Today’s media are breathlessly reporting that the WHO is predicting 5,000 – 10,000 new cases of Ebola virus disease per week by the beginning of December. There is no written documentation on this, but I did find this study in the New England Journal of Medicine (NEJM) from the WHO’s rapid response unit which suggested 20,000 cumulative cases by 2nd November, which would be 10,000 more cases than we are seeing now (roughly) in just two weeks, so 5,000 per week in November. Given the doubling times in that study were estimated to be approximately one month, that does suggest a rough number of 10,000 cases per week by December (if anything that number is probably slightly optimistic). If so we can expect to see 40,000 cumulative cases by the start of December (20,000 to 2nd November, then 20,000 more in November), and 80,000 by the end of the year. Assuming the same doubling, we will see another 20,000 a week in January, which takes us to a rough 150,000 by the beginning of February, assuming that there is no successful intervention by then.
The case fatality rate is now estimated to be about 70%, so those time frames would give respectively (and approximately); 30,000 deaths by the start of December; 55,000 by the end of the year; and about 100,000 by February. Those are large numbers, but on a national basis what does that mean? In this post I want to look at the implications of these numbers under three different scenarios, but first let’s just look at the number of deaths by the end of the year, and do some rough calculations of the implications.
First, let’s look at just Liberia. The NEJM article puts about 50% of all cases in Liberia, so if we follow that proportion forward, we can expect about 27,000 deaths by the end of the year, and 40,000 cases. It’s not necessarily wise to assume that proportion is static, since the disease appears to have taken hold in the capital of Liberia and Liberia seems to be the worst affected, so the disease may spread faster there or may burn out sooner; but for lack of better evidence let’s just go with that proportion. Liberia, according to Wikipedia, has a population of 4 million, and its capital Monrovia has a population of about 1 million. At first blush, 27,000 deaths is not a lot of people in a country of 4 million … but in 2005-2010 Liberia’s mortality rate was 12 per 1000, for a total of 48,000 deaths in 2014 (my estimate). The 30,000 extra cases of Ebola in Liberia that will occur by the end of the year will cause 21,000 deaths, 50% of its annual total. In just 2.5 months the disease will kill as many people as usually die in 6 months. That’s a traumatic increase in mortality, such as usually happens only in times of natural disaster and war.
In addition, however, controlling the epidemic requires isolation and monitoring of an enormous number of people. Consider this report of an outbreak of Marburg disease in Uganda in September. The disease – which is very similar to Ebola – was identified in a single person in a small town in Uganda, and killed the index case after 17 days. Contact tracing was carried out, and the WHO reports that
As of today, a total of 146 contacts have been identified and are being monitored for signs and symptoms compatible with MVD. Eleven of the contacts developed signs and symptoms compatible with Marburg virus disease.
In order to properly contain this disease, the doctors had to track down 146 people, and of those 11 developed signs and symptoms (fortunately in this case none of them were positive). In the Liberian context this would mean that for every case, more than 100 people need to be traced and 11 isolated as suspected Ebola. Even if we assume that people are starting to catch on to the risks, and so are having less contacts and less need for isolation, we can probably still safely assume that to properly control the disease we need to isolate 4-10 people and trace 100 or so. For 30,000 new cases from now till the end of the year that will mean isolating 120-300,000 individuals, for a period of as long as 21 days. The top end of that figure is about 8% of the population of the country.
Finally, the toll on health care workers of the first 10,000 cases has been genuinely shocking. The latest WHO situation report tells us that 201 health care workers in Liberia have caught the disease, and 95 have died. Assuming that rate persists, adding 30,000 more cases will lead to the death of 300 more health care workers. Wikipedia, again, tells us that Liberia had 5000 full- or part-time health care workers in 2006, of whom 51 were doctors. By December Liberia will have lost almost 20% of its entire health workforce, leading to huge setbacks for health in one of only seven countries in Africa to have met its Millenium Development Goal 4 (under-5 mortality) targets.
