Belmont Club

Pink Elephant Repellent

A highly regarded doctor of medicine sent me a link to an article in the Atlantic, The 21 Days, which was an extended interview between Dr. James Hamblin, MD, the magazine’s senior health editor and Steven Hatfill, who readers will recall was a defense contractor in the field of biological warfare who was falsely accused of engineering the anthrax attacks of 2001.  The note along with the link said: “in the absence of a vaccine or available therapy, how are how health care workers going to W. Africa from here helping beat Ebola there?”

The gist of the Hatfill interview is that Ebola is theoretically far more serious than the CDC ever took it.

Hamblin: So what led to us treating it with such relative casualness? The CDC not having experience with Ebola in the U.S.?

Hatfill: [Thomas Frieden, CDC director] has become a political animal, in my opinion. And when you’re dealing with this type of agent with no cure, no real vaccine, you must always err on the side of caution. They ignored a lot of published data. We’ve known for years now that the skin is a site of viral replication. The Langerhans cells, the antigen-presenting cells in the skin, are major targets for Ebola. The strains we know of.

Hamblin: The idea of a travel ban has been so controversial.

Hatfill: Not to other countries.

Not to the US military either. US soldiers are being quarantined in Italy after returning from their humanitarian mission in West Africa. And yet there is a definite sense in the public narrative that the Ebola crisis is on the wane. The WHO says all signs point to the epidemic beginning to slow at least in Liberia.

Virtually everyone in Liberia agrees on a new, stunning fact: Ebola cases in Liberia are dropping.

“New case numbers are going down. Admissions into ETUs [Ebola treatment units] are going down…. The amount of bodies being picked up is going down,” says James Dorbor Jallah, the deputy incident manager at the National Ebola Command Center in Monrovia, the capital of Liberia.

Data analysts, body removal teams, ETU managers and other health officials confirmed Jallah’s assessment. And any Liberian you pass on the increasingly busy streets of Monrovia will say they notice that the shrill peal of ambulance sirens cuts through the humidity much less often than it did two or three months ago, when Liberia’s caseload was exploding.

Back then, symptomatic patients might sit for hours outside an Ebola ward, waiting for a bed. Today, 50% of the beds in those wards are empty.

So does that mean that the dangers of the outbreak were overblown? One prediction,  the PLOS epidemic modeler predicted  tracked the Ebola numbers perfectly, but most importantly, it predicted that the epidemic would start to burn itself out in December of 2014.

The main thing here is the d, which is a factor representing some discount function that changes through time, so named because it resembles discounting in financial models. Here it’s meant to represent the efforts taken to control the epidemic, vaccinations and quarantines etc. The larger d gets, the smaller the I result, which is the number of total infected individuals….

predict changes in an epidemic’s immune and susceptible populations, gives us some other useful predictions: The expected time an epidemic is likely to stop growing, an estimated maximum number of total infected individuals, and so on. …

If the IDEA model continues to predict the epidemic with the same accuracy, we can expect Ebola to start burning out in December, with a total of 14,000 cases.

The doctor’s note, “how are how health care workers going to W. Africa from here helping beat Ebola there?” probably meant that it wasn’t medicine but quarantine that was killing the beast.  For whatever reason the beast was done for now. The doctors, despite their dedication and selfless sacrifice didn’t stop it.  The major factor was behavior modification and human adaptation  — assuming that the epidemic is actually burning out.

The most interesting insight in Hatfill-Hamblin article is the observation that many defensive measures we consider effective are perceived to work because they have not experienced a serious attack. Many of the West’s defenses are like Pink Elephant Repellent Powder, which can be explained this way: once a man was observed dusting powder around the house. He was asked what what it was for and replied that it drove away pink elephants. When told that was ridiculous, he retorted: “It works. Do you see any pink elephants?” Hatfill made much the same point.

Hamblin: Travel-ban opposition is largely based on the claim that it would impede our ability to help stem the epidemic in West Africa.

Hatfill: You know, I went for a Department of Defense interview years ago. They wanted a scientist down at the Pentagon that could invent stuff that would support presidential policy. … They just wanted a spokesperson that could kind of come up with a plausible explanation to explain a higher-up directive. And I think this is the same thing.

Hamblin: I’m wondering what is driving—

Hatfill: There are no cases in Kenya.

Hamblin: And they have a travel ban?

Hatfill: Yes. Sanjay Gupta, who is a neurosurgeon, did probably the best demonstration I’ve seen on why the CDC protocol failed. He dressed up in the recommended protective equipment and they put chocolate syrup on his hands. As an experienced neurosurgeon, how many times he’s donned and doffed this gear? He took off his gear, and, yep, there were chocolate splashes all over his skin. There’s a reason we use front-zipping Tyvek suits and not gowns. If an experienced neurosurgeon can’t do it, what do you think a poor gal just out of ICU training is going to do?

The nurse that got infected knows she’s in there with an Ebola patient, and God bless her for volunteering to do this. It’s a very, very brave thing to do. But it’s not just issuing a guideline. You have to practice implementing it. And the whole hospital has to practice. You can’t come up with it at the last minute.

Hamblin: Do you think this outbreak will—

Hatfill: It’ll burn itself out. Nigeria’s already got control over theirs. Why? They follow the rules.

The West African Ebola outbreak of 2014 is one of many known outbreaks of the Ebola, according to the CDC.  The disease in its earlier incarnations went away or was beaten back,  only to return  again. This time the Ebola outbreak was particularly deadly. But it will be back. The argument Hatfill was making is the fact that it went away does not necessarily mean the beast was turned back by the current procedures, any more than the Forbidden Planet monster was turned back by the blasters directed on it.

Two of the greatest epidemics in recorded history — the Black Death and the Spanish Flu — came, killed millions and vanished. To this day nobody really knows why. As for Hatfill:

His advice to the CDC, though no one has asked him for it, centers on the fact that as new antiviral treatments are developed, the need for rapid medical response units will become paramount. These treatments have to be administered quickly, but they could stem outbreaks before they become significant. Medical response units would need to be able to enter remote areas for on-site diagnosis and administration of antiviral medication. They would need isolation transportation and BSL-4 treatment facilities in the United States. Because outbreaks like this one will happen again, and they are best addressed by focusing containment and treatment efforts at the source of the outbreak.

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