3 ms·

"I think as long as the U.S. situation is limited to a small number of known, managed cases" How do you reconcile that with my above "[we] allow unconstrained

by hga 12y ago

"I think as long as the U.S. situation is limited to a small number of known, managed cases" How do you reconcile that with my above "[we] allow unconstrained export of Ebola from its current epidemic nations"? According to Congresscritter Ed Royce, the US Embassies in the three afflicted nations are receiving 100 applications for visas every day. He doesn't say how many on average are getting them, there is of course some screening, but as Duncan shows an asymptotic carrier who doesn't declare close contact with an Ebola patient (for whatever reason, no need to go into the weeds there) can get through. An incubation period of as many as 21 days is a serious problem. This current US outbreak has, so far, a R nought of 2 (1 patient infected 2), and I don't expect other hospitals including the 4 specialist ones to necessary do a whole lot better when an unheralded patient arrives at their ER. (You're know we're finally serious about it when ERs station someone in isolation gear in outside to triage patients.) Unlike sending a known Ebola patient to one of those 4, as we've done 4 times, with 2 cases finished, I can't call cases like Duncan "known" or "managed", at least not initially. I fully support the known -> specialist hospital cases, if for no other reason than that we desperately need to learn more about EVD. But the random importation cases ... how can you be sure future ones will be qualitatively less of a nightmare like Dallas (which played out yet). E.g. I read someone mentioning how fortunate it was these two nurses are single and (appear to?) live alone. Imagine one having children and transmitting it to one or more of them ... that'll get ugly in a lot of ways. And in the meanwhile the authorities continue to shred their credibility and legitimacy. Which we may not be able to afford if it gets really bad. Ah, I didn't really answer your 2nd proposal. Why not a formal, enforced quarantine? It's not like that's required to be a terrible thing in this era of the Internet: put in the room a computer with a fast connection, a flat screen TV with a good package, and a cell phone (or more likely cell phone charger) and they should be OK until the watch period is over. Today's medical social distancing doesn't have to be severe in the directly social sense.

maxerickson 12y ago
I don't agree with your premise that travel is unconstrained, especially air travel (I don't have a terrific understanding of the land borders, but they are fairly long and I guess much of it is wild, completely eliminating travel across them seems impossible). The first limit on travel is that a large portion of the population in the outbreak countries can't afford air travel. Then there is the Visa system. Then there is screening prior to boarding the flights. There is proof that this system is not 100% effective, but I don't take it as obvious that 100% effective is an attainable standard.
- hga 12y ago
  Who gives a damn about an 100% effective system? Perfect is the enemy of "good enough", or in this case significantly better. Worse, it's pretty clear that too many cases in the US will use up various finite resources, from those 23 beds really able to handle this well, to healthcare workers outside of them willing to work on Ebola patients, unless future outbreaks turn out a lot better, to PPE supplies. Not to mention the extreme expense of dealing with each patient added to already financially strained hospitals, who's ability to provide services once an Ebola patient shows up gets degraded (is the Dallas hospital ER back in operation?) There's going to be leakers. The idea is to minimize them, and the human and economic costs they impose on us.
  - maxerickson 12y ago
    I didn't mean to imply that Duncan was a known or managed case (it ended up in a managed state, it didn't start there), I was describing the situation today, where the patients are admitted for appropriate care and high quality contract tracing has been done. Anyway, as I said to you a few days ago, unless you are at least willing to revisit this in a few months or a year and consider whether the system in place was "good enough", rather than us getting lucky, there isn't much more to discuss (yes, I'm implying that my read is that you would maybe dismiss a positive outcome as luck; I don't mean to do so sneakily, nor do I intend it as an attack). I'm at least ambivalent about whether the U.S. is prepared for the situation, the repeated mishandling of things in Dallas was not encouraging.
    - hga 12y ago
      Oh, I'll most certainly revisit this later. I didn't reply to your question 8 days ago in part because at this point I simply cannot envision only ~2 deaths in America (not counting the medevaced from a hotspot, 4 patients so far). But this is fantastically path dependent. I think we discussed that just before news of Duncan's death was released; in strict terms of impact on foreign importation, that obviously decreased "Ebola tourism". Not that Duncan, or Nigeria's index case were precisely examples of that; I've just started reading Camus' 1948 The Plague because at every level in these situations a lot of human behavior seems to be universal. Moving on, suppose the 2 nurses who who were infected by Duncan die, that'll change things in directions making it less likely others will die in the future (for the most part; there are results that could increase the death rate). We don't yet know if Dallas missed a contact who contracts it. And I can't imagine we won't get more Duncans until a travel ban significantly cuts the potential of them. Unless, of course, we don't get any more Duncans, in which your hope likely becomes true and we don't implement a travel ban. But I don't think that's the way to bet right now.

by hga 12y ago

maxerickson 12y ago

I don't agree with your premise that travel is unconstrained, especially air travel (I don't have a terrific understanding of the land borders, but they are fairly long and I guess much of it is wild, completely eliminating travel across them seems impossible). The first limit on travel is that a large portion of the population in the outbreak countries can't afford air travel. Then there is the Visa system. Then there is screening prior to boarding the flights. There is proof that this system is not 100% effective, but I don't take it as obvious that 100% effective is an attainable standard.

hga 12y ago
Who gives a damn about an 100% effective system? Perfect is the enemy of "good enough", or in this case significantly better. Worse, it's pretty clear that too many cases in the US will use up various finite resources, from those 23 beds really able to handle this well, to healthcare workers outside of them willing to work on Ebola patients, unless future outbreaks turn out a lot better, to PPE supplies. Not to mention the extreme expense of dealing with each patient added to already financially strained hospitals, who's ability to provide services once an Ebola patient shows up gets degraded (is the Dallas hospital ER back in operation?) There's going to be leakers. The idea is to minimize them, and the human and economic costs they impose on us.
- maxerickson 12y ago
  I didn't mean to imply that Duncan was a known or managed case (it ended up in a managed state, it didn't start there), I was describing the situation today, where the patients are admitted for appropriate care and high quality contract tracing has been done. Anyway, as I said to you a few days ago, unless you are at least willing to revisit this in a few months or a year and consider whether the system in place was "good enough", rather than us getting lucky, there isn't much more to discuss (yes, I'm implying that my read is that you would maybe dismiss a positive outcome as luck; I don't mean to do so sneakily, nor do I intend it as an attack). I'm at least ambivalent about whether the U.S. is prepared for the situation, the repeated mishandling of things in Dallas was not encouraging.
  - hga 12y ago
    Oh, I'll most certainly revisit this later. I didn't reply to your question 8 days ago in part because at this point I simply cannot envision only ~2 deaths in America (not counting the medevaced from a hotspot, 4 patients so far). But this is fantastically path dependent. I think we discussed that just before news of Duncan's death was released; in strict terms of impact on foreign importation, that obviously decreased "Ebola tourism". Not that Duncan, or Nigeria's index case were precisely examples of that; I've just started reading Camus' 1948 The Plague because at every level in these situations a lot of human behavior seems to be universal. Moving on, suppose the 2 nurses who who were infected by Duncan die, that'll change things in directions making it less likely others will die in the future (for the most part; there are results that could increase the death rate). We don't yet know if Dallas missed a contact who contracts it. And I can't imagine we won't get more Duncans until a travel ban significantly cuts the potential of them. Unless, of course, we don't get any more Duncans, in which your hope likely becomes true and we don't implement a travel ban. But I don't think that's the way to bet right now.