finished, I can't call cases like Duncan "known" or "managed", at least not initially.
I fully support the known -> specialist hospital cases, if for no other reason than that we desperately need to learn more about EVD. But the random importation cases ... how can you be sure future ones will be qualitatively less of a nightmare like Dallas (which played out yet). E.g. I read someone mentioning how fortunate it was these two nurses are single and (appear to?) live alone. Imagine one having children and transmitting it to one or more of them ... that'll get ugly in a lot of ways.
And in the meanwhile the authorities continue to shred their credibility and legitimacy. Which we may not be able to afford if it gets really bad.
Ah, I didn't really answer your 2nd proposal. Why not a formal, enforced quarantine? It's not like that's required to be a terrible thing in this era of the Internet: put in the room a computer with a fast connection, a flat screen TV with a good package, and a cell phone (or more likely cell phone charger) and they should be OK until the watch period is over.
Today's medical social distancing doesn't have to be severe in the directly social sense.
The first limit on travel is that a large portion of the population in the outbreak countries can't afford air travel. Then there is the Visa system. Then there is screening prior to boarding the flights. There is proof that this system is not 100% effective, but I don't take it as obvious that 100% effective is an attainable standard.
Perfect is the enemy of "good enough", or in this case significantly better.
Worse, it's pretty clear that too many cases in the US will use up various finite resources, from those 23 beds really able to handle this well, to healthcare workers outside of them willing to work on Ebola patients, unless future outbreaks turn out a lot better, to PPE supplies. Not to mention the extreme expense of dealing with each patient added to already financially strained hospitals, who's ability to provide services once an Ebola patient shows up gets degraded (is the Dallas hospital ER back in operation?)
There's going to be leakers. The idea is to minimize them, and the human and economic costs they impose on us.
Anyway, as I said to you a few days ago, unless you are at least willing to revisit this in a few months or a year and consider whether the system in place was "good enough", rather than us getting lucky, there isn't much more to discuss (yes, I'm implying that my read is that you would maybe dismiss a positive outcome as luck; I don't mean to do so sneakily, nor do I intend it as an attack).
I'm at least ambivalent about whether the U.S. is prepared for the situation, the repeated mishandling of things in Dallas was not encouraging.
I didn't reply to your question 8 days ago in part because at this point I simply cannot envision only ~2 deaths in America (not counting the medevaced from a hotspot, 4 patients so far).
But this is fantastically path dependent. I think we discussed that just before news of Duncan's death was released; in strict terms of impact on foreign importation, that obviously decreased "Ebola tourism".
Not that Duncan, or Nigeria's index case were precisely examples of that; I've just started reading Camus' 1948 The Plague because at every level in these situations a lot of human behavior seems to be universal.
Moving on, suppose the 2 nurses who who were infected by Duncan die, that'll change things in directions making it less likely others will die in the future (for the most part; there are results that could increase the death rate). We don't yet know if Dallas missed a contact who contracts it. And I can't imagine we won't get more Duncans until a travel ban significantly cuts the potential of them.
Unless, of course, we don't get any more Duncans, in which your hope likely becomes true and we don't implement a travel ban. But I don't think that's the way to bet right now.
High minded global concern says you probably let qualified medical workers travel out of the country, because it's probably a net positive to let them in, and letting them out is sensible in that case. I guess most of those folks would already be doing sensible quarantines.
For the U.S., I don't think there is much of a legal framework for preventing expats from traveling back to the US (but maybe somebody should just make an order anyway and face the consequences later?). I think other countries tend to treat citizens similarly.
For citizens of the effected countries, if they can get a Visa to travel to another country, I don't see the majority of them waiting until after they have a likely exposure to make their travel plans. So they would leave seeking refuge, not treatment.
The other types ought to go into 21+ day isolation/quarantine; while the risk might be low, the consequences are grave, and enough doctors have been irresponsible that I'd like it to be mandatory. Those who already have Ebola go straight to one of our 23 beds for that, as we've done with 3 people. ADDED: Now both of the nurses are going to those, the 2nd is already at Emory, the 1st is now said to be going to the NIH in Bethesda. Leaving only Montana's 3 beds untested (they've never treated a case). This vote of no confidence in a perfectly fine major hospital for "normal" problems is telling (and another strike against our idiot CDC director), as will the lawsuits that will almost certainly bankrupt it. Who wants to be next?
As I understand it, public health law allows us to temporarily quarantine incoming expats and citizens, I'm not talking about a simple ban for them.
When you say "I don't see the majority of them" we get to one of our fundamental disagreements, going back to https://news.ycombinator.com/item?id=8464603 up in this subthread. I just don't believe it's responsible to think about this like that; in this case your language admits that a non-majority will be seeking treatment.
