Like everyone else, I have been following the nearly continuous news briefs on the Ebola epidemic, and feel compelled to express some of my concerns. I have been watching the NIH guy who seems to be on the cable news channels at all hours. I will give him credit for endurance, but I must confess that I am a bit skeptical of some of his pronouncements. I get the feeling that his job is to reassure, and that the powers-that-be are more worried about panic amongst the populous than the spread of a virus with a 60% mortality rate. Contrarian that I am, I can’t help wondering if a bit of low grade panic might be indicated. As of this writing, the second case of Ebola has been contracted inside the United States.
Let the Blame Game Begin
As has become standard operating procedure, we can now let the blame games begin. The nurses blame the CDC. The CDC blames the nurses and the hospitals. The hospitals are quick to retaliate and join the nurses in blaming the CDC. All this is done using polite terms but the inference is clear. Predictably, it did not take long for the loudest and most vocal of all blamers to enter the fray—oh yes, the politicians saw this as an opportunity to make hay. They blamed everyone except themselves. It seems lost on them that they were the ones who cut the budgets of both the NIH and CDC, or that the position of Surgeon General had been vacant for over a year because they had refused to confirm his appointment, allegedly due to pressure from the National Rifle Association. Perhaps he was not confirmed because he was opposed to people shooting people.
But do not fear our fearless leaders have already mounted their white horses and are getting ready to convene multiple congressional inquiries. I am sure this will solve the problem in short order. They are now well rested from their vacation and will be full of vim and vigor. They will be able to prance and preen, adopt expressions of concern only occasionally glancing at the TV monitors to see if they are being seen back home. They will give opening statements as to how this issue is much too important to politicize it, prior to launching into a diatribe as to why the opposing party is responsible. Yes indeed, it is true as someone said, we have the best government that money can buy.
Experts in Incompetence?
I am not convinced that all of the reassurances offered by our experts are justified. Initially we were told that an infected person was not communicable until symptoms such as fever occurred. Later that was modified from impossible to “very unlikely.” We were also told that because this was not an airborne virus, it could only be contracted by direct contact with an infected person’s body fluids. They did of course include saliva in the list of body fluids that could harbor the virus, and I was reminded of a friend who usually violates my space during a conversation and I find myself recipient of significant amounts of his spittle. I guess this is not what they meant by “airborne.”
History of the Containment of Viruses before Vaccines
Although I am by no means a virologist or expert in communicable diseases, I was, an eon or so ago, a family doctor in the days before there were vaccines for many of the viral diseases. Quarantine was our only weapon to prevent measles or chickenpox from infecting an entire school. Nearly all adults had developed immunity to most of the childhood viruses because they were so prevalent that nearly everyone had been infected during childhood. For anyone else, even minimal contact guaranteed infection. They all had incubation periods that were quite predictable, as does Ebola. One of the difficulties in preventing the spread of viruses was the fact that the children were often infectious before they exhibited symptoms. However, tiny lesions inside the mouth called Koplik spots could often be seen a couple of days prior to development of the rash from Measles. A testament to the success of measles vaccinations is that during a recent outbreak of measles in Southern California (due to misguided information to parents who refused to have their children vaccinated) there were few pediatricians or family physicians who had ever seen a measles rash let alone Koplik spots.
The incubation period for Ebola, as for all such viral illnesses, is the time it takes for the virus to replicate itself until there are sufficient numbers to cause symptoms. During that entire time, there are viruses present in the body and I find it difficult to believe that the number of organisms necessary to infect another person is exactly the same as that which will cause a fever. We were taught in medical school to never use the terms never or always as there are always exceptions. With this in mind, the idea that one is safe until full blown illness develops seems questionable.
Since there is no definitive treatment for Ebola, it has become necessary to revert to some of the tried and true methods of the past which were used to limit the spread of infectious diseases. Before antibiotics or vaccinations, local health departments were responsible for case finding and initiating quarantines. It was not unusual to see a card in a window announcing that the family was under quarantine for some of the more serious illnesses, such as scarlet fever. It was mandated that such illnesses be reported to the local health department whose job it was to monitor the patients, and their contacts. This was especially true for venereal diseases, and although this could be embarrassing for the afflicted patient, the public’s health trumped privacy or personal embarrassment. As a matter of fact it was routine policy for a serologic test for syphilis to be done on everyone admitted to a hospital. Positive results would be reported, even though it was not convenient for an infected person to have his or her spouse notified.
Penicillin and Subsequent Antibiotics
In the 1940s penicillin was developed, which revolutionized the treatment of many bacterial infections. Other antibiotics soon followed, which were effective in treatment of some of the diseases in which penicillin was not.
Penicillin became the treatment of choice for everything in John Q. Public’s mind, and he wanted a shot of it for every conceivable problem including but not limited to snotty noses, ingrown toenails, and common colds. I recall several instances where patients left my office in a huff after I refused to give them penicillin. Consequently, penicillin and subsequently developed antibiotics were misused, and given even for viral infections for which they were not effective. Farmers even now feed antibiotics to their livestock to promote growth so we all may be unwittingly ingesting small amounts of these drugs. There was also the problem of compliance. Often, people would take their medication long enough for symptoms to disappear before all the offending pathogen could be destroyed. These factors conspired to result in the development of resistance to the drugs in the case of many bacteria. Now hospitals struggle with trying to rid themselves of MRSA and C-Diff for example, and it is said that 20% of all admissions will develop some kind of infection while hospitalized. Tuberculosis, which had been all but wiped out is now making a comeback—this time in a form which does not respond to available medications. It seems we consistently underestimate the versatility and tenacity of those little buggers. They are too small for us to see, yet they continue to adapt and ultimately outsmart us.
