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Belmont Club

The Ordinary World

October 11th, 2014 - 4:23 pm

A Jewish friend of mine said that the Holocaust created a crisis of faith for his people because as he put it, “if a merciful God existed, then how could could Hitler come to be?” Bad times have a way of raising such questions. Wikipedia cites at least 3 occasions  when humanity suffered so badly it believed that God himself was chastising them: the Black Death, the invasions of Attila the Hun and the depredations of Genghis Khan.

Poll after poll shows that America is in a pessimistic mood.  Time quotes Southern Command’s General John Kelly as gloomily concluding that “if it [Ebola] breaks out [in Central America], it’s literally, ‘Katie bar the door,’ and there will be mass migration into the United States. They will run away from Ebola, or if they suspect they are infected, they will try to get to the United States for treatment.”

Yet it could be worse, as no less than the president told an audience in Rhode Island, “the truth of the matter is that the world has always been messy. In part, we’re just noticing now because of social media and our capacity to see in intimate detail the hardships that people are going through.” But in reality “this is not something that is comparable to the challenges we faced during the Cold War.”  The New York Times said of the presidents perspective:

Governing at a time of war, terrorism and disease, and frustrated on multiple fronts at once, Mr. Obama finds himself trying to buck up supporters heading into a crucial midterm election season. The succession of international crises has taken a toll on the public mood, not to mention his own poll ratings, and he seems intent on reassuring Americans that the challenges are manageable.”

It is hard to argue with the proposition that “if you survived the Atomic Age, you can survive me”. These may not be the best of times, but as the president said, neither are they the worst of them.

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The President as a Hallucination

October 10th, 2014 - 5:57 pm

The New York Times tries it best to convince itself that the “Darkness” — at it puts it — isn’t real. In an article titled “Cry of G.O.P. in Campaign: All Is Dismal”, Jeremy Peters tries to shake his readers out of a funk.

Darkness is enveloping American politics …

Hear it on cable television and talk radio, where pundits and politicians play scientists speculating on whether Ebola will mutate into an airborne virus that kills millions. See it in the black-hooded, machine-gun-brandishing Islamic extremists appearing in campaign ads. Read about it in the unnerving accounts of the Secret Service leaving Mr. Obama and his family exposed.

But get a grip on yourself … the bad news … doesn’t really exist.  It’s just an illusion conjured up by Repubicans.  Democrats, the president warned, “get depressed too easily”.  Obama warned that “we live in such a cynical time, partly because of how the media is now structured”.  Stop reading the news, quit looking out the window and you’ll see the light.  The hostess of a recent fundraiser, Hollywood actress Gwyneth Paltrow, turned her face toward the true sun. “You’re so handsome that I can’t speak properly,” said Paltrow, introducing the president at her home.

The Democratic Party finds itself in a position not unlike Ivan Karamazov, who imagines the Devil is sitting in his sofa and begins to talk to him.  Ivan is not perturbed because he is convinced the Devil is not real;  just a hallucination, simply a bad dream.  In that way he can be accepted as harmless, a simple facet of our own character.  Something ultimately susceptible to baths, therapy or elixirs.  Nothing to fear. But the Devil shakes his confidence by pointing out that,if Ivan truly disbelieved in his existence then why was he talking to him?

“Never for one minute have I taken you for reality,” Ivan cried with a sort of fury. “You are a lie, you are my illness, you are a phantom. It’s only that I don’t know how to destroy you and I see I must suffer for a time. You are my hallucination. You are the incarnation of myself, but only of one side of me… of my thoughts and feelings, but only the nastiest and stupidest of them. From that point of view you might be of interest to me, if only I had time to waste on you-”

“Excuse me, excuse me, I’ll catch you. When you flew out at Alyosha under the lamp-post this evening and shouted to him, ‘You learnt it from him! How do you know that he visits me?’ You were thinking of me then. So for one brief moment you did believe that I really exist,” the gentleman laughed blandly.

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I’m Just a Gigolo

October 8th, 2014 - 3:08 pm

A mistress seldom reflects that if she can persuade a husband to betray his wife she might someday be the next to be cheated on. For any arrangement founded on dishonesty suffers from the danger that you may be deceived in turn. In the context of politics the relevant question to ask is why the administration, having betrayed the Kurds, should not betray someone else. The Kurds have long been a pawn in regional politics.

