Ebola requires thorough preparation, not panic
20 October 2014
In 2007, Lebanese-American risk analyst, statistician and author, Professor Nassim Nicholas Taleb, published a book called The Black Swan, which has since been described in a (US) Sunday Times review as one of the twelve most influential books since World Ward II.
In this book he sets out what he calls the Black Swan Theory - a metaphor for high-impact events that are so far beyond the realm of our expectation, that we simply cannot fathom the probability of them taking place.
However, when these events do occur, there is invariably consensus after the fact that "it was bound to happen".
The event that no one could foresee, seems perfectly predictable in hindsight.
The name comes from a Western belief - firmly held until late in the 17th century - that all swans were white.
When, in 1697, a Dutch explorer discovered black swans in Australia, it had a profound effect on zoology.
In hindsight - and upon reflecting on the colour variations of other animals - it seemed not only plausible, but in fact obvious that black swans had always existed.
The emergence of the Human Immunosuppressant Virus (HIV) and AIDS was a Black Swan event, which has, in the last 30 years, cost at least 36-million lives. HIV/AIDS and its consequences were statistical outliers, for which nothing in history could have effectively prepared us. We are still battling to deal with it effectively. Clear evidence of this is the 2,3-milliion new infections in 2012 (the last year for which global statistics are available).
The current outbreak of the Ebola virus in West Africa could also fall into the "Black Swan" category.
It is instructive to understand what has happened since December 2013, when the first case was reported in a remote part of southern Guinea.
According to the World Health Organisation (WHO), by 14 October there had been 9,216 confirmed infections - almost all in Sierra Leone, Liberia and Guinea - of which half (4,555) resulted in deaths. It is widely accepted that this number is substantially under-reported.
While this is still a comparatively small number (compared to AIDS deaths, for example), it is the speed at which the Ebola death rate is increasing that is causing so much concern.
The WHO has predicted that the number of new cases could reach 10,000 per week by December. That's around ten times the current rate of infection.
An estimate by the US Centre for Disease Control (CDC) - which they admit is a "rough guess" - puts possible infections by January at 1.4 million.
Because of missing data due to people being treated and dying at home, this number could be out by a long way.
This is not a disease that's slowing down. And it likely won't remain confined to three or four countries.
Already, four infected travelers have died in the USA, Spain and Germany after contracting the virus in West Africa. In Spain and the USA, the first infections outside of Africa took place when medical workers caring for the infected returning travelers contracted the disease.
No country in the world is "safe". So what should we be doing in South Africa?
Let me begin by saying that what we should not be doing - and that is to panic. Panic compromises clear-headed thinking, and we need all the clarity we can get right now.
People who panic jump the gun. They repeat unconfirmed reports and they spread rumours. They cause others to panic. And social media enable panic to spread at a faster rate than the virus itself.
When the first case of Ebola surfaced in the USA (through a man traveling from Liberia), one of his geographically-challenged compatriots thought Liberia was in South Africa.
Soon, a wave of angry and misinformed tweets were calling for a travel ban from South Africa to the USA. Visitors began canceling their flights here. (This was not without irony, given that there have been three cases of Ebola in the USA in 2014 and none in South Africa.)
On the other hand, we must avoid complacency, and draw a clear distinction between panicking and preparing.
What is called for now is a level of thorough preparation that overshoots any of our existing predictions.
We must ready ourselves for this Black Swan event as if we knew, up front, the extent of the worst-case scenario. We simply cannot be over-prepared. It will require clarity, leadership and a lot of will.
So, is South Africa sufficiently prepared to deal with the Ebola virus?
In terms of our healthcare infrastructure, we are in a far stronger position to shut down the spread of the disease than any of the affected West African countries. We have the facilities to isolate patients, we have the medical expertise and we have the necessary logistics (ambulances, laboratories) to handle a potential outbreak.
What remains to be seen is whether we can coordinate our efforts across provinces and across political divides to act swiftly and decisively, should it be necessary. Because elsewhere, this has proved to be the difference between containment and an outbreak.