Other Viruses: AIDS and Our Response
Viruses such as flu, AIDS, or Ebola to name a few are a different story. They are not affected by antibiotics; although the so called cocktail of meds has been effective in altering the course of AIDS. Both AIDS and Ebola originated in Africa, and are transmitted to humans through body fluids. The vector for aids is thought to be subhuman primates (monkey family) and for Ebola, bats. Both diseases were thought to be contracted by using their respective vectors for food.
The story of HIV is particularly poignant for there was much misinformation, and discrimination. Since AIDS was thought to have been brought to this country by a world traveling airline attendant, who was apparently quite promiscuous. He is postulated to have infected many other gay men and initiated the epidemic.* Consequently, fear was coupled with homophobia, and AIDS patients were subject to discrimination both socially and in the workplace. This mistreatment and discrimination was the subject of a Tom Hanks movie in 1993 entitled Philadelphia for which he was nominated for an academy award. As the disease spread through the homosexual community, some TV evangelists preached that this was God’s punishment for the sin of homosexuality.
Ryan White was a 13-year-old hemophiliac who contracted AIDS in the early 1980s from a drug transfusion. Ryan was the first hemophiliac to contract AIDS, which considered a “homosexual disease” at the time. Due to fear of contagion and the fact that the spread of the disease still wasn’t understood, Ryan White’s middle school expelled him. He and his family were shunned. The case received international attention as the Indiana teenager fought to be allowed to returned to school. “It was really bad. People were really cruel, people said that he had to be gay, that he had to have done something bad or wrong, or he wouldn’t have had it. It was God’s punishment, we heard the God’s punishment a lot. That somehow, some way he had done something he shouldn’t have done or he wouldn’t have gotten AIDS,” said Ryan White’s mother recounting the early days of his diagnosis at ryanwhite.com.
Soon there was a backlash from saner sections of populous, but as is usually the case, the pendulum swung too far in the laudable direction of preserving privacy.
My Experience with the AIDS Backlash
During the early days of the AIDS epidemic, I was called upon to serve on a panel to discuss the problem. At the time, the medical community was still learning about the virus and how it spread. I had the temerity to suggest that it might be a good idea to use some of the case finding techniques that had been helpful in the past, by adopting procedures to allow health department workers to find those who had been sexually involved with the identified patient.
The rest of the panel jumped on me with a vengeance for even suggesting that we violate an AIDS patient’s privacy by reporting their illness to an agency. Their reasoning was that even if the agency honored confidentiality agreements, the contact person would know. I can’t help but wonder if this refusal to use time honored public health measures didn’t contribute to the rapid spread of the disease. According to the CDC, there are now 1,100,000 people in the United States who are HIV positive 20% of whom are women. 40,000 of these people die each year; although admittedly not all die from AIDS alone. Many are drug users who use dirty needles and some are prostitutes. In any event those numbers suggest to me that the AIDS epidemic is not over.
Back to Ebola: We Did Know about It and Chose to Ignore It.
Nearly 20 years ago, Laurie Garrett authored a book titled: The Coming Plague, newly emerging diseases in a world out of balance. One of the chapters was a history of the 1970s Ebola epidemic, and the heroic virologists who were involved in its study. It was self contained largely because it affected very rural villages at great distances from each other in Africa. In many of the villages there was over a 90 percent mortality rate. It was felt that had it affected areas more densely populated, the effects would have been much more devastating. The investigators realized this organism had not disappeared from the planet and was likely, even surely, to appear again. But the complacency about which Garrett warned in her book set in, and here we are woefully unprepared. Could a vaccine have been developed? Who knows? What is obvious is that there could be little money to develop treatment for a disease when no one had it. There was also the problem that it was an African disease, and there has always seemed to be some reticence to spend resources on those folks. Yes, it appears the world is still out of balance.
Will we learn anything from this episode? I am not optimistic. Ms. Garrett outlined all of the conditions necessary to virtually guarantee an eventual worldwide pandemic and we do little to change that course or to prepare for what will most probably come. There have been many other lessons never learned. Bubonic plague is said to have killed nearly 40 percent of all Europeans. The flu pandemic of 1917-18 killed 50 million people. There have been major epidemics recorded throughout history. Not long ago, we were told that bioterrorism was something we must guard against. Anthrax, which so far has been susceptible to some antibiotic,s was a suspected weapon. I take little comfort in the knowledge that no longer are any antibiotics manufactured in the United States. But, not to worry, I am sure that the countries where they are manufactured would be happy to give us the highest priority in getting us what we need in the event of an epidemic whether man made or naturally occurring.
I imagine that there will be books written about all the major screw ups in our attempts to deal with the current crisis. The question to be answered is what have we learned?*Gaëtan Dugas, the Air Canada flight attendant, has never been definitively pinpointed as “Patient Zero” (the first North American with AIDS) by the scientific community, but he gained notoriety as such in San Francisco Chronicle reporter Randy Shilts’s notorious book, And the Band Played On: Politics, People, and the AIDS Epidemic.