If you are only going to read my introduction or the piece posted after it, I'd suggest the piece posted after it. It is comprehensive and scientific. It covers a lot of ground, and I wish that everyone would listen to it. My introduction isn't bad, but it doesn't match the quality of the posted piece.
I believe and have been discussing this with others that the WHO, CDC, the government (federal, local, state), the health departments, etc., have been doing us all a disservice by treating us like children. What we want is simply the truth, the facts. We don't need it sugar coated. It is true that historically Ebola has not been easy to transmit. We understand that this is probably still the case, but quit giving us absolutes. Quit telling us we are absolutely sure the only way to transmit Ebola is via direct contact with blood, urine, feces, vomit, etc. Explain that not being airborne does not mean someone sneezing can't spread the virus, that sitting next to someone with a cough can't spread the virus. Tell us the truth. Admit, that you simply cannot say these things with one hundred percent assurance. We need to also quit acting like public health is a perfect science, that contact tracing is always right on the money. I know. I've been there. We can't pretend that guidelines are facts, that mistakes are never made. It's ridiculous to make these absolute statements we have seen so much of in regard to Ebola. We've never dealt with an Ebola outbreak anything like what we are seeing in West Africa today. We can't compare it to the outbreaks we have seen before in remote areas. We have never dealt with Ebola in large cities, in urban areas. We have never dealt with this strain of Ebola. We haven't done it. We are learning on the fly because we have refused to prepare (and even if we had adequately prepared, we'd still be operating by the seat of our pants). We have refused to fund public health, we have pretended that epidemics and pandemics are a thing of the past, even though we have always know that not to be true. The conservative mantra (and the liberal echo) of lower taxes and budget cuts actually mean something in the real world. Finally, and of course, public health and healthcare workers are human beings, mistakes are made, will be made. No one is perfect.
The big problem here is that every time we are told something is absolute, and we find out it isn't, the level of trust necessary to fight an epidemic decays until no one believes anything anyone says. That is not a happy scenario when one is trying to prevent or halt and epidemic. So tell us the truth. We are adults. We can take it.
Finally, let me add my one caveat that I keep making to all this. Ebola is one thing. Avian flu is quite something else. This country, the world, is in no way near ready to deal with an epidemic of say H5N1 or H7N9 flu. All bets are off when avian flu arrives (and it will, sooner or later). All viruses mutate, flu is a master. Flu transmission is simple and efficient, mortality high (H5N1 and H7N9 upwards of 60%), chaos here for sure. You can't shut downs the borders when the virus flies in on the wings of migratory birds. On top of everything else, we simply don't have the resources, the beds, the healthcare workers, the supplies, the stockpiles, the anything, to deal with that type of pandemic. We should. We don't. We have no public health system and no one is in charge. No one knows if the CDC, HHS, the state or county or city health department has the ultimate authority to make decisions. The truth is no one does. (I'll tell you this, from experience, if we leave it to the local authorities, as we are currently doing, good luck to everyone. If my city, county or state health department is in charge, say good night. I had to deal with them during the early days of the AIDS epidemic. Take my word for it, you don't want to depend on your local health department for this). One case of Ebola in the USA has caused a large stir, imagine millions of cases, tens of millions of cases of avian flu, hell, imagine hundreds of millions in the USA. Imagine billions throughout the world. Get the picture.
I haven't even mentioned the rise of antibiotic resistant bacteria and the dawn of a post antibiotic world.
Trust me, I am not an alarmist. I am a realist. I have studied this stuff for years and worked in the field of public and community health. I don't know when it will happen, a year, ten years , three decades, I don't know, but I know it will. To those out there who want to save money on the back of healthcare and public health, well, your savings will, I say absolutely will, lead to misery and death, but then Global Capital isn't concerned about that. Global Capital is concerned about accumulation and profit. We either need to get rid of Global Capital at best, or at least, explain to them there is no money to be made when the world is sick and dying.
It is therefore in the end up to you and me (maybe not this time, but maybe the next). We can make a stand or, well, we can wait and see what gets us first - global climate change and environmental destruction, or the viruses and the bacteria.
NOTE 1: Oct. 3 - WHO tally: 3,438 dead out of 7,491 suspected, probable and confirmed cases in West Africa. But the real number is likely much, much higher.
