Ebola at a glance

There were more people than I expected. Although with Dr. Paul Farmer involved there were bound to be a lot of people. The first time I saw him speak was in graduate school, my first semester of graduate school, the seats were filled early, the aisles shortly after, and the final surge was relegated to the overflow- their ears straining to hear what he had to say. That was before I knew he was the golden boy of international public health. An MD PHD. Medical doctor slash anthropologist who also started an international nonprofit (in Haiti) while getting those degrees. 

Yeah. That guy. 

Most famous for his work in Haiti, his presence is all over the developing world. Working to make antiretrovirals available in their generic form so that low-income countries can afford to provide them for their citizens. That isn’t the half of it. 

I wasn’t sure how he factored into the Ebola discussion he was slated for, but as soon as I saw the advertisement I bought a ticket. His finger is on the public health pulse the world over…he’d have something of note to say.

Settled in my seat an hour before his start time, an attempt to avoid the lines and craze I anticipated, I stared at the chairs on stage and wondered who would be joining him. 

We started the evening with humor. One of the five men on stage, seated at a jaunty angle, introduced himself as the host, “not the parasitic kind,” he assured us. And the Nourse theater giggled in public health geekery. Drs. Paul Farmer, Dan Kelly, Raj Panjabi, and Ambassador Eric Goosby, a collection of men with impressive letters behind their names and decades of experience in Africa and beyond under their belts, began a very elegant, if abstract conversation about the Ebola outbreak epidemic pandemic.

Of course there were the basics. How it spreads, where it started, a brief mention of treatment. There was a glossing over of what the situation looks like on the ground. At least two of the doctors were freshly from Liberia and Sierra Leone and they fluttered briefly over what care, treatment, and patients look like. What it feels like to be there. 

The bulk of the discussion was big picture thinking. What are the implications for America? What is necessary to get Ebola under control? How do we evade the current worst case scenario of 1.4 million infected by January? 

There was assurances that we are safe here. Not because Ebola has preferences or because it isn’t mobile –our first case in Dallas proves how untrue that is- but because we have a public health and medical infrastructure – hell, a social and political infrastructure, that offers protection (or at least a very convincing idea of protection).

Controlling it is something else. Controlling it is complicated and full of questions and “if, then” uncertainties. 

How extensive is the under-reporting?

How reliable is airport screening?

How feasible is it that people will employ basic universal precautions while working with the sick?

If we deploy 3000 troops now then…what?

If we have beds but no clinicians then…what?

If all the promises of resources and staff from other countries doesn’t come until next week, or next month, or next year then…what?

And we can’t really know. We can speculate and hypothesize. We can create contingency plans for all of the foreseeable possibilities but we are ultimately at the mercy of time and reality. 

There are, of course, other things to consider. The public health professional in me is screaming out how crucial it is that we use this as an opportunity not to respond to Ebola – as everyone is imploring – but that we respond to the yawning gap in public health services and infrastructure that are inherent in developing nations. 

When the first case of Ebola appeared in Nigeria I was fearful. Lagos, population 21 million, with slums flanking the sprawling city, could have been a teeming petri dish of infections raging out of control. 

It wasn’t.

And while comparing it to Liberia is Apples to moon rocks, it is the most logical place to push an agenda of infrastructure building. 

Nigeria had one initial case (that led to 20 total cases) but its handling of that one case was admirable. Some of the success was luck (no one on the flight got infected), but it would be shortsighted to attribute luck to its success ta holding Ebola at bay. Nigeria has infrastructure. It has doctors and nurses and community health workers. It had a polio Emergency Command Center the Bill and Melinda Gates foundation provided in 2012 and transformed it into an Ebola Operations Center. Nigeria had recently cross-trained 100 doctors on basic epidemiology and they deployed 40 of that cohort to oversee the 18,500 contact follow-ups of 900 people. 

Yes, Nigeria was lucky. But Nigeria was also quick thinking and prepared.