So let’s bear those basic figures in mind. 40,000 cases= 28,000 deaths, 120-300,000 isolated individuals, 1.2 – 3.0 million individuals being monitored for signs and symptoms, 20% of the health workforce dead. Also, a very large number of foreign health workers coming in to help, and entire new hospitals being constructed in a country with no suitable infrastructure. Now let’s consider three different scenarios, based around the UN’s 70-70-60 goal, which is to be able to isolate 70% of cases and bury 70% of bodies safely, within 60 days. The low basic reproductive number of Ebola – below 2.0 in most cases – means that preventing 70% of secondary cases should be sufficient to kill the epidemic (just!) So let’s assume that if this goal is reached and maintained, the epidemic will plateau and then begin to decline, in about the same time that it took to escalate. For simplicity we’ll count that time period in terms of numbers of cases – so after the disease peaks, we will assume as many new cases occur as the disease fades away as occurred in its growth. This is not unreasonable – most epidemic patterns don’t crash, but tend to go through a decline that looks roughly symmetric to the increase. This may not apply with a disease as fatal as Ebola, but no one will know till we come out the other side, so let’s assume it will behave as most other epidemic patterns do. This means that if we have x cases by new year, and the UN goal is attained at new year, we should expect to see a further x cases before the disease is gone.
The best case scenario: Liberia meets the UN goal on time
If the sudden inrush of aid workers and soldiers enables Liberia to meet the UN goal on time, we will reach 70-70 in 60 days from now, i.e. by mid-December. That means there will have been 60,000 cases by the time the epidemic begins to decline, or maybe 100,000 by its end. This means 70,000 deaths, 300-700,000 isolated individuals, and pretty much everyone in the country being monitored. About 50% of the workforce will be dead. If we assume the decline takes a few months, say until March, we can guess that we will see nearly two years’ mortality in just 6 months. Between 10-25% of the population will have been isolated for about one month during this period, unable to work or care for others. The goal of safely burying 70% of the dead means 50,000 bodies will need to be buried by specialist teams. The difficulty of their work can be seen in this excellent brief report from the NY Times, but I think it’s obvious that burying 50,000 bodies is going to have to be done in a very different way to this. I wonder if there is even a protocol for mass burial of highly-infectious bodies?
This is the best case scenario. On the basis of the numbers alone it is clearly a catastrophe for Liberia, but it isn’t enough to bring the country to its knees (at least with outside help). Less than 2.5% of the country is dead, and although the economic effects are alarming and the long-term destruction of the health system will set the country back years from its health goals, it doesn’t appear to be a recipe for total collapse (at least on paper). There is hope here, and if the containment efforts are good so that the epidemic crashes really fast, then we can expect it to have a much less significant effect on the health workforce.
The realistic scenario: Attaining 70-70-60 a month late
Suppose instead that the UN goal is missed by a month, taking us to mid-January. That will correspond with about (very roughly) 100,000 new cases by the time the epidemic peaks, or 200,000 by the time it finishes in probably March or April next year. From our calculations, this means 140,000 deaths, 600,000 – 1.5 million isolated individuals, and the remainder being monitored. The entire health workforce will die in this scenario, and about 100,000 bodies will need to be buried safely. Only 54% of the Liberian population are working age, or about 2 million; it’s quite possible that a large part of the adult workforce will be in isolation for more than 3 months, with a large part of the rest involved in basic Ebola-combat activities (burying bodies, contact tracing, logistics). The death toll is equivalent to three years’ mortality in 6 months. What this would mean for the agriculture sector I cannot guess, but it doesn’t seem good. At this level of disease spread, I think we are looking at a society on the verge of collapse, where trade-offs have to be made between isolation/contact tracing on the one hand, and maintaining basic functions of civil society on the other. If the UN goal is missed by a month, alternatives will need to be found to isolation systems, and a huge increase in available health workers will be needed.
