To fight Ebola, we need a Florence Nightingale — although the Marines are good too
Tonight, we attended a talk with Paul Farmer, Dan Kelly, Raj Panjabi, and a fourth fellow whose name I can’t remember. The topic was Ebola. All four speakers had front-line experience, having spent a great deal of time recently in Ghana, Sierra Leone, and Liberia. All of them are affiliated with non-profit organizations that have as their sole purpose bringing long-term and emergency healthcare solutions to third world countries. They are all admirable men and masters of their material.
That’s why it was disappointing that the evening was so horribly dull. Rather than the four of them presenting a coherent analysis covering both Africa and America, they engaged in a repetitive, jargon-filled talk that kept reiterating the key points. The key points were interesting, and probably could have been covered in about fifteen minutes. I wasn’t able to take notes, but here’s what I got:
1. Liberia and Sierra Leone have both suffered tremendously from civil wars that utterly destroyed their infrastructure and left them with virtually no health care. I believe it was Liberia that ended up with around 51 doctors for the entire nation. The American equivalent would have been 8 doctors for all of San Francisco.
2. When the latest Ebola outbreak began in a remote village with an infected two-year old child, there were no systems in place to stop the disease’s spread.
3. Because there are no doctors, no buildings, and no supplies in these forsaken African countries, a few things happen:
a. The mortality rate is 70% to 90%.
b. People view hospitals and medical clinics as death traps, which they are.
c. People therefore avoid hospitals and medical clinics, furthering the disease’s spread.
4. To the extent there are any systems on the ground in Ghana, Liberia, and Sierra Leone, they are the NGOs represented at the talk, plus WHO, the CDC, a British government agency, and a few disparate other groups. They are trying to coordinate, but are behind the curve. The local governments are helpless.
5. Money is starting to come in, but little of the money pledged actually makes it to the situation on the ground.
6. If the situation does not approve, we can expect 500,000 to 1.4 million dead in Africa by the end of January 2015.
7. If, however, the money rains down and the existing organizations are able to train health care workers, open clinics, and have medical supplies on hand to treat people, the number of dead may stop at around 70,000.
8. Bringing the current Ebola crisis to heel in Africa, even under the best of circumstances may take 18 to 24 months.
9. A military organization is best suited to imposing structure on these dysfunctional regions. (When I heard this, I thought to myself “So that’s why Obama sent in the Marines.”)
10. Taking a page out of the Borgia book for poisons that can be absorbed through the skin, Ebola can transmit through people’s skin. It’s not enough to keep your hands away from your nose and mouth. If someone’s infected blood, vomit, fecal matter, semen, spit, or sweat just touches you, you can become infected. Even picking up a stained sheet can pass the infection. Additionally, scientists do not know how long the virus will survive on a surface once it’s become dehydrated. The current guess is that Ebola, unlike other viruses, can survive for quite a while away from its original host.
11. The Ebola virus is from the same family as the Marburg virus, which found its way to Germany in the 1960s, killed a few people, and was then quickly contained. That’s good news for Westerners and their medicine.
12. If patients get Western medicine that treats the symptoms — drugs to reduce fever and to control vomiting and diarrhea, proper treatment if the body goes into shock, and blood transfusions — the mortality rate is “only” 25% — which is still high, but is significantly lower than the 70%-90% morality in Africa, where patients get little to no treatment. (See point 3 regarding the disease-spreading negative feedback loop of the high mortality rate.)
13. This is a genuine crisis. If anything, the media is erring by downplaying what’s been happening in Africa, and governments are most certainly responding too slowly to a problem that must be fixed in Africa, rather than just being stopped here (as if that were possible).
In sum, Ebola is a really bad disease, made horribly worse by the complete post-civil war dysfunction and poverty in these three West African nations. With enough money and man power, the disease can be brought to heel. The only problem is getting the money and manpower in place.
Hearing that the problem is one of men and manpower, I immediately thought (as everyone must) of Florence Nightingale. I’m sure all of you remember her story, but I’ll tell it again for my satisfaction. Florence was born in 1820 to a very wealthy, very well-connected, very upper class British family. She was expected to do the ordinary thing: become a “finished” young lady, get married, and have the next generation of wealthy, well-connected, upper class British children. Florence, however, wanted something different. She wanted to be a nurse.
To appreciate just how shocking Florence’s career goal was, imagine your own sweet, young daughter looking up at you and saying “Mother and Father, I want to become a prostitute, and work in the worst slums, with a lot of filthy, disease-ridden people. Oh, and I’m planning to numb myself against the horror of my chosen life with strong drink and opium.” By saying that, your daughter would have described precisely what many nurses were like back in the middle of the 19th century, or at least what upper class people thought they were like.
Understandably, Florence’s parents said “No!” and kept saying “No” despite Florence’s certain belief that God himself had called her to the job of nursing. By the time she was 24, Florence ignored her parents and began to study what she could about nursing. She also traveled widely around Europe and the Mediterranean. During her years of work, study, and travel, she met several important men whose wealth and connections would aid her in the coming years.
When Florence was 30, she visited and was much impressed by a Lutheran community at Kaiserswerth-am-Rhein in Germany, where the Pastor and several deaconesses dedicated themselves to caring for the sick and poor. Florence worked and studied at this community for several months, an experience she wrote about later. It provided much of the basis for her believes about cleanliness and good nutrition for the sick. (Her beliefs about cleanliness did not extend to germ theory, something that was of little interest to her.)
