Back on July 28 I posted that, should the epidemic reach Lagos, we would be doomed, and we would be seeing quarantines of flights.
If only.
I was wrong in this case: in Lagos, those who defied quarantine were shot, and that is what it may take to control the outbreak in populated centers. And instead of Amsterdam and Rome, we are seeing the first swallows of sorrow in Dallas and Madrid.
We re now 6 weeks behind this epidemic. The problems are:
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Institutional arrogance.
The CDC has very smart folks. Smart folks are exactly the wrong people to manage this problem; they actually believe that they know things. (Witness the incredible naivete of Fauci, and various spokesman, and their righteous assertions that the virus can only be spread by the symptomatic, or that a person must have fever to be infectious, nonsense about animal vectors, etc. None of these assertions were based on science or fact or observations from prior epidemics.) What they do not know will kill us. -
Bayes theorem.
Screening at airports is ridiculous, not just because we cannot train everyone in time–we are 6 weeks late. Fever monitoring will have a high false-negative rate.
And we are starting the influenza season. The airport personnel–if they are to competent at all–are going to have far more false positives (flu cases relative to ebola cases), and this will overwhelm the screening system. -
The incompetence of the well-meaning.
Tyvek suits? Non-latex gloves? Ask Baxter why there is a shortage of IV fluids. In a massive epidemic, these will be unavailable, leaky, and as we have now seen, used badly, infecting health care workers. What health care worker is now going to be willing to take care of salvageable patients–or suspected patients?
Our track record is clear: just look at the sterling success most hospitals haven controlling c. difficile enterocolitis.
There should be an absolute quarantine on flights out of West Africa. A few health care workers can return under quarantine. Sorry, people will die in West Africa regardless. For those who argue that this is heartless, I point out that every Ebola epidemic has ended, not mby human intervention, but because it has “burned-out,” i.e., it has exhausted the host population.
For those that argue that people will find a way to migrate into our borders from third countries, I point out that if one believes that the incubation is as long as 3 weeks (and I do not) then the lengthened travel time will perforce serve to sort out the sick from the salvageable.
Anecdote:
My brother recalls a time when he served in a large port city as a medical resident. The ER had a special room for screening travelers from abroad. If there was fever and a palmar vesicular rash, the intern was obliged to push a large red button, and an iron door would descend, locking as prisoners both patient and doctor in the room for a week. One took care of the other through the course of smallpox.
Imagine a world where such a room was not just imagined, but executed, and expected to be used.
This is the attitude we should have about Ebola in this century. But we have the gall to presume that scientists have the knowledge, and that others–doctors and nurses–will sacrifice themselves, rather than demanding that the necessary extremes be taken.
