Op-Ed: Bill Foege on how to make Ebola worse

Bill Foege in the hills near his boyhood home of Colville, Washington

Editor’s note: Dr. William Foege is the physician-epidemiologist credited with devising the strategy that rid the world of smallpox, former head of the CDC (when AIDS first emerged) and, full disclosure, is also a good friend to Humanosphere. We asked him to offer perspective on all the finger-pointing attending the Ebola hysteria.

By Bill Foege

It is easier to be a critic than a participant or helpful observer.

That goes for me as well, but I am concerned that the straight-forward, science-based approach taken by public health officials to limit  Ebola’s potential spread in this country has spawned such harsh criticism that the critics themselves may be a bigger risk to public safety than this virus.

It’s important to realize Ebola is a living creature. Control of infectious diseases is a continuous evolutionary contest between microorganisms and humans fighting for turf.  Science inches ahead as it gains more understanding of those organisms, which often leads to new medications and vaccines.  Then we may find those very organisms evolving in response.

Chloroquine was once a wonder drug against malaria and we could almost see the inevitable defeat of that enemy.  But the parasite found how to resist and essentially sideline that drug.  Antibiotics seemed ready to make some infectious diseases obsolete.  But gonorrhea defied penicillin; staph overcame many antibiotics; and tuberculosis learned to live with multiple drugs.  All these organisms are too small to have a brain.  Yet they figured out how to beat us.

Vaccines are better than drugs, in general, because organisms don’t develop resistance.  But even with these great tools, these organisms have co-opted some parents who refuse immunizations for their children. So measles and whooping cough are now able to rebound even in the face of great protective vaccines.

But humans are also ingenious.  Working with the best information available, public health workers continue to change strategies.  Smallpox workers evolved and suddenly a virus that had perfected its business plan for immortality was outflanked and it disappeared in a few years.  Through a similar concerted global campaign, measles deaths have plummeted from over 3 million a year to less than 10 percent of that figure.

This same evolution is now occurring with Ebola.  With the experience of 38 years and multiple outbreaks in Africa, the pattern seemed clear.  Transmission between humans could be broken in fewer than five or 10 generations of the virus, a time frame of months.  Humans would then remain free until the next transfer of the virus from bats to humans.

With another human case, the scenario would be repeated with intense human efforts to find cases, isolate them, treat them and avoid virus spread. Public health workers would find contacts, isolate them at the first sign of illness and help the community to dispose of the dead to stop viral transmission to others.  Within months, the outbreak would cease.

But in 2014, the virus changed tactics and took advantage of a slow human response.  The change in tactics led to a new phenomenon, spread of the virus to high population density areas.  Control measures should have remained the same, mimicking the surveillance/containment strategies of smallpox eradication.  But the greater volume of cases complicated isolation of patients.

The need to find, follow and refer for isolation large numbers of contacts overwhelmed an anemic public health response.  Indeed, the need to find and follow all contacts of patients was not on the WHO “critical steps” list as late as October 2014.  The result has been a disaster for West Africa.  Half way measures are not sufficient and the public health community is now adapting and attempting to organize a large scale response.

Doctors Without Borders combined the experience of earlier outbreaks with the treatment of thousands of cases during this outbreak.  They have done this under such difficult field conditions that it was assumed that most large hospitals in the United States could have done the same thing safely.  That turned out not to be true and protocols quickly reflected this new information.

While the autonomy of state and local jurisdictions is a given in this country, the federal government has responded with assistance and personnel exceeding any previous investigation and control effort.  Human evolution and response to unexpected problems will contain the virus in this country.

The screening of travelers is not simple and it is certainly not fool-proof.  But again, public health recommendations have been tightened to improve the chances of finding people entering the country with the virus.  Some of the same people critical of the public health approach seem very tolerant of politicians calling for a travel ban from affected countries or governors placing travelers in quarantine.

Past experience indicates that people are clever enough to travel to other countries first if they really want to come to this country.  And they will hide their exposure to Ebola patients if it means being placed in quarantine.  That simply increases our risk.  There is no evidence that such quarantine would be better than finding contacts and taking their temperatures twice a day to detect the first evidence of illness.

When the governor of New York says he is instituting quarantine out of an abundance of caution, most can read the real reason as an “abundance of politics.”

Will there be more cases in the United States?  The chances are high that some will get past the travel-filter and that we have not as yet seen every possible error in blocking transmission in this country.  But with steady and solid decisions based on past experience and new findings, the response will stop every chain of transmission promptly.

In fact, the public health response in this country has been far better than we could have expected, given the cutbacks in the public health infrastructure of recent years made worse by the private care system sometimes making decisions based on cost or insurance status rather than health needs.

Time will make clear the value of the wisdom of the advice given by the  CDC and state health authorities. The hard work of thousands of health workers is not helped by media-generated panic or illogical political decisions.

Finally, as worrisome as Ebola is, it pales next to 1,000 deaths a day due to tobacco, thanks to reluctant politicians over the decades, or to the more than 1,000 deaths a week due to infections patients did not have when they entered the hospital, or the staggering toll of guns and influenza.

If only we, as a country, could show as much ingenuity in responding to our major health problems as we show with our criticism of the public health workers laboring to make the world safer.

Bill Foege, while working as a medical missionary in Africa and on assignment for the CDC, came up with the strategy known as “ring containment,” which led to the eradication of smallpox. In 2012, President Obama honored Foege for his public health work with the Presidential Medal of Freedom. Foege is also on the board of directors for Humanosphere.

