Dr. Craig Spencer of New York-Presbyterian/Columbia University Medical Center went to Guinea in September to help combat the Ebola epidemic. He returned to New York City on Oct. 17. He rode on the subway, went bowling, and basically led normal life until his temperature went up to 100.3⁰F. It turns out that he was infected with the Ebola virus while in Guinea. He is the first Ebola patient in the megalopolis of New York City.
The incident triggered a storm of controversy. What’s interesting is that there seems to be a distinct class aspect to it. Common Americans, as well as populist-leaning politicians are up in arms demanding that all flights from West Africa must be immediately stopped. On the other hand our political elites seem to be relatively blasé about the whole thing. One gets an impression that they are simply going through the motions, because there is an enormous popular pressure to do something.
There are two possible explanations about this “class divide” on Ebola policy: the cynical and the benign. Let’s start with the cynical one.
Historically, the elites were always less vulnerable to epidemics than common people. Here’s what I wrote in my book, War and Peace and War about the epidemic of Black Death:
In general, epidemics always cause a higher mortality among the poor, who suffer from malnutrition, greater crowding, and a lack of bedcare and medicines. But in the case of the plague the best way to avoid it was flight. While the urban poor died in droves, the rich had their country estates to escape to, like the young aristocrats in Decameron who left Florence for a pastoral palace “removed on every side from the roads” with “wells of cool water and vaults of rare wines.” It is generally estimated that the first outbreak of plague in 1348–9 carried away some 40 percent of the English population. Monks who ministered to the dying suffered an even greater mortality. The mortality of tenants-in-chief, on the other hand, was only 27 percent. At the top of the social pyramid, the peers lost barely 8 percent of their number. The only reigning monarch who died from the pestilence was king Alfonso XI of Castile.
There were around 30 states in Europe in 1348 (ignoring a lot of microstates like German Imperial cities and tiny Italian principalities), so one dead head of state translates into a 3 percent estimate of the probability of a European head of state dying from Black Death.
Europe during the 14th century
This results in the following table:
Mortality rates (%) of various social classes in England during the years of plague outbreaks, plus an estimate of the mortality of European heads of state. (From Table 2.11 in Peter Turchin and Sergey Nefedov. 2009. Secular cycles. Princeton University Press.)
| Social class | Mortality, % |
| Monks | 45 |
| Beneficed clergy | 40 |
| Tenants-in-chief | 27 |
| Bishops | 18 |
| Peers | 8 |
| Heads of State | 3 |
Monks had a higher mortality rate probably because they were likely to minister to patients struck by the plague.
After that there is a clear effect of social rank on the probability of dying.
Returning to our cynical explanation, the elites, whether they are the Bishops and Peers in Medieval England, or CEOs and top government officials in modern America, simply are not worried about the epidemic in personal terms. The chances that they or their family members contract it are vanishingly small. On the other hand, they value their ability to flit around the globe, and they really wouldn’t want to restrict it.
So that’s the cynical explanation. What’s the alternative? Well, Ebola is a very deadly disease, killing between 50 and 90 percent of those who contract it. But it is not a particularly infectious disease. As the following graph shows, it is nowhere near as bad as, for example, measles.
This means that fairly elementary methods of public sanitation would be sufficient to prevent a serious outbreak. For example, quarantine. In fact, could someone explain why Dr. Spencer wasn’t quarantined for 21 days on his arrival in New York? Whoops, I am afraid I am backsliding to the cynical explanation, again.
Truth is in between, as usual. NO excuse for complacency, and the CDC gets horrible marks for it (nb, I am married to a top-level health professional and get this from the source). On the other hand, the right wing is deliberately exploiting it for utterly evil reasons, as e.g. claiming the poor immigrant kids from Central America are riddled with it (they know perfectly well it does not exist there). Meanwhile, it turns out that spreading medical lies can get even lower than that:http://www.bmj.com/content/342/bmj.c5258.long
“it is not a particularly infectious disease”. Or is it? By now everyone has seen pictures of medical professionals, dealing with Ebola patients, in special overalls, gloves etc. I presume, Dr. Craig Spencer used all imaginable precotions, so he firmly believed that he couldn’t get infected, but he did. How come? The same goes for other infected medics.