Hopefully none of the exposed people will fit this scenario but you only need one free infectious person you don't know about.
Now, how many US hospitals will be bankrupted by the measures needed to get ready for, and deal with such patients, is another question altogether: http://pjmedia.com/tatler/2014/10/14/ebola-preparation-will-...
Heck, I keep reading such crazy, Onion level stuff in the "right wing" alternative media sources I follow that I've been going to the primary sources to confirm that "yes, the CDC director really said that". Not that I really distrust those sources, aside from Drudge, which gets a little too enthusiastic with their summary headlines. It's just the "extraordinary claims demand extraordinary proof". Which is seldom lacking.
On the "right wing" side I've caught only one case where my reading of the NIH historical budget charts didn't match the text claims (http://www.powerlineblog.com/archives/2014/10/a-word-on-the-...): After a steady, overall near doubling in constant dollars from FY94 to FY03, extra steep after 9/11, it's been in a slow and moderate constant dollar decline except for some big dollops from the stimulus bill, but it's not gone much below its FY01 level as of now, and its 70% above the FY94 level (again, in constant dollars). See http://fas.org/sgp/crs/misc/R43341.pdf
Which make that NIH guy;s "we would have an Ebola vaccine today if not for the eeeeevil Republicans" a clear lie. The NIH's remit is genuinely and legitimately very very broad, whereas the CDC's shouldn't be, it's all a matter of priorities, and even to this day, real work on Ebola is not a priority. Or perhaps I should put it this way, per robomartin's long essay https://news.ycombinator.com/item?id=8463558 a number of people have some explaining to do.
Well, after we replace the current clowns running the show with real public health types.
The nation worked together in conjunction with some foreign health workers to aggressively tackle the spread. We were quite lucky that the first known case occurred in Lagos and the doctors at the hospital (on of whom died) were very proactive.
And of course seeing two US nurses get it from one patient illustrates that our healthcare system is not prepared to contain it. Hopefully that will be fixed within a couple of months.
There is no indication that it's changed to be more transmissible. Have you read the report that the Dallas nurses gave to the nurses union? Here it is, if you haven't:
http://www.latimes.com/nation/la-na-ebola-dallas-20141014-st...
It's a private hospital and is self-policing when it comes to preparing for and implementing CDC protocols. Based on the allegations, they clearly had not made the necessary preparations, so the nurses were very poorly protected and almost certainly came into contact with excretions from the patient. The fact that the nurses had to release this information via a union that didn't represent them because of fear of whistleblowing probably has a lot to do with how this situation came about.
Americans actually believe this.
Unfortunately there are always incompetent nurses, staff, and probably even doctors that hide among the competent. You always find a couple of them in the hospital. Thankfully I've only ever encountered incompetent nurses, or nurse aids. Especially nurse aids. Doctors have been OK.
They are really hard to get rid off because they do just enough to not get fired. They also work really hard to mask their mediocrity.
Of course, I have not been able to experience the health care of other countries so there is a chance that USA's health care is worse than I think. I'll be extremely happy once we are able to automate health care.
I don't mean this as a criticism about the content of you're message, but I'm just wondering why this happens. Are you commenting from an unusual type of browser, or are you manually adding hard returns, not realizing that simply writing and adding hard returns at logical points (rather than screen positions) is the best approach?
Either way, I strongly recommend you start avoiding the 'return' key except when you want to start a new line of thought (e.g. a paragraph). It would really make it easier for me and perhaps others to read your comment.
/Facepalm
> During this contact tracing process, officials made a staggering 18,500 face-to-face visits.
Who here thinks the CDC has done anywhere near the same level of review?
The level of hubris is striking. "It won't happen here" is not a comfort when our hospitals can't contain an infection.
What have you been doing since 9/11?
Context:
It was fair to assume, after 9/11 that some kind of a bio or chemical attack could have been in the cards for the future. Such weapons had been used in the Middle East.
As various agencies were realigned in order to deal with the new threats and Homeland Security was created it only stands to reason that some of the objectives had to be to engineer, plan, drill and prepare for quick and effective response to a wide range of potential attacks.
I am not a biologist or chemist nor do I have any real experience or knowledge dealing with these kinds of attack scenarios.
This is going to sound really weird, but, well, I have three large German Shepherd Dogs and I've had cases of all three coming down with diarrhea. Having to clean up such a mess teaches you a thing or two about the spread and handling of bodily fluids.
