Monday, February 9, 2015

MSF: J'accuse toi; en ce qui concerne le virus Ebola

While Ebola has pretty well vacated the news as cases wind down or folks become calloused to the terrors that came with this plague, it is crucial to find out why was this outbreak was so terrible.
The governments  and civil society of Liberia, Guinea, and Sierra Leone were fairly well non-existent and life was truly brutish and short, even without Ebola.  The governments were corrupt and ineffective in delivering even the most basic public health policy. And most important there was no oversight or regulation of health facilities and clinics.  So perfect freedom for a health institution to do whatever one wished was available to any medical business, for profit or non profit.

This Ebola outbreak was so virulent, and that the outbreak was contained to only these three countries was so unique, that even this setting was not adequate enough to explain the scope of this plague, So folks in the know started to talk about how this  Ebola was a unique genetic mutated version.  The Great Plague reborn.  But if this Ebola was a genetic freak, why did it fail to take hold in other Western Equatorial Africa.  Why did, once certain parameters met, it disappear as all previous Ebola plagues?

Ebola has always existed in such places, it almost seems to be a prerequisite for the disease as the flint of winged bats or "bushmeat" strikes the steel of corruption and poverty.  Yet all prior  Ebola outbreaks in areas just as chaotic and hellish  did not reach such  terrible numbers as this Ebola outbreak.

This Ebola outbreak was so obviously different  and more terrible from all  previous Marburg and Ebola outbreaks.


The civics in the three Ebola countries were basically nonexistent, and what did exist was chaos and corrupt, but so too was/is Nigeria, or Mali or when Ebola broke out in the past in Uganda or Congo - yet those countries either swiftly ended the Ebola outbreak as in Nigeria, or quickly responded and ended the disease as in the Congo and Uganda in prior outbreaks.  What is different about these three countries? What common factor of explanation is present among the three that was not at other near equally desperate and corrupt countries?

These three countries were the primary location of one of the main MSF African efforts.

The CDC offers a good starting point to frame this deadly differentiation. CDC reduces the disease to  standard epidemiology math - which is robust and effective in all outbreaks.  However 
the CDC models were surprised with the outcome  of this outbreak and had to provide, now 9 months later, "corrections".

The corrections was the number of  people who attended health facilities at the start of the outbreak was far greater than "reported" and there were more contagion from those health facilities than the models estimate in general.  Whats more, which is my main point here, the lead and often only health facilities were managed or established by Doctors Without Borders or Medicins Sans Frontieres. There is likely no other NGO that is held in higher regard, yet the models depict that MSF acted with little responsibility and were likely the main cause of why this outbreak was so deadly and massive.

The CDC model had to be corrected in terms of the cumulative cases that occurred by the summer:

And it seemed obvious this was the causative, that the number of hospital stays was way lower than the model predicted:

And the factor  that was changed in the beginning so the model calibrates with these two charts is the virulence factor for those who were not quarantined nor in a hospital.  Otherwise the number of infected and the growth does not make sense.  This gave the thesis that this Ebola strand was different.  But this correction, makes sense of the initial numbers, but  doesn't jive with the the drop in cases to the recent lows towards the end of the outbreak.  The original model says that if 70% of those infected were either quarantined or found a hospital bed  the outbreak would end, effectively speaking. And that is what happened in all other outbreaks.  This is a link to the CDC 3 factor  model, made available since September of last year.  It is a straight forward but elegantly designed Excel spread sheet and allows the three factors, those in society, those abandoned at home, and those in a hospital, to be directly changed and "what ifs" applied.  Changes which are required to reach to the swift ramp up above was to decrease hospitalization and increase those in society.  But then a problem occurs, for by changing the factors,  the "70%" hospitalized rule is changed and the Ebola plague should still be ascending.  Instead the disease did decline in the number of cases to reach the current levels just as if the original assumptions of hospital stay and virulence always existed.

The predicted hospital beds and the corrected:

This also corresponds, the corrected, with the unexpected number of Ebola cases.

But the fact still remains, that when 70% of the infected were quarantined or hospitalized the disease cycle swings down and then effectively ended, and this did happen almost at exactly the day the model predicted it would - within 10 months of the outbreak start.  

This is very important because it means this Ebola outbreak was no more or no less virulent than past outbreaks.

 The model "worked", that it was robust and accurate as these "Susceptible Infectious Recovered" or SIR models are to be. The CDC Ebola model has 3 states to the Infectious phase being hospitalized, quarantined and in the general public and uses an infection factor for the three states - low single digit transmission for hospital and quarantined and a high 30% for those infected in the public space.  This number is based on the  sanitation and public procedures with the quarantined are left to die with only occasional morbidity from loved ones who are compelled to help.