In 1975 Congress, concerned by Watergate and possible illegal clandestine activities, created the Pike Committee to examine CIA effectiveness and its cost to taxpayers. It soon clashed with the CIA and the White House over access to classified documents. Although Congress voted to never publish the Committee’s report, copies were leaked to the Village Voice. The report noted, among other things, the Kurds had agreed to resume their war for autonomy against the Iraqi Government with support from the Shah of Iran and assurances from the United States Government that it would help as well. The report stated that while Barzani often “expressed his distrust” of the Shah, he trusted the United States. It concluded the United States and Iran actually “hoped that our clients [the Kurds] would not prevail. They preferred instead that the insurgents simply continue a level of hostilities sufficient to sap the resources of our ally’s [Iran's] neighboring country [Iraq].” Of course, “this policy was not imparted to our clients, who were encouraged to continue fighting. Even in the context of covert action, ours was a cynical enterprise.”

They’ve been shafted again. The editors of Bloomberg note that the Turks are watching ISIS destroy the Kurds, in much the same way as the Soviets stood by and let the Nazis crush the Warsaw uprising. You will remember that the Second World War, “Winston Churchill pleaded with Stalin and Franklin D. Roosevelt to help Britain’s Polish allies, to no avail. Then, without Soviet air clearance, Churchill sent over 200 low-level supply drops by the Royal Air Force, the South African Air Force and the Polish Air Force under British High Command. Later, after gaining Soviet air clearance, the US Army Air Force sent one high-level mass airdrop as part of Operation Frantic. The Soviet Union refused to allow American bombers from Western Europe to land on Soviet airfields after dropping supplies to the Poles.”

What’s old is new again. Bloomberg describes how the Turks are watching the Kurds die:

In blocking the resupply of the Kurdish fighters who are trying desperately to hold off a siege by Islamic State in Kobani, Syria, Turkish President Recep Tayyip Erdogan is making a decision that may haunt Turkey for years to come.

This is not just about Turkey’s failure to join the U.S.-led coalition against Islamic State. It also threatens Turkey’s fragile truce with its Kurdish minority, many of whom are growing impatient with the sight of Turkish soldiers watching, from their side of the border, as Islamic State attacks Kobani.

As in the days of the Shah, the Kurds who had no faith in  regional allies put their trust in America. Why? Maybe that old black magic, some residual sentimentality compounded of Shane and High Noon and Saving Private Ryan and Mr. Smith Goes to Washington persuaded the Kurds against their better judgment to roll the dice one more time. But it’s come up snake eyes.  Like CNN says “several senior U.S. administration officials said Kobani will soon fall to ISIS, which calls itself the Islamic State. They downplayed the importance of it, saying the city is not a major U.S. concern.”

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Paradigm Shift

October 7th, 2014 - 3:51 pm

I had the idea that narrative in crisis  goes through 3 phases: denial, overconfident half measures to restore normalcy and when that fails, panic.  What follows the panic is probably a paradigm shift.  It’s time for one. The current PC paradigm has been failing for some time. The rise in terrorism and Ebola have highlighted its shortcomings, although the old players are still trying to force the new situation into the same old tired talking points with ever more absurd results.

For example, Jesse Jackson has descended on Dallas “to address the virus scare and ‘seek the best humanitarian relief.’”   Even more tragi-comic is Spain’s response to accusations that a nurse was somehow infected through her protective garments. They’ve decided to shoot the patient’s dog.

Spanish authorities plan to kill the dog of the nurse who tested positive to Ebola in Madrid.

The woman’s husband, who has been put in quarantine, said in an interview with Spanish newspaper El Mundo that he … received a phone call by Julio Zarco [director general of the Patient Care of the Community Madrid] who told [him] that the dog should be killed. He asked me if I can give the authorisation, but I didn’t give it.

“But he told me that if I don’t give my authorisation they will ask the judge for a permission to enter my property and kill the dog,” he continued.

Spain has gone from complete confidence in its systems to public accusations that the nurses attending its two repatriated Ebola patients were not provided with Level 4 protective clothing.