After experiencing that just once I put into place a system and a kit to be able to deal with the situation more effectively. It's nasty and I really didn't want to suffer like I did the first time. I am happy to say that my planning worked well.
Now, using that example, had I been involved with DHS and CDC back in 9/11 I would have devoted serious time and resources to creating and equipping rapid response teams to deal with chemical and bio attacks in all major cities.
I would have designed and tested container-based (as in converted cargo containers) emergency response systems. I would have developed a set of isolation environments within containers. I would have staged these in every major city in the country at appropriate locations. And, of course, I would have conducted quarterly drills in order to ensure that everyone who might potentially have to be involved in dealing with a chemical or bio attack was trained to the best of our abilities.
I probably would have included both civilian and military personnel in this system.
All that would be missing would be that music that plays in the Transformers movies when the trucks, planes and ships deploy to do battle. In other words, I would require a system that was that ready to go into action. Just like the movies.
So far, I've watched every CDC conference surrounding this Ebola business. It's embarrassing. It's scary. It is absolutely astounding to me that no reporter is asking this simple question: What have you been doing since 9/11? And I say so because the story coming out of the CDC sure sounds like, well, amateur hour is too harsh, but let's just say it is obvious they were not ready for this.
When you have the director of the CDC on camera saying things like "We now have two teams supervising operations at the hospital so we can make improvements". In other words, one team wasn't enough, you guys didn't have your act together, you have left the response to these kinds of incidents to the random training, equipment and judgement of any random hospital in the US (because there was no way to know where the index patient might land, right?). Why weren't these drills, supervised by not one, but five teams of observers and experts conducted five or ten years ago. Why now? Why do you have to figure it out now?
To say that it is obvious that these people have squandered 13 years is a grotesque understatement. What would happen if we had twenty patients arrive into twenty different cities? Was there a plan? Is there a plan? No. Of course not.
I am trying like hell to not get political here. But, you know, every corner we turn we see example after example of just how bad big government can be. They can't manage building a website that a team of five college dropouts could have aced in six months. And we trust them to protect us from bio hazards? What have they been doing during the last thirteen years? If they are not incompetent, what are they?
Here's reality, going back to my dog example. I take a nice large building and spray the interior with liquefied dog shit. I then take a group of engineers and task them with cleaning said building. They have all the tools they need to develop protective gear, tools, equipment and procedures to do it quickly, safely and thoroughly. And they are also tasked with developing these systems and procedures such that we could easily containerize them and scale them to be able to instantly deal with liquefied dog-shit attacks anywhere in the US.
How long do you think it would take to have an absolutely amazing system in place if we took that away from government and held a contest open to any and all private entrepreneurs? Each of 100 teams gets a ten million dollar grant from the US government. The winning team walks away with a contract and a $100 million dollar prize. A year? At the most? I would think so. The CDC and DHS have had 13 years to accomplish exactly this and prepare for the potential of a massive chemical or biological attack in the US and the best they can do is what we are seeing now? With sick nurses getting on planes? And television anchors breaking quarantine? And "breaches of protocol"? What protocol?
Unbelievable. In my world this isn't about firing someone it goes way beyond that. This is criminal. This isn't even political as it spans administrations controlled by both major political parties.
Now, don't get me wrong, I happen to think that this is reasonably unlikely to fully derail here in the US. Not because the CDC and DHS have it together. Nope. Simply because Ebola doesn't is hard to transmit and we don't have a ten, twenty or a hundred cases spread all over the place. We had ONE guy that got through. And that was enough to expose just how fucked the response system happens to be. I really hope nobody else dies.
It might get a little scarier before it gets better, but I think we will be OK. What's got me rattled is that we are watching our response system engage in real time experiments with people's lives in front of the entire world when the fundamental procedural aspects having to do with responding to something like this should have been fully worked out, tested, verified, re-tested and forward deployed years ago. Not now. Years ago. Dealing with fighting a specific virus is a different story, that's biology, that's not procedure and readiness in terms of forward deployment of resources to deal with containment, etc.
Again, simple question:
What have they been doing since 9/11?
Are we ever going to hold any of these people accountable?
Why doesn't anyone ask the right questions?
I personally believe we will experience another nuclear disaster in the next 10-15 years. People will be wondering why after Fukushima it was still possible to be so unprepared. But maybe it will be something else altogether, like a huge solar storm.
Our human short-term view was a boon during our civilization early development, but as the world get inherently more complex and intertwined, our culture need to really change, or it will come back to bite us quite fiercely.
The very existence of the CDC is step 1, and the "outbreak" in the US has so far been limited to 1 single person as far as I can tell. Prevention of spread from that single person looks likely to be 100% effective, due principally to the preparedness of all those involved, from the CDC to the hospital to the airline.