This is clear in West Africa right now. Guinea, Liberia and Sierra Leone aren't the only three African countries to have had Ebola infections. Both Nigeria (20 infections, 8 fatalities) and Senegal (1 infection, 0 fatalities) managed to detect and contain the disease before it had a chance to spread.
Through quick, decisive action - and, in Nigeria's case, some impressive detective work in tracing back all the infections to the same Liberian man - they did not give the virus a chance to gain a foothold.
This appears to be the case in the USA too. After some initial complacency in missing the Liberian traveler and allowing one of the infected nurses to travel between states, they now seem to have everyone - from federal government to state and local government - pulling in the same direction.
In South Africa, our last brush with the virus was back in 1996 when a nurse looking after a doctor from Gabon at the Morningside Clinic in Johannesburg became gravely ill. Only when Marilyn Lahana (a former school friend of mine) was in an advanced stage of viral haemorrhagic fever, did laboratory tests confirm that she had a strain of Ebola. She died shortly thereafter.
The response, following her death, in tracking down her contacts was swift and no further infections were reported. The same Ebola outbreak had killed more than 240 people in what was then Zaire in the previous year. The speed and accuracy of the response is often the only thing that stands between containment and a potential epidemic.
Despite the dedicated efforts of Health Minister Aaron Motsoaledi to date, we need to do a lot more to ensure that we are ready to contain an outbreak in South Africa.
It is crucial that all 11 Ebola treatment hospitals identified by the minister are immediately brought to a state of readiness. This includes equipping ambulances, planes and helicopters so that they can clinically isolate patients that need to be transported from ports of entry.
It is also not enough to simply place screening technology at these ports of entry, if we don't staff them with specialists who can recognise and diagnose infected travelers.
Finally, and perhaps most importantly, Minister Mostoaledi needs support.
To date, neither President Zuma nor bodies such as the African Union (AU) and the Southern African Development Community (SADC) have shown any real leadership on the issue.
In the Western Cape, our preparations are advanced. I'm loath to say, "we're ready", because you never reach a point where you stop improving in preparation for such an eventuality.
We have identified Tygerberg Hospital as our isolation and treatment facility. All other hospitals and clinics in the province have explicit instructions on the quarantining and transporting of people who may be infected.
We also have the benefit of learning from other countries' mistakes. We know now it is wrong to "lock down" an entire community where an outbreak occurs. Forcing non-infected people to remain alongside potentially infected people poses an even bigger security threat than the virus, and inevitably leads to panic and civil unrest. The unintended consequence is that people do not come forward when they have symptoms, nor do they report sick family members.
Instead, an infected person should immediately be taken out of the community and placed in an isolation ward. Health workers must then be sent in to the community to determine whether there are more infections, along with an extensive investigation to ascertain exactly whom the infected person had contact with.
Another crucial lesson we should learn from affected countries is that this disease will carry on spreading as long as cultural taboos around burial customs are skirted. The Ebola virus survives in bodily fluids for days after death. In fact, the body of an Ebola victim is at its most contagious shortly after death, and it is during burial preparations that many of the victims are infected.
The outbreak of a deadly virus such as Ebola places the world in an emergency situation, and it is imperative that some cultural practices around burials are suspended until an outbreak has passed.
Our hospitals have incredibly strict protocols on dealing with the bodies of Ebola victims, but this will have little effect if similar caution is not applied outside of hospitals.
We'll be ready, as long as we don't panic.
Our health infrastructure is robust enough to deal with the threat. With the right kind of management and clarity of strategy, we can ready our hospitals, we can staff and monitor our twenty or so points of entry into the country, and we can establish and communicate a single, standard operating procedure across nine provinces.
As long as we are thorough in our preparations, Ebola will remain manageable, and will not be classified as one of history's "Black Swan" events.
This article by Helen Zille first appeared in SA Today, the online newsletter of the leader of the Democratic Alliance.
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