walkitout (walkitout) wrote,
walkitout
walkitout

A few remarks about someone else's remarks about a disease that has been in the news lately

A friend posted a link to a blog post written by a nurse, about ebola. I didn't like it. (Are we surprised? No, we are not surprised.) I waited a while to respond, and chose _not_ to respond where the link was originally posted, because FB comments are just not great for the way I like to write about things.

Please feel free to go, ugh, I never want to hear about that stupid disease again and skip right on over this post.

I am not a health care professional, altho I am related to some; perhaps one or more of my friends and relatives will chime in with an improvement to this.

Here's what started me writing about ebola:

http://dtolar.wordpress.com/2014/10/01/ebola-a-nurses-perspective/

I have some really serious problems with this writeup.

The most significant problem I have is the idea that you could infect someone before you had any symptoms.

"Just like with the flu or hand foot and mouth disease, you can be spreading it to others before you show a symptom*(apparently not many see the *, so please read the elaboration at the bottom).”

You generally do have symptoms. In the case of the flu and ebola, the symptom may be a general run-down feeling and a low grade fever which isn’t definitively any one particular illness. But it is a symptom. I am trying to understand why we think an unenforceable travel ban would somehow be useful — but we aren’t talking about things like, say, asking everyone who has a low grade fever and a general run down feeling to maybe stay 3 feet away from everyone until they are clearly, identifiably sick with whatever they are sick with. You know, paid sick leave from the government, type of thing. That wouldn’t just help with the terrifying but low-probability ebola, but the less terrifying, more probable flu. Which we are now in the season of. It would also deal with the doesn’t-have-ebola-but-might-spread-it person, too (whether sticky-fingered or asymptomatic carrier).

In the lower part, the author talks about how someone can have matter from a sick person on them, spread it around, but never get sick from it themselves. This is true, altho the relevance to the discussion is pretty limited, and tends to spread fear more than anything else. The kind of contact tracing and isolation we are doing is actually addressing this kind of risk. Otherwise, they wouldn’t be bleaching the crap (literally) out of a middle school attended by kids who were on the same flight as someone who really did have ebola. Kids who in all likelihood, don’t have ebola and never will, just like the lab tech on the cruise ship, but who we are asking to limit the amount of people they have contact with until we know for sure.

The second problem I have is the idea that this is a disease we are unfamiliar with because of where it is from. Laurie Garrett (“The Coming Plague”) and Richard Preston (“The Hot Zone”) both did books about this 20 years ago that are still in print (and available in ebook form) and still sell well. A bit over wrought, and with their own problems, but anyone who read them Back In the Day is well aware of how ebola kills.

"It is foreign to the US, both literally and figuratively.”

"Imagine if cancer was infectious, and you lived in a country with zero cancer, and someone thought it would be a good idea to fly a few people in. I think there would be a different attitude.”

Here’s the deal. (For the moment, we’re going to ignore the fact that some cancer actually is infectious, because the author of the piece appears to know that and to have simultaneously forgotten it. Plus, cigarettes.) If you ban something that people really want to do, you’d better fucking well have an amazing plan for how you are going to enforce it. Because if you _let_ people do it while regulating it, you have a chance. If you _ban_ it, and there are ways to sneak around it, they will. And in the meantime, language that focuses on how it comes from Over There feeds into a lot of terrible politics and fear and bad policy and etc. that we don’t need more of. (viz Republican Duncan Hunter saying IS are crossing over the Mexican border and he knows because we’ve already apprehended some. Denied immediately by the Homeland, obvs)