The virus is transmitted by blood, feces, and vomit. It’s rather large as viruses go, so it doesn’t aerosolize and fly across a room the way influenza or noroviruses do. It also doesn’t persist as long on in the environment. Unlike some diseases, viral load of the patient also ramps up as the infection worsens. People in the early stages of the disease are probably still not shedding a large amount of virus. None of the people who shared their apartment with Duncan when he was first coming down with the disease ended up contracting it, even though they were (in the case of his girlfriend, at least) sharing a room/bed and using the same bathroom facilities and so on. But two nurses did.
The nature of advanced ebola symptoms, however, does make it so that health care providers are at elevated risk, since they’re caring for the sickest people. Needle sticks are always a potential source of infection that can get through gloves and suits, though presumably a doctor or nurse would know if that had happened. But even when everything goes as planned, they’re likely to be sprayed with the infectious fluids at some point. If there’s any tear or breach in their gear, or if any mistake gets made when it’s being removed, there’s the potential to get very infectious blood, vomit or feces on their skin or mucous membranes.
I agree that they need to do more research into ways the risk can be lessened for health care workers. We need to learn how they’re getting it, and when and whether it’s appropriate to quarantine someone a medical worker who is returning from an affected country.
I’d be interested in seeing the proportions in numbers of each social class!
Mean while it seems no one – not even doctors honor a voluntary self imposed 21 day quarantine, that’s really scary!
And it’s even more scary but, maybe New York will soon test this Ebola research conclusion!
Ebola Can Spread by Air in Cold, Dry Weather Common to the U.S.
http://www.infowars.com/u-s-army-ebola-goes-airborne-once-temperature-drops/
U.S. Army: Ebola Goes Airborne Once Temperature Drops
Ebola can go airborne but hasn’t in West Africa because it’s too warm, researchers conclude.
Help Reduce the Risk of Spreading Ebola!
https://petitions.whitehouse.gov/petition/have-faa-ban-all-incoming-and-outgoing-flights-ebola-stricken-countries-until-ebola-outbreak/FFJHH9yX
Go Vote – Go Vote!
Are there any direct flights between North America and the affected countries at all? As far as I know, pretty much everybody flies via Europe. And it only takes ten bucks to avoid having your passport stamped in any of these countries. So any travel ban would be totally ineffective. Besides, the people most likely to bring Ebola to the US are American doctors, nurses and missionaries. You can’t really ban US citizens from returning to their own country, can you?
vdinets, quarantine. As simple as that. It took months and many ebola cases ( and a market drop as a reaction to the news that Ebola was in the City ) for US authorities to understand that.
‘(Reuters) – Connecticut placed six West Africans who recently arrived in the United States under quarantine for possible Ebola exposure, a move that comes as the United States starts new restrictions on those coming from the countries hardest hit by the deadly virus.
The family of six West Africans, who arrived Saturday and were planning to live in the United States, will be watched for 21 days, Connecticut state health authorities said Thursday.’
http://www.reuters.com/article/2014/10/23/us-health-ebola-usa-idUSKCN0IC1VN20141023
‘(Reuters) – New York and New Jersey will automatically quarantine medical workers returning from Ebola-hit West African countries and the U.S. government is considering the same step after a doctor who treated patients in Guinea came back infected, officials said on Friday.
….
The new policy applies to medical workers returning from the region through John F. Kennedy International Airport in New York and Newark Liberty International Airport in New Jersey. In the first instance of the new move, a female healthcare worker who had treated patients in West Africa and arrived at the Newark, New Jersey, airport was ordered into quarantine.
“Voluntary quarantine is almost an oxymoron,” New York Governor Andrew Cuomo said. “We’ve seen what happens. … You ride a subway. You ride a bus. You could infect hundreds and hundreds of people.”‘
http://www.reuters.com./article/2014/10/24/us-health-ebola-newyork-idUSKCN0IC2CU20141024
That’s great in theory. The problem is, a lot of people will lie about the countries they’ve been in just to avoid being locked up for three weeks. Quarantine for medical workers and missionaries makes sense, but quarantine for all people arriving from West Africa would be very expensive and ineffective. Also, note that the panic and the market reaction are completely illogical, and will happen after every new case, be it in quarantine or not.
I think there is a bit more to it than this. Scott Alexander has a smart piece up on this that gels quite well with your observations and theories about elite competition & polarization in the USA.
