Sunday 19 October 2014

Ebola: equal opportunity pestilence

A long time ago I decided to look at human error in the context of the risks of nuclear war. I read the published literature, including the US Congressional Record, and the work done by James Reason and others on the psychological underpinnings of mistakes. I was aware of journalistic accounts about nuclear accidents, drug-taking nuclear guards and the like, but did not give them much space. Eventually I was invited to a Pugwash Conference in Geneva, an East-West summit forum where I met US intelligence experts, Russian generals, think tank researchers and interested scientists. Chatting with senior figures about accidents they initially gave me to understand that everything was under control, but as the weekend progressed many told me that if I wanted to know what was going on then the alarmist journalistic accounts were probably closer to the reality than the official accounts I had been reading.

The official story on Ebola was that, nasty as it was, it would be controlled. Now, late in the day, courtesy of Associated Press, we have been given the internal WHO view as to why it was not controlled in West Africa. It said the heads of WHO country offices in Africa are 'politically motivated appointments' made by the WHO regional director for Africa, Dr. Luis Sambo, who does not answer to the agency's chief in Geneva, Dr. Margaret Chan.

Dr. Peter Piot, the co-discoverer of the Ebola virus, agreed that WHO acted far too slowly, largely because of its Africa operation. 'It's the regional office in Africa that's the front line. And they didn't do anything. That office is really not competent,' Dr Piot said. “What should be [the] WHO’s strongest regional office because of the enormity of the health challenges, is actually the weakest technically, and full of political appointees.” He also questioned why it took WHO five months and 1,000 deaths before it declared Ebola an international health emergency in August. 'I called for a state of emergency to be declared in July and for military operations to be deployed,' Dr Piot said.

In late April, during a teleconference on Ebola among infectious disease experts that included WHO, Doctors Without Borders and the U.S. Centers for Disease Control and Prevention, questions were apparently raised about the performance of WHO experts, as not all of them bothered to send Ebola reports to WHO headquarters.

WHO said it was 'particularly alarming' that the head of its Guinea office refused to help get visas for an expert Ebola team to come in and $500,000 in aid was blocked by administrative hurdles.

On 3 April, MSF first warned WHO about the outbreak, saying it was unusual because far from being in a forest village it was in an urban centre on the border of three countries, thus making control difficult because of different bureaucracies and a reluctance to admit to the Ebola infection because of the economic consequences. WHO responded by saying the numbers were still small. A dispute then broke out on social media between MSF and the WHO’s spokesman, who insisted it was all under control.

So, the West African national organisations screwed up. However, Nigeria and Senegal seem to have done well, so we need to do a discriminant function analysis sometime soon. The key patient is always Patient Zero. Nigeria seems to have had a sharp diagnostician, and sufficient toughness among key health workers to face down threats from the Liberian embassy. Nonetheless they lost 8 citizens because they tried to help an uncooperative infected Liberian diplomat. However, they have saved their fellow citizens, so far. A success story.

Next, the USA. Before launching into lamentation, we need to do a mini meta-analysis. The USA has been tested by an Ebola carrier who did not tell the truth about having been in contact with Ebola. This is the real test for the Western world. Not everyone fills in forms correctly. The US response has not been brilliant, but it might improve as they move their cases to specialist centres. What is clear is that one case can put 2 lives at risk even in supposedly competent hospitals. It can also damage the equanimity of many citizens, who are put at risk. Having worked on the Camelford water pollution case in the UK, I know that these health scares can be a source of medium term, low grade worry, even when the health authorities do their best to be reassuring.

Spain has less excuse for its record. They knew the returning priests had the disease, but did a poor job of protecting their medical staff. Britain handled its one case well, in a super-specialised unit. (He wants to go back, imagining that his having caught Ebola in the first place is an additional qualification). Germany and other European countries have handled their pre-booked cases well, in the sense of no further infections. These figures from the BBC may be a little out of date, but the overall Western death rate is 4, with 6 recovered, and 7 in treatment. It is much better than the African experience of 70% death rate, but it is a bit early to say that the fancy drugs, blood transfusions, and close contact nursing are winning the day. The death rate might turn out to be 4 out of 17, which would be very good. Currently it seems likely that all the infected new cases might survive.


So, we do not have a good estimate of how many new infections will be caused in the West by each unannounced Ebola carrier, but 2 per case seems likely, in line with the African estimate. There is evidence from Ng and Cowling (2014) that the virus lasts longer in cooler and moister climates, which might be relevant in the US and Spanish cases.

What now for the Western response to Ebola. Health services have not always made life easy for whistle blowers. On the contrary, the UK experience is that they can be ostracised. The airline industry was on top of this years ago. They allow pilots to admit errors anonymously, which means they can confess a mistake which acts as a warning to other pilots, and gives guidance to systems engineers as to what needs to be improved. We should have a similar system for health workers (and for car drivers, no doubt).

Above all, estimates of human-to-human transmission of any virus need to take into account human foolishness. For every “public awareness” health campaign predicated on average intelligence and average public spiritedness we have to apply a realism coefficient: an allowance for human error in following protocols, plus selfishness, indifference, egotism, deluded altruism and occasionally downright malevolence. Human stupidity is infection’s fifth column. From the viewpoint of any virus, we serve as useful fools. The stupider the human carriers, the higher the eventual human cost. So, every measure of the infectiousness of a disease is also a measure of our intelligence. Adjust the Ro calculations for the IQ calculations.

Finally, what are we to make of the view that the key to solving Ebola is to rush to Africa with trained staff and resources, in order to put out the fire at the source? From a global point of view, given the ubiquity of the wide body jet and the apparent political imperative to keep borders open at all costs, Ebola is being given a free ride, as if it were only fair that it should take hold across the planet: an equal opportunity pestilence. In that sense, going to Africa is an understandable policy, simply because it is the one way left to control the disease. However, health colonialism runs up against some contradictions. If local governments block the prompt rollout of resources, or refuse to publish the true death rates, or fail to pay their health workers, how should the Western health colonialist respond? Should these powers edge towards to imposing good governance, or should they try to battle to bail out the ship of failed nations while corrupt and incompetent local strongmen keep drilling holes in the hull of the sinking ship?

This probably a problem Western government should leave to the Chinese Politburo, who have taken over the colonialist mantle in Africa. 

Leading indicator: watch how many Chinese in Africa get Ebola. If all threats are the ultimate IQ tests, then the Chinese should have a low rate of infection. Equally, the virus should be controlled easily if and when it reaches the Chinese mainland.

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