Ebola and the management of mass psychology: public health or public relations crisis?

In the discussion about Ebola there appears to be a public relations message that we are all expected to accept that it is far less likely to run out of control in “developed countries” which have healthcare systems. In an article yesterday the chief concern of the Guardian‘s health editor, Sarah Boseley, was one of the management of mass psychology, the headline being: “Spanish Ebola case requires rapid response to allay western fears. It is important to ascertain exactly how Madrid nurse was infected to prevent inaccurate scare stories circulating on the internet.”

As one person commented after this article:

“No, it’s important to prevent the frigging ebola virus from infecting more people, especially medical staff and their families.”

In a potential epidemic situation like this we really all are in this together and it irritates the f*** out of me when journalists, officials and managers see it as their main job to “reassure the public”. This is because this “reassuring the public” starts from a presumption that everything will be OK – in other words it starts with the smug complacency that we always hear from “senior people” – that we can trust them, that they know what they are doing, that they are somehow immune from making mistakes and screwing things up. It is exactly the same attitude with fracking – oh there will be no problems here “because we have the best regulations in the world”.

And yet the experience in Spain and the USA shows quite clearly how the real world deviates from the ideal world which we are supposed to believe in – once we delve into it we find that staff at the hospital were protesting about the inadequate equipment and protective clothing for example and used the same lifts used by everyone else to take out infected materials and how they were generally unprepared for what happened. Exactly what you would expect from a lumbering management bureaucracy in the face of a complex challenge.

In this regard the situation in the USA in Dallas shows a similar failure to think things through in advance – like no arrangements to remove sweat-soaked and infected bedding, like the need to trace people who are difficult to trace like homeless people.

Let me say in this regard that it does not seem obvious to me that the provisions for disease control and preventing an epidemic in “developed countries” are much more robust than in places like West Africa. That’s because (1) although there are a tiny number of super sophisticated centres for containing highly infectious diseases there is obviously a threshold magnitude of imported infections beyond which the arrangements for containing the disease would outstrip these resources and the system would likely break down entirely; (2) because the “developed countries” have much more mobile populations using mass transport systems where anonymous contact with large numbers of people can take place and (3) because there will be reluctance to impose the necessary controls because of the economic disruptive effects until it is too late – by which time (4) the economic disruptive effects could feed back into and amplify the chaos.

Let me explain each of these points in turn.

Firstly even a cursory reading of descriptions about medical procedures shows that containing this disease is highly resource intensive. In Nigeria at this time it looks as if the importation of the virus by a single traveller who flew in has been contained. But how has this been possible? It is interesting to note that from a single traveller there were 19 confirmed cases of further infection. 8 of these resulted in death and the last was detected on 31st August. So how on earth have the Nigerians contained it. The answer is that they have had a polio eradication programme using much the same procedure and skills and this programme has spare capacity because of its success. But get this:

“It took two weeks for the first isolation ward to open and health workers were initially reluctant to work in it. However, 1,800 health workers were eventually trained, protective gear was provided, and safe wards with enough beds and access to chlorinated water were set up so that patients could be treated safely. In total, health workers made 18,000 visits to 900 people to check the temperatures of possible contacts. As with polio eradication, this wasn’t easy but it was imperative to stopping the disease in its tracks.”[1]

So just one man entering the country requires a resource effort of 1,800 workers, properly trained and equipped with safe wards to fall back on – able to make 18,000 visits and checking 900 people!

Is our health service ready to do that? To deploy that level of resources? It seems to me that the resource intensity of this is such that there is likely to be massive overwhelm if there are not one but a few cases – for example an infected family not an infected individual comes into the country, the children go to a school and the parents travel around on work commitments.

This brings me to the second point. West African countries are by and large settled communities by comparison with our society. Yesterday I started to think about these matters when I wanted to get on a Nottingham tram just before 9 in the morning to go an get a flu jab. I let a couple of trams go by because of the difficulty that would be involved in getting in to the cram. Someone vomiting in a mass transportation system like this would be rather difficult to follow up – as indeed in a shopping centre or in the loos of my local pub. How would an epidemiological team follow that up? Or how do they follow up if and when infection circulates in a network of drug addicts?

