The Ebola Response

by Wayne Myers

As the United States responds to the Ebola outbreak in West Africa, some aspects of the turmoil are striking.  First, it's not the dimension of the threat, but the strangeness of the disease that seems to drive our public response.  Ebola has been recognized as a human illness in rural West Africa since 1976.  It's believed to make its home in tropical fruit bats.  It's not been sufficiently contagious to sustain an epidemic in humans until the last few months.  At that point it reached densely populated areas lacking sanitation, public health and clinical services.   In that setting it could gain enough momentum to become self-sustaining.  In the current outbreak it is believed to have killed about 5,000 people.  If Ebola were as contagious as some people imagine there would be no one left in West Africa.

What has Ebola to do with rural America?  The American military has been called to service in West Africa against the Ebola epidemic to build facilities while missionaries and other volunteers provide direct patient care.  Our military is disproportionately rural in origin.  I have the feeling rural people may also be overrepresented among the missionary volunteers, but I have no data.

People underestimate the risk posed by familiar dangers and overreact to strange and foreign hazards.  Medical bloggers are struck by Americans' panic response to this new disease compared to the “ho-hum” drawn by the old maladies.  Josh Freeman, writing in Ebola, Fate and Appropriately Assessing Risk on October 19^th, points out that we have an average of 22,000 deaths per year from influenza, but it's hard to get people to get their flu shots.

I use tobacco as my mental perspective piece.  Tobacco is estimated to kill 480,000 Americans per year.  That figures out to 1,315 people per day, 54 people per hour, or just a little less than one person per minute.  We seem to find that risk tolerable if not acceptable.  Our societal response has been to tax tobacco products heavily, to make minors find others to buy their cigarettes for them, but to prohibit regulators from requiring realistic pictures of the damage smoking causes on the packages.  Such pictures might scare kids out of smoking before they become addicted.

The second aspect of the Ebola situation that makes people crazy is their fear of what they imagine might happen.  The public has some sense of the risk posed by 20,000 influenza deaths or nearly a half million deaths caused by tobacco. People have learned to live with those risks, but their imaginations run wild when confronted with a new risk from a distant place with a strange name.

What probably frightens people is not a reality-based perception of risk, but some apocalyptic vision of pestilence spreading unchecked like plague in the 13th century.

Looked at objectively, that risk seems to me less likely than, say, that of a nuclear war erupting next month—that is, infinitesimal.  The Ebola virus isn't built for it.  As the younger folks say, “Ain't gonna happen.”

Lagos, Nigeria, is a great, filthy city with population estimated at over 20 million people.  Ebola got a foothold there, yet it was eradicated.

Although we in the United States have seen our town, city and county health departments decimated in the name of budget cuts, we should be able to perform, with respect to Ebola, at least as well as Nigeria, a country known for its poverty and corruption. Though it has limited public health resources to work with, the whole country of Nigeria has been declared Ebola-free. We have our notice that we should rebuild our public health infrastructure.

Public officials defend their fear-based plans and policies on the basis of “an abundance of caution.”  We hear the same rationale for unnecessary antibiotics for viral infections…. millions of courses of them.  The result is patients and hospitals and communities laced with antibiotic-resistant bacteria.  Likewise we see lots of unnecessary knee, back and breast surgery “just to be on the safe side,” with results no better, or perhaps worse, than medical treatment.  Parents are declining to get their kids immunized against whooping cough based on concerns long since disproven, a special concern for extremely vulnerable infants (think of whooping cough as the Ebola of the newborn).

Fear, plus odds and ends of poorly understood information, is a scary mixture.  If it's just a matter of sore joints, it doesn't matter much.  When it comes to epidemic disease, it's a small world and we're all in it together.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

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