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Humanosphere will sometimes post articles from authors from around the globe. Although these folks are not regular contributors, we hope you enjoy this change of pace.

  • GemJack

    I generally agree, with the exception that public health workers are not above criticism, in fact, they should be held to a higher standard than the rest of us and in times of a crisis not given a pass.

  • San Diego Sunshine

    The problem is there is NON-zero risk of contracting Ebola from an infected person during the incubation time, which the CDC and WHO and NIH are representing as a 0.00000 risk.

    • LanceSmith

      There is also a non-zero risk of walking down the street and getting hit by a car, but you do that don’t you?

      • San Diego Sunshine

        No, but that is a truly silly analogy – just as is the argument that we all have to die from something. The CDC is not responsible for informing of the risk from walking down the street and getting hit by a car. No one, particularly the President of the United States, Congress, State Health Departments and the like, relies on the pronoucement of the CDC in assessing the risk from walking down the street and getting hit by a car.

        • S

          Actually, the CDC is responsible for informing us of the risk of getting hit by a car. The CDC is responsible for protecting Americans from all key health threats. They monitor everything from Ebola to obesity to seat belt use.

        • Origami_Isopod

          Conservatives really ought to stop pretending that the CDC is responsible only for addressing disease, rather than for all issues affecting health in the US. At the very least, you should stop pretending that you’re not the one with the agenda when you do so.

  • Dree Harris

    Thank you for a voice of reason and wisdom in the midst of the chaos around Ebola.

  • Leland Stanford

    Health care workers have projected an abundance of hubris and sadly that includes the former head of CDC who has succumbed to political based analysis.

    It took three months to discover that the malay in W Africa was Ebola. cite: Vanity Fair this month.

    Ebola is spread through sex and particles in coughs and sneezes.

    Dr Spencer lied to NYC police about his public exposure. Fox News yesterday

    Quarantine is an old, tried and true means to protect the public. And even though the doctors who serve in W Africa are heroes, they are not above the law as the Nurse in Maine thinks she is.

    If our elected leaders make a reasoned decision that the public is best served by placing doctors who treated hundreds of Ebola patients under quarantine, then the doctors ought to obey the law as the Stanford Surgeon did yesterday.

    We should pay everyone placed under quarantine, but no one should be above the law.

    • LanceSmith

      I think perhaps you either didn’t read the article or didn’t understand it. The problem with quarantines was presented in the article. Now you can disagree with the conclusion drawn in the article, but then you need to actually refute the point made in the article. As it stands, you didn’t do that and you simply created some sort of strawman about about the law (which was not really discussed in the article except to say that politicians do all kinds of things because of an “abundance of politics”).
      So if you wish to refute the point made in the article, then please do so in an intelligible manner. But simply stating something – as you did – does not make it so (regardless of how many politicians and talking heads you are listening to).

      • Bill

        All the author said about quarantines was:

        “There is no evidence that such quarantine would be better than finding
        contacts and taking their temperatures twice a day to detect the first
        evidence of illness.”
        That sounds more like an “opinion”. I sure there are epidemiologists who would disagree.

    • William Reid

      Sorry but ebola is not transmitted through particles in coughs and sneezes. You have to come in contact with bodily fluids….those who were affected, cleaned bedpans, urine and possible vomit and blood, that was how they came in contact with it. You even reference your source for that airborne information….Fox Spews (lies), which isn’t interested in preventing an outbreak, but ginning up panic among the public to some unseen threat. The nurse in Maine, had no symptoms, no fever, and a blood test came back negative, yet you want to quarantine her. What about all the other doctors and nurses that are treating the doctor in New York, and the nurses in Dallas, they were exposed more than anyone else….where is the call to quarantine all them that came in contact with those people??? There is none….

    • Origami_Isopod

      You do not know how the virus works. Maybe you should not be criticizing health professionals who do, or lambasting them for their “hubris.” Any of them is worth at least a hundred people calling for them to lose their basic rights under the U.S. Constitution with no scientific reason for it.

  • guest

    Was the author thinking as clearly as CDC director during the beginning of the AIDS epidemic?

    • Frank lee

      I think that given the politics that were prevelant in the Reagan administration his hands, and voice, may have been somewhat tied.

  • Colleen Posadas

    The Doctors article is full of his political opinions.

    • Origami_Isopod

      Everything is political. You and his other critics certainly have your own agendas, and don’t pretend these agendas don’t come through loud and clear when you call for health workers to lose their Constitutional rights based on claims unsupported by science.

  • Colleen Posadas

    He also did not address banning any flights from these countries ( or people from these countries) from coming here.

    • isol93

      There are no direct flights to the U.S. from these countries

      • Bill

        Ever hear of “passports”? They show where the traveler has been.

  • Who can I trust

    Your second to the last paragraph, “as worrisome as Ebola is, it pales ….tobacco….guns….influenza….” Tobacco is a choice, I can get a flu shot, and
    guns has nothing to do with disease and CDC. This is a political remark spinned into an
    article introduced as information from a former head of the CDC. You lost my confidence
    when you made it political.

    I do greatly respect your medical accomplishments, and thank you very much for that.

    • S

      The CDC is responsible all causes of mortality and other factors that reduce the health or lifespan of US Citizens.

      Take for example this MMWR article on preventing violence through firearm laws.

      http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5214a2.htm

    • Origami_Isopod

      Addiction is not a choice. Not everybody can get a flu shot, for health reasons or because they cannot afford it. And militant right-wingers with trigger fingers are threats to life and limb. The only people who find the article “political” are the sorts of conservatives who do not understand how public health works.