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Posts Tagged ‘Ebola’

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This will be a long post to wade through, but the issue warrants the length. Our feckless leadership in the war against Ebola can best be understood through history, and a different kind of president.

In the early days of the US Civil War, President Lincoln needed to raise an army, and fast. He could look out of his window and see General Robert E. Lee’s house atop a hill just across the Potomac River in Arlington, VA. To his north, Maryland also wished to secede, and was kept from doing so by force. The nation’s capital was surrounded by forces determined to destroy the union. An army was needed to defend the capital and then preserve the union. Enter, General McClellan.

General McClellan was a dashing figure, filled with bravado, and a damned fine West Point graduate and engineer. He built and outfitted the Grand Army of the Potomac in record time. He wooed the ladies at the homes of the leadership with his assurances of how quickly he would dispatch the rebels and restore the union. But little Mac wouldn’t go out to fight. At the sound, or even the thought of a canon’s roar, he persuaded himself that Lee had him outnumbered at least three to one. The little general’s biggest battles were with Lincoln and the War Department, constantly calling for ever-greater numbers of troops and supplies.

At wits end with a feckless general, Lincoln relieved McClellan with these words:

My dear McClellan: If you don’t want to use the army, I would like to borrow it for a while. Yours respectfully, A. Lincoln.

And so it is today that we have at the head of the Centers for Disease Control and Prevention (CDC) a feckless bureaucrat in Dr. Tom Friedan. He may well have been a good peacetime administrator, a good little builder as McClellan was, but in the war on Ebola he simply won’t come out to fight. In some respects, he is worse than McClellan. Little Mac was loved by his troops because he had their best interests at heart. He was concerned about casualties in the ranks of those who did the actual fighting, who bore the horrors of war. When McClellan played the blame game, he went after his superiors.

This week a nurse who cared for Eric Duncan in Dallas was herself diagnosed with this dread disease, whose mortality rate has risen to 70%. Reflexively, Dr. Frieden blamed the nurse for “Breach of protocol.” This, despite the fact that CDC’s protocols are so shamefully inadequate as to be be of little value at all. If for no other reason than throwing this nurse under the bus, Dr. Frieden has forever branded himself a coward and compromised his ability to lead others in battle. But there is so much more to Frieden’s appalling ineptitude.

When voices have called for a travel ban on all people coming from the endemic regions in Africa, Frieden scoffed at the idea. He claims that restricting air travel would actually make matters worse by not allowing aid into the country. When repeatedly challenged on that assertion with the counter of having chartered flights for relief supplies and personnel, Frieden just dismisses the idea with the back of his hand. Watch the video interview below before reading on:

To be clear, we need to contrast the levels of protection promoted by Frieden here with what third world doctors are doing in the endemic regions. Consider this typical level of suiting up in Africa:

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Note the use of a buddy system where the outer layers are first sprayed with bleach in order to destroy any virus that may be contaminating the surface. Note how there are layers of protective gear, and that no part of the body is exposed. Now watch the video produced by CNN medical correspondent Dr. Gupta as he demonstrates the frightening inadequacy of a protocol approved by Dr. Frieden.

The juxtaposition of these two levels of protection cannot be overstated, as CNN notes the casualty count among health care workers in Africa who are using the greater level of protection:

There are so many caregivers who’ve become patients. At least 416 health care workers have contracted Ebola, and at least 233 have died, the World Health Organization reports. In Liberia, the worst-affected country, the virus has killed more than 100 medical workers.

And we see that the CDC level of “protection” has gained us two infected nurses from one patient, and who knows how many more cases incubating. At a ratio of two infected healthcare workers per patient, it would be only a matter of months before we lost most of our physicians and nurses in a major outbreak.

And Frieden had the temerity to blame the nurse.

Then there are Frieden’s claims that one cannot contract ebola from sitting next to an infected individual on a bus. This while the airplane traveled on by the second nurse to contract the virus from Duncan (and cleared by CDC to travel with a fever!) is about to undergo its FOURTH cleaning! Yet CDC maintains the fiction that ebola can only be transmitted by direct contact with infected bodily fluids, while not acknowledging that surfaces contaminated by those fluids can maintain viable virus for hours to days, depending on temperature and humidity.