Smart indeed.
An excellent piece, indeed. Thanks, T. Greer
It seems a little selective to argue that the ‘elites’ are downplaying the danger of an epidemic while at the same time acknowledging that ‘populist-leaning’ politicians, which accounts for a large swathe of the US political fraternity, are fear mongering at every attempt.
There is also the clear confound that the virus epidemiologically isn’t as much as a threat as the media and more sensationalist sources are making out. So those who are arguing for precautions while noting that the virus poses a very small threat to countries with developed medical infrastructure are simply listening to what the experts are saying.
In this post, for instance, you highlighted that the doctor went about his normal life until his temperature spiked, but 1) that’s not quite true (see http://www.forbes.com/sites/davidkroll/2014/10/24/ny-doctor-craig-spencer-followed-msf-protocols-for-staff-returning-from-ebola-stricken-west-africa/) and 2) with ebola there is almost no risk of transmitting the virus until the carrier is symptomatic so focusing on his interactions when asymptomatic is a red herring. What we care about is how many people he interacted with after becoming symptomatic and rather than flaunting protocols, it seems he adhered to them strictly and thus only came into contact with 3-4 people, including his fiancee, and none of these are yet displaying any symptoms. All of those individuals are also now in quarantine so chances of further contamination seems very low and thus this episode, rather than being an example of how elites are ignoring the seriousness of the disease, seems to be a rather good illustration of how quarantine protocols work in a developed healthcare system.
As for the claims made in this thread that ebola becomes airborne in low temperatures, that’s complete nonsense, but is indicative of how poorly informed the conspiracy drivel from alex jones’ infowars site is. I’m surprised to see it cited by any reader of this blog but I’d strongly recommend using better sources, including maybe actual epidemiologists and contagious disease experts, if you want to have a realistic, informed opinion about ebola and its relative level of threat.
Even a broken watch shows correct time twice a day:
http://www.bbc.com/news/science-environment-20341423
Hi vdinets, that research showed that contamination was possible without direct physical contact and speculated that it could have been due to airborne transmission but they note themselves that:
“The design and size of the animal cubicle did not allow to distinguish whether the transmission was by aerosol, small or large droplets in the air, or droplets created during floor cleaning which landed inside the NHP cages (fomites).”
We already know that “pigs can generate infectious short range large aerosol droplets more efficiently then other species” and that Ebola symptoms can be spread by sneezes or coughs if saliva or mucus hits an individual’s eyes, nose, or mouth. So while this paper was interesting it does not support the claims made on the infowars site that in human’s, ebola is already an airborne virus in lower temperatures:
This summary page on the CDC provides a good overview of the evidence to date, look at the bottom for discussion of the experimental studies: http://www.cdc.gov/vhf/ebola/transmission/human-transmission.html
Chris Kavanagh, “We already know that…Ebola symptoms can be spread by sneezes or coughs if saliva or mucus hits an individual’s eyes, nose, or mouth.”, so the virus is transmitted not just by blood, feces, and vomit?
To cite again Governor Cuomo: “We’ve seen what happens. … You ride a subway. You ride a bus. You could infect hundreds and hundreds of people.” By sneezing or coughing, not only by vomiting, right?
I am looking and can’t find an explanation how medics get infected if theu wear biohazard gear.
It can be transmitted by mucus but not over large distances and actual outbreaks indicate that this is very rarely the transmission vector. Viruses which are properly airborne have a significantly different transmission pattern than ebola. Cuomo’s comments sufgest that if someone with ebola sneezed on a bus all the passengers would be infected but the reality is you would only have a possibility to be infected if you ingested some of the mucus of the individual. If you were more than a few feet away there would be no chance of this.
“As for the claims made in this thread that ebola becomes airborne in low temperatures, that’s complete nonsense … I’m surprised to see it cited by any reader of this blog but I’d strongly recommend using better sources, including maybe actual epidemiologists and contagious disease experts”
did you read the Infowars article? it was about the two (attached) U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) articles (1995 & 1996) which they quoted from which appeared to say that ebola does become airborne in low temperatures. were these people not “actual epidemiologists and contagious disease experts”?