The worst case scenario: Failure to contain the epidemic by February
Failure to contain the epidemic by February means 150,000 cumulative cases by February, and probably at least 300,000 (maybe more) over the next few months, with no sign of a slowdown. Every month we will see another doubling of the rate (40,000 per week in March, and so on). Just taking the minimum value here of 300,000 cases, there are 210,000 deaths, 840,000 – 2 million individuals in isolation, and the entire health workforce decimated. In this scenario most of the adult working-age population is isolated, and the entire economy has shut down. Without a huge influx of foreign aid – in food, water, field hospitals, and probably thousands of medical staff – the disease will break out of any containment system that might be left in place, and the only limit on its spread will be its own voracity. This suggests to me that we have until January to get an effective containment system in place, or Liberia as a country will cease to exist in any functional sense. We should assume, furthermore, that in the general breakdown of the social order that will ensue many people will leave the country, and the risk of the epidemic spreading to Nigeria will be very great.
Caveats and limitations
These figures are all rough guesses based on huge assumptions. The number of people who need to be isolated will not scale linearly with disease spread, for example, because one individual will begin to have multiple case connections, and as the disease spreads and social contact reduces, the number of people a new case will have actually touched or been near will decline rapidly. So my estimates of effects on the working age population are inflated, and these are the key cause of social breakdown, I think. Without the effect of isolation and disease containment efforts, even 300,000 cases and 210,000 deaths is not a society-ending event in a country of 4 million people, though nobody wants to think about how horrible that will be. My assumption that the downward side of the epidemic will cause as many cases as the upward side is based on the assumption that the basic reproduction number will be reduced only just below 1 by the 70-70-60 plan; this means each existing case gets a chance to cause another, but if the epidemic is contained more effectively once the plan is in place that assumption could be an over-estimate. Also there are geographical limits on the spread of the disease (especially once things get desperate and all travel within the country is shut down); this will mean that the disease rapidly burns through its available cases and dies out before it can spread fully. And finally, I don’t know what the time trend in deaths of health workers is, but I suspect these deaths were mostly in the early stage of the disease before the word was out, and that deaths are now declining rapidly towards zero. Given all these constraints, I think that an aggressive plan enacted now, aiming to achieve the 70-70-60 goal, and followed through aggressively thereafter, will probably stop the disease somewhere before the numbers provided in my best case scenario. This will still cause a years’ worth of mortality in a couple of months, take up to 10% of the working age population out of work for isolation, and kill up to 20% of the Liberian health workforce. It won’t cause a national collapse, but it is a catastrophe easily as bad as a tsunami or some other huge natural disaster.
What should this mean for the future of health planning in Africa?
We often talk about “fragile health systems” and “extreme poverty” in Africa, but in the rich nations we’re used to thinking of health system failure as poorly-managed diseases and unpleasant medical experiences, but it’s worth remembering that at the extremes of medicine there are disasters: car accidents, pandemic influenza, and incredibly horrible diseases like Ebola. In the best of times in Africa, “fragile health systems” means excess deaths due to preventable infant, maternal, HIV- and malaria-related mortality. But in the worst of times it means huge waves of mortality due to natural disasters, war or epidemics. This Ebola outbreak is showing the rich world what “fragile health systems” really means, and also showing us that we are not able to completely disconnect ourselves from these failures. We can’t expect to isolate ourselves from emerging infectious diseases forever, except perhaps at the cost of our humanity, so instead of trying to isolate ourselves we should try to seriously tackle the fundamental problems affecting health systems in Africa and some parts of South Asia. This is not like a military intervention where the best of intentions can bring about the worst of results; we know what works and we simply need to find the political will to make it happen. Once this disease is back in its box, and all three affected countries are able to contemplate a return to normality, we in the rich world should make a serious, final effort to fix global poverty and most especially to end the grotesque inequality in health systems around the world. It’s almost certainly not going to happen, but we have to recognize that any country with a fragile health system is one weird event away from a terrible humanitarian catastrophe, and we need to start thinking about how to stop this from happening again. That means we have to act to help those countries to genuinely strengthen their health systems, and achieve the kind of economic state that is able to sustain them. This may mean we fat, rich westerners pay a little more for our chocolate, coffee and clothes, but it’s a price I hope we are all going to be a little more willing to pay now that the threat of dying horribly in our own body fluids has begun to make itself felt.
