From five years ago in the New York Times, As Ebola Ebbs in Africa, Focus Turns From Death to Life by Norimitsu Onishi. Juxtaposing the tail end of one of the more recent global contagion scares with that swirling around Corvid-19 now.
No expert here, but a more than passing awareness. I have read perhaps two dozen or more plague/disease related books from a history and from an economic development perspective ranging from Justinian's Plague through the Black Death to epidemic collision between the Old and New Worlds post 1492 into the modern era with the 1918 global pandemic and ultimately the rash of Hot Zone type books of the past 20-30 years. Also, books such as The Ghost Map, In the Wake of the Plague, Plagues and People and other similar historical accounts which are less focused on the diseases per se and are more focused on their historical consequence.
And of course being old enough to remember our societal responses to Herpes, Legionnaires' Disease, Lyme Disease, AIDS, and the hysteria over Satanic Ritual Abuse in the 1980s. Not to mention SARS, Swine Flu and the various other panics.
What is fascinating to me is that the pattern of panic is reasonably common and predictable.
We hate uncertainty, particularly in the face of mortal fear.
With emergence of any such panic, we know that there will be arguments and recriminations based on the conflicting goals of waiting to act until there is a clear and convincing empirical problem versus nipping the problem in the bud by early and aggressive action. Both strategies have merit when there is a known threat. The problem is when the threat is unknown, unquantified, and unresearched.
Any new disease has a handful of critical questions attached to it.
How lethal (mortality rate)?The answers to these questions determine multiple scenarios.
How contagious?
How long an incubation time?
What vectors of transmission?
A highly contagious disease that has a high mortality rate sounds catastrophic but actually is very containable as long as it also has a very short incubation period. If it kills everyone who comes into contact with it within 24 hours, it creates a very effective fire break.
On the other hand, a highly contagious disease that has a high mortality rate but also has a very long incubation period is the trifecta of bad outcomes.
Accurate determination of the answers to the four questions is essential to determine appropriate reactions.
Until the answers are known with high demonstrated confidence, we are just guessing and can end up making things worse while hoping that we are making them better. However, there are innumerable barriers between the emergence of the disease and our capacity to put some numerical parameters on it.
With the current instance of COVID-19, what is the mortality rate? We don't know. Mortality rate is determined by the number who contract the disease and the number who die from it.
We know China has a strong incentive to hide the magnitude of the problem and is notorious for shaky information in general. But since they are ground zero, we really need to know the real numerator (in this case the number of deaths) and the real denominator (the number of people with the disease). Deaths are easier to measure - they are a bit more obvious and harder to hide. The problem is with the denominator - the number who have the disease.
Since we are in flu season and the visual characteristics of COVID-19 are virtually identical (without testing) to regular flu, it is extremely difficult to know the denominator.
This appears to be what is happening out in Washington. Early evidence suggests that COVID-19 has been circulating far longer than was originally anticipated. The death rate appears high simply because we haven't really been looking for the disease.
Transmission rates, mortality rates, and incubation periods are all largely unknown at this point. In part owing to the factors mentioned above but also because of differences in population vulnerability (hard smokers, bad air pollutions, etc.) and also due to differences in cultural norms around personal hygiene, public cleanliness, personal space, etc.
What is certain is that this is following typical patterns of spread and variability of impact. What is certain is that it will, even with the best goodwill, take significant time before we begin effectively treating or containing this new disease.
What is certain is that even the "experts" will propagate bad advice and bad forecasts. New diseases for which we have little information are inherently Uncertain. They may be an existential danger, they may be a minor exacerbation of risk. We don't know. We cannot know until some time has elapsed.
And it has little to do with strategic choices. Stupid mistakes can be made but until greater clarity is obtained we are guessing whether the decisions today are premature or too late and that there will be a cost one way or another.
Which is where the NYT article post-Ebola is relevant. It highlights exactly this dynamic.
New Ebola cases in Liberia, where streets were littered with the dead just a few months ago, now number in the single digits, according to the World Health Organization. In neighboring Sierra Leone and Guinea, the other two nations in the Ebola hot zone, new cases have fallen sharply in the last month, dropping to fewer than 100 in a week at the end of January — a level not seen in the region since June.Which leads to the other common characteristic which is challenging and abhorrent to the deterministic mind. Emergent order. The experts have one view of things but people, individually and collectively, frequently have a different view.
With a virus as deadly as Ebola, officials warn that the epidemic will not be over until cases reach zero in all three countries. But after nearly 9,000 deaths from the disease, the W.H.O. announced last week that it was focusing on a goal that had seemed out of reach for much of last year: ending the Ebola epidemic, no longer simply slowing its spread.