Alex Jones is a very cautious Mr. Jelly type chap but he generally provides better quality information than you get from the BBC, Fox news and the like which targets the demographic that tends not to do much thinking. I would have had no idea about that US Army Medical Research. However, because it is completely new to me I also don’t have a context to put it in. If this US Army Medical Research is done by non-specialists then it would explain your point.
The doc said he was feeling weak for a couple days before his temperature rose. Feeling weak (aka “lethargy”) is a symptom. In fact, it is a recognized symptom of Ebola. Hence he was “symptomatic” for Ebola two days before he noticed that his temperature increased by 2.7 degrees. In those two days he rode the subway, went bowling, etc. So he was traveling and approaching people within the 3-6 foot Ebola aerosol safety zone while symptomatic with Ebola. He approached way more than 2-4 people while symptomatic with Ebola. Q.E.D.
The reports I’ve seen indicate that after he reported feeling tired he monitored his temperature and saw no spike during 2 days. The fact that he subsequently became symptomatic doesn’t mean that feeling of tiredness was due to ebola or indicative of the onset of the highly infectious period. Either way unless he exchanged bodily fluids with the people he travelled with or was in proximity to they have no way of contracting the virus. Lets see in 3 weeks how many people he spread the virus to, I’m betting that there will be no-one, aside possibly from those already in quarantine.
Yes, I read the article, it infers from selected quotations from those articles that ebola is already an airborne pathogen and thus a greater threat to the US than is being made publicly communicated but that’s an entirely unjustified position if one actually examines the current research literature, or for greater convenience consults “actual epidemiologists and contagious disease experts” about the possibility. Finding articles that speculate about airborne transmission being a possibility is not difficult, but the consensus based on the evidence is that aerosol transmission is not a significant risk and would require mutations that virologists suggest are incredibly unlikely and have never yet been observed in actual viruses.
See this short non-jargon review by the CDC for the context:
http://www.cdc.gov/vhf/ebola/transmission/human-transmission.html
And here is an even shorter summary from the WHO:
http://www.who.int/mediacentre/news/ebola/06-october-2014/en/
Here is also a nice popular article that references experts accurately and correctly summarises the risk from airborne transmission: http://www.vox.com/2014/9/19/6543157/ebola-is-unlikely-to-go-airborne.
I understand the difference, thank you. But the articles you cite are a bit misleading, too.
Let’s start with the last one: it claims that viruses never acquire new modes of transmission. That’s simply not true: lab studies have shown that in some cases, simple mutations can allow a virus to become capable of airborne transmission in a new host: http://www.the-scientist.com/?articles.view/articleNo/32247/title/Five-Mutations-Make-H5N1-Airborne/ I am not saying it can happen with Ebola virus, but it is possible for some viruses.
Contrary to numerous claims, Ebola viruses can survive on dry surfaces for a few days: http://link.springer.com/article/10.1007/s00705-010-0791-0 Indeed, one of the articles you cite mentions a case where someone was infected through a used blanket.
Finally, it is entirely possible that unknown modes of transmission do exist. A few years ago, an Ebola outbreak swept through gorilla populations of Central Africa, causing severe drops in numbers and even some local extinctions. Gorillas live in relatively isolated groups that seldom come into contact, so it’s extremely unlikely that direct physical contact was the only mechanism of the virus’s spread.
The last article is a popular article summarising the relative (lack of) risk that the virus will become airborne. It does not suggest that it is impossible, but rather, as the headline states, that this is “very unlikely”. The virologist quoted saying “we’ve never seen a human virus change the way it is transmitted” is discussing actual real world outbreaks. We have been able to experimentally induce mutations that produced airborne transmission in entirely different viruses, but the differences between H5N1 and ebola are significant, as is the fact that the lab induced mutations also mutated the virus into a non-lethal version, “suggesting there may be a tradeoff between virulence and transmission.”
As far as the ebola epidemic in gorillas:
1. Gorillas are not humans. The simian strains of HIV are significantly less lethal in gorillas and chimpanzees for example.
2. There is no evidence that the ebola outbreak in the gorilla populations was due to airborne transmission. Gorillas do transfer between groups and this occurrs more frequently during outbreaks: http://www.ncbi.nlm.nih.gov/pubmed/24995485
I’m not saying that being concerned about or taking precautions against ebola is not a good idea. I’m saying that the general level of hyperbole surrounding the virus and a lack of reference to expert consensus is causing an unwarranted hysteria.
