Friday, December 5, 2014

Ebola in 2040: will stigma save us?

One of the few perks of being a psychologist in a medical school
(apart from occasionally running to a colleague to check a personal
health matter) was talking to researchers about the real state of
knowledge in any particular field.

The Middlesex Hospital Medical
School, which started in 1746 and was subsumed into UCL in 1987, had a
great talent for developing new services. In a very minor way I added to
that trend by setting up, with two other colleagues, a national
referral centre for post-traumatic stress disorder, which is still in
operation as an NHS clinic. 

However, of much greater importance
was the clap clinic. At a time when the usual appellation was Venereal
Disease, two clinicians got together and decided, over a glass of
champagne, to move it from the dark basement to the full daylight. In
1964 Duncan Catterall established the first Chair of Genito-urinary
Medicine at the Middlesex Hospital Medical School, and so when the first
symptoms of a strange sexually transmitted disease showed up in the
very early 80s, James Pringle House started seeing the first cases and
was at the forefront of European research. I went to seminars, talked to
colleagues, and sometimes met the guest speakers for a canteen lunch.
The greater the expert, the quicker they were to admit that no-one knew
what the hell was going on. 

To my dismay, the public management
of the disease quickly veered away from traditional public health
concerns, and became a political battlefield. At the WHO headquarters in
Geneva senior colleagues muttered that they had been criticised for
saying the virus came from Africa: a colonialist perspective, they were
told. Even years later, those who worked in the field in London talked
sadly, and privately, of the difficulties they encountered with giving
straightforward health warnings. I wanted to design a simple poster to
illustrate the relative risks, but it got no further than a large page
in my filing cabinet. Such, dear readers, were the difficulties of
quickly disseminating an opinion before blogging became available. 

was clear to researchers that blood was the key vector of transmission
(contaminated blood transfusions had a 90% chance of resulting in the
recipient getting HIV), so that shared needle drug injecting and to a
lesser extent anal intercourse without condoms were high risk
activities, but public broadcasts talked vaguely about icebergs, and
suggested everyone was at risk. I did some research on public
perceptions of risk at that time, and AIDS figured high in the public
mind. The common folk knew that it was a “gay plague” but the expert
emphasis seemed to be on getting heterosexuals to use condoms. The great
and the good were interviewed and asked to say the word “condom” on
camera which they valiantly did. The correct way of putting on a condom
was demonstrated on television, using a cucumber. This led to some
worried calls about whether one could catch AIDS from a cucumber. 

it was generally agreed that the UK government had done “rather well”
and had got on top of the crisis. Now, with Ebola in the news, I thought
it worthwhile looking at the current situation for the HIV virus in the
UK, 30 years on from the first outbreak. This might give us a possible
scenario for imagining what Ebola might look like in terms of

In fact, the UK response to HIV seems to have been at
the European average. Statistics vary in different parts of the world,
but I imagine that European statistics have a modicum of accuracy.
Finland, Germany, Malta, Norway (and Cuba, see below) did very well (0.1
%); Denmark, Greece, Netherlands and Sweden and Israel pretty well
(0.2%) and Belgium, Iceland, Ireland, Luxemburg and the United Kingdom
were average (0.3%). Austria, France, Italy, Spain, Switzerland were a
bit worse (0.4 %) and Portugal very much worse (0.7%). Of course, these
are not sub-Saharan African levels (as high as 25% in Swaziland and
Botswana) but given that the governments knew what was coming, and had
resources available, they are not stellar achievements.

Cochran mentioned the case of Cuba, which had forewarning of the virus
in the US and two years to prepare for their first case.

quarantined patients for 8 weeks of health education, tracked contacts
in a very determined way, and used their relative isolation to put
public health before private liberty, an approach which comes naturally
to the regime. Their resultant prevalence of roughly 0.1% is one-sixth
the rate of the United States, one-twentieth of nearby Haiti.

probably moved from monkeys to humans before the 1950s, although the
first cases were recognised in 1981 in the US. About 100,000 people in
the UK are infected, mostly homosexuals, and heterosexuals from
sub-Saharan Africa. More than 20 per cent of them do not know it, and
are several times more likely to transmit the virus to their partners
than those who have a diagnosis. Half of the newly diagnosed cases in
the UK seek medical help when they are in the late stages of disease. In
2012, there were 6,360 new diagnoses of HIV, which is 17 a day in case
you find that more dramatic. In England the local authorities with the
highest prevalence of diagnosed infections are London, Brighton and
Hove, Salford, Manchester, Blackpool and Luton, and in Scotland,
Edinburgh. Treatment with antiretroviral drugs reduces the risk of
transmission by more than 90 per cent. The cost of these drugs is said
to be £20,000 a year and given the current almost normal life spans of
HIV patients, 20 years of medication seems a prudent minimum for
budgeting purposes. The money spent per capita on NHS services in
England was £1,979 in 2011, so each patient with HIV consumed at least
10 times the resources of an average patient every single year.

possible explanation for the apparently lacklustre performance of the
UK may be that many of the cases are imported: that is, brought in by
Black Africans infected in Africa. Looking at the demographics of the UK
in 2011 that shows that 55,730,000 persons are classified as White and
1,905,000 are classified as Black or Black British. Looking at the HIV
figures (this is broad brush, because I have omitted the “mixed” groups)
the HIV rates per 100,000 are as follows:

Whites: 93 per 100,000

Blacks: 2015 per 100,000

the rate seems to be 21 times higher among Africans. The fact that so
many Africans have come to the UK cannot be blamed on the quality of UK
public health warnings aimed at changing the behaviour of the local
population. The White rate is exactly comparable with the best European
nations at 0.1%

Nonetheless, considering that about 36 million
people in the world are infected by HIV and that 30 million have died,
the management of HIV is hardly a global success story. Does this give
us any help in looking ahead to the prevalence of the Ebola virus in 30
years’ time? Prediction will depend on whether treatments or
vaccinations become available, but my impression, no more than that, is
that the spread of the virus should be much slower, very much slower.
HIV can be passed on whilst the carrier still looks good for sex, and
sex is fun, so HIV gets an easy ride. Ebola can only be passed on (if
the experts are right) when the carrier is looking pretty ill and
unattractive, and dealing with ill people is a duty, and not much fun.
Furthermore, Ebola is so virulent at the moment that immediate death
rates are high. With simple precautions it should be contained. Even
when “protocols” fail, the reproduction rate of the virus in human
carriers should be low. Despite all the worrying news, it should be a
simple matter to avoid the spread of the disease. 

On a more
speculative note, perhaps we shall be saved by stigma. By fearing all
people who look as if they are ill with Ebola, stigmatising them and
avoiding all contact with them, definitely not putting ourselves at risk
by helping them, particularly not touching them when they are dying or
dead, the virus will die out. So, in one corner we have the virus, in
the other corner the uncertain public, caught in an awkward tussle
between altruism and abject fear. Ebola has its best chance of spreading
in societies which don’t believe it exists (like in parts of Africa),
and to a lesser extent in those which don’t believe that, given the
virus does exist, the absolute priority is to change our behaviour
quickly (parts of the wealthy West). Informed opinion ought to be right,
but with every failure of both treatment and containment in Western
hospitals public belief is eroded.

Although it goes against altruistic instincts, futile attempts at interventionist treatments may be making matters worse.


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