Jeffrey Sachs talking:
that was a very specific point that I think President Obama should be backing up his real Ebola leader, Tom Frieden, the head of the Centers for Disease Control, rather than appointing somebody who obviously lacks the necessary knowledge and experience to head an Ebola effort. This was politics. It’s a kind of modest point. It’s not really at the center of the fight against Ebola per se, but it was a response to the real disgraceful show in Congress, when congressmen, who know nothing and who had been cutting the CDC budget for years, then went after Frieden, who is one of the world’s most experienced leaders in public health. And rather than the congressmen asking, which they should have, “What can we do for you, Dr. Frieden, to help ensure a quality U.S. effort?” from their, you know, high horse, they start making accusations and stupid statements. And I thought the president should just have come out and said, “Stop it. We have a highly experienced leader of the world’s most important public health institute. Let’s get on with it.” Unfortunately, he didn’t do it; he appointed this fellow, Ron Klain, who—I don’t know if he’ll do something useful. I hope he doesn’t do something just to add to the confusion.
a note from Jubilee USA saying right now Guinea is spending more on debt than on public health. Sierra Leone, Liberia, Guinea spend together nearly $200 million a year on debt. Imagine what that money could do for funding healthcare, they asked, in their countries and what it could do—could have done to help stop the Ebola even before it started. They point out, in 2010, the U.S. passed a law supporting debt relief for Haiti after the earthquake. What about doing the same thing with these countries?
a year ago I tried to raise funds for Liberia for community health workers, before the Ebola epidemic had started. And the answer from all of the international agencies is, “Oh, there’s no money here, anyway. Liberia is not much of a priority. Come back in the next funding cycle,” and so forth. There is a fundamental principle both of decency and common sense, which is, we should not leave people anywhere in the world bereft of a basic, functioning primary health system. And it is clear as day that we do that for—with hundreds of millions of people, especially in rural sub-Saharan Africa. The attitude here is, “Well, what difference could it possibly make? Who cares?” which is both shameful, from an ethical point of view, but absurd, from a practical point of view. This isn’t exactly the first epidemic, and it’s not going to be the last one we face. And it’s a similar region, by the way, where AIDS began some decades ago and spread to the world from the forested regions of West Africa. We are so irresponsible in thinking that it somehow is decent for—and plausible for impoverished people to have no access to healthcare.
What you heard from the MSF nurse in her wonderful testimony just a moment ago was that the essential question on controlling an epidemic is the ability to identify people who are potentially infected, test them—if they are infected, to move them safely to a facility where they can both get care and be isolated so as to not spread the disease to others. This is a logistical problem. It’s a resource mobilization problem. It’s not the highest science. Maybe the highest science can produce a vaccine or new medicines very quickly, but the basic public health strategy—of case identification, testing, isolation, treatment—is a workable and will be a successful approach, if the resources are mobilized to do this. We’re scrambling like nothing because the resources weren’t there at all, because the international community did not sound an alarm as Ebola spread, thinking that it would just fade out on its own, as it had in earlier epidemics, but instead it was a wildfire, and now it’s spreading throughout the region and indeed to other parts of the world.
The basic approach of getting this under control, as I’ve described, is identifying potentially infected individuals—either through contact tracing of those who have come into contact with the earlier Ebola-infected patients, or the people who develop symptoms that are suspicious, even if they weren’t on a contact list—getting them quickly tested, getting them safely taken to a treatment center in the event that they are Ebola-infected, and then having appropriate supportive care, as you just heard.
Well, building that, from almost nothing, in a matter of weeks is the real challenge. The problem with an epidemic is it doesn’t just stand still, of course. It is a chain reaction. It has geometric growth. In the case of Ebola, a doubling period—in other words, the time to double the number of cases—is roughly every three weeks right now. So this is an absolutely ferocious race against time, where the resources have to come from the outside, in financial terms. Much of the equipment has to be flown in. It’s a massive logistical problem. It’s a social problem, obviously, to enter into communities that are scared, fearful, without traditional contacts with the health teams, and to find, of course, the people and train them that can do this safely. So this is exactly what we’re trying to focus on, every aspect of this.
One of the key points that we’re quickly trying to bring to bear is information, through smartphones carried by front-line workers who can quickly put in information about a new patient—what kind of contact, what the symptoms are—get the information flowing so that there is a logical chain of support, of testing, of transport, of arrival in a clinic, of contact tracing. And we’re working ’round the clock right now with the programmers at developing new Ebola applications, working with MTN and Orange, the phone services, with Ericsson, the telecoms provider, with the president’s team, and of course, with a bunch of international agencies and with MSF.
But the scramble is phenomenal. If you can see how much we’re turned upside down by a few cases in the rich and populous United States, think about the thousands of cases that roiling West Africa right now, with all the impoverishment and the logistical challenges. It’s a very practical, minute-to-minute problem where speed is of the essence.