Keep calm and carry on. Don't panic everyone into instituting a whole raft of expensive and ineffective TSA-like measures.
http://www.washingtonpost.com/business/economy/an-epidemic-o...
Maybe I'm wrong but I read that two nurses that worked on that patient have now contracted the virus.
I'm unable to edit my previous comment.
[1]http://www.theguardian.com/world/2014/oct/15/dallas-nurses-a...
]2]http://abcnews.go.com/Health/wireStory/dallas-nurse-ebola-tr...
(There are 4 US hospitals truly set up for this, with a total of 23 beds.)
I rather like the interface.
We are lucky we only had one imported case of Ebola. Had we had twenty these people would be running around like chickens with their heads cut off. That much is obvious today.
The truth is they've been sitting around not dong anything of substance to prepare against a bio/chem attack. And I phrase it like that on purpose.
If there ever was a wake-up call to get ready for events with potentially massive impact that call was 9/11. The threat of a bio/chem attack could not be dismissed. And agencies should have prepared for swift and effective response. They, obviously, are not ready. They wasted thirteen years of our time and money. The consequences could be dire. Do you think terrorists are not watching our news?
Spending time, money, and effort on combating ghosts is a ridiculous waste - just look at the TSA for a perfect example of this.
And if you admit to the possibility of biological warfare attacks, the same analysis we were doing a few weeks ago about the collapse of the facade of extreme competence of the Secret Service applies.
We can be sure our adversaries are taking note of this and factoring it into their plans. Your claim these are "ghosts" by an absence of action during the period our defenders maintained their perception of competence is less than reassuring going forward.
You are missing a very important point. It is my fault for not making it explicit. I've been using bio/tech attacks as a general term and yes, there's an immediate association with terrorism. The problem is far deeper than that.
What do you think is going to kill us all?
Here "us" isn't an egocentric "USA" but rather a "humanity" us.
What will kill us all?
Nuclear bombs?
War?
A meteor?
Nope.
Evolution.
Not ours. Bacteria and viruses.
We have built a world that makes it easy for these organisms to quickly move across the globe. We already have bacteria that cannot be killed with most antibiotics. And while we spend billions developing weapons to kill each other we seem to be neglecting the reality that we are not the enemy, evolving bacteria and viruses are.
In that context terrorism might not be a factor. If viruses or bacteria get past that evolutionary "click" that turns them into, well, weopons of mass destruction, terrorism will be the last thing we have to worry about.
Now, what we, the world, have to do is take a 100+ year view of humanity, grow up and start moving towards the things that really matter. I would be shoveling, no, trucking money into programs to develop all manner of systems, products and organizations to fight a war that could be an existential threat to our species.
So, you see, when I worry about e CDC or government wasting over a decade getting ready for patient one of an unknown killer event I am thinking well beyond Ebola. I am thinking we've squandered thirteen years of work towards understanding how to effectively protect our entire species.
Let's put it this way, we are not going to solve the problem by building more churches. We need to enter an age of intense scientific enlightening and stop building smart bombs and stealth fighters. We are not the enemy.
> We already have bacteria that cannot be killed with most antibiotics.
The spread of which is blocked by even the simplest of cleanliness protocols. Hardly an existential threat.
Although we do already have existential threats to the species - e.g. the potential for a recurrence of the 1918 flu pandemic, for example, is already terrifying the people whose job it is to worry about these things.
While we indeed don't want to get political, that's impossible and I have to point out Jim Treacher's comment on the role of the US national media:
https://twitter.com/jtLOL/status/501493192953319424
Modern journalism is all about deciding which facts the public shouldn't know because they might reflect badly on Democrats.
For example, yesterday I caught the Washington Post in a vile and consequential lie (CDC director Frieden is a political hack, going back to the ban on large drinks etc. in NYC, see also his contradictory comments in two back to back sentences on bus travel); the author is "a general assignment national reporter for the Washington Post":
http://www.washingtonpost.com/national/health-science/dallas...
From the beginning of the Ebola crisis, disease experts and Frieden in particular have insisted that U.S. hospitals have the training and equipment to handle a highly contagious patient. On July 21, Frieden said that “Ebola poses little risk to the U.S. general population.” Any advanced hospital in the country has the capacity to isolate a patient, he said. “There is nothing particularly special about the isolation of an Ebola patient other than it’s really important to do it right,” he said at the time.
Did you notice the quick shift from and to direct quotes with a paraphrase in the middle? I noticed that because the real quote is now infamous and disastrously proven false:
"Essentially any hospital in the country can take care of Ebola. You don't need a special hospital room to do it," Dr. Tom Frieden said Oct. 2. "You do need a private room with a private bathroom."
