Commencing case isolation protocol 666

Commencing case isolation protocol 666

Media reports today that the Spanish government has killed a dog. Not just any dog – this was Excalibur, the hapless pet of the nurse who is quarantined for Ebola in Spain. The nurse, Teresa Romero Ramos, is being treated for Ebola after contracting it while treating a returned missionary; her husband is in isolation to be monitored for signs of the disease, and there are fears that the dog might have it too. It’s not clear whether dogs can get or transmit Ebola, though there is some vague evidence that they are at least at risk, so in theory there was some justification for the execution of an innocent dog, but in my opinion this is a huge public health mistake.

Because there is no treatment for or vaccine against Ebola, our only effective intervention to prevent its spread is case isolation, which in turn depends on early identification of cases, and rapid and effective contact tracing. This method alone has been effective in every previous outbreak. Although not airborne, Ebola is highly infectious with close contacts, so early identification is important to reduce the subsequent contact tracing burden, but symptoms are vague (fever) and easily confused with other possible illnesses – especially as influenza season approaches. So it’s really important that people with fever be willing to attend a doctor early, and that they be willing to risk putting their lives into the hands of public authorities on the basis of nothing more than a suspicious fever.

This kind of early identification, case isolation and contact tracing depends fundamentally on trust. The person with a fever needs to trust that they and their loved ones will be treated well, and that people contacted through them will be treated well. In general – I’m going to go out on a limb here – shooting someone’s dog does not fall under the definition of “treating them well.” It is, in fact, kind of mean.

Of course we all know that in times of emergency, the government will kill our dogs. If Ebola jumps the shark, you can bet that pets of all kinds will be seen as mere collateral damage in an extremely authoritarian and aggressive public health response. But since we don’t want our society to get to that point, our first goal in public health responses should be to ensure that everyone who might need to attend a doctor does so as early as possible, without fear of the consequences. Notice the emphasis on might – that is an important word in this context. If you want to give people the impression that they don’t need to fear the consequences of reporting their fever, you probably shouldn’t shoot their dog.

Now, many people might think that this is a public health emergency and in public health emergencies dogs aren’t very important. This is probably very true. But a public health response has to be built on the possibility that not everyone will agree with you about that; or that they might not understand the dynamics of infectious diseases enough to realize the dangers of letting their dog go; or that they might not have the same understanding of their own disease risk that you do. If anyone who thinks in any of those ways gets Ebola, and you have given them reason not to trust the authorities, they will delay their attendance to a hospital, and/or lie about their circumstances. This doesn’t just extend to crazy scenarios like refusing to admit they have Ebola because they don’t want you to kill their dog. The most likely scenario is much more bland: someone with a fever misjudges the risk that it is Ebola, and because they have a general worry that their dog will be shot if they go to hospital, they decide to just “wait and see” for a few days. During that few days they definitely infect their dog, and a few other people, before they finally accept that the bleeding eyes are the giveaway that they really do have Ebola.

But shooting a dog isn’t just about dogs: it’s about the general possibility that you’ll be treated like shit just because you have a fever. There are lots of other situations where such a fear could cause delay: the dude who has a fever but spent last night cheating on his wife, and is worried that a government that shoots dogs won’t be particularly discreet about contact tracing; the potential Ebolaee who has friends with prizewinning breed dogs, and doesn’t want to have the government shoot their friends’ dogs so decides to just wait a few days to be sure it isn’t Ebola; the person who gets really sick at work, but whose cat is outside, decides to check himself in to hospital but figures cats don’t talk to strangers, and doesn’t want all the cats in the neighbourhood being shot, so doesn’t mention it; the dog lover who doesn’t think they have Ebola and doesn’t want to take the risk, so hands their dog to a neighbour before going to hospital. Any one of these scenarios is a potential nightmare of contagion, and they can break down at any point in that identification-isolation-contact tracing process.