It goes without saying that to the extent Ebola is contained in the cloud of nasal spray in people sneezing on that bus (or anywhere), the virus is indeed airborne in that vicinity, and contaminates whatever surface the droplets land on.

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Meanwhile, teams have been dispatched to clean and decontaminate the apartments of Duncan and nurse Pham. An airliner has been quarantined, and the passengers who flew on the next five flights in that plane have been added to a watch list that has risen to hundreds.

All from the index case of Eric Duncan, who lied to get here.

That historical fact must not be allowed to become historical footnote, as self-reporting at airports is the furthest Dr. Frieden is willing to go in order to reduce the viral load entering the United States. Of course any exposed Liberian or other African who desperately seeks entry to the US for treatment will be entirely honest about their exposure status and voluntarily elect to stay home to die.

Just ask Duncan.

Patients can take high doses of tylenol and motrin to knock down a fever, and even if they are asymptomatic, a 21 day incubation means that potentially thousands of infected individuals will come here and spread the disease.

Frieden’s repeated assertion that keeping ebola cases in Africa will not stop the spread (you read that right), while allowing for travel will not increase our risk here (you read that right as well) shows that he is not the doctor for this job. Consider him in his own words:

“The only way we’re going to get to zero risk is by stopping the outbreak at the source… Even if we tried to close the border, it wouldn’t work. People have a right to return. People transiting through could come in. And it would backfire, because by isolating these countries, it’ll make it harder to help them, it will spread more there and we’d be more likely to be exposed here.

So, paying no heed to increasing the viral load here (through unrestricted migration) is the best way to end the problem there.

Not exactly.

And then there is the threat posed by our very porous southern border… A topic for another day.

This nation is witnessing the unpreparedness we have for treating and containing ebola cases here. Our hospitals have been doing a miserable job at containing nosocomial (hospital acquired) infections in general, and antibiotic resistant pathogens in particular. In one study, it was estimated that the 2002 incidence of nosocomial infections was 1.7 million in US hospitals. In the medical literature, physicians and nurses are repeatedly identified as being weak when it comes to hand washing between patients.

When the fundamentals are not habitual, it strains credulity to hear the CDC director repeatedly claim that any US hospital is fully qualified to handle ebola patients. In Texas, the amount of medical waste from Duncan alone piled up with uncertainty and confusion about proper protocol for disposal. Not all hospitals have large autoclaves for the sterilization of the bulk waste generated from the care of even one patient.

It is a sad and scary spectacle to see the CDC Director being taken to task by journalists with a firmer grasp of the threat and how to minimize it than the nation’s top administrator in charge of infectious disease prevention. It is bewildering to consider why the Acting Surgeon General has not weighed in as the chief public health officer of the nation.

In fact, the only medical society to weigh in with the truth has been the Nurses union in Dallas, decrying the lack of protection, protocol, and training. Leave it to the nurses. They’re usually the ones to get the ball rolling on patient advocacy, and this loops us back to General McClellan and the need for us to get rid of the McClellans among us.

We don’t really need a mediagenic CDC Director. We need a fighter. We need someone who may have bumps and warts in their background, but can recognize and speak truth as a matter of habit, who can invite in the nurses union from Dallas and work collegially and rapidly to get a handle on this mess.

Lincoln would go through several incompetent commanders before he found Grant, who was the opposite of pretty boy McClellan. He was rough, and unkempt, a drinker, but he fought tenaciously. When one of McClellan’s sympathizers sniffed that Grant imbibed too much whiskey, Lincoln’s classic response was to find out what whiskey it was so that he might send a barrel to all of his commanders.

Lincoln was a wise man, and was willing to overlook the personal foibles of the commander, so long as the results were favorable in the fight for the life of the nation. It’s time for this nation and this president to get serious and follow that admirable example.

The events of the past three weeks have confirmed for us that we cannot get caught up in dithering over the rights of people to enter this nation while potentially harboring ebola. We need the following immediately:

A ban on all immigration from anyone who has been in the endemic regions for the last three months.