By 1853, Florence was offered a job as superintendent at the Institute for the Care of Sick Gentlewomen in Upper Harley Street, London. Between her pay from that job and the very comfortable allowance her father gave her, Florence did quite well doing the work she loved.
All of the above was a prelude to Florence’s moment in history. In 1853, the Crimean War began, with Russia squaring off against an alliance of France, Britain, the Ottoman Empire, and Sardinia. This was probably the last of the Christian religious wars, since Russia was ostensibly fighting for the rights of Orthodox Christians in the Holy Land, which was under Ottoman control, while the French went to bat for the Catholic Christians. In reality, the fight was really about preventing Russia from gaining land from the dying Ottoman Empire. But I digress….
Initially, fighting centered on Sevastopol, on the Black Sea. The Russians had it, and everyone else wanted to make sure they lost it. Beyond that, I have little to say about the Crimean War. The war introduced the Balaclava and the Charge of the Light Brigade, began the divvying up of the modern Middle East, created a variety of new states in the Caucasus region, forced Russia to engage in some political reform . . . oh, and it gave us the legend of the Lady with the Lamp.
You see, by 1854, horrific stories were coming back about British war wounded and casualties. They were packed into filthy, crowded hospitals, had their limbs hacked off, were given opium, and were basically abandoned to death unless they were strong enough to survive on their own. This humanitarian disaster called out to Florence.
Exactly 160 years ago this month, in October 1854, Florence brought 38 women (including 15 nuns and her own aunt) to Scutari (which is now known as Üsküdar, in Istanbul). Florence was a formidable administrator. She cleaned out the filthy wards, washed the men, and made sure they got food. She demanded that her friends back home help her with money, supplies, and pressure on the British government.
Florence could do nothing about the fundamental filth lurking in the sewers (a problem she understood only much later, when she compiled her report about events in Scutari) or about the overcrowding. Men therefore continued to die in appalling numbers during her first six months there, not just from their wounds, but from typhus, typhoid, cholera, and dysentery. Florence herself almost died from one of the infectious diseases.
Even though she was unable to reduce the death rate, Florence accomplished two things. First, as history records, she was able to make the men feel cared for. Yes, they were still dying in ever greater numbers during her first 6 months there,, but the Lady with the Lamp brought them tremendously important things: physical comfort and hope. Second, through the publicity Florence brought to bear on the medical barracks in Scutari, the British government finally took upon itself the task of cleaning the filthy, disease-ridden sewers, improving ventilation, and providing more space for the sick and wounded.
As the panel convened in San Francisco kept talking on and on and on about the key problem — organization and money — all I could think of was Florence Nightingale who, with her formidable organizational skills and vast network of wealthy and powerful friends, was able within a very short time to bring a mortality rate of over 40% down to 2%. She most certainly did not do it on her own, but she was a dynamic catalyst. It’s doubtful if, without her, anything would have been done to improve the lot of those poor British soldiers.
The Ebola crisis in Africa needs a Florence Nightingale: a formidable, fiercely well-organized, extraordinarily well-connected person who can bridge the gap between what is — chaos — and what should be — a well-ordered system that provides needed care starting at the village level. Listening to the doctors speak, I did not come away with the sense that such a person or entity will come along any time soon. The affected geographic region is too vast, the infrastructure too shattered, and the population too difficult to control.
That last point — a vast, dispersed, frightened, and ignorant population — is why the fourth man, the one whose name I can’t remember, must have repeated five or six times that the military is best equipped to impose organization from above in a situation such as this one. Our 3,000 Marines will be helpful, insofar as they are splendid organizers, but I suspect it will take more than 3,000 Marines to bring three impoverished, backwards, dysfunctional nations into line so as to control an incredibly hardy, opportunistic, and deadly virus.
Tonight’s talk ended with the panel insisting that we must bring medical justice to the third world through redistribution of medical care, a conclusion that had the San Francisco audience cheering. Like all good Leftists, they hoped that this crisis wouldn’t go to waste insofar as it would rejigger the world’s medical system. They are certainly right that we live in an interconnected world. A sneeze in Africa can become a disease in America.
Where their utopian dream about medical equality broke down is exactly in the same place it breaks down when they speak of Ebola. They see what is (a first world with good medicine versus a third world without) and they know what they want (equal medical care for all), but it was quite obvious they even they recognized the futility of somehow forcing the whole world to transfer its wealth to Africa and the Asian subcontinent. Instead, they just kept talking about the money flowing from crisis management.
They made more sense when they acknowledged that improved care in third world countries has to come from within and cannot simply be imposed from above. However, to the extent they made sense, they diminished somewhat my good will when they seemed incapable of acknowledging that it’s not just a money problem in Africa, but a more profound structural one. Both Sierra Leone and Liberia were fairly functional African nations until they fell prey to civil war, something no first world money could help. The doctors also failed to understand that it wasn’t activists who really brought about treatments for AIDS; it was First World fear of AIDS that spurred the research and discovery that led to breakthroughs. Simply transferring money from here to there will not cure systemic failures, nor will it inspire new medicines and treatments.