BTW, to my general knowledge, ER rooms do not have private bathrooms.
Anyway, my current research into this is reading Albert Camus' 1947 La Peste (The Plague); inevitable partisanship aside, I'm getting the impression a lot of this is universal when humans are faced with such a dire thing. It's not like we don't have millennia of experience with plagues.
First off, your ideas are awful. Your little entrepreneur contest is 20% of the CDC's annual budget before a contract with the winner is even signed. All your big talk about quarterly drills takes an even bigger chunk. All the while, you have pretty much targeted only easy bioweapon vectors that are not airborne. It also is all response based, and doesn't address anything like 1) recognizing an attack (unlike ebola, we wouldn't have the benefit of advance notice or know what the pathogen is in advance) 2) isolation/identification of an unknown disease during an active attack 3) non-medical considerations like medical/military/police/international responses ... so many other things that just aren't worth the effort to poke holes in your surprisingly shallow for the length post.
All of that is before the CDC's primary, more mundane, goal of tracking and controlling non-terrorism related diseases that kill hundreds of thousands in the US per year.
Again, the overwhelming arrogance is striking. I almost wish you could be put in charge of the CDC so that you could implement everything you've talked about, and then miss a worse than average seasonal flu that would kill upwards of a million citizens. Then you could have a bunch of armchair expert/monday-morning quarterbacks calling for your scalp and maybe you'd gain an ounce of perspective.
This doesn't even go into budget, since even the incomplete strategies you've outlined would probably cost more than the existing $6B USD annual CDC budget. Maybe you missed it, but the CDC got hit by sequester and _I'm trying like hell not to get political here_ but it seems that one party in particular seems to have no interest in good governance or increasing government spending whatsoever outside of the military supply chain or private/credit based spending. Maybe you ought to think about holding them responsible, and maybe the people that vote for them, too.
And yes, I could probably do a better job of running the CDC. Do you know why? Because, as a seasoned entrepreneur who has made plenty of mistakes in life the one thing I have learned is that surrounding yourself with the best people you can find is perhaps the most crucial success factor for any venture. I certainly would not be on TV with a deer-in-the-headlights look constantly spewing shifting information. And I certainly would have had systems in place a decade ago to deal with chem/bio attacks.
This is not a difficult problem is you are proactive. You can turn something relatively simple into a nightmare if you ignore it for long enough. Just don't file your taxes for thirteen years and see what happens.
Anyhow, I do not and have not disputed the CDC's valuable contribution to society. All I am proposing is that they have wasted 13 the 13 years since 9/11 not getting ready for a bio/chem attack in the US.
You are also wrong about the proposed private enterprise contest being 20% of the CDC's budget. Why? Because it would have been done once about ten years ago. So, the real percentage would have to be to the sum of CDC spending for ten years. I don't have the time to do the math. I'll just guess we are talking about maybe 1/8 of your number or somewhere around 2.5% of what the CDC spent in the last 10 years.
You are also missing another very important point: This was a seat of the pants hypothetical scenario. My guess is that you could have a very effective contest with just 25 to 50 companies and grants not much higher than a million a piece with a ten million dollar prize. Yes, I was exaggerating to drive the point that even with such a ridiculous contest we would have better results than what we have now.
And that's the point you are missing on all of this. It is beyond obvious that the CDC and ALL of the other agencies you mentioned, including private hospitals are overwhelmed and rendered almost dysfunctional with just four cases of Ebola temporally spaced across weeks from each other.
Had this been a case where we had twenty or thirty "index patients", to extend the term, in a dozen or more different cities it is likely you would be witnessing something potentially horrific.
If Ebola had been airborne or if we were talking about something equally deadly that was airborne it is also painfully obvious that we do not have the systems and procedures in place to deal with it.
You point about blaming sequestration for the CDC dysfunction is also wrong. Firstly, it appears that in real dollars the CDC budget has been on a constantly increasing trend: http://goo.gl/RXoVQ4. Second, and this is VERY important, and revealing of your philosopy: Not everything is solved with more money. Stop thinking that way. If you have an agency or a department that is wasting money, as most do, shoveling more money at them isn't going to solve the problem.
Proof: This Ebola problem should have been addressed at least thirteen years ago. With procedures and systems put into place in every major city in order to guarantee immediate, precise and effective response. Throwing more money at the CDC today or five years ago obviously wasn't going to change the type of thinking and mismanagement that causes an organization to ignore, utterly ignore, one of the elephants in the room for at least thirteen years.