However, the hospital’s health workers said that the suits worn to attend the priest and the missionary did not meet the necessary safety requirements, Spanish newspaper El Pais reported. The nurse should have worn fully waterproofed-clothing with biosafety level 4 and with breathing autonomy. However, the suit used had only biosafety level 2.

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Unless Otherwise Directed

October 6th, 2014 - 4:42 pm

A Spanish nurse became the first person to contract Ebola outside of Africa.  She helped treat the second of two priests who had been evacuated from Liberia with the dread disease.  One might be forgiven for thinking Ebola was contagious. But this as the Daily Mail says the CDC told the stepdaughter of Texas Ebola victim Thomas Duncan that it was alright for her to return to work as a nurse’s assistant in a local hospital.  Fortunately, Ms Jallah has decided not to return to work — yet.

Ms Jallah whose contact with Mr Duncan – who remains in a critical condition – was far more intimate and prolonged than that of her husband, told MailOnline on Monday: ‘The CDC came yesterday. They said I can go back to work but I do not know what I will do. I will not go back yet.’

Doctors say that no-one is at risk of catching the virus unless they come into contact with a sufferer who is exhibiting symptoms.

All-clears are all important. Just now authorities gave the all-clear to allow the Dallas hospital to use an experimental medicine called brincidofovir to treat Mr. Duncan, probably inasmuch as his condition is “critical” and there is not much hope without trying a new tack.

“We are hopeful that brincidofovir may offer a potential treatment for Ebola Virus Disease during this outbreak,” Dr. M. Michelle Berrey, the president and chief executive officer of Chimerix, said in a statement released Monday by the company.

Chimerix is working closely with the Food and Drug Administration to finalize a clinical trial protocol early this week to assess the safety, tolerability, and efficacy of brincidofovir in patients who are confirmed to have an Ebola infection, said the statement.

The story of brincidofovir is itself the tale of regulation, permissions and guidelines. Modern medicine is as much about law and protocol as it is about treatments. Brincidofovir was recently in the news as part of a campaign to make it available for a dying boy.

David Kroll at Forbes explained it is generically known as CMX001 and developed as part of an anti-bioterrorism initiative. Although it showed great promise, the active ingredient cidofovir was extremely toxic to patients and could not be stored for any length of time. A company called Chimerix, however,   spliced cidofovir with lipids thereby synthesizing a drug which could be stored on a shelf and administered orally. It was also, for some reason they could not completely understand, far less toxic that cidofovir.

the lipid attachment had two immediate benefits. First, it increased the antiviral effect by 40 to 400 times that of cidofovir. Second, oral CMX001 was taken up into the bloodstream of animals – and later, humans – more than 50 times better than cidofovir.

Hostetler noted that another advantage of adding this lipid was that it neutralized a chemical charge on the cidofovir molecule that caused the drug to concentrate in the kidney via a pump that we normally use to rid ourselves of certain acidic substances. Since CMX001 wasn’t used by this pump, it didn’t seem to concentrate in the kidney like cidofovir does.

But drugs are not merely chemical substances.  They are political objects. Chimerix found that developing a last-chance drug attracted the attention of the desperately ill and put them in the vortex of a legal, media and compassionate crisis crisis.  Chimerix, despite the poorly understood safety, became the subject of “relentless pressure to provide its potent antiviral drug to Josh Hardy, the Virginia first-grader who received a bone marrow transplant and is now fighting off the potentially lethal adenovirus.”

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The Anatomy of Surprise

October 5th, 2014 - 1:41 pm

The World Health Organization’s (WHO) handling of the Ebola outbreak in West Africa was  called into question by Peter Piot, the Belgian virologist who discovered it decades ago. In recent interview in the Guardian, Piot asks, ”why did WHO react so late?” He answers the question himself.

it was because their African regional office isn’t staffed with the most capable people but with political appointees. And the headquarters in Geneva suffered large budget cuts that had been agreed to by member states. The department for haemorrhagic fever and the one responsible for the management of epidemic emergencies were hit hard. But since August WHO has regained a leadership role.

The accusation was amplified by an article in NDT, citing Medecins Sans Frontieres officials who say the regional WHO response was absent. “In all the meetings I attended, even in Conakry, I never saw a representative of the WHO,” said Lugli, deputy director of operations for MSF Switzerland. “I didn’t see it the first three weeks and we didn’t see it afterwards.”