There is sometimes (but not always) a tradeoff between virulence and transmission, but that’s hardly good news because a less virulent strain would be more difficult to contain.
Virology is a young science, and if something hasn’t been observed yet, it doesn’t mean that it doesn’t happen. In fact, there are numerous pathogens that have changed their mode of transmission in the past (we know they did because they are transmitted differently from their relatives). Also, non-viral pathogens have been observed to change their mode of transmission (just the most recent example: http://blogs.discovermagazine.com/bodyhorrors/2014/10/24/sporothrix-felines-brazil/#.VEq6q_l4pcR warning: graphic images).
Gorillas are not humans, but they are closely related and almost certainly very similar in Ebola epidemiology. The outbreak spread across large rivers (which gorillas never cross) and decimated some populations known to be isolated (i. e. in a gorilla rehabilitation center in PRC), so it cannot be explained by between-group movements. I think it was probably transmitted by some yet unknown vector, or maybe it was a visible manifestation of an unrecorded outbreak in some reservoir species. We can’t be sure until that reservoir is identified and studied; I suspect that it hasn’t been found yet because it’s not a vertebrate.
So yes, there is unwarranted hysteria and hyperbole, but complacency and pretending that we know everything when we don’t are potentially even worse.
vdinets> Do you have references for the claims that the spread would have been impossible via known transmission routes? I can’t find any so I’m genuinely curious.
It’s certainly not impossible that there are other vectors but it seems that invoking vectors that are regarded as extremely unlikely, such as a new airborne mutation strain for a virus that is very unsuited to such transmission, is unwarranted. Are there no scavengers that could disperse infected remains across rivers or are there other species which are known to be able to transmit the virus in the relevant areas, such as fruit bats? These kinds of possibilities seem to be much more likely than a mutation which genetic researchers of viruses say is extremely unlikely.
Well, if you look at the list of areas that were affected by the outbreak and then at the map, you’ll see that a number of large rivers has been crossed. But no, this wasn’t published because nobody knew what to make of it.
I can’t think of any scavenger that would pick up a piece of a gorilla corpse, fly it across a river and drop for another gorilla to find. In fact, I have no idea how the outbreak could spread the way it did. But it did cross those rivers somehow. This is the point I’m trying to make: until we know (not guess, but know for sure) how the virus circulates in nature, we cannot claim that it is not particularly dangerous, or that we can contain it. Remember, a few years ago all experts were confident that eating cooked cow brains was absolutely safe. And then a completely new type of pathogens was discovered, with its unique ways of transmission, and all books on epidemiology had to be re-written.
Ok, no problem but which specific outbreak are you referring to and which populations of gorillas are completely isolated?
Also do you have a reference for the claims about cooked ‘cow brains’ are you talking about BSE?
And just to clarify vdinets, I’m not just being contrarian here, I am genuinely interested in both the gorilla case and what you are referring to in regards the novel mode of transmission discovered. I would have thought that certain pathogens being able to be spread by consuming contaminated meat and surviving cooking temperatures would have been known about prior to BSE but maybe I’m wrong/you are referring to something else? If we are going too far off topic feel free to email me directly and thanks in advance for any relevant links.
Unfortunately, I can’t tell you much about the gorilla/chimp outbreak. It devastated many national parks and killed some gorillas that people had spent many years habituating, but almost everything about it is still a mystery.
Until the discovery of prions, the only pathogen suspected of being capable of surviving boiling was kuru (as we know today, a prion), but it was so exotic that very few people knew about it; besides, it was extinct.
Note that figuring out how pathogens spread is not an easy task. We still don’t know how leprosy is transmitted (some people think it’s airborne, some think otherwise), and it’s been studied for centuries.
Here is an article that nicely summarizes the issue with only a few minor errors.
http://www.nature.com/news/the-ebola-questions-1.16243
Thanks, Vladimir – a very informative piece in Nature
The most comprehensive article about Ebola that I have read. Thanks, vdinets.
The one that began in 2002 and didn’t end until at least 2007. It affected Cameroon, Gabon and both Congos. It crossed all major rivers in the area, and killed 80% of gorillas and 70% of chimps in many national parks and sanctuaries, including Lossi, which is separated from the nearest gorilla populations in Odzala National Park by a broad belt of savanna and gorilla-less secondary forests.
