Friday, December 5, 2014

Solving Ebola

The press have been discussing the current outbreak of Ebola in West
Africa. They stress that it is an awful way to die, that there is no
cure, and that health workers are dying despite apparently taking all
necessary precautions. More learned writers have been explaining that
Ebola is quite hard to catch unless you come into direct contact with
contaminated bodily fluids, and that simple precautions should be enough
to contain it. Yet other commentators are pointing out that the death
rate is very low compared to other well known diseases, and that we need
to keep the threat in perspective. So, we have an intelligence test
item to solve.

The World Health Organization, in partnership with
the Ministries of Health in Guinea, Sierra Leone, Liberia, and Nigeria
announced a cumulative total of 1440 suspect and confirmed cases of
Ebola virus disease (EVD) and 826 deaths, as of July 30, 2014. Of the
1440 clinical cases, 953 cases have been laboratory confirmed for Ebola
virus infection. Previous outbreaks have been more often in the Congo,
Gabon and Uganda.

Infectious disease dynamics can be modelled,
and controlling this outbreak should be pretty easy, at least from a
conceptual point of view. This disease is a short-incubation period
(about three weeks), relatively low transmissibility, high lethality
infection. Whereas a sneeze can transmit pathogens with great
efficiency, hence the easy airborne spread of influenza, avoiding fluids
is easier. Soap, water, disinfectants, protective clothing for nurses,
body bags for victims, quick burial in chlorine covered graves or better
still cremation, quarantine for all contacts, and the same procedures
for those quarantined victims if they die: all of these should be
sufficient. In terms of disease control it should be noted that men who
have recovered from the disease can still transmit the virus through
their semen for up to 7 weeks after recovery from illness. Severely ill
patients require intensive supportive care. Patients are frequently
dehydrated and require oral rehydration with solutions containing
electrolytes or intravenous fluids. No specific treatment is available.
New drug therapies are being evaluated. Barrier nursing is required to
protect health staff, but the standards of protection required are very
high, and hard to observe when health workers are subject to high
ambient temperatures. If treatment is really unlikely to help victims,
then in a big outbreak it might best to avoid attempts at close contact
nursing, and rely on quarantine and subsequent disinfection as the best
way to save more lives. Perhaps hydration packs distributed to homes
under quarantine would be best, but that is for public health
specialists to judge.

Why isn’t all this happening? Many of the
locals either do not understand the transmission method (from forest
animals like bats), or chose to disbelieve it, and are not changing
their behaviours regarding funereal procedures, which involve bathing
and kissing the corpse, all of which are part of altruistic respect for
the dead person. The locals are also prey to false correlation: they see
people who are mildly ill going into hospital, and then taken out dead
soon afterward by space-suited Western health workers. In terms of
Kahneman’s Type 1 fast and sloppy thinking, this is understandable.
Ebola hospitals are dangerous places. Westerners in space suits are
unusual and disturbing, and in fact even the notion of a hospital may be
the wrong strategy in these outbreaks. However, if a populace suspect
that health workers spraying disinfectant may be malevolently spreading
bottled Ebola, then there is a massive health education challenge to be

Western doctors very much want to help, but getting to the
outbreak locations they quickly find that local facilities are
inadequate, that barrier nursing is very difficult to achieve to a high
standard and, although this is less often conceded, that nursing might
be of little real help. However, early treatment improves outcomes, and
about 40%  are pulling through at the moment.  Hence the wish to provide
treatment, and some groups like Medecins sans Frontieres have not lost
doctors to Ebola. Wanting to help others is humanity at its best. These
missionary doctors write heart-wrenching diaries about families being
wiped out, and about their lack of resources, about the stigma with
which the afflicted are treated and about their guilt at seeing ill
patients dying without comforters next to them. They don’t publically
question why the countries in which they operate are in such a mess. The
conventional answer is that they are poor and wracked by conflict.