This situation should also serve as a warning about the dangers of ignoring very rare but high-risk events. Ebola has been known for 40 years, and this is the first time it has ever escaped containment. Work on a vaccine has been delayed or ignored partly, I think, because the risk of this disease escaping its bounds is so low that people considered it negligible. I hope my calculations show that the cost of this disease is only negligible provided it never happens, and that once it does happen all our risk assessments look incredibly stupid. We need a new way of assessing risk which puts a serious value on low-probability events. In the era of climate change the implications of this are obvious. At the tail end of some of the global climate models there are some extreme, civilization-ending events that have been largely overlooked by policy-makers because they are so unlikely to happen. Hopefully this Ebola outbreak will convince the world that it is time we started looking more at the tails of our probability distributions, and not at the comforting bulges down near the low-cost events.
Compromise and Conceit 
October 16, 2014 at 9:13 am
final effort to fix global poverty and most especially to end the grotesque inequality in health systems around the world
The problem in your statement here is you’ve allowed your biases to predetermine your solution.
You want an end to poverty and a more equal distribution of healthcare. [1] But an end to poverty doesn’t appear to be critical to stopping things like ebola. Only the healthcare aspect actually influences it. These people could be dirt poor but if the healthcare infrastructure and basic health information available in the community then ebola would be a non-event.
Now the high correlation between extreme poverty and crappy healthcare makes this a lower priority issue, but that correlation is still caused by historic observations. We could have Western tax payers provide just hospitals and I’d bet the degree of correlation would drop.
This sort of reasoning is dangerous in situations where the correlation is lower (or just a pure assumption). For global warming, may arguments (e.g. Monbiot’s) conflate poverty reduction/reductions in inequality with steps for treating AGW. But I’ve never seen these people actually put forward an argument on why this has to be the case. A simple example would be: Liberia using solar power instead of coal would reduce emissions. This reduces AGW. But increased education or healthcare or discretionary spending in Liberia is going to either have no effect or worsen AGW. Why should a Western opponent of AGW support any such goals?
The simple answer is “Because the person putting forward the anti-AGW plan has a stack of biases they want to address and they see a transformative event like AGW as an opportunity to do so.” I strongly suspect that some of the opposition from the Right on AGW is driven by Left-wing assumptions that have been driven into AGW plans without any supporting reasoning being provided. This suggests that in order to address the actual problem of AGW some of its supporters are going to need to careful cut out their biases and be willing to focus on the core problem. Use of market mechanisms (i.e. carbon pricing) is a good example of this being done. It’d help more if every time Monbiot opened his mouth to address AGW he didn’t put forward a plan where everyone gets the same level of service/material possessions at the end.
We need a new way of assessing risk which puts a serious value on low-probability events.
I can understand that you’re trying to make sure that low probability high impact events like ebola are addressed. But you’re overlooking that these things are already factored into the risk assessment process. Saying “Ebola could end the world but it’s really unlikely. Nevertheless we should treat it as as bad as malaria which is not going to end the world but is absolutely going to be a massive pain in the ass (and the end of the world for the stacks of people it kills).” means that you’ve abandoned any rational attempt at resource allocation.
The core fact is we have limited resources to address endless problems. We could probably beat the crap through a small number of these if we really tried (e.g. cure cancer and AIDS in a decade or two) , but it’d leave us crippled on every other front (e.g. every other disease on the planet given we’ve picked just two to focus on).
Therefore in a risk assessment, the probable cost has to be factored in alongside the likelihood. Ebola has a potential huge cost but an expected tiny likelihood. Malaria has a large cost but a huge likelihood. Now select how to allocate resources across these two. Remember that every couple of dollars you put towards ebola is a kid who definitely will die due to lack of some low cost easy solution.
Now before you say “Then we should increase the resources so we can do both” you have to internalise that doing so is just going to take the money from something else you want. There is no escaping the limits of our resources. We are not the Culture or Star Trek. The best we can do is allocate our resources in a way that maximises our probability of a good outcome.