Third point. It is obvious from this that, at a particular point, the level of infection, or protective measures against infection, are likely to be severely disruptive of “hub interdependencies of society” – like transport networks. Beyond a certain threshold magnitude of infection people are going to be fearful of using shared facilities – I can think of times I have not wanted to use a cash machine that someone appears to have spat upon. One such hub interdependency in a global economy is air travel itself. An article by an ebola expert in the German news magazine Der Spiegel mentions his fear that ebola will spread into the slums of India via air traffic hubs in the middle east. “Dubai could become a location of super contagion for those who change planes there are not subjected to any kind of health monitoring and travellers from Europe, America and Asia all sit together in the transit area in a colourful mix with people from Guinea, Kenya, Nigeria with no controls at all. Then they fly off to everywhere in the world”.[2]

Now the point here is that the logical thing to do would be some form of quarantine arrangements for a number of weeks before travel is allowed between countries but the consequences of this on the world airline industry would be catastrophic – and quite soon we are talking about a collapse or severe disruption of a large part of the global economy. Yet we know how our betters react to this – when “Mad Cow Disease” was identified in the UK it took 6 months to acknowledge the problem for the public so great was the fear of disrupting the meat market. And of course a disruption of the global economy should not be talked of lightly anyway – the pharmaceutical giants who, in principle, might eventually deliver us a treatment operate transnationally too.

In the meantime though there is a threshold, a tipping point in which a disease outbreak would be amplified by disruption to the economy. We can already see that in West Africa where ebola has led to rising food prices because it has disrupted the cultivation of food. In our own society it is easy to see that we cannot easily withdraw from close interpersonal contact without economic effects – for example it seems obvious that schools might be vectors of infection yet closing schools has profound effects on the ability of parents to work….

So…should we be fearful? I think that we should and if we could direct our reasoned fear at the politicians, officials and health managers to wake them up from their complacent attitude and devote a lot of resources and attention then that would be a thoroughly good thing….

More to follow…for now let me conclude with the following remark: in 1348 – 1349 probably one third of the population of the UK died from the Black Death that had already killed millions of people in India and the middle east. It then re-occured repeatedly over the next few hundred years. The depopulation of the Americas by disease introduced by the invading europeans was even more startling – with a death toll from disease by a startling 90%.

It could happen again – if we don’t want it to we will need a lot more focused attention and resources to prevent it – and a lot less complacency.

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PS [added at 15:41, October 8]: People are very concerned about airborne infection and I think a concern about droplet infection assumes that people are “producing droplets” – yet, I’ve not heard of coughs and sneezes from Ebola victims.

It seems to me that the problem is more likely to be that, once ill, people may soil themselves, vomit, sweat, bleed and pee too – and that has to be cleared up somehow. It has to be cleared up in a specially constructed highly controlled medical setting ideally – but there will be a need to deal with this in their own homes, in hotel rooms, on trains and planes, perhaps in public loos and so on – and in many cases it may not be known to the person concerned or those clearing up that this might be infectious stuff because this is at the early stage of the onset of symptoms and a diagnosis has not yet been made.

So what are the protocols for clearing up in these multiple different settings and for cleaners, nurses or family members, working in a hotel or public lavatory, for knowing whether a drunk just spewed up because s/he had too many or there is something more serious on the floor of a public lavatory?

What do you say to people who have been living with someone found to have ebola – what are they to do with those sheets? How does a teacher or nursery nurse know that the small child that soiled itself is from an infected family?

And here’s another thing to be concerned about. I’ve translated it from the latest copy of Der Spiegel (Issue number 41: 2014 page 117) This really is an example of Murphy’s Law

“Protective suits becoming scarce

Because of the ebola infection in west africa the demand for suits to protect against viral infection has risen so steeply that there is a threat of a bottleneck in the supply. DuPont, one of the world’s largest suppliers of these protective suits, is speaking of a “critical situation”. Because the the overalls can only be used once the need of international health organisations can barely be met. Already many hundreds of thousands of such protective suits are used every month according to DuPonts business manager Albrecht Gerland. There will soon be a need for a million. The Dutch business Imres, which has also produced more than 270,000 protective overalls since the beginning of the epidemic, is complaining that the production of overalls is becoming ever more difficult”

Further discussion of the effects of a global pandemic can be found in David Korowicz’s paper Catastrophic shocks through complex socio-economic systems: a pandemic perspective.

Endnote

[1] http://www.theguardian.com/global-development/poverty-matters/2014/oct/07/nigeria-ebola-experience-teach-world
[2] Der Spiegel 40/2014 (Print Issue ) “Seuchen. Indien ist schutzlos” Interview with Gerd Antes page 104

Feautered image: Ebola virus. Source: http://en.wikipedia.org/wiki/Ebola_virus#mediaviewer/File:Ebola_virus_em.png