Politics was at the heart of the problem, according to unnamed sources. “Insiders say the WHO is amongst the most politicized of U.N. agencies, with governments holding sway over its regional operations. The director of its regional African bureau (AFRO) based in Brazzaville, Congo, is appointed by governments and has access to locally raised funds, allowing autonomy from Geneva.” It didn’t help that WHO Director-General Margaret Chan of China unduly deferred to local governments even when it was clear they were phoning it in.

Peter Piot, a former WHO official who co-discovered the Ebola virus in 1976, said the delay in doing this was a crucial factor in allowing the epidemic to reach unprecedented levels.

“It took another five months and 1,000 deaths before the WHO declared this a public health emergency,” said Piot, director of the London School of Hygiene and Tropical Medicine

For its part, AFRO claimed they were in the dark because their subordinates  had suppressed the bad news.

WHO officials say the epidemic raced ahead of efforts to control it from the start because Guinea took more than three months to notify the agency of the disease.

Only on March 13 did Guinea notify the WHO, which sent a team to the southeast the next day. Samples dispatched to a laboratory in France showed on March 21 what many feared – Ebola had struck a completely unprepared region.

“It was way too late,” said AFRO’s [Dr. Luis Gomes] Sambo, “Hundreds of unidentified people were already infected.”

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My Hull is So Big and the Leak is So Small

October 3rd, 2014 - 3:17 pm

A Missouri doctor made news the other day by checking in at the airport wearing a Hazmat suit to dramatize his belief that the CDC is “lying” about the dangers of Ebola by downplaying it.  He subsequently made a number of headline-grabbing statements which some may regard as scaremongering or alarmist.  CBS talked to Dr. Gil Mobley to get his point of view. Mobley said:

“For months, doctors in my community — since we had a meeting six weeks ago — have been convinced that the United States will be importing clusters regularly. Right now, on the continent of West Africa, there are a million people in isolation, in quarantine, because of Ebola, and ten thousand passengers leave West Africa every single day. It’s just a matter of time before this disease is carried to every corner of the world.”

“They said the chance of importing a cluster — just two weeks ago — was extremely small, yet we knew that it was a sure thing. And the very same day that the President echoed [Director Tom] Frieden’s sentiment at the CDC that it’s very small, that very same day, they made the misdiagnoses in Dallas and sent this infectious guy home to infect these other people.

“They said the chance of importing a cluster — just two weeks ago — was extremely small, yet we knew that it was a sure thing. And the very same day that the President echoed [Director Tom] Frieden’s sentiment at the CDC that it’s very small, that very same day, they made the misdiagnoses in Dallas and sent this infectious guy home to infect these other people.”

Is Dr. Mobley crazy? After all the CDC asserts that the “chances of importing a cluster [are] very small”. But that may be true without contradicting Dr. Mobley’s argument because they are talking about different things.  The CDC is talking about probabilities (or “chances”) as expressed in percentages while Mobley is talking about expected values which is the number of Ebola patients you can predict will arrive over time.

What is expected value? “In probability theory, the expected value of a random variable is intuitively the long-run average value of repetitions of the experiment it represents.” Think of it as the long run value of a bet. If you have a ten percent chance of winning $500 the expected value of the bet is 0.1 x $500 or $50.  If you’re playing 10 percent for a million the bet is more valuable.  It is .1 x $1M or $100,000.

The chances of an Ebola infectee coming to the US  is the sum of the probabilities it can arrive by all possible paths.  If node 5 in the diagram below represents the US, then it can be reached from node 1 via 1-2-6-5, 1-2-3-5 or 1-3-5.  If the chance of the first two are .0001 and the odds of  the latter are .001 then the total chance of getting from 1 to 5 by all possible routes is .001 + .0001 + .0001 or .0012.

Expected Values and Isolation

Expected Values and Isolation

When the CDC says the probability of a diseased person reaching the US is “very small” they are talking about the betting odds, which in our hypothetical example was 12/10,000 or .0012. But remember that expected value has a second term: the stake at the table.  If there is one Ebola patient with a .0012 chance of reaching America that is one thing, but if there 10,000 people each with a .0012 chance of getting through that is another.  The CDC is saying that they have a revolver with thousands of chambers and only of them has a cartridge in it. Mobley is saying that’s true but if you keep playing Russian Roulette long enough you’ll eventually hit upon a loaded chamber.