Black swan events will happen. And when they do we will be badly prepared. But the alternative is putting large amounts of money into picking a couple of barely visible low probability events (pissy little African disease that is always easily contained suddenly not being easily contained) and hoping that the next disaster isn’t something that is totally “impossible” (zombie plague, stranglet, grey goo, Spice Girls reunion) or completely unforeseen (magnetic pole reversal, ice age).
It’s life. If you spend all your time dreading the “what ifs” then you’ll never get to actual live it. And you’ll probably die without seeing your fears come true.
[1] These aren’t bad aims. The mistake you’re making is not explicitly stating your biases and that makes the solution you’ve selected appear out of left field without any actual reasons behind it. We see this frequently in US politics where the answer always seems to be “Vote for my party” regardless of the situation or even their proposed solution.
October 16, 2014 at 9:15 am
Here’s a simple example:
http://www.theage.com.au/national/public-service/public-servants-demand-ebola-isolation-units-be-set-up-in-canberra-20141015-11681h.html
Public servants in Australia are demanding a quarantine process be put in place for public servants coming back form effected areas.
Would you prefer to see this money put towards the quarantine in Australia or treating the actual outbreak in Africa [1]? When making your decision, remember that an outbreak travelling to Australia and only being able to be stopped by quarantine sounds like a black swan event to me…
[1] Let’s imagine for an instant that the decision won’t be made on political grounds.
October 16, 2014 at 10:53 am
Paul I think you have misunderstood the intention of my comment on a “final effort to fix global poverty…” I should hope the biasses in my desire to end the grotesque inequality in health systems are obvious, but the reason for my statement about fixing global poverty is not that I demand those two projects go together for moral reasons. Rather it is that strengthened health systems in low-income countries are not sustainable without also improving the economies of those countries. This is sometimes referred to as making “fiscal space” in the health financing literature. I’m not arguing here that the sudden onset of Ebola demands that we make everyone rich and healthy because reasons; rather that I want to see (for moral reasons) an end to the poor health care available to so many people in the world, that I think rich countries will need to pay to make this happen in the short term (i.e it is going to cost us money and we should prioritize that), but that in the long term for those health systems to remain strong and functioning, those countries have to be lifted out of poverty. Note that this doesn’t mean reducing inequality (if we can simultaneously make the rest of the world richer); it simply means improving the economic situation of those countries. Improving health care systems is not actually a particularly expensive or difficult task, it doesn’t require huge amounts of money either in the short or long term, but it requires certain social systems to be functioning, and certain basic economic stability. As an example that might appeal, many of the poorest countries don’t have any form of private health insurance systems, so even the rich in those countries have difficulty regularizing their health costs. I don’t think this is because insurance wouldn’t be profitable, I think it’s because the financial and legal systems in those countries are not sufficiently stable to support such a market. If you want a market-based solution to health system strengthening in those countries, you will need first to lift the entire economy to a level where it can support such a system, and also improve governance and regulatory frameworks to make it viable. In the case of Liberia and Sierra Leone, just emerging from civil wars, getting foreign investment requires ensuring peace, and this may not require any specific short-term investment, simply a US or UK guarantee to intervene if things go out of hand[1], and a decent peace framework.
I would certainly like any health system strengthening that occurs in post-Ebola Liberia to have a strong focus on equality sub-nationally, but I don’t advocate lifting Liberia out of poverty because I think transnational health system inequality and economic inequality must be fixed together. I advocate reducing poverty (in this context) because it’s necessary to sustain any investment we make in reducing health inequality.
The same is true with my opinion about responses to AGW: I would like to see them take into account transnational inequality, and also justice (not requiring equal efforts from countries that aren’t equally responsible), but I don’t believe the response to AGW is necessarily tied in with these concepts. I do however think that on a practical level, arguments for AGW mitigation that don’t take into account the demands of developing nations for justice and equality will probably not be very successful. In the case of AGW there isn’t really a debate to be had with the political right about what the correct course would be, since the political right is trapped in denial of the whole problem and only deploys equality or distributive arguments when they suit its program of delay and obfuscation; but in the case of health system strengthening there are elements on the political right who support free market solutions to poverty and health inequality, or who don’t necessarily believe fixing one is intrinsically tied to fixing the other. That’s a debate I’m happy to have because I think it happens in good faith; the same debate can’t happen for AGW until such time as the free market right give up their Dunning-Kruger comfort blankets.