The third problem I have, which could be the worst of all, but probably isn’t actually that big of a deal because everyone in this country is so terrible at understanding numbers anyway, is the idea that we know how deadly ebola is. We don’t. Here are some things we _do_ know. It is actually kind of difficult to catch. It is survivable _without_ modern nursing care, especially if your ancestry is from the region in which ebola has animal reservoirs. We’re just starting to really understand this right now, but sometime in the next few years (or decades), we’ll probably have some testing to determine how resistant a given person will be to ebola. Now that ebola has moved _outside_ that area, and into an area with more mobile, urban people, it is more lethal than it typically is where it originated (altho it is not completely clear why that is). Here’s another thing that anyone who read Laurie Garrett knows: ebola is THE classic example of nosocomial amplification. And that nurse didn’t fucking mention it _at all_. When you have a seemingly unstoppable ebola epidemic, the way you stop it is simple: close the hospitals and tell everyone to stay home. About a month later, it’s over. Why does this work? The people who die, die. The people who live, live. And the people who might have caught it by helping or being around someone who was sick, or by being tested by health workers who are themselves sick … don’t.

What we’re going to find out with this epidemic is whether the hospitals we (the British army, Doctors without Borders, Samaritan’s Purse) build in Africa are better than the ones which amplified ebola in past epidemics. They probably are. And then we’ll find out what the side effects of that are, because if you have hospitals that don’t amplify themselves but you don’t have enough space in them, you may get waiting spaces that amplify. Sort of like the circles of hell.

In the meantime, let’s not lose track of the numbers so far, in our fears about the numbers in the future.

http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html

Those numbers are showing about 5000 deaths out of about 9000 total cases. And WE KNOW that the total cases number could well be way bigger proportionately than the total deaths is. That is, we’re probably closer to the right number of deaths from ebola than we are to the total number of cases of ebola.

How do we know this? Well, people have been going around checking for antibodies to ebola and finding them in people who weren’t identified as cases. Quite a few people, actually. And we also know from every other studied epidemic _EVER_ that when the panic subsides, we find out that the identified cases were a tiny fraction of the total cases, but a lot of diseases that seem disastrously lethal turn out to fly under the radar of, Oh I Just Thought I Had a Really Bad Cold in many people. Or, as in Typhoid Mary, no cold at all, just the last person you want preparing food for other people.

http://www.nbcnews.com/storyline/ebola-virus-outbreak/what-if-lots-people-have-ebola-proof-blood-n228346

“In some outbreaks, up to half of people at high risk of infection who were watched never got sick, but they had antibodies against ebola in their blood.”

And this is true of stuff we “know” is 100% lethal. “One study showed that people in Peru appeared to have survived rabies … One in 10 people tested had antibodies to rabies but many couldn’t recall having gotten sick.”

So should we worry about Ebola Mary?

http://www.nytimes.com/2000/06/27/world/people-carrying-ebola-in-some-cases-may-be-free-of-symptoms.html
"Dr. Leroy's team studied 25 individuals who never developed symptoms although they lived with family members and cared for them without using gloves and other precautions in two outbreaks in Gabon in 1996.

Using standard virologic techniques, the scientists from Gabon, Germany and France said they could not detect the virus in the blood of the healthy contacts. But Dr. Leroy's succeeded by using a technique known as polymerase chain reaction to grow the tiny amount of virus present."

That’s a _really_ low viral load. Probably don’t need to worry about that. (ETA: Altho we might need to worry about the lab techs PCRing ebola virus -- and then catching it themselves, giving it to their family, etc. This is why we don't even let people study smallpox anymore. People's lab technique is frequently Not Good Enough.)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870608/

"Although there is evidence of asymptomatic carriers, the very low levels of virus detected in these individuals suggest they do not pose a significant source of transmission.”

(That article actually has a really nice discussion of R0 if you can sit through it. The R0 analysis does not take into consideration cultural context — but the control intervention analysis at the end does, qualitatively.)

There are things we _really_ should be freaking out about. I nominate global warming and the need to take well understood steps to stimulate our economy (repairing infrastructure and other large projects with a high degree of public support that provide jobs and get money moving around again), along with protecting access to reproductive health care for all women. I’m sure you’ve got a few of your own. As long as it isn’t ebola or IS, or Miley Cyrus twerking, I’m happy to listen to the arguments as to why there is a problem and what we should do about it.
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