No, the problem isn't money. The problem is something else. My knew-jerk reaction is to label it "government incompetence" of the kind that can't even build a website with a billion dollars. Except, in this case, people die.
Perhaps it is unfair to focus on the CDC. I'll admit not knowing what their official charter might be. Perhaps they are not even supposed to be an emergency response agency. They sure are at the front of this thing right now. If they are not supposed to be an emergency response agency, who, then, is responsible for responding and protecting us from bio/chem events? And then we go full circle:
What have they been doing for the last thirteen years?
NIH has been looking at mass bio events, man made or natural, since 9/11. They only do basic research. They have nothing to do with field ops in the case of events. FDA working with DOD does that.
BARDA is an agency created in 2006 during the Bush administration to specifically deal with terrorist threats of the bio/chem nature. Ebola and related was on their list.
Impression so far: Lots of research but potentially no centralized response organization and testing pre-event.
More to come.
“I have responsibility for getting the nation prepared for public health emergencies—whether naturally occurring disasters or man-made, as well as for helping it respond and recover,” Lurie said. “It’s a pretty significant undertaking.”
Here's the official page: http://www.hhs.gov/about/foa/osleadership/aspr.html
The mission of her office is to lead the nation in preventing, responding to and recovering from the adverse health effects of public health emergencies and disasters, ranging from hurricanes to bioterrorism.
Lots more here: http://news.pennmedicine.org/inside/2014/02/nicole-lurie-a-d...
She's among other things still a practicing physician, and as the uniform indicates, a U.S. Public Health Service officer, a 2 star Rear Admiral, Upper Half.
Here are the facts:
We have a bunch of agencies who purport to be looking after various aspects of these kinds of problems. Some from the research perspective and others in execution.
We have an impressive array of people involved with and running these organizations.
All of them have budgets in the billions.
Yet we did not have the systems, personnel, technology and response capabilities to keep ONE patient from infecting two nurses who cared for him.
One patient.
Would they have been ready for twenty?
The gentleman running the NIH told Congress during the hearing that the NIH facilities have TWO, count them, TWO beds suitable for the isolation and treatment of highly infectious patients.
I stopped watching the testimony once the politicians started talking. They are disgusting, on both sides.
We are lucky in that we do not have a really serious problem in our hands right now. There is no reason to panic. This is currently limited to just two people and a few in observation who are not sick. I hope I am not wrong when I say that this is, at this point, contained.
My problem is with what is seems to have revealed: That we are truly not ready. And that the agencies that are supposed to be ready to go on this at the drop of the dime have to figure things out during an event rather than being ready to go before it happens.
That should be disturbing to all. If twenty or fifty cities had cases it sure looks like we'd be in serious trouble. Again, I hope I am wrong. I am not impressed by intelligent sounding speeches in Congress. Everyone has political angles to protect of push forward, including some of the Doctors running these organizations. In that sense the entire thing is disgusting.
What's important is to watch what they are actually doing and what results they are producing. A virus is a heartless and has no political alignment. It really does not care if you believe in big government or total anarchy. It just is. It does what it does while you burn time playing games. The only time it stops is when you destroy it. In that sense, it is a really brutal performance review.
It is clear that the CDC and other agencies have procedures in place to deal with the outbreak of infectious disease, and that you are 1) unaware of these, and how they work, and 2) prepared to agitate for a wholescale overhaul without understanding how disease is both spread and controlled.
In the present situation, the only obvious failure of the system to contain a disease outbreak is the fact that Amber Vinson traveled while infected. Note that she did not have symptoms of Ebola when she traveled.
The only rational alternative to her traveling would have been to quarantine every single person who had been in contact with Thomas Eric Duncan, a possibility that does not require radical overhaul of any existing systems.
Keep calm and carry on.
Believing things are serious does not equal "border[ing] on panic". Neither panic nor Panglossian bromides are called for right now.
There have been cases of Ebola in the UK and France, which were contained without causing the national panic that appears to have gripped the US.
One concern I have is that if this panic is allowed to gain enough political headway it will lead to expensive, oppressive and ineffective policy decisions, mirroring those that created the TSA.
And yet Spain's isolation failed, perhaps because the government closed the infectious disease ward some months earlier, and only restarted it on an emergency basis when the first missionary became sick. All we know is that their PPE protocols were not up to snuff if the stories about closing gaps with adhesive tape were correct.
I also just notice on Wikipedia as of today there's a nurse who treated the French patient who "developed a high fever and was transported to the same hospital for treatment for suspected Ebola" (https://en.wikipedia.org/wiki/Ebola_virus_epidemic_in_West_A...).