The immediate deployment (to the endemic regions) of 20,000 US troops to build enough ebola treatment and quarantine centers to accommodate by the end of November the case load projected for the end of December (Get ahead before it’s too late to catch up).

A series of quarantine stations offshore for a thirty day stay before American troops and aid workers can be physically repatriated here at home.

Three state of the art isolation and treatment centers here in the US designed and modified to handle treating ebola patients, incinerating waste, and decontamination suites and facilities that are second to none.

A cooperative arrangement between the Gates Foundation and other foundations willing to fund such facilities.

Extensive training in ebola protocols for Emergency Department workers at American hospitals, and the training of three crack treatment teams of physicians and nurses at the proposed specialized treatment centers.

Protocols for the rapid transfer of ebola cases from around the nation to the specialized treatment centers.

Quarantine stations here at home for those who have been potentially exposed to the virus.

Unfortunately for Dr. Frieden, he has thrown his credibility away. We need a new CDC Director, a real physician or scientist and not a bloodless bureaucrat, who can lead the way. We also need a president and congressional leaders who are willing to put aside politics for the sake of the life of this nation.

Without overstating the case, in light of WHO’s assertion that we have until December 1st in Africa before this spirals entirely out of control with 10,000 new cases per week, we may be looking at our last chance to get this right.

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The nation has become gripped with fear, a healthy fear, of the Ebola virus and how easily it might spread out of control in our crowded urban centers. The fear has not yet turned to panic, and one can feel the struggle of our public health personnel as they try mightily to prevent panic and still do what must be done to prevent a full blown outbreak here at home. Naturally, people wonder if the government is telling us the truth about the minimal danger it claims Ebola poses.

So, are we being told the truth about Ebola? Is the government lying to us simply in order to prevent a panic?

It all depends on how one defines terms such as truth and lying. There is the unvarnished truth, therapeutic doses of truth (which contains lying by omission), etc. We do well to stop and consider the full dimensionality of the moment we are in, and consider the historical lessons from the beginning of the AIDS pandemic. Critiques offered here are not political, and indeed there is plenty of bipartisan criticism to go around. We are not in a political moment. We are in an American moment, facing an indiscriminate killer. Sound public policy will require rising above petty politics and sniping, while seriously evaluating current and historic national policies that will drive this crisis one way or the other. We must leave politics behind, as we are at the water’s edge.

Currently we have an administration in Washington that sees no need to restrict air travel from the endemic areas in Africa, has committed 3,000 troops to fight the epidemic in Africa (with no detailed articulation of what that mission might be), and has no articulated plan for how to bring them all back safely.

At this writing, we have in Dallas a Liberian who lied on his immigration papers regarding contact with an infected person at home. He reported to a hospital in Dallas when he felt ill, was misdiagnosed, and sent home with antibiotics. As his illness progressed he called an ambulance, vomited in the parking lot of his complex, and has exposed at least 100 people who are now under surveillance, and many under quarantine. Further, many parents are keeping their children home from school, as some of the exposed are children.

There are no quarantine stations to which people are being sent to wait out the 21 days it can take Ebola to manifest itself. Indeed, some of the people being monitored have attempted to leave their homes. These policies and lapses have the makings of an outbreak of unprecedented magnitude. They can also generate a panic which could cripple the national economy if people begin to lock themselves up at home. So, what to do?

First, we do well to remember some history from the AIDS pandemic. In the early days of the pandemic, we were told that this virus could only be contracted through transmission of bodily fluids such as semen, vaginal secretions, and blood. All true, but incomplete. We were told that there was no evidence that HIV could be transmitted by oral sex, and that was an early, deadly error. Many lesser authorities would extrapolate from this that stomach acid would kill any virus swallowed during oral sex.

“No evidence,” in science does not translate into, “Impossible.” It simply means that there is not a study establishing the behavior as a risk factor. It turns out that the lining of the esophagus contains a great many cells that are a part of the mucosal immune system. They transport viruses and bacteria across to waiting immune system cells, the very cells HIV attacks. So in those early days, in the absence of definitive proscriptions on sexual behavior, and before condoms and dental dams were recommended for use during oral sex, many may well have contracted the virus through that transmission vector.