[Anyway let’s not turn this into a debate on AGW; let’s just accept that I agree with your point that the solutions to AGW and inequality are not intrinsically linked and we don’t necessarily have to assume that fixing one will or should involve fixing the other]
On the issue of free market solutions to health system strengthening that reduce transnational health inequality but don’t necessarily interfere with subnational inequality, or have poverty alleviation at their heart, I think George Bush’s work in Africa on HIV/AIDS might work here. He set up a huge fund (PePFAR) to invest in HIV prevention in Africa, but he also worked to introduce a wide range of reforms and market changes that would lead to free market action too – I think his administration helped to solve the intellectual property problems that were preventing delivery of affordable treatments, and as a result of his work South Africa developed a native pharmaceutical industry. But he also set up PePFAR with the goal that it would end and countries would take over the challenge. I think there will be problems with this because Obama is not as interested in Africa as Bush, and so as PePFAR comes to an end insufficient political and technical (non-financial) support is being given to the transition.
As a final point, when I wrote the words on “fix global poverty” followed by fat rich westerners paying more for chocolate, I was primarily thinking of one simple solution: a final, comprehensive liberalization of trade laws to allow the poorest nations to compete fairly in open markets. Alongside this I was thinking of liberalization of migration laws to allow better movement of cheap African labour (can’t see this happening now!), along with strong labour rights for those labourers, and strong legal interventions from the rich nations to force businesses working in poor nations to actually pay the taxes they should pay. I don’t think these interventions necessarily require a lot of government money, though they may lead to increased coffee prices, but they would change the economic structure for poor nations, make it easier for governments of those nations to raise money and raise (and pay) debt, and probably allow more infrastructure development. When I say “fix poverty” I’m not *always* thinking “Big State for the Win!!”
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fn1: Because we all know this works so well!
October 16, 2014 at 11:03 am
Regarding risk, yes I know how risk assessment works. The problem I see is that the low-probability/high-cost events are not being incorporated into risk assessments the way you say they are. For example, a low-probability/high-risk event should incur some kind of consideration, even if minor, and it is obvious that the Dallas hospital at the centre of the US scare didn’t have a protocol for dealing with Ebola. Writing a protocol isn’t difficult: you just email the CDC to get theirs, and then write a couple of pages of guidance for your particular hospital, get some clinical directors to okay it, and save it on the server. It’s unlikely that the Dallas hospital functionaries don’t have time for that! But even that wasn’t done. The second US case, Ms. Vinson, was authorized to fly by the CDC when she had a temperature about 0.4C below their threshold. The cost of preventing the black swan event[1] in this case was one domestic airfare. Failure to take into account these basic considerations makes me think that the risk assessment for Ebola has not been “it’s low probability and high cost, so let’s put a little bit of effort into preparing for it but not much”; it has been “low probability, so let’s forget about it.”
On a government level, I suspect there are lots of things that could have been done that also don’t cost much, but have been neglected because of the same misapplication of risk assessment. I think Obama is not interested in Africa, and his administration has dropped the ball on basic things that might help to prevent these diseases: changing laws to encourage American investments in Liberia, supporting peace plans that would secure borders and lead to reduced military spending by poor governments, preparing protocols for border control during such events, legislation for emergency funds and response measures, that sort of thing. As a small example, the UK and US canceled flights into Sierra Leone, which stranded a bunch of judges outside the country and has brought Sierra Leone’s justice system to the verge of collapse. Couldn’t they have arranged a special flight to get those guys back? Doesn’t cost much, but makes a big difference. My suspicion is that they have no “ebola flight cancellation” plans, they just canceled flights and anyone who is stranded in the UK, well, that’s just their bad luck. Even if they happen to be one of Liberia’s 51 doctors.