Obviously when the outbreak goes epidemic, this will all become academic, but right now it’s not epidemic: there are a few people under observation, and two people in quarantine. The decision to kill the dog sparked a global protest. Would it really have been so difficult to tranquilize the dog, put it in some kind of quarantine, then tweet pictures of it with a dumb-arsed chewy toy and the phrase “Spanish healthcare: no dog left behind”? A tiny bit of extra work, for a huge public relations win. You can always shoot the dog a few days later and claim it got Ebola and it was the “humane thing to do.” If you really really can’t figure out a way to keep a dog alive for a few days without touching it, I think you aren’t really trying – and I think every pet owner will agree with me about this. Also – and this might prove important later in the epidemic – we don’t know if dogs can transmit or even become symptomatic for Ebola. It might be nice to know that, and right here we have a dog with potential Ebola. More specifically: there are a lot of cat owners out there, and cats wander, and fight. If one of those cat owners has Ebola and lets their cat out at night, it would be really really handy to know whether domestic pets are a risk. If only we had a dog with Ebola … oh, but we shot it.

Basically the Spanish government just told everyone who thinks they might have Ebola that even though they are nowhere near emergency stage, they’re already willing to act like complete dickheads. So anyone who has a fever and something to hide, a pet, or a group of people they really don’t want to annoy, is going to be thinking that maybe they should be really sure that it’s Ebola before they cash in everyone they know to a pack of ruthless dog killers. That suspicion may only delay their presentation for a day or two, it may only make them lie a bit during the contact tracing phase, but that’s enough – the disease gets spread. And as we have seen from Africa, stopping the spread of this disease early is crucial to stopping it at all.

Also, if I survive Ebola, I would quite like to go home to rapturous greeting from my (uninfected) dog. Shooting Excalibur was just a dick move.

Since I’ve been talking a bit about HIV lately, I’ve also been thinking about Ebola, and so while I’m here I thought I’d make a few other points about the media treatment of Ebola, and the associated public perception, that I think are important. I also would like to share the Science collection of articles on Ebola, which have been made open access for the duration of the epidemic. These include some fairly accessible media descriptions of the issues, and also some interesting survivor interviews. The Guardian has also devoted one of its (horrible) live “Blogs” to a day of coverage of Ebola, which is reasonably informative (it also includes survivor interviews). Make no mistake: this disease is easy to prevent and really, in the modern era, should not be a serious public health threat, but it is a terrifying phenomenon once it gets wild.

Ebola is not less important than Malaria and HIV

Quite a few media articles have been complaining that Ebola is getting more attention than malaria and HIV, which are the worst killers in Africa. Articles on this theme usually show  a mixture of motives, primarily a desire to criticize media sensationalism, complaints about westerners just throwing money at dramatic attention-grabbing problems rather than core health problems, criticisms of the amount of money available in aid[2] for these major diseases, general bullshit about the WHO[1], or misjudgments about risk. But let’s be clear about this: it’s a completely bullshit argument, probably racist and definitely annoying. First of all, huge amounts of aid money are committed to malaria and HIV every year: the Global Fund, Bill and Melinda Gates Foundation, WHO, PEPFAR, GAVI – there are billions and billions of dollars, whole inter-governmental organizations (e.g. UNAIDS!) and large portions of international aid budgets devoted to the biggest killers in Africa. They are not under-resourced, though of course all these diseases could (and should) have more money. Also this disease is not something you can sensationalize enough: read the reports from survivors, and you see that it is a truly terrifying and destructive phenomenon. It is also possible for us to walk and chew gum at the same time: pouring resources into Ebola doesn’t suddenly mean HIV will lose its money, and if anything the opposite will happen: a society forced to commit all its medical resources to a sudden wildfire epidemic will not be able to maintain routine health care, and other conditions (in Africa, maternal and child mortality) will get worse. This is a fairly obvious thing to say, but because opinion writers are usually idiots, it needs to be spelled out: a society facing a medical apocalypse cannot also maintain routine maternity services. As an example of this, I know a man whose cousin had arranged work as a paediatrician in Sierra Leone, starting in November. She’s now changed her plans, and will be starting work in an Ebola containment ward next week. That’s what happens when a hemorrhagic virus goes full retard: paediatricians don 77 layers of rubber and head into the hot zone.

But the thing that’s most annoying about this article is its reduction of all of Africa to a single entity, or as the infectious disease blog haba na haba put it, Ebola is only the Kardashian of diseases if you think Africa is a country. Yes, malaria and HIV kill lots of people in Africa, but the death numbers for these diseases cover the whole continent. Ebola is killing people in just three countries, and it has probably now killed more people this year than HIV and malaria combined in those countries. Unless you think national boundaries don’t matter for health and economic policy, it should be fairly obvious that while most of Africa is struggling primarily with HIV and/or malaria, in these three countries Ebola is a catastrophe unfolding on a grand scale.