Then there was the disparity between what the CDC was saying and what the AIDS activist (read homosexual) community was advocating with condom use. This is a key piece of history that shows what happens when political and ideological issues run up hard against scientific truth, and the blind spots in the extant data that well-informed scientific and medical judgement can fill in. The following is from a series I wrote five years ago dealing with the condom issue as it related at the time to AIDS activists excoriating Cardinal O’Connor for not giving church approval for their use in combating HIV. What is striking is the very different posture assumed by the NIH and CDC. From the article:

Certainly Cardinal O’Connor and the Bishops knew all too well the rise in promiscuity following widespread access to the pill in 1968. They knew the CDC data linked here which show the steady rise in STD rates. (Click on “all slides”). Fast-forwarding to today for a moment, Research out of Harvard agrees with the Church that Condoms can make HIV worse in Africa, among other places.

In the mid-80’s, the New York Times, the self-styled ‘paper of record’ carried several articles which cast a long shadow over the absolutist claims of condom safety by AIDS activists.

On August 24, 1987 the Times reported “20% of Condom Batches Fail”.

On May 12, 1988 the Times reported that 33 million condoms had been recalled in 1987 with a failure rate of 4/1000. The paper failed to reconcile those numbers with the 20% failure rate reported in August of the previous year. The paper did report that the 4/1000 was an improvement over the 4.8/1000 rate in 1986. These rates for domestic condoms were better than the 6.5/1000 in 1987 and 7.3/1000 in 1986 for imported condoms.

On August 18, 1987 the Times ran a major article entitled “Condoms: Experts Fear False Sense Of Security”. From the Article:

“MANY health officials have begun to voice concern that the campaign to encourage condom use to curb the spread of AIDS may be misunderstood, creating a false sense of security in people whose behavior continues to put them in danger.

“Experts say condoms should minimize the spread of the AIDS virus among the heterosexual population, especially when used with spermicides containing nonoxynol-9, which has been found to kill the virus in test tubes. The experts say this justifies recent campaigns promoting the devices.

“But they stress that it is unknown just how much protection condoms offer. The officials note that condoms have been widely rejected as a method of birth control because they frequently fail, and say the devices may be no better – in fact, may be worse – at curtailing AIDS. They warn that sexually active men and women should not assume that they are protected simply because they use prophylactics.”

The article is filled with notable quotes from experts, all expressing doubts.

It was an interesting time. Because the spermicide nonoxynol-9 was found to have killed HIV at high concentrations in test tubes, it was added as a lubricant and fail-safe against condom tearing or slipping. In recent years we have learned two devastating truths.

1. Nonoxynol-9 in the low concentration on condoms is ineffective against HIV.

2. Nonoxynol-9 in the low concentration on condoms causes ulcerations in the vaginas of women who use them frequently, such as sex workers. This means that N-9 does not kill the virus when condoms tear, and facilitates infection by compromising the vaginal and rectal epithelia.

Finally, a week after the desecration of Saint Patrick’s Cathedral by ACT-UP (reported in Part I), the Times reported that The National Women’s Health Network requested the FDA to remove approval for two new condoms:

“A public-interest health group said today that it had petitioned the Food and Drug Administration to withdraw marketing clearance for two new types of condoms because neither had been tested for effectiveness in preventing pregnancy or protecting against disease.

“The National Women’s Health Network, a nonprofit group based in Washington, charged that the Federal agency had erred in approving the devices under a legal provision that waives testing requirements if a new device is substantially like one already approved.”

It was an interesting time. Anti-retroviral medications were being hastened to market. New condoms were being hastened to market all in a desperate attempt to throw the entire arsenal at this virus. But desperate measures can have unintended consequences.

In time, what will be most remembered is the stubborn insistence of so many to having sex outside of a life’s commitment to mutual monogamy with ONE individual in the face of a disease that is so devastating.

Where were the AIDS activists when these reports were being published by the Times?

A candid and sober reflection on those early missteps in assessing HIV and its spread, what we thought was safe, and how wrong many of those assurances were should temper and guide our steps with an overabundance of caution with a far deadlier virus that threatens to erupt into a full-blown pandemic.

In part II we’ll consider the missteps being made with Ebola, and how to correct them while there is still time.

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