So yeah, better risk assessment: we need it. Maybe just attention to the tiny things that make a difference before you ramp up your emergency response. I guess this means I’m in favour of NASA drawing up a meteor-response protocol. Or better still – do they have a protocol for what they will do if the Mars One project goes to hell in a handbasket? I bet you they don’t, I bet you that if that project gets to Mars it will go to hell in a handbasket, and I bet the handwringing we see could have been largely prevented by publication of a protocol…
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fn1: can we please not use this horrible phrase again? Thank you!
October 16, 2014 at 1:59 pm
On Mars One:
1. I don’t care what level of expectation is attached to it. I’m expecting all noise and no footsteps on Mars. At least not on any of the timelines their publishing. [1]
2. Assuming I’m wrong on 1 (Ha!), I really hope the protocol is “If anything happens on Mars, we put the same level of effort into fixing it that we would expect Mars to put into fixing a similar situation on Earth.” So basically a nicely worded sympathy card. And I’m flexible on the wording of the card.
In a broader sense, any intervention or assistance to Mars should be based on a cost/benefit analysis. Exploring another planet and spreading our species there is a big benefit and justifies a high cost. Providing humanitarian assistance to another planet should basically never happen unless every conceivable humanitarian goal on Earth has already been met (Ha!), because they’re never going to be the best cost/benefit ratio.
On black swan events:
What’s your problem with this phrase? The only other options are “Out of context problem” from the Culture series, which isn’t what we’re really talking about, or “Extremely low probably events with massive costs” which is a really wordy way of saying the same thing.
On ensuring policies/processes are in place:
I wouldn’t expect the government (or any organisation) to have a policy on a particular rare disease because any cost/risk calculation on a disease that has never been a threat before is going to return cents worth of expected spend on it. On the other hand it would be reasonable to have an “Oh shit” disease policy that can be readily applied to a range of nasty things even if some of the steps aren’t 100% necessary for the individual cases that could come up.
[1] A project manager predicting failure on a project he knows nothing about? Is this a sign of cynicism or hard won experience?
October 16, 2014 at 2:38 pm
I’m entirely in agreement with the nicely worded letter approach, but I don’t think that’s what will happen, especially if there are children involved. There will be huge pressure to mount a rescue, and if they haven’t been adequately warned in advance that rescue isn’t coming, I think governments will have to cave in to the pressure. Having a secret plan in advance to mount a scientific mission as part of the rescue would solve part of this issue, but I bet that doesn’t happen. Because while you say that it would be reasonable to have an “oh shit” policy, it appears that such an idea is out of fashion with those in power at the moment…
I also think there’s an embarrassment factor at play. no one wants to get the reputation for being the kooky dude at the office who wants to role-play a rare and catastrophically fatal disease outbreak – what are you, some kind of apocalypse fetishist?! I bet the people who thought of suggesting it a year ago are regretting holding their peace right about now …
October 17, 2014 at 11:25 am
The last major disease scenarios I’ve heard of were a rash of “zombie attacks” that authorities ran containment scenarios on a couple of years ago. Those were explicitly noted as nonsense, but a useful exercise because any real disease was likely to be less than 100% fatal, 3 days to death and capable of infecting after death. And if we compare it to ebola, we see that those assumptions are right.
So maybe the issue is less that people are worried about suggesting edge cases as they’re not embracing off the wall shit often enough. If there was a yearly mock-disaster where the scenario explicit had to be “zombies” or “invasion from hell” or “10% of the populace vanishes” then those (highly memorable) scenarios and plans could easily be adapted to more realistic events.
PS That’s not to say that such events should be deliberately insane, but that a risible and memorable reason should be created to mock up more realistic long shot disasters.