Dr. Nancy Kass talking:
some pretty significant messaging that goes out to the American public when an official says the only thing safe to do is keep people locked up in a tent when they arrive. It turns out that’s an inaccurate public health message. And what we’ve known about public health for a long time is that we need to give the public clear and accurate information consistently. This becomes a confusing message, because the public health people are saying, “Take your temperature. If you’re symptomatic, we then have to isolate you and give you care quickly. If you’re not symptomatic, it’s OK.” By putting this out, it’s a very confusing message to the public.
The other concern is that all of our state public health authorities have something that they’ve had for more than a hundred years—called the police power. It’s a really critically important type of power for public health to have. It allows public health to lock up—to close restaurants when they’re dangerous, to lock up animals when they’re dangerous, and even, in extreme circumstances, to confine people if there’s a risk. But ethically, we always have to be assuring the public that we will only do that when it’s the necessary measure. By using police power when it’s not necessary is a very troublesome approach both to how our government’s working and, again, to the public health messaging to the public.
we have no idea whether the ZMapp is what saved Kent Brantly’s life and Nancy Writebol’s life. They received the best supportive care available. And what we’ve seen from other people who have been brought back to wealthier countries, like the United States, is that supportive care is what people really need. People who get sick with Ebola end up vomiting a lot. They end up having diarrhea a lot. They need this supportive care. And we didn’t do a trial with them, for understandable reasons. And even though they, thankfully, have survived, there’s no way to know whether or not the ZMapp or the serum that they got from people who were Ebola survivors were in any way responsible for their recovery.
Now, it’s a really important question to figure out who gets access to this experimental kind of medicine. It certainly is true that when people like Ms. Hickox or Ms. Guild go off to another country, there are certain commitments that we make to them as sort of the international people who go and come back. We make commitments to give them the best protective equipment, that not everybody locally has. We give them commitments that we will fly them back, we will take care of them, we will pay them during their recovery period, and we will give them the best care possible. So the fact that there were certain kinds of privileges given to the first two people who were infected, when they brought back, is not, to me, necessarily problematic. That’s a really different question than “How do we figure out whether these experimental drugs work?” Certainly, right now, the best intervention are all the public health interventions that Dr. Sachs mentioned. But we have to figure out whether the vaccines or the treatments work. And uncomfortable as that may be, we’re going to have to be doing that with larger numbers of people, with people who are sick, in terms of the treatments, and if it looks like they’re not working dramatically well, we’re going to have to make some hard decisions about whether to do a randomized trial, where some people get the treatments and some people don’t.
we need different kinds of people on the ground. And what I think gets the most publicity are the people providing direct care in the treatment centers to sick patients. And obviously that’s really important. And my understanding is that it has been slow for a variety of reasons. Certainly, when the United States finally and ultimately committed that 3,000 people would come through the Department of Defense, that was a good thing. The Department of Defense has the logistical know-how to move operations like that quickly. Unfortunately, my understanding is that those 3,000 people are not there yet, that it’s been fairly slow to mobilize. And despite the amount of work that MSF is doing—and they have really been, again, remarkable heroes from very early in this epidemic, long before the United States was paying attention—there are far too many patients, and we need more healthcare workers.
I certainly have a colleague at Johns Hopkins, just as one example, who was in Liberia last week training—helping to train 1,000 healthcare workers from the Democratic Republic of Congo. Obviously, Congo has experience with Ebola from past outbreaks, and they were willing to send a thousand healthcare workers to Liberia, who were being trained both in the treatment aspects and, to some degree, some of the outreach that Dr. Sachs was talking about.
I do think it’s interesting that we don’t tend to cover as much the outreach that he was describing. And until we have enough treatment beds, what is really going to make a difference is all of the public health outreach. Public health outreach is traditionally, whether in the United States or in West Africa, what has ultimately stopped epidemics from spreading. And fortunately, you can have people who don’t have quite the same sophisticated skill set to participate in that kind of—that piece of the response.
what I do for a living, I’m not the one designing trials. There are people who are designing trials. My understanding is that there are a variety of drugs that are being considered. They each have different sort of kinds of histories. I think the real challenge is how they’re going to be tested. And if it turns out that a drug is dramatically effective—for example, you give it to 10 people who are really sick, and nine of them recover or 10 of them recover—you don’t need to do a randomized trial. If it turns out you give it to 10 people, and six or seven people recover, it’s a little bit hard to tell whether that was the drug or whether they would have recovered anyway. So, to some degree, my own view is that you can start to do some initial rollout, give it to everybody. If you see a dramatic result, you go ahead, and you’re pretty excited—good news. If you don’t see a dramatic result, you may need to do what’s called a more adaptive design, to start to move into some people get it and some people don’t. It sounds inhumane, but we’re going to know much more quickly whether or not these new drugs work or if they don’t.
— source democracynow.org
Jeffrey Sachs, leading economist and the director of The Earth Institute at Columbia University. He recently authored an article headlined “We Don’t Need an Ebola Czar.” The Earth Institute is working with the government in Guinea to battle the Ebola epidemic and is holding a conference today titled “The Ebola Crisis: What It Means for West Africa and the World.”
Nancy Kass, professor of bioethics and public health at Johns Hopkins University. Her article in the Annals of Internal Medicine is “Ebola, Ethics, and Public Health: What Next?”