Last night Paul Farmer repeated on several occasions West Africa’s dearth of Ses: stuff, staff, space, and systems. 

Gloves drying in the sun in Bong County Liberia

Stuff- the material resources necessary to provide service. Basic right? So easy to take for granted that a clinic or hospital will have gloves or medication, but when I was working in Liberia (years before Ebola) the clinics I had were so desperate for gloves they washed them and left them to dry on the grass or on bushes. Sun and latex is not a great mix and either is reusing single use latex anything. 

Staff- trained individuals who understand what care needs to be given and the proper way to protect themselves from infection. Health care workers are dying too. Exposed through imprecise precautions or the possible mistake (inadvertent needle prick or contact with contaminated materials). Not to mention the sheer number needed. In resource poor areas like Guinea and Liberia, trained professionals can be hard to come by and poorly paid. Tack on the short intervals that care can be offered while donning an impermeable PPE (personal protection equipment) in the sweltering almost-equatorial sun and things are even more complicated.

Space – is in high demand. How many beds are there? Where are they? Can people get to them? Are they properly equipped? Space can seem like the easiest of problems to solve but as West Point town in Liberia discovered, it is not. 

Finally, the most complex issue of all. Systems. This circles back to at least one of the reasons Nigeria was able to get out in front of the spread of Ebola on its soil. 

Of course all of this conversation dangles its feet in the pool of health disparities. Who has access to what? Why did American doctors get access to the blood serum of recovered patients (an old technique for fighting diseases with no known cure) and experimental medicines while African doctors and patients were left to die? 

A West African friend of mine had a much more America forgiving point of view.

“There is popular saying that 'charity begins at home'. Why is the west being blamed for not taking the lives being lost in West Africa seriously...when over the many years and many wars and many bad governments and many deaths past...Africans have not demonstrated that we value our own lives? And I get that we live in a 'resource constrained' part of the world and it is morally reprehensible for richer countries not to act...but for how long will we our lives continue to be at the mercy of aid?

Charity begins at home can be interpreted to mean 'others will value us and quickly jump to our aid to the extent that we value ourselves and add more value than burden to other countries of the world.

I am just tired of belonging to the part of world that is so helpless problematic and looked down upon.”

 But I disagree – not to the notion of Nigeria or, on a macro level, Africa, developing agency and self-sufficiency, but that it somehow makes it ok for America, Americans, to only appreciate the need that threatens us personally. Where is our humanity if we only care about a sprawling scourge on the world because someone we can relate to is impacted…because we might be?

One of the last questions of the night came from a woman who works with MSF (Doctors Without Borders). Freshly back from working in West Africa, she was passionate about how big the need and how understated our civil discourse on it had been. We were talking in abstractions and meanwhile MSF was at its limit. She wanted to know where the discussion about the reality on the ground was…where was the worry that we are still uncertain about leadership, next steps, and timelines.

I would have liked to see her on the panel. I would have liked to see a less abstract perspective on what it looks like and feels like. A closer examination of the naked need to temper the theoretical macro thinking that I realize is also essential. If you haven’t seen what hospitals in resource poor areas look like on a good day, how can you truly understand what they look like in crisis…what is needed in crisis?

When I worked in rural South Africa I would write and talk to my parents about my schools, how poor they were, how much they needed. My dad was a new teacher and working in a poor school in Texas and he would emphatically share that he knew exactly what I meant. I assured him that he did not and with all of the certainty in the world he would end the conversation with the affirmative. He knew.

When my family came to visit me I took them out to one of my schools. My dad walked in through the gaping hole in the side of the building that the kids also used instead of the door. He saw the 20 or so rickety desks that seated three kids at a time, and looked at the rotting chalkboard (that was only useful when we actually had chalk). He didn’t assure me that he understood anymore.

We need to visit the classroom. Not to rally pity or fear but so that we have a realistic understanding of the fight we are in for and where we are starting.