Late Night Thoughts on Pluto & Monrovia

I have been drinking a fair amount of alcohol tonight here in Monrovia, enjoying the company of some remarkable people at a dinner in the city center. We drove from there to our flat in Congo Town, about five miles away, where I sit and write this now.

The ride back along Tubman Boulevard was quiet as we listened to an extended BBC news report of the Pluto fly by of NASA's New Horizons spacecraft. I haven't actually seen many of the new pictures of Pluto given limited bandwidth here; mainly I check my email, and splurge on New York Times headlines every second or third day, but generally avoid the stories with high-resolution graphics as my internet access cuts out during the download.

Nevertheless, even listening to the radio program, it is hard not to feel a sense of wonderment at the magnificence of the event. This icy piece of rock, that circles the sun at an unimaginably long distance from our home, has become linked to us in a new and profound way; we are just a little more a part of a bigger and more amazing environment as a result of some electronic signals emanating from a piece of metal about to leave the Solar System. It is humbling. It is wonderful. It inspires awe.

Earlier today I stopped by the John F. Kennedy Hospital to check in on my resident. I didn't actually find him, but instead saw a 17 year-old who had been in terrible respiratory distress two days ago. She has an enlarged heart and had retained fluid around her lungs. I couldn't tell you the cause, though I have a few guesses--but without the resources to order the proper tests, they will remain only guesses. One of the residents--a true star, every bit as good and frankly better than many of even my high-quality residents back home--had taken the fluid off her lungs the previous two days, so that when I happened to wander in this afternoon, she had smiled for the first time I had seen her.

Her future remains tenuous, but for the moment, she thrives, and that has filled me with a certain hope, not merely for her, but somehow for Liberia, a country that has gone through much over the past year and yet moves ahead with hope and ambition. Along Tubman Boulevard, going from Congo Town to the JFK Hospital, there's a Coca-Cola billboard advertisement that wasn't there during the outbreak. It is simple. It merely shows a man, maybe my age, emerging from a car door, looking straight into the camera with a content appearance. "I'm confident of better days ahead," reads the caption.

I tend to brood, but perhaps tonight I am as well.

--Billy

Ebola: How Many Will Die?

It's a crude question, one that turns an international tragedy into a football score. Part of the fascination that Ebola holds for people is the death toll, and news outlets love to tally the stats as we see the bodies accumulate, though from our safe spectator perch in the US.

So I'm not precisely thrilled to frame this entry by focusing primarily on raw numbers, but there's a reason for it if you'll bear with me for a few grafs. It arises from a comment in this recent Salon post by Andrew Leonard. Leonard refers to the WHO estimates that the outbreak may infect as many as 20,000 people, resulting in a death toll of perhaps half that, and then quotes an infectious disease physician who thinks that the WHO's estimate is low "by an order of magnitude."

I was that doctor, and at the moment I'm still standing by my general assertion that 20,000 cases is a dramatic underestimate. Here's some very basic reasoning:

One: disease surveillance in Sierra Leone and Liberia, the two hardest-hit countries, is minimal in some small areas and non-existent everywhere else. The population of these two nations is about ten million people, and that number appears to be reasonably accurate based on 2008 Liberian census data published by the UN. But the report hides a telling fact: that such a census basically wasn't possible without substantial outside help from the international community. After the census ended, those people left, and Liberia was left to its own devices for surveillance. In other words, Liberia doesn't have much internal monitoring resources, for population, or disease, or any other kind of demographic information. Tracking sick people of any kind is beyond their capacity at the moment, and it is only marginally better in Sierra Leone. The international effort is coming, but coming slowly out of an appropriate abundance of precaution that the aid groups are taking to ensure the safety of their staff.

Two: so when we see these numbers of Ebola cases, we're really only seeing the cases that are coming to attention, and we know that there are more cases out there. Many locals are terrified that Ebola treatment facilities are just death mills or worse, are probably keeping their loved ones at home, "hiding" them from official eyes. This has caused Sierra Leone to take the unprecedented step of placing the entire country under quarantine so that officials may conduct a house-to-house search for three days in an attempt to dig a trench to stop the fire from spreading. (MSF, more commonly called "Doctors Without Borders" in the US, heaps skepticism on this plan here.)

Three. when patients are coming to attention, they are trying to mask their symptoms. This is probably how Rick Sacra, the latest American doctor to become infected, contracted the virus. Sacra was not working with Ebola patients, but was rather providing care in an obstetric ward. He was--one hopes--careful enough to check his patients' temperatures before administering care. But anyone can make a fever go away for a few hours with some Tylenol, although they are no less infectious during this period.