"expensive, oppressive and ineffective policy decisions"
Specifically what? I'm not aware of any that would be "ineffective", or ones that would necessarily be "expensive" to the US. This is of course assuming "panic" enhanced by more Dallas failures, or other imports from West Africa does not grow massively.
How many Americans have to get and die of Ebola before "oppressive" policy decisions happen---as if the current clowns running the show at the national level would continence them?
An isolation ward for one or two patients is easy to set up. It takes only a few hours, and doesn't require the President's intervention.
Edit: The article linked to by the OP shows how Ebola was contained in Nigeria, a place with many fewer resources in this area than the US.
Are you sure about the number of beds at the NIH? The word up to now is that they have 7, but that ward, or maybe there's more than one, has multiple uses, including things like live virus vaccine tests. So maybe they can only dedicate 2 to this sort of thing, which means the national capacity is under 20 as I first heard, a total of 18.
4 of which are in use, because the first nurse, Pham, is being moved from the ex-Dallas Ebola Magnet Hospital of Excellence to the NIH. (Emory got nurse #2 Amber, and is handling another medevac, and Omaha has the NBC cameraman.)
Per the always energetic Daily News (http://www.dailymail.co.uk/news/article-2795480/texas-presby...) that might be because even after Duncan, Dallas Presbyterian did not have proper PPE (e.g. a big gap below the chin), and I've heard rumors its ER is shut down by a walkout, with the ICU almost to that point. Which these nurses' reports buttress.
And don't forget Dallas Presbyterian is an above average hospital, everything I'm hearing is that normal ones are just not architecturally, let alone culturally or equipment wise set up for pathogens this bad. Emory's lessons learned from their first two patients shows even they had to improvise and adapt, but not with PPE and the like.
Ah, I should mention I got some experience at one of my local ERs when my father got sick in the spring of last year. They were very good, but he was non-contagious (anemia).
As for "twenty or fifty cities", do you believe Duncan is the last Ebola tourist we'll receive on our shores?
"A really brutal performance review" indeed. I'll close by noting that it sure looks to me like the heads of the CDC and NIH are acting like politicians, and not doctors or researchers.
http://dfw.cbslocal.com/2014/10/15/ebola-patient-traveled-da...
http://en.wikipedia.org/wiki/Fever
> characterized by an elevation of body temperature above the normal range of 36.5–37.5 °C (97.7–99.5 °F)
Also note even the professional WelchAllyn units are not 100% accurate, they're rated for 0.2 F plus or minus (I bought one not long ago after my old el-cheapo BD one died and Amazon reviews revealed today's el-cheapo ones are by and large worthless. Heck, 3M even created a new consumer brand, no doubt to avoid brand damage to BD).
It seems to me that if we're dealing with an unusually high-risk situation, it's better to err on the side of caution, no?
If the threshold was set too low, then the screening process would have too many false positives and potentially overburden it beyond being effective at all.
Now, the chances that anyone else on the same flight got infected is very very low, close to zero. That's even more true for the people who took other flights on the same plane, even the people who were sitting in the same seat that she sat in - though it's non-zero, as I doubt the airline disinfects the armrests and fold-down trays after every single flight. But just doing the contact tracking and being prepared to field telephone and email inquiries from all the other people who traveled on that plane with and after the nurse did is going to consume a bunch of CDC resources that could be better spent elsewhere.
Meanwhile, it seems that staff at the hospital were not wearing adequate protective gear for the first 2 days after Duncan was admitted until they got a positive blood test for Ebola: http://thescoopblog.dallasnews.com/2014/10/presbyterian-work...
False positives are bad but IMHO they're a lot cheaper than false negatives. When dealing with the limited subset of people who had contact with known Ebola carrier at the Texas hospital (a total of 76 medical personnel AFAIK), the slight economic cost of limiting travel and monitoring all of them for a few weeks seems low compared to the new situation.
If half a dozen people are kept off of every plane and quarantined, that's thousand of people a day. That's an overburdened health care staff. I have more sympathy for the problem.
I'm talking about a nurse who already knew she had spent days treating a patient who died from Ebola and who made several telephone calls to the CDC advising them that she felt feverish, who at a hospital that had already screwed up badly when that patient first presented, and whose administrators changed their story about this multiple times.
How you manage to ignore these additional risk factors and conclude that I was talking about screen all fliers is just beyond me. I believe I made the context abundantly clear: When dealing with the limited subset of people who had contact with known Ebola carrier at the Texas hospital (a total of 76 medical personnel AFAIK), the slight economic cost of limiting travel and monitoring all of them for a few weeks seems low compared to the new situation.