The phases in the model for the three group break down:

So to match the model to the results, the CDC changed the numbers in the hospital but kept the infection rates of single digits for those being treated or isolated and kept the general public infection of 30% for those in the public unchanged.  And that is what occurred - the disease did have a general infection rate of 30%, that any person untreated and in the general public would infect 30% of those the people  that  came into contact with.  So the model was "right".

That means one of the other transmission rates in the "safe" categories was wrong.

Those quarantined did have a infection rate of the  model's 3% as one's family broke the rules or those burying the person became infected - but it was occasional and folks were left alone to die alone.  The idea that the area had crazy funeral rights that turbo charged the transmission was a myth. Almost all died a terrible lonely death, alone in a room.

The model's "error" was the hospital infection rate.  To have the cases that did occur and the numbers in the hospital, the hospital infection rate has to be almost the same as those infected in the general public, 30% or slightly lower.

Later, as the hospital infection rate dropped to the model's 2%, the disease abated, right on cue.  If the three countries had provided guidance or regulation that required those treating Ebola in the first 6 months,  making those in health care follow normal sanitation rules - not even the moon suits all were seen walking around in at the end - this Ebola breakout would have been 1/20th the outcome.  This Ebola outbreak was not unique.  It was the lack of supervision by those who were expert in health care that caused this to be a unique outbreak.  And this is where things get ghastly.  If the medical supervision or sponsor of those health clinics, as rudimentary as they were, were expert - they knew with certitude that they were killing their staff and that the SIR outcome would occur.  That for whatever reason the sponsor, who was expert, deliberately kept those clinics open and deliberately instructed staff to carry on, fully knowing 30% of the staff would die and take the plague home and infect another 30% and so on. This is damning and shocking stuff, but it is impossible to use the tried and true SIR model and arrive at another conclusion. 

While  government must apply basic public health for their citizens - Mali and Nigeria did so - it is the hospitals that implement and provide the standards of that care.  The hospitals in the three countries were not only hapless, but they were aggressively intentionally  risky in the initial treatment of Ebola.  Malfeasance knowingly allowed.  Almost all of these hospitals were under the administration and control of Doctors Without Borders/ Medecins Sans Frontieres.  The hospital staff were following their directions and administering aid accordingly.  MSF seemed to callously and willfully allow their staff to provide dangerous and, for many of the health worker,  suicidal care.  The healthcare workers died and become part of the 30% infection rate in the general public.   This catastrophic failure in not following the most simple and basic rules of healthcare is the only way the numbers that resulted fit the model.

Epidemiology math is robust, simple and effective.  It is linear though obviously geometric in growth.  It is what it is.

If one tracks the MSF press releases on the disease, there is an obvious pattern.  First, in April 2014,  "this is a tough job but we know Ebola and the people are lucky we are here and we will deal with it"; then by July the MSF goes quite and the meme that this is a most unusual Ebola with unique virulence appears.  That is a cover-up.

Until more clarity is provided, the numbers suggest that MSF requires a thorough investigation in terms of what appears to be their callous indifference to their staff and patients welfare  and their general deliberate incompetency.

The model provided by the CDC can provide "what ifs" that suggests that the difference in this Ebola outbreak was MSF.

Chaos and lack of regulatory oversight did exist in Liberia, Sierra Leone and Guinea, but this allowed MSF to apply  willfully shoddy care.  In the first few months it is obvious MSF facilities did more harm than good as they acted as central junction points - the sick came to the clinic -  and turbo charged the spread of the disease, more often than not via the MSF workers.

It appears to me the  lack of government oversight in those three countries was exactly the setting required for the MSF fund raising: highlighting romantic  disaster-medicine tourism for volunteers who bravely leave Toronto, say, to save the poor savages in Africa, and yet they had to  provide the low standard health care that they did so as to make ends meet.  The MSF clinics were basically  a PR stunt.  It is a crime.  If the MSF care applied to Ebola was in any other countries, MSF officials would be jailed.  

The WHO is apparently going through a re-organization and one of their first tasks should be to force a general licensing  and oversight over such organizations like MSF.  But just as likely those reading this right now, they wont go near this issue for surely MSF would never be so callous if not evil.

'First, do no harm."

I offer the thesis - hopefully refuted quickly not with emotion rock star adulation emotion, but with simple robust math as per CDC model  - that suggests  MSF caused this Ebola outbreak.    I cannot find the refutation.

But what possibly could be MSF motive to commit such malfeasance - perhaps fund raising given all the great headlines they received from January to June 2014?