NOTE 2:With exactly ONE Ebola case confirmed in the USA, I am already seeing plenty of signs (and some totally overt comments) that lead me to believe that we may see the very same type of stigmas attached to Africans and even African Americans that we saw toward Haitians early in the AIDS epidemic. Ain't that America...
The following is from The Peter M. Sandman Risk Communication Website. This article is long. It is also extremely important, incredibly accurate, amazingly well written. You simply must read it.
Ebola Risk Communication:
Talking about Ebola in Dallas,
West Africa, and the World
|Email 1:||Tom Frieden’s SOCO and Other Aspects of U.S. Ebola Risk Communication|
|Email 2:||What Needs to Change in Ebola Risk Communication: Pivoting away from Dallas|
|Email 3:||Three Ebola News Stories: Dallas, West Africa, and What-If|
The First Email (October 3, 2014):
Tom Frieden’s SOCO and Other Aspects
of U.S. Ebola Risk Communication
by Peter M. Sandman and Jody Lanard
(email reponse to query from Sharon Begley of Reuters)
Unlike West Africa, the U.S. will stop Ebola cold by isolating patients quickly and locating and monitoring their contacts – tried and true public health strategies in which we excel. Because we have such a good public health system, you’re very safe here unless you’re one of the handful of people who were in close contact with Duncan after he became symptomatic. Job One is still in West Africa, not here.
We know that there are travelers from places where there is Ebola, we know it’s possible that someone will come in, if they go to a hospital and that hospital doesn’t recognize it’s Ebola there could be additional cases where their family members could have cases. That’s all possible. But I don’t think it’s in the cards that we would have widespread Ebola in this country.
While it is not impossible that there could be additional cases associated with this patient in the coming weeks, I have no doubt that we will contain this.
Uncertainties, Reversals, and Screw-ups
I want to acknowledge the importance of uncertainty. At the early stages of an outbreak, there’s much uncertainty, and probably more than everyone would like. Our guidelines and advice our [are] likely to be interim and fluid, subject to change as we learn more….
The person fell ill on Sept. 24 and sought medical care at Texas Health Presbyterian Hospital of Dallas on Sept. 26. After developing symptoms consistent with Ebola, he was admitted to hospital on Sept. 28.
Overconfidence and Over-reassurance
- The categorical claim, endlessly repeated, that asymptomatic people cannot transmit Ebola.Nobody doubts that Ebola sufferers get more infectious as they get sicker. But the boundary between well and sick isn’t as rigid as this dichotomous claim suggests. And distributions have tails. Almost everything we know about Ebola we know from observing (with difficulty) what happens in African outbreaks. We know very little about what sorts of Ebola patterns might emerge in the developed world, including patterns that are atypical and unusual but not impossible.Sooner or later somebody will transmit Ebola to somebody else while credibly claiming to feel fine. Then the experts will say that s/he must have had mild symptoms of which s/he was unaware – a bit like a tree falling in the forest with nobody there to hear it.“Science says that if you are not exhibiting symptoms of this, there is zero chance that you can transmit this,” Dallas Mayor Mike Rawlings said on October 1. “Not minuscule – zero.” “Minuscule” would be more sustainable, we suspect.Despite what they say, Dallas and Texas officials are acting as if the risk posed by asymptomatic people were nontrivial. Duncan’s closest contacts have been forcibly quarantined, including the children, although they are asymptomatic. (This is at least in part because of concern that they might be lost to follow-up.) The schools the asymptomatic children attended have been specially scoured by janitors in hazmat suits (some with exposed skin and no hoods).We realize that these actions are motivated chiefly by the need to reassure anxious citizens. But they’re being justified as “an abundance of caution,” and little is being said by Dallas officials, Texas officials, or federal officials about the fact that they’re contrary to the CDC guidelines. We doubt this sounds like “zero” to the citizens of Dallas. It certainly doesn’t to us.During SARS, Singapore leaders took certain actions at schools that their health department said were not medically necessary. The Prime Minister announced the health department’s opinion, but respectfully said he was taking the measures anyway because so many parents and teachers felt strongly about them. He didn’t say “abundance of caution.” He said, “We are responding to your concerns [because] you are understandably afraid.” He gained enormous trust and credibility.Frieden fell more deeply into the symptomatic/asymptomatic trap at his October 2 news