Monday 20 October 2014

Wall Street Journal: Ebola a busted stock?


The Wall Street Journal is a reassuringly capitalist newspaper, and they have a reassuring article about Ebola by a distinguished epidemiologist, the talented Dr Larry Brilliant. There is much to commend in the article, based on his experience of the treatment and containment of smallpox and other infectious diseases. However, there are some points worth debating.

Dr Brilliant begins with a vivid description of an awful smallpox outbreak in 1974 in India. Yet, as he reassuringly points out, 6 years later smallpox had been eradicated. However, his article does not reiterate the obvious point that a vaccine for smallpox had been made available by Jenner in 1798. A commonplace in much of the world, (I still have my Uruguayan vaccination certificate somewhere) it had not been given to everyone in the world, and when mass vaccination achieved global herd immunity the last cases were tracked down. On 26 October 1977 a health worker dealt with the very last case, a moving moment in medical history. (I can remember the team being given an award at a medical conference I attended in the 80s).

Dr Brilliant says: The signs are optimistic that we will have an Ebola vaccine soon—hopefully in months. Even in its absence, we still have good tools. To fight Ebola, our tools are early detection, innovative diagnostics, isolation, epidemiologic tracing of contacts and good clinical care.

I did not know we would have an Ebola vaccine so soon. Hope so. At the moment we don’t have one, so our policies must be based on there being no vaccine. Isolation is important (though often not being achieved). Tracing of contacts appears to have been achieved in Nigeria and Senegal, but not elsewhere in West Africa. Good clinical care is also often not being achieved, and invasive clinical interventions might not be a good idea if they cover health workers in large viral loads of fluids.

Early detection: First, we must find new outbreaks faster. The current Ebola outbreak, initially misdiagnosed as cholera, had a head start of four to six months, enough to account for most of its unprecedented size.

Agreed. However, at the moment we have a big outbreak, and must deal with that.

Second, we need two kinds of technological innovations in diagnosis: one for the airports and points of entry, and one for the field and hospitals. For passengers and visitors, we need a rapid finger stick test that delivers results within minutes while a passenger is held at an airport.

Agreed. However, we don’t have one yet.

The second diagnostic breakthrough we need is for the hospital….tests that immediately diagnose if Ebola is present and suggest the best medical plan. The technology is also coming soon.

Agreed. However, we don’t have one yet.

Third, we need to learn from the past successes of smallpox, polio and Guinea worm how to contain an outbreak. In the smallpox program, we used rewards of a few dollars to stimulate reports of disease, a rumor register and searches and visits to temples and mosques, along with two billion house calls in India alone. When a case was found, we initiated complete isolation, including paying for a guard from the community to prevent anyone from entering or leaving the home. At times, WHO even paid for and sent meals to smallpox patients so they had no incentive to leave the house. If a patient still managed to leave a village, we notified next of kin and any place that person might be going, as well as health authorities. Along with vaccinating residents around each infected house, we monitored every infected village and patient for six weeks after each case.

Strongly agreed. I wish West African governments had followed these policies. The paid guard outside the isolated case’s home makes great sense. That policy would have saved lives in Guinea/Sierra Leone/Liberia. Implementing those sorts of policies has, as far as I know, not been agreed in West Africa. They have not handled the outbreak well.

Now, with mobile technologies, cloud computing and participatory epidemiology, we can make this a much more efficient process. Specifically, we need a modern, digital contact tracking system. Then travelers would answer questions about any symptoms and take their temperature, perhaps with their phone.

Agreed. I had suggested that last point myself, and am pleased to see it supported by an expert.

Fourth, we need improved coordination among public health systems, particularly across borders. The West Africa outbreak has put out in the open what many in the public health community have long feared: that fundamental impediments in the funding and structure of the WHO hamstring it at moments like this. There is no cavalry coming from Geneva when it comes to pandemics, no entity with a fully prepared SWAT team to tackle an outbreak. The WHO is not entirely to blame, but rather its member states, who have politicized the organization while also cutting funding.

Agreed. However, the national and international health authorities have not yet achieved that level of performance.

So far I have been agreeing that, once new technology is in place, things will be much easier than they are now, when the outbreak in not yet under control in West Africa.

Dr Brilliant says: Our real enemy is a hybrid of the virus of Ebola and the virus of fear. As the famous World War II British poster reads, we need to keep calm and carry on.

Here I have a point of disagreement. Fear need not be our enemy, and can be protective. Fear stops us walking into danger. The thoughtful approach is to balance alarm against too much calm. In the Second World War the authorities did not want the public to spend the night in the underground tube stations. They feared that they would never come out again. The great British public simply bought a ticket late at night, and camped down on the platforms with a thermos of tea and some blankets. The authorities capitulated. Citizens spent the night underground and came up to work in the day, and lives were saved during the Blitz.

Far from really panicking, all Western nations are carrying on with their lives at the moment, (not staying at home and hoarding food) but they are also trying to understand the risks and the best protective strategies to adopt. At this point most citizens would very probably like to see Ebola cases isolated, and a guard placed on their houses. Dr Brilliant makes an important point that this ought to be part of the armoury of disease control. It is right to be alarmed if the virus is carried to new territories. Why take risks just at the moment regarding travel, when better diagnostics may be available soon, thus making sure that the virus is not carried far afield? Better wait for a brief finger-prick test to become available than tracing hundreds of worried contacts.

Interestingly, Dr Brilliant does not mention another virus, HIV. Arising in modern times, even with all the armoury of diagnostics and pharmacological innovation at hand, it has killed 30 million, and infected another 36 million so far (rising by 2.5 million a year) all of whom are dependent on expensive medication for survival (one order of magnitude higher than an uninfected patient), and might well become infectious again if that treatment lapsed. It keeps spreading, but antiretroviral treatment seems to have reassured the public that the threat is over. In many ways current perceptions of Ebola mirror the perception of HIV decades ago, though not in the way that the authorities imagine. Far from panic, there is alarm that yet another virus will spread when it could have been contained in the early stages by strict measures of control. It looks as if an opportunity is being missed, and that saddens and alarms people, as it should.

On a brighter note, if Dr Brilliant’s policy advice about isolating cases in a guarded house can be implemented, that could make a major contribution to the control of Ebola. It will increase prompt human and financial costs in the hope of a future benefit, an example of deferred gratification: the public health equivalent of the famous “marshmallow test”.

Finally, on a more general note: none of us deserve to die because our personal or collective errors have given the virus an easy ride. Infectious diseases certainly test our intelligence and our personality, and collectively test the morality of the societies which we have created. Some governments will do their best to protect us. Others will do their best to protect themselves. Governments can be well organised and humane, or incompetent, indifferent, over-confident, untruthful and corrupt.  No deaths have to happen, nor is any purpose served by them. Nonetheless, many of us will have died stupidly if we are outwitted by a virus which is easy to control.


  1. not very intellectual of me, but i read that as "ebola - a busted sock" which made me ponder down a different path, but it led to the same place:)

  2. Perhaps a busted sock is the better analogy.