October 17, 2014 at 5:12 pm
Another problem with this kind of plan is the modern habit of using departments like the CDC as a means of political attack, and not assessing their work independent of the politics of the govt of the day, as in with McCain’s infamous attack on the Parks and Wildlife Service for studying polar bears (<- I may have every single fact in that clause incorrect, but I can't be bothered googling it because you could replace various words with "mickey mouse," "benghazi" and "fruit juice" and you'd probably get an actual event in modern American politics). If the CDC actually spent a day doing an entertaining but actually quite interesting (from a public health perspective) and informative "zombie outbreak wargame" it would be pilloried in senate hearings – even though as you say the disease shares a surprising number of dynamic properties with Ebola. Heads of Dept in the US seem to have to be quite risk averse when it comes to their internal activities. This is certainly true in Australia, though it tends to be more the tabloid media that run the witch hunts. I remember working in a hospital in Sydney, and we couldn't even use just $100 or $200 from our budget for our christmas drinks; when we wanted to hold our annual planning and review day somewhere nice (in a winery outside Sydney) we had to do a fundraiser for it, because we couldn't use a single cent of government money for anything nice. We actually once had an argument with the adminstrative office about setting aside a portion of our budget for biscuits in the staff area. Fucking biscuits. You can imagine what would happen if we had a three hour session on the dynamics of zombie epidemics, especially if it came with … biscuits! My guess is that the CDC has to make all its work look like it is related to current risks, not speculative. I can imagine for example that a two day research retreat about the threat of emerging infectious diseases due to climate change could get the CDC into a lot of hot water if the wrong people found out about it, yet it is obviously part of the CDC's responsibility to consider that stuff. Wargaming a massive Ebola outbreak would probably count as similarly speculative.
Although I'm using the political right for my examples, I am sure this would cut both ways. All those articles bemoaning "why do we care about ebola" from left-wing sources, which I was complaining about a post or two ago, would manifest as criticism of the CDC for wasting taxpayer money on "sensationalist" diseases, if the Democrats were in opposition. (And oh, don't those articles look stupid now …?) As someone who worked in the public service for a while, and felt like I did genuinely good things on a low budget, I find this politicization of their work really frustrating.
To get the thread back onto the topic of the effects of Ebola on civil society, I found an article in Science today about the death of five authors from a single study. The study traced the genetic origins of the current Ebola outbreak, so was probably similar to the HIV study I reported a few days ago. The authors, all Sierra Leonian, represent a huge loss to medical science both within Sierra Leone and globally. Between them they had 66 years’ experience treating Lassa fever, a similar disease to Ebola, and were world leaders in the management of the disease. One was a senior figure in the Ministry of Health. Three of them died from Ebola contracted treating a pregnant nurse, and two from Ebola contracted in other ways. It’s easy to think of low-income countries as lacking medical expertise sufficient to contribute to the body of public health knowledge on a global scale, but as Greg Laden observes somewhere in comments on his Ebola posts (I can’t find where anymore), a lot of the expertise on tropical medicine is actually in the countries where the disease occurs and they do actually contribute a lot to our global understanding of these diseases. It will take a generation to replace these people, and their loss makes fighting the current epidemic more difficult.
October 18, 2014 at 5:54 pm
As a taxpayer, I’m open to the idea that government agency time can usefully be spent preparing for dragon attack because that would be similar to X or Y or Z and all of those are bad. I’m less open to the idea that this planning needs to happen over two days at a winery. [1] But you can have biscuits and the newspapers in your break room.
Not that I get biscuits anymore. And even when I did they were the cheap ones because my (then) employer felt that Arnott’s was too expensive or something… [3]
I’ve actually worked with one guy who was with a bank long enough (10+ years) that when they took the free news papers out of the break rooms his comment was “I remember the last two times they did this.” I think he intended to just not follow current events until they came back again 🙂
So yeah. Thread derailed…
On topic, the deaths of experts such as you mention is a tragedy in its own little unique way on top of the broader disaster.
[1] I’ve been on precisely one junket to a winery for my job(s). And it was a complete waste of time. As someone who’s participated in the employee share scheme I demand they not run such a thing again and next time just give me a case of beer while locking me in room. [2]
[2] I’m flexible on whether there needs to be any event/training/planning when this happens.
[3] Seriously. We had an employee feedback process where “bring back the better biscuits” was our major feedback item. Frigging as dry as dust biscuits. I’m still a little angry about this, and I was one of the moderates.