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The Trouble With Armor

October 2nd, 2014 - 3:52 pm

There’s a famous picture from the Liberian civil war showing a militiaman geared up with “body armor”.  The militiaman’s body armor is actually a flotation device or life jacket.  But it sort of looks like body armor and he may think it’s going to work. It may give him some psychological protection, but the life jacket is of doubtful ballistic worth.

Cargo Cult Body Armor

Cargo Cult Body Armor

The proof of any defensive system is whether it actually works. In the case of body armor, it is whether the gear stops projectiles of a certain type. In the case of defenses against disease, the test is whether it detects and hinders disease carriers. The protective screen between the West African Ebola outbreak did not stop a Liberian man from flying to Texas.  This has prompted a bipartisan group of lawmakers to inquire into the adequacy of America’s epidemiological body armor.

After a Liberian man arrived in Dallas and became the first confirmed Ebola case in the U.S., lawmakers are urging more aggressive action and some said they would convene hearings. Ohio Republican Senator Rob Portman renewed a call for the U.S. to check travelers for Ebola symptoms, pressing Thomas Frieden, head of the Centers for Disease Control and Prevention….

In a letter yesterday, congressional Democrats led by California’s Henry Waxman, said lawmakers should hold a hearing to examine, among other things, whether U.S. officials are “adequately screening travelers to and from Africa to prevent importation of additional cases into the United States.”

Jason McDonald, a spokesman at the CDC, said the agency has no intention of raising screening process at U.S. airports from passive to active.

Does it really work, or is it like the Liberian militiaman’s armor, more reassuring than real? The reason the CDC retains confidence in its defenses is because it regards the arrival of Thomas Eric Duncan an example of a ‘freak shot’. He transited the defensive belt in the time gap before he became symptomatic, which to the CDC’s way of thinking is before he became contagious. Abby Phillip of the Washington Post describes the CDC’s reasoning.

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Can Do

October 2nd, 2014 - 7:25 am

More than 80 people are now suspected to have been in contact with the first US Ebola case. ABC News says “the number of people who came into contact with Texas Ebola patient Thomas Eric Duncan has zoomed from as many as 18 to 80, health officials in Texas announced in a statement today.”  That number probably does not include those he came into contact with earlier, as it transpired that “he flew on two airlines, took three flights, and had lengthy airport layovers – including one at Washington Dulles International Airport – before reaching Texas on Sept. 20.”

And just now the count has clicked up to perhaps 100 persons exposed, according to the NYT.

Not to worry, say the Feds because only actually sick people are contagious. “The Metropolitan Washington Airports Authority and various federal health agencies maintained late Wednesday that other passengers on the flights were at no risk of infection because the man had no symptoms at the time of his trip.”

This is the standard screed. Tom Skinner of the CDC said “I want to underscore that Ebola poses little risk to the U.S. general population.  Transmission is through direct contact of bodily fluids of an infected person or exposure objects like needles that have been contaminated with infected secretions.  Individuals who are not symptomatic are not contagious.”

Under this model of transmission, those who attend to the sick are in the most danger. Thus, doctors, nurses, attending family members and Good Samaritans are at greatest risk unless provided with protective clothing. Helping out is what got patient zero Thomas Eric Duncan infected in the first place.

It appears an act of compassion led Thomas Eric Duncan to contract Ebola, and become the first patient diagnosed with the deadly disease on U.S. soil.

Just four days before he boarded a plane bound for Dallas, Texas, Duncan helped carry his landlord’s convulsing pregnant daughter to a Liberian clinic to be treated for Ebola, the New York Times reports.

That’s the theory anyway. There’s some difference of opinion about whether only symptomatic individuals are contagious. The basic objection raised is that the boundaries around symptomatic are fuzzy, that there remains some residual chance that pre-symptomatic and post-symptomatic individuals can still pass on the disease, albeit with a lower probability.  Science Blogs says, for whatever it’s worth:

According to the usual sources (WHO and CDC for example) the following is probably true. When someone gets Ebola, typically, after a while they get sick. This means they show symptoms. If they did not show symptoms they would not be “sick” even if the virus was in them and even if the virus is multiplying in them. Presumably people are infected with a sufficient number of viroids that they become a host for the disease, the virus starts to multiply above some level that makes the person sick, and we can say at that point that they “have Ebola.” This is when the infected person is able to transmit the disease to others through bodily fluids that might come into contact with wounds or mucous surfaces in the downstream patient.