I believe it to be a good sign for the republic that the government has not resorted to do so.
http://www.nytimes.com/2014/10/16/us/ebola-outbreak-texas.ht...
Check out the prefatory language of IETF RFCs, they generally give you a run down of these sorts of words.
Would it have been wise to quarantine her and keep her from traveling? in hindsight definitely.
Is it justifiable to restrict one's individual freedom on such a weak basis as "she's not feeling well, but is below the temperature threshold established by experts"? Here you can IMHO lean either way. If you are more utilitarian, you might argue for it. If you are more about individual rights, you might argue against it.
There, now your question is factually complete.
Perhaps the cost of allowing a lot of personal discretion from the CDC workers who make these decisions would be even higher than either.
If the threshold was set too low, then the screening process would have too many false positives and potentially overburden it beyond being effective at all.
That said, there was a recent PLOS article that suggested that a longer waiting period might be called for: http://currents.plos.org/outbreaks/article/on-the-quarantine...
There's also a cost-benefit analysis involved here. More transmissible/serious diseases call for a larger margin of safety, while at the same time enforcing a longer quarantine takes a toll on total available infrastructure.
From the article: "The 42-day period is twice the generally accepted maximum incubation period of the virus. However, some incubation periods are longer - that WHO said that in 95 percent of cases the incubation period was between one and 21 days. In 98 percent it was no longer than 42 days."
http://en.wikipedia.org/wiki/Ebola_virus_disease
That's backed up by two citations, from the CDC and WHO. I think I'd also read something, before this epidemic started, that said the longest known incubation period was 21 days.
I've since found a bunch of articles, and one WHO press release, that say the 95th percentile was 21 days and 98th was 42 days. I'm a little skeptical of them, though: they all trace back to that one WHO press release, which is based on the West Africa epidemic, where (because transmission is endemic) it's quite possible that a patient was re-infected at a later date and that's why the incubation period seems longer. Unless I see evidence from a country where the cases are all contact-traced, I'd be inclined to believe the earlier studies about the virus and not the latest articles.
Ebola is spreading and doubling rapidly -- every 20 days with the most recent data I've seen, and the case count in both Liberia and Sierra Leone exceeds that of the early-September projection made in the New England Journal of Medicine. It's not only well above the _median_ prediction, but it exceeds the 95% confidence bound.
UN WHO have stated flatly that we've got to achieve a 70% effective containment to stop spread of the disease or we're entering a stage for which they have no plan.
Not only is the prospect of failed containment concerning, but so is the fact that there's currently no contingency plan should that occur. It strikes me as an epic failure of imagination.
Given growth rates and prospects for loss of containment, it could be far more than a quarter of a continent at stake.
I wonder how many of those 19 infected people died? Did they attempt to save them, or did they essentially wait for them to die? Depending on the answer, it could make the reaction of health workers and patients in Nigeria behave very differently.
Normally, we have to complain that news articles don't link to their sources!
2) The article says '....A single Liberian man, who traveled to Nigeria in July, infected 11 hospital staff in the time between his admission to a hospital and when his test results were received...'
What that statement failed to point out was that a) Nobody initially knew the guy had been in contact with an Ebola patient because the guy lied serially about it - [1]. Because of this, the man had initially been treated for Malaria and so the hospital staff did not wear protective gear. When they finally discovered he was from Liberia and suspected Ebola, his diagnosis came fairly quickly. b) The article also failed to say that the man once yanked out his 'drip tubes' spilling his blood, and peed in the room forcing the health workers to flee [2].
3) WHO says on their website [3] - '...In a piece of world-class epidemiological detective work, all confirmed cases in Nigeria were eventually linked back to the Liberian air traveller who introduced the virus into the country on 20 July.
[1] http://allafrica.com/stories/201408261017.html
[2] http://www.frontpageafricaonline.com/index.php/news/2506-saw...
[3] http://www.who.int/mediacentre/news/ebola/14-october-2014/en...
However, it does not deserves the down-votes. Specially because it is probably correct. People tend to claim victory a bit too early.
There hasn't been a new reported case in Nigeria in 30 days. That data is coming from the WHO, which is not under the control of the Nigerian government.
not really.
http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case...
"*Case counts updated in conjunction with the World Health Organization updates and are based on information reported by the Ministries of Health"
2) Secondly, what does the Government gain by saying they have controlled Ebola if in fact they haven't? People will still be dying and the news will leak.
3) I don't think it's proper to use a blanket statement such as 'one of the most corrupt government...'. You are simply tarring everybody who works in Government as being corrupt