Yes, BSE and other prion infections. Until prions were discovered, it was universally believed that boiling kills all pathogens; you can still find this claim throughout popular literature and even in some medical texts. Prions can remain infectious after prolonged boiling in an autoclave. https://en.wikipedia.org/wiki/Prion
Another interesting article:
https://medium.com/message/ebola-the-real-reason-everyone-should-panic-889f32740e3e
(via Fred Bartels)
This is a great article and emphasises that our concern should be with the nations with a lack of sufficient medical infrastructure and that helping them is also in the self interest of the developed nations. Unfortunately, the mainstream media focuses most of its attention on the US cases and in demonising doctors who go to help, like Dr. Spencer, damages the necessary relief efforts.
Chris Kavanagh, there is no explanation offered why all these doctors and nurses contracted Ebola despite all the precautions. These are not just the US cases, there are nurses in Spain, six of them, who volonteered to care for two Catholic priests with Ebola and got infected. Both priests died.
Common sense tells me that either we don’t have full understanding how Ebola spreads, or all these doctors and nurses disregarded precautions for whatever reasons.
Whatever it is, quarantine is warranted. It’s a normal procedure, no need ‘to feel like a criminal’. They are offered compensation for loss of earnings, which we, taxpayers, are willing to pay.
If Ebola epidemics starts here, it will not help Ebola victims in Africa in any way, quite the contrary.
The ruling elites are clearly downplaying the danger, see the article below.
Ebola: US nurse ‘to take legal action’ over confinement
http://www.bbc.com/news/world-us-canada-29782389
A US nurse held in quarantine in New Jersey after treating Ebola patients in West Africa says she will challenge her confinement in a federal court.
Kaci Hickox said she was made to feel like a criminal after returning from Sierra Leone last Friday.
Her lawyer says the case has raised “serious constitutional and civil liberties issues”.
The White House and mayor of New York have expressed concerns over new strict quarantine orders in several US states.
…..
On Sunday New York Governor Andrew Cuomo announced an easing of the quarantine restrictions in his state.
Under the latest guidelines, returning health workers who have displayed no symptoms can return to their homes for the quarantine period, where they will be monitored twice daily. Compensation will be offered for loss of earnings.
The US ambassador to the UN, Samantha Power, said that all returning US health workers should be “treated like conquering heroes and not stigmatized for the tremendous work that they have done”.
O. Voron, the existence of precautions does not preclude human error or accidents. Protocols are designed to minimize risk but there will always be the potential for contamination when you need to deal with their bodily fluids of a person when they are highly infectious. Doctors and nurses know these risks and so generally are careful to adhere to precautions, especially in specialised clinics, but they are still human and inevitably mistakes happen, which is why there should always be contingency plans in place. Ebola is a dangerous virus and it is highly infectious when in close proximity to symptomatic individuals whose bodily fluids you are required to be exposed to. Nobody is denying this, or that strict quarantine procedures should be in place. The issue I’m raising is in regards relative risk and claims that the ‘elites’ are downplaying the danger.
The example you present is of a nurse challenging the constitutional nature of her enforced quarantine, note that the quarantine was imposed by the state, so what are you arguing here? That a medical nurse is somehow more of an ‘elite’ than the state authorities? Should she not be allowed to defend her constitutional rights if she feels they have been infringed?
And as per quote from the US ambassador… she is right. Those risking their lives to help stem the ebola outbreak in badly affected countries are heroes. They are the ones who actually do endure a severe risk for infection, unlike essentially all of the US citizens who are decrying them. Quarantine procedures and medical facilities in the US are developed to the level where a massive ebola outbreak is extremely unlikely. It’s not impossible but in terms of relative threat you would be much better spending time fretting over fatty foods or a lack of exercise.
Have you overlooked the explanation that many people, especially those committing their lives to public health, actually want to stop the outbreak in Africa? And unnecessary quarantines hinder this effort.
Doctors who risk their lives and take time off work to fly to Africa are not blase about quarantines because they don’t care about the American masses. They hate the quarantines because they know they are based on public relations BS and not public health.
This blog post reminds me of news articles that talk about evolution-vs-creationism by saying that people disagree about it. The world is more than just free-floating signifiers: there is an underlying reality, and it’s worth occasionally coming into contact with it.