This is what the WHO and CDC literature on Ebola says, and this has lead bloggers and news outlets to state incorrectly that Ebola is only transmitted to others when the person shows symptoms. Unfortunately this is not true in one or possibly two ways.

It appears that people who have had Ebola, live, and get “better” (i.e., their symptoms go away) can still carry Ebola for a period of time, and in this state, they can still transmit it. What has probably happened is their immune system has started to fight the virus enough that it is attenuated in its effects, but it isn’t’ entirely gone yet. Medical personnel like to send someone home only after the virus has cleared. Even so, men who are supposedly virus free by that standard, when sent home after surviving Ebola, are told to avoid sex for several weeks because there is still the possibility of sexual transmission of the virus. Meaning, of course, that the virus is still knocking around in some individuals at this point, and still transmittable. It is not clear how likely that is to happen.

This is very important. Most people would interpret “only transmitted by people showing symptoms” (or words to that effect) when they read it in a news outlet as meaning – well, as meaning exactly what it says. But post-symptomatic patients may still transmit the disease.

Is it possible that pre-symptomatic people can transmit the disease too? Personally I think it is possible even if it is generally unlikely. In a disease that kills over half of those who get it, “unlikely” is not comforting.

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Ebola in America

October 1st, 2014 - 12:33 pm

News that Ebola has arrived in the United States from Liberia and that many people may have already been exposed to the disease was yet one more reminder that “they” cannot completely protect everyone.  There was always the chance it would arrive. By plane, or over open border — but somewhow. The spread of the disease has been modeled by the CDC as a Markov chain which measures the probability of going from one state to the other.

There was always a joint probability that someone from an Ebola zone could make their way across a series of paths to your city. In the beginning it was a nonzero but relatively small percentage. When applied to a small number of infected, the Markov value it would arrive in America was small. But as the population exposed to the disease increased, the number of times the dice was rolled increased until suddenly bingo: Ebola in Texas.

Nobody beats arithmetic. Not even “they” can. By opening the borders, or avoiding the trouble of preparedness in the belief that “it won’t happen to me,” they’ve changed the physical odds in favor of the virus. And the physical odds are what count. It’s witch doctor thinking to rely on “assurances” from political shamans for protection. Assurances are nothing but amulets from public policy voodoo doctors to make you think “they” can alter reality.

Chris Matthews found out that fact the hard way when he confronted Zeke Emanuel with the objection that “the president promised”:

On MSNBC’s Hardball tonight, host Chris Matthews tussled with Obamacare architect Dr. Ezekiel Emanuel over the how serious a threat Ebola is to Americans. Matthews and Emanuel also spar over President Obama saying it was “unlikely” that an Ebola case would strike the U.S.

“Obama said it was unlikely. It has happened. It’s here,” Matthews said.

The actual exchange went:

CHRIS MATTHEWS: I’m just trying to follow the logic here. Everybody’s being told, don’t worry unless they have the infectious symptoms, you can see them, that you don’t have to worry about catching them. Yet, this guy picked up the disease apparently from somebody who did not have the infectious symptoms.

DR. EZEKIEL EMANUEL: Again, don’t hypothesize because we just don’t know. We have no idea what he did or didn’t do and how he got it. I’m sure that’s going to be vital information to try to understand the transmission, but the idea that there’s going to be a widespread outbreak here, I think is just, again, it’s a bit of fear mongering. We have a single case. This is not a big, widespread –

MATTHEWS: Yeah, yeah, but I’m just going back to the president’s statement, doctor, and that is that the president said it would be unlikely if we had a case in this country. Unlikely to even have one case. You want to see the tape again?

EMANUEL: He said there wouldn’t be an Ebola outbreak.

MATTHEWS: No, and in the second part of his sentence he said in the unlikely case someone brings it here. In the unlikely case someone brings it here. Well, they’ve done it. We’re living in the world of the unlikely already. That’s all I’m saying. I’m not fear mongering. I’m stating the facts and I wonder if everybody else is.

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