conference. As reported by Denise Grady of the New York Times:The disease is not contagious during the incubation period, and patients do not transmit it until they develop symptoms, [Frieden] said. And those with symptoms will probably feel sick enough to stay home. People are highly unlikely to catch the disease on the bus or subway, Dr. Frieden said.”Frieden’s claim that those with symptoms will probably feel sick enough to stay home is not true for a significant number of Ebola patients, early in their illnesses. Ebola-infected healthcare workers have even gone to work in the early phase of their illnesses. After treating an Ebola patient who recovered, the late Nigerian doctor Ikechukwu Enemuo developed symptoms on August 11. He continued to treat patients until August 13 – including two surgeries – when he got too sick. Then he stayed home with his wife and baby for another three days. He infected his wife, his sister, and a third person before he died. Some Ebola-infected healthcare workers have even continued to socialize during the early phase of their illnesses, during which time they infected others. Some Ebola Treatment Unit healthcare workers, feeling poorly but certain they didn’t have Ebola, have continued to come to work out of a strong humanitarian sense of dedication. Some of them infected others before they got too sick.It is really wrong to tell people that an asymptomatic person can’t transmit Ebola, and also tell them that a symptomatic person will be too sick to be out and about. The first half is almost certainly true almost all of the time – but there is not always a bright line between perfectly well and mildly symptomatic. The second half is far from true much of the time – there is often a fairly broad line, a couple of days wide, between mildly symptomatic and flat on your back.
- The oversimplified claim that Ebola transmits only via direct contact with bodily fluids.Here again, the point is probably almost entirely true but overstated. What gets across to most people is that to catch Ebola you must actually touch a sufferer’s feces, vomit, or blood. Not that most people think that’s the truth; they think that’s what officials are saying, and they decide for themselves that Ebola can probably sometimes transmit in subtler ways as well.The scenarios that officials tend to shy away from are the ones that don’t sound like “direct contact with bodily fluids,” but actually are. Shaking hands at a party with a sweaty new acquaintance from West Africa, and then rubbing your eyes. Riding in a taxi whose previous passenger left hard-to-interpret slightly damp stains on the seat. Making love to a man who has recently recovered from Ebola, whose sperm still carries the virus. Standing less than three feet from somebody who spits a bit when s/he talks (as we all do).The last one got Frieden into hot water in an October 1 CNN interview with Sanjay Gupta. Standing right next to Gupta, Frieden said: “Well actually, Sanjay and I, if one of us had Ebola, the other would not be a contact right now. Because we’re not in contact. Just talking to someone is not a way to get infected. It’s not like the flu, not like the common cold. It requires direct physical contact.”CNN host Michaela Pereira pointed out that sneezing would change the situation. And Gupta objected that “I am within three feet of you…. My understanding, reading your guidelines, sir, is that within three feet or direct contact – if I were to shake your hand, for example – would both qualify as being contact.”At that point Frieden should have said, simply, “You’re right. I misspoke. Ebola can sometimes transmit by droplets (for example, from a sneeze or saliva when people talk), or by fomites (for example, from a handshake). That’s pretty much the same pathways as flu, although Ebola is a lot less contagious than flu via the droplet route. Ebola spreads mostly via contact with bodily fluids.” What he actually said: “We look at each situation individually and we assess it based on how sick the individual is and what the nature of the contact is. And certainly if you’re within 3 feet, that’s a situation we’d want to be concerned about.”Not his best moment.The word “airborne” is also problematic. What airborne transmission means to a virologist is transmission via much smaller particles that can travel much further than large droplets. By that definition, Ebola isn’t airborne – although some experts are worried that the Ebola virus might mutate in a way that would permit airborne transmission.But what does “airborne” mean to ordinary people when they hear an official assure them that there’s no risk of airborne Ebola transmission? It means through the air. And by that definition, Ebola transmission is sometimes airborne, for example when people sneeze, cough, or emit droplets of saliva while talking. In this sense projectile vomiting is also airborne.
Talking about West Africa
- We must develop and mass-manufacture an Ebola vaccine.
