Belmont Club

Can Do

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.

Still the basic probabilities do not seem to be in doubt.  Nigeria showed that health people can shut Ebola down by thorough contact tracing and rigorous isolation. It’s basically like fixing a plumbing leak, a task which Joe the Plumber would understand.  Changing the broken part fixes most of the leak.  The residual trickle round the sides can be stopped by gaskets, seals, packing etc.  By corralling all the infectious people the vectors around the edges diminish to insignificance and the arithmetic starts to work in your favor.

But just because a problem can be solved doesn’t mean it will be solved. As with most governance problems — and plumbing — identifying what ought to be done is straightforward. It’s carrying it out in the face of politics that makes the straight road crooked. After all, it wasn’t hard in theory to secure the White House against a single mentally disturbed individuals, but theory is of no help when implementation fails.

One of the biggest dangers to implementation is the false assurance or  security blanket. Just now the New York Times published a piece describing the “screening system” protecting the US from the West African outbreak. The name “system” is grander than the reality.  The CDC sent a bunch of experts to West Africa to train the locals with some helpful hints. The knowledge imparted was sound, insofar as it went, but here again “implementaton” raised its ugly head.

But the system has its limits, relying on the traveler to reveal whether he or she has been exposed. And it leaves it to local officials to conduct the screening as they see fit, Dr. Cohen said. It is unclear how consistently or effectively those screenings are conducted across West Africa, and Dr. Cohen said she did not know how many potential travelers had been caught by screeners — if any.

“Our expectation is that people who are sick or people who are exposed should be getting the message they shouldn’t be traveling.”

Airlines have not taken any specific steps to deal with Ebola, representatives from several carriers said. They follow general guidelines issues by the C.D.C. and the World Health Organization. They have also informed their flight attendants about the hazards of Ebola, its symptoms and how the disease is spread. Delta has increased the supplies of gloves and sanitizers on board. But beyond taking simple precautions, airlines said they were not responsible for screening passengers.

Etc, etc. In other words, the Ebola “screening system” was nothing like foolproof.  It was a ‘logical implementation’ but it wasn’t  really a ‘physical implementation’, like code you sort of wrote but which is not actually running on any particular hardware.

The “screening system” was made up of tired  and probably underpaid and hungry people or of  harassed airline workers who have neither the aptitude nor interest in playing Dr. Kildare. Theory is one thing, but carrying it out is another, for  a “system” is just a word until somebody does something to make it happen. For example, the Ebola victim’s nephew called CDC because the “system” to that point hadn’t reacted.

“I called CDC to get some actions taken, because I was concerned for his life and he wasn’t getting the appropriate care,” Duncan’s nephew, Josephus Weeks, told NBC News on Wednesday night. “I feared other people might also get infected if he wasn’t taken care of, and so I called them to ask them why is it a patient that might be suspected of this disease was not getting appropriate care?”

The next biggest problem is the political system’s addiction to speeches. There is this strange modern notion that a televised address or ‘messaging strategy’ is the substance of work. The telephone, the pen and the teleprompter. The fundamental assumption of this worldview is that if you say something then ‘someone’ will do it.  But ultimately, “they” is “us”. Unfortunately, in dysfunctional or incompetent organizations, “they” is always somebody else.

Yet the chain has to end with some identifiable person. Every plumber has a name because in the end an notional plumber cannot turn the wrench, only an actual one can, Organizations often appoint a chief executive to make sure the cogs turn. In the US system of government, the person who ensures that stuff gets done is the president. It’s an actual job that was created by a nation back when results were still valued.

Once upon a time America was the “can do” nation. Results were second nature. Things got done by people who understood “do”.  Stopping Ebola is a ‘do’ job in that most basic sense. That’s all it is and all it needs to be.

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