Even as experts are measuring and testing and diagnosing, the population itself experiencing the outbreak are in turn modifying their behaviors and practices.
Experts are trying to understand how the disease, which has defied the ominous predictions of the world’s top infectious disease researchers, appears to be extinguishing itself with surprising swiftness. In September, the United States Centers for Disease Control and Prevention had projected that, by Jan. 20, the outbreak could reach 1.4 million cases in Liberia and Sierra Leone alone, but by that date only 21,797 were recorded in all three countries.There are many elements that go into successful disease control, not all of which are present in all countries/communities at all times.
While many have emphasized the enormous assistance hauled into the region by the United States and international organizations, there is strong evidence, especially here in Monrovia, that the biggest change came from the precautions taken by residents themselves.
“Fundamentally, this is about the extent to which societies change their behaviors, how they change them, and the speed at which they change them,” said Dr. David Nabarro, the United Nations special envoy on Ebola, who made frequent trips to the hot zone at the height of the epidemic. “I believe for various reasons people in Liberia changed quickly and dramatically. I believe Sierra Leoneans changed quickly in some areas and less quickly in some areas.”
When Ebola struck the densely crowded neighborhoods of Monrovia over the summer, the first time a capital city had faced Ebola’s full onslaught, the impact was devastating. Hundreds of new cases appeared around the country every week, hospitals collapsed or overflowed with patients, and sick people lay along the road, sometimes dying before help could reach them.
Disease Watchdogs
Reeling from the explosion of infections in August, volunteer Ebola watchdog groups sprang up in many neighborhoods, typically overseen by local elders and led by educated youths, drawing from a long history of community organizing to survive war, poverty and government neglect.
With little or no outside help in the early months, the groups educated their communities about Ebola, a disease new to this part of Africa, and collected money to set up hand-washing stations at key spots. They kept records of the sick and the dead. Many also placed households under quarantine and restricted visits by outsiders. As the sick were turned away at the gates of treatment centers because of a lack of beds, people inside homes began protecting themselves better, covering their arms in plastic shopping bags as they cared for ailing relatives. The gear became known as Liberian P.P.E.’s, or personal protective equipment, a reference to the more impermeable suits worn by health workers.
By mid-October, new cases in Liberia had dropped precipitously, to dozens from hundreds per week. A few clinics run by Liberians and international charities had opened, but the drop took place a solid month before any of the treatment centers built by the American military had even begun accepting patients.
Knowledge is important as well, but at the beginning of a disease cycle, when fear and uncertainty are prevalent, knowledge simply does not exist. We have experts with past experience. But with something new, we still don't know. Everything is yet uncertain and we simply do not know and cannot know until time has passed, reliable data has been collected and we begin to get a handle on vectors of transmission and causal conditions.
We are not good at processing real uncertainty. We are, as humans, not good at collectively processing and comprehending a statistical view of the world, and we are not good at understanding the role of emergent order as a mechanism of response to new conditions.
The statist and deterministic mind incline in one direction and reality inclines another.
As an aside, the experience of these episodic bouts of contagion out of China in the past couple of decades provides a basis for answering a long-standing historical speculation.
Virtually all deaths in the New World post contact in 1492 were the result of novel disease in virgin populations. It went both ways. A few New World diseases spread into the old but the majority of the flow and the majority of the impact were Old World diseases wreaking havoc in the new.
Many progressive historians craft a narrative of genocide but the numbers do not support that hypothesis. Disease and social collapse from demographic collapse resulting from disease were the primary vectors of catastrophe.
The question then becomes whether the vectors of old world contagion had any culpability in a pre-germ theory world, for the negative outcomes. The easy and knee-jerk answer is - of course not.
A better way, I think, is to consider, had they known and understood, would there have been any way for them to have done something to prevent the consequences of pathogen exchange? Yet another way to formulate that is to ask - If we were to unexpectedly discover an untouched continent inhabited by people never before exposed to Old World (or New) pathogens, would we today, with all our technology and prosperity, and capacity to deal with emergencies, be able to prevent the spread of contagion and death?
I have long reasoned that the answer is no. With COVID-19, with SARS, with H5N1, with Swine Flu, with the outbreaks of Ebola, I think it is increasingly demonstrable that the answer is solidly no. We are highly incented to protect our population from emergent diseases. Yet with our technology, sophisticated knowledge sharing, emergency capabilities, etc. in each of these cases, containment has been of limited success and resolution has most depended on our capacity to develop appropriate vaccines. An approach which takes time, during which the disease spreads and people die.
And these are typically diseases which are usually just variants on things we already know and understand. We are not dealing with truly strange and novel diseases.
Disease works its own consequences on the human condition and history and our cleverness has only limited impact in the near term.
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