Les Roberts – “Day 23: The building next door is on fire!”

Les Roberts – Freetown, Sierra Leone – October 27th, 2014

Day 23: The building next door is on fire! But fire is dangerous, so anyone who enters will have to be quarantined in there for 21 days after the fire ends.

There is grim news to report from the vantage of Freetown. There is a deadly outbreak threatening worldwide safety: an outbreak of unadulterated insanity in the US. In our beloved State, the Governor, and his neighboring New Jersey Governor, has decided to enforce a three-week quarantine on any health workers returning from West Africa.

MSF has now had over 500 expatriates come to West Africa and return home. They have had several staff become infected, several of whom were evacuated to Europe, and I believe, none of whom are known to have infected anyone else. They have had an unknown number develop mild or asymptomatic cases. They have had at least one develop disease after going home. Their strategy for protecting the lands to which they repatriate is to have their staff monitor their temperatures twice daily and report-in to the MSF monitoring network daily for three weeks. The logic is that people can go about their daily lives with virtually no threat to those around them up to the point where an Ebola infection produces fever. Thus far, their record has been… perfect. That is, an R of zero! Of course, there will be cases in the future and this system will not be perfect if this outbreak keeps up. Of course, having CDC and health departments chase down hundreds of contacts is expensive and resource consuming. But since the outbreak began, thousands of people have returned to the US from this region and almost none has triggered contact following and significant public expenditure.

Stop and ponder, if Europe, or for that matter, the entire world followed the New York example. Almost certainly, this outbreak would blossom and spread and extend to Europe and wash across the US borders within the coming years. Global quarantine of the three affected nations would almost guarantee Ebola remaining prevalent here for a long, long time. Like measles or shigella or any of those other more transmittable and opportunistic diseases that blossom among the world’s poorest, travelers would be bringing the infection to our shores continuously as they do with measles and shigella. While less transmittable, Ebola has a noteworthy difference from measles – it is significantly more deadly. The best “high probability” approach we have to not being on hyper-alert for Ebola in the US for many years to come is to stomp this out now In West Africa. The US is doing its part here, as are the British and the Chinese and many other nations. But these nations would never find enough people and the right people to deal with this crisis if they established New York and New Jersey type quarantine rules.

I was just today in Romeni, a town under quarantine with military posted at each end of this one-road town of a few thousand in an attempt to keep infectious cases in the town. No one except health workers can go in and out. It was a little bizarre to see large numbers of adults hanging out in the middle of the day. Most chiefdoms now have a rule against allowing a stranger to sleep at your home: there is a $100 penalty for this act. These protected towns usually have young men guarding the edges against strangers coming into the town. While WHO does not endorse all of these quarantine approaches, in this setting, with this culture, I am not sure if these quarantine controls are a bad idea; there is no track record for evaluating this. (I am quite sure all of the quarantined towns that are not getting any food are a bad idea, but that is another discussion.) In contrast, we have a pretty good body of evidence that before infected individuals are febrile, they do not shed the virus and pose almost no risk to others. Keeping such people out of your state or off your subway probably produces no measurable benefit but creates a great barrier to allowing New York and New Jersey residents from being part of the solution.

There is a deadly outbreak threatening the globe. I fear we will not be safe from the scourge until a vaccine is developed that can prevent governors unencumbered by scientific evidence or logic from becoming infected with Presidential ambitions.

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