This last argument comes down to another simple problem with modern media and their interpretation of health policy: misinterpretation of risk.

Ebola is only harmless while we make it so

Ebola is not as infectious as measles or mumps, or even HIV, but it is remarkably virulent and its ability to infect people after death means its growth is not necessarily constrained by its high case fatality rate. This makes it a rather unique virus. But there are many articles in the media suggesting that we are over-reacting to Ebola, and that it is not that serious a concern. These articles are largely based on past experience of Ebola, but they miss an important point about how we manage disease outbreaks: Ebola is only not a threat so long as we take it very seriously. Provided we take Ebola seriously, and act quickly to stamp out even the smallest evidence of it, it is not a serious concern. If we decide that therefore it is not a concern, and lower our guard, it will spread and cause huge damage. But the various critics of epidemic policy are always looking for the latest disease threat that didn’t materialize – SARS, avian flu, H1N1 – and claiming that the health authorities overreacted, when in fact that “overreaction” is the main bulwark between civilization and chaos.

And if you want to see what happens when that bulwark collapses, visit the Ebola zone now. In this article, Senga Omeonga talks about his colleagues who were struck down by Ebola. He is a doctor, and only just survived the disease. He says, of his small unit,

In total two brothers, a Spanish priest, a sister, two nurses, one x-ray tech, one lab tech, and one social worker died. Two other doctors, two sisters, and one orthopedic tech survived. They closed the hospital after the outbreak.

So many skilled health workers died because of one index case. Ebola preferentially targets healthcare workers, and the associated people who are needed to support the work of doctors. Even if these countries manage to defeat the disease, they are facing a future with a massively depleted healthcare workforce. Some of these countries have less than 100 doctors, and less than 1000 nurses: every single death in this workforce is a huge loss, and the loss of a massive amount of national capital. Even if the disease doesn’t spread enough to decimate the population – a possibility that is looking increasingly likely – it is probably going to set the health development program in these countries back by decades. The result of this epidemic will be a long-term reduction in capacity to handle HIV/AIDS, malaria and maternal and child mortality. But a lot of coverage of this disease is predicated on the assumption that health systems are overreacting, and that the disease can be assessed simply in numbers of deaths, rather than their strategic location; and a lot of media reports (and let’s face it, probably a lot of government policy) has been focused on the risk of rich nations being infected, rather than on the threat to health systems in poor countries.

Once the health system collapses, any disease gets a free run. The health systems in these countries are on the brink. Even the World Bank – which has spent years resisting Universal Health Coverage – has been forced to recognize that these health systems are fragile and underfunded. When these countries emerge from this epidemic, let’s hope that western governments will have finally learnt the lesson global health policy makers have been pushing for years, and recognize that in an interconnected world robust health systems are a social good. Maybe then they will start to find creative ways to create the fiscal space for effective health systems in even the poorest countries. Any program that looks for such a fiscal space is going to need to recognize that poverty and underdevelopment do not support universal health coverage, and make policies to genuinely support economic growth. Let’s hope Ebola is a turning point towards shifting the economic relations between low- and high-income countries, to the unequivocal betterment of the former.

fn1: If you google “ebola WHO priorities” you’ll find this article by Henry I Miller being syndicated across the world. It’s incredibly negative about the WHO – the organization that eradicated smallpox! – and also incredibly wrong. It’s worth noting that Henry I Miller was specifically identified as an advocate for Big Tobacco in the Tobacco Papers. The campaign against tobacco is one of the WHO’s greater success stories, so it’s no surprise that he takes every opportunity to slander the organization, and no surprise that the Hoover Institute is willing to employ someone this oily. It should come as no surprise, then, given the history of Big Tobacco in funding global warming denialists, that this greasy little man is also a global warming denialist. Yet idiot newspapers around the world have reproduced the anti-WHO rantings of this paid defender of Big Tobacco. Do they have any understanding at all of how to check sources?

fn2: I particularly like the use of a picture of a semi-naked dead person being sprayed with disinfectant at the top of an article about our “empathy deficit.” Stay classy, Huffington Post!