Sierra Leone, Liberia, and Nigeria, the countries in the front line of
this particular outbreak, share West African environments. Sierra Leone
and Liberia have a particular history, in that they were formed and
settled to take repatriated American slaves. From some points of view,
they should be models of governance. That has not been the case. If all
these countries had been governed well even remote country hospitals
would have had basic resources, and there would have been widespread
knowledge of basic hygiene and disease control. Quarantine would have
been explained, established and monitored. 

Can we deduce
anything from the failure to deal with the epidemic? The governments of
these countries may have regarded their poorer citizens as being of
little interest to them, living as they do in poverty in remote villages
near tropical forests. Government officials tend to be snooty, and
African governments have often disregarded the needs of their citizens.
They say that they have given plenty of public health warnings, but the
disease keeps spreading. Disasters test the morality of the organising
structure, and those structures have often been found wanting.

it be that these countries simply don’t understand the threat and don’t
understand how to deal with it, or that they don’t do so in sufficient
numbers to provide an effective response?

Little is known with
certainty about intelligence levels in these countries. Those
governments do not measure cognitive ability, nor do they participate in
the PISA and other international scholastic studies. If one gathers
together various published papers on intelligence test results, then the
IQ figures for the Congo are in the 64 to 73 range; for Guinea 70; for
Ghana 60-80; for Nigeria 64-70; and Sierra Leone 64. Some of the samples
are of reasonable size, one and a half thousand, so it is not all a
patchwork of tiny studies, though there is plenty of room for
improvement. The figures are so low by Western standards that they are
hard to believe, but when educational elites in South Africa are tested
they are often in the IQ 100 range, consistent with being the top 2% of a
population which has an actual mean of IQ 70.

Botswana is an
exceptional African country in many ways, has put a lot of money into
education, and has participated in Trends in International Mathematics
and Science 2011, and Progress in International Reading Literacy Study
2o11. Botswana is a test case, an exemplar of the current achievement of
an African country which takes education seriously. If you look at
their scholastic achievement and compare it with the achievements of
countries with well established IQ measures, then Botswana comes out at
an estimated IQ of 70. Sub-Sarahan African intelligence test results
have been much debated by intelligence researchers, and the estimates
range from about IQ 70 from Richard Lynn to IQ 80 from Jelte Wicherts.
The key argument is about the representativeness of samples. The tests
seem to be OK, much to popular surprise. Humans in all continents appear
to solve basic problems in the same way. Africans have the same
cognitive operating system as other continental groups. There are power
differences, but not operating system incompatibilities.

Are the
behaviours of the average citizens in these countries consistent with
these estimates? Western critics of international intelligence testing
regard these estimates with considerable scepticism, particularly
considering that IQ 70 is seen as too low to lead an independent life
and earn a living in Western economies. However, that is the way the
results come out, and the match with achievements is reasonably close,
certainly when scholastic achievements are measured. Although all
countries have the equivalent of witchdoctors, in the West these are
usually a homeopathic side-line and less dominant in public health, but
in African countries they still sway many people on important health
matters. Seen from afar, the response to Ebola has not been intelligent.
Equally, the response to HIV has often been weak and contradictory. 

should we be less alarmed about Ebola, and be more scared of measles,
malaria and car accidents? Those who would ask us to bear in mind these
comparative statistics misunderstand human nature. New threats demand
great fear, which is the prudent reaction till the true nature of the
predator is known. We humans are also concerned about how we die.
Bleeding to death from a galloping haemorrhagic fever is far more scary
than our favoured exit, to breathe our last as peacefully as possible,
expiring gently, entirely unblemished, while lying in clean sheets in
our own house with our loving family in attendance. Furthermore, as even
the dullest actuary must know, the statistics on Ebola are comforting
only at the moment. If this outbreak continues to be mismanaged, the
numbers could look very different in a few year’s time. Then we would
have to say that we had failed a simple test in public health.

Hope not.


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