- We must insulate ourselves from the hot zones, refusing to allow people from there to come here unless they can prove themselves Ebola-free.
- We must break the back of the epidemic in West Africa, chiefly by isolating those who are sick, and then tracking their contacts.
- We must provide decent basic medical care for West Africans with Ebola, not just for humanitarian reasons but also because otherwise too many will flee, and some will take the virus with them.
Three Miscellaneous Points
- “The window is closing”We wish Frieden – and all Ebola commentators – would stop telling people that “the window [of opportunity] is closing” in West Africa. They never say when the window will be closed, and after a while everyone figures out that they will never say that the window is now closed.If they really mean what they say, they should tell us what they think should happen after the window closes.
- ToneThe determined, Churchillian tone that we like when Frieden is trying to rouse people to take a risk seriously can come off as cocky or even smug when he’s telling people everything is under control and they should just calm down and let the people in charge get the job done.But we think the experience of the past three days may have solved that problem already.In crisis communication, the best combination is a confident tone and tentative content. You don’t know what’s going to happen next; you may have to change a bunch of policies after you see what works and what doesn’t; you’re building your boat and sailing it at the same time (David Heymann’s words); you know there will be screw-ups. But you’re used to that. Coping with chaos and uncertainty goes with the job, and it’s not freaking you out.The opposite combination – saying confident things in a tone that suggests you’re in over your head – is of course disastrous. So we’re not urging Frieden to change his tone, just his content.
- Alternative precautionsThis is particularly relevant for frontline healthcare workers and Personal Protective Equipment (PPE).When prescribing precautions, it’s always wise to give people a choice, and thus a sense of control. Ideally, we advise clients to try to offer an X, a Y, and a Z:At least do X. Even if you think we’re over-reacting, X is the minimum protection we think is necessary. We recommend Y. Y is more hassle and more costly than X, but it is also more protective than X. We think it’s worth it – but if you disagree and want to stop at X, okay. Z is still more bother and expense than Y, and again more protective. We don’t think it’s worth it; that’s why we recommend Y rather than Z. But if you think we’re not going far enough, if you feel more vulnerable than most people or more worried than most people, by all means go that extra mile and do Z, with our blessing.If there is a whole menu of X precautions, Y precautions, and Z precautions, that’s better yet.Two good things happen when you bracket your Y (your preferred recommendation) with an X and a Z. First, you get more Y. Because people feel more sense of control, they tend to be more willing to comply than when faced with a one-size-fits-all prescription. Second, you get less long-term rebellion. You have framed the choice of precautions so people who prefer X or Z to Y are still inside the system, not rebels. That makes them more receptive to your next precaution recommendation.In Dallas and around the country, a lot of people are looking for Ebola Z’s. Local officials want to quarantine asymptomatic contacts. Talk radio hosts want to close the border. Healthcare workers and cleanup workers want better PPE. If the CDC wants to avoid unacceptable Z’s, it will help to prescribe some acceptable ones. You can’t give every healthcare worker a moon suit like the ones we’ve all seen on television. But for many of them a surgical mask just doesn’t feel protective enough, even though you say it ought to be in many cases. So make N95 respirators your Z.Other people are in need of an X. Some contacts, for example, resist the prescribed quarantine protocol. This may be denial; they’re at risk and can’t let themselves believe it. Or they may rightly sense that you’re “casting a wide net,” as you say, and their risk is really negligible. So offer them a choice of protocols, including a less onerous X.
The Second Email (October 5, 2014):
What Needs to Change in Ebola Risk Communication:
Pivoting away from Dallas
by Peter M. Sandman and Jody Lanard
(email reponse to query from Kai Kupferschmidt of Science)
- The Dallas “outbreak” needs to be stopped – stopped at one, ideally, but that die is cast. Either other people are already infected or they are not.
- The screw-ups in Dallas need to stop. The two big ones so far: letting the patient go home from the hospital on September 26; and leaving the family in enforced quarantine inside a contaminated apartment for days.
- The screw-ups in Dallas need to be acknowledged and apologized for – repeatedly. When a Texas official said they are “continuing to improve,” it sounded hollow and grossly insufficient, juxtaposed with news that the family had at last been removed from their apartment.
Four Responses to the Epidemic
- We must try to develop and mass-manufacture an Ebola vaccine.
- We must insulate ourselves from the hot zones, refusing to allow people from there to come here unless they can prove themselves Ebola-free. (Among the proposals: 21-day quarantines before release into the U.S.)
- We must break the back of the epidemic in West Africa, chiefly by isolating those who are sick, and then tracking their contacts – the traditional public health response, which has never been tried in a hemorrhagic fever epidemic as enormous as this one.
- We must provide decent basic medical care for West Africans with Ebola, not just for humanitarian reasons but also because otherwise too many will flee, and some will take the virus with them.
Improving Ebola Risk Communication
- Teach the world how exponential growth works. Explain that the CDC’s worst-case estimate of 1.4 million Ebola cases by mid-January is essentially the same estimate as 700,000 in late December and 2.8 million in early February. Reducing the doubling time of Ebola requires reducing the number of contacts sick people have a chance to infect. Isolation is – tragically – a much higher priority than treatment. This isn’t a humanitarian crisis. It is a global health crisis. And it is a global security crisis. Armies may be a more important part of the solution than healthcare workers.
- Teach the world what’s in store for us all if Ebola isn’t stopped. It’s about more than numbers. Paint vivid pictures of what life would be like if Ebola were to establish itself throughout the developing world the way it has established itself in three West African countries so far. Talk about the likely impact on supply chains, on the world economy, on political stability. Point out that developed countries can probably extinguish the sparks that come their way, at least if there aren’t too many – though with greater difficulty and greater pain than we’re imagining. And point out that developing countries probably can’t. Lagos and Port Harcourt somehow managed to extinguish the spark that ignited after Patrick Sawyer brought Ebola from Liberia to Nigeria, as few thought they could. Almost nobody thinks the developing world can extinguish spark after spark after spark.
- Teach the world why finding, testing, mass-producing, and actually distributing an Ebola vaccine is the only realistic way to end this global disaster-in-the-making. Investigate the vaccine development story in detail. Find the choke points that need to be smoothed. Figure out what else could be done to improve the probability of success and the speed with which it happens. Report in detail on what’s hopeful and what’s not so hopeful in the Ebola vaccine story so far. Assess – and keep assessing – whether a vaccine is a pie-in-the-sky deus-ex-machina or a reasonable hope. (This in particular is a job for Science!)
- Teach the world why “spark suppression” – reducing the number of Ebola sparks emanating from West Africa – is essential to buy time for the desperate attempt to find a vaccine. Don’t settle for the false dichotomy – the claim that since border closings never work perfectly, there’s no point in inhibiting travel. Foster a thoughtful debate about various proposals for reducing the number of sparks, and thus reducing not just the burden of extinguishing those sparks but also the chances of Ebola establishing itself in additional countries. Help assess which proposals will probably backfire, which will do little good at great humanitarian cost, and which will do comparatively more good at comparatively lower cost.
- Teach the world to endure uncertainty. The Ebola virus might mutate in ways that would make it even more dangerous than it is now – to enable airborne transmission, for example, or to enable an infected person to function longer in the world and thus spread the disease to more people. At the other extreme, Ebola might somehow burn itself out. Or it might become endemic in Africa without spreading widely elsewhere in the world. More important than any individual scenario is the reality that we know so little about which scenarios are likely and which are vanishingly unlikely or even impossible. Until now, our knowledge of Ebola comes almost entirely from small outbreaks in African villages; now we are learning from a big epidemic in West Africa. We still know next to nothing about how an Ebola outbreak might play out in a developed country in the northern hemisphere.
- Don’t worry about panic (except in places where Ebola is actually epidemic). Treat people like adults. Tell them painful truths.
- Avoid over-reassurance and over-confidence , the evil twins of poor crisis communication. Keep telling people how little you know and how upsetting this is, not just for them but for you as well.
- Acknowledge errors, omissions, uncertainties, and policy changes. Better yet, predict them … and then acknowledge them after they happen.
- Ask more of people. Find ways to harness people’s willingness to help – including the willingness of people who are not prepared to serve a tour of duty in West Africa.
- Be willing to speculate. Risk communication and crisis communication are all about what-ifs. Focus on both likeliest scenarios and worst case scenarios.