Four. combine these three factors and witness a lethal virus on the loose in a densely packed neighborhood like West Point in Monrovia, which has a population of 50,000--or maybe 75,000, or maybe 100,000 depending on your source--and one can only currently guess at the results. Just by sheer concentration, the outbreak has the potential to flourish into the thousands in West Point alone. West Point was cordoned off during the last week of August, and the level of paranoia and misunderstanding there is profound, to the point that locals attacked an Ebola quarantine center, taking away infected patients as well as bed linens and other material covered in the body fluids of probable patients. This single act almost certainly consigned dozens, perhaps hundreds, perhaps thousands, to death in West Point.

Five. people are doing everything they can to flee outbreak areas, and while many of these people may not be infected, all it takes is one infected person to bring disease to an entirely new place. The Nigerian government did a remarkable job containing the outbreak after Liberian Patrick Sawyer brought Ebola to that country in his own effort to outrun the virus. (Sawyer, the article notes, was trying to fly to the United States for treatment, having a ticket that would bear him to Minnesota. Surely that would have grabbed Americans' attention in an entirely different way, and I'm somewhat amazed that this wasn't really broadcast by the US media.) They thought that they had contained it, only to discover that one of their own medical personnel had carried the outbreak from Lagos to Port Harcourt as he fled the government-imposed quarantine.

When viewed on a region-wide scale, these factors suggest to me that we're not even close to some semblance of control over this situation. More than 20 million people live in the three most severely afflicted countries of Guinea, Sierra Leone, and Liberia, and there's no evidence that the outbreak is even slowing down. So I simply don't understand where the 20,000 figure came from, and I wouldn't be surprised that we've already passed that number as I write this. Indeed, at least one academic adept at statistics notes a best case scenario that is not quite double the WHO estimate, with a "medium" estimate close to my casual remark that WHO has underestimated by an order of magnitude, and a "nightmare" scenario that I'm too terrified to repeat--look for yourself.

So why obsess about numbers? Because we're possibly looking at the societal collapse of a good-sized chunk of West Africa unless we appreciate the scale of this disaster. Comparing this to, say, the Haiti earthquake may be too generous. Think more like Rwanda in the early 90s or Cambodia in the 70s: a complete disintegration of anything resembling order, replaced by fear, distrust, and quite likely violence. At the moment, I still think there's a chance to contain this and avoid this kind of total breakdown. But the window is closing, and I'm not yet sensing the level of alarm in government responses that will be required to stop it.

--Billy

Ebola and Abraham Borbor

I couldn't help but get slightly irritated at the initial reportage about "the death of a Liberian doctor given the experimental drug ZMapp" yesterday. The Associated Press article that can be found today on many news websites from The New York Times to Fox News does provide the critical detail that was missing in the early report, which is the name of the doctor. Take, for instance, a clip from NPR's report yesterday:

NPR radio host Alec Siegel: Now, there is word today that a Liberian doctor who was infected and who was given the experimental treatment serum ZMapp has died. Is that right?

NPR field reporter Nurith Aizenman: Yes. And on top of that, a British doctor working in a government-run Ebola care center in Sierra Leone has tested positive. He's been evacuated to the U.K. And then another health worker from Senegal who was working at a different facility in Sierra Leone now has Ebola. He was employed by the World Health Organization. They're working on getting him to another country for care.

Given that the AP included this information today, perhaps it was just that the journalists didn't have access to his name, although I can't recall a moment when we didn't know the names of Kent Brantly and Nancy Writebol, the doctor and nurse from the US who had become infected with Ebola. Their names were plastered on every news piece about Ebola in the first week of August. The Liberian doctor's identity has hardly invited concern, similar to the coverage of Dr. Sheik Umar Khan, whose death merited less coverage than a discussion about the ethics of giving him ZMapp.

The Liberian doctor's name was Abraham Borbor.

I knew him personally and admired him greatly. I came to Monrovia last November to spend a few weeks with the internal medicine residents at John F. Kennedy Medical Center. The Liberian medical community, piecing itself back together after two decades of a savage civil war, had re-opened its medical school a few years before, and now they were taking the next step by forming a graduate training program. A colleague of mine in pediatrics had been going back and forth for several years, and asked if I'd be interested in going.

I jumped at the chance. It is not often one is able to see a profession at its inception, much less play a small role in fostering it, but through sheer good luck I happened to be at JFK just as the residents were in their first month of training. I was expected to give some lectures devoted to infectious disease topics, knowing nothing about what these residents did or didn't know. I gave it my best shot. Sometimes I wildly overestimated what they knew: as a side moment in the middle of a lecture about immunity, I asked them if they understood Toll-like receptors, and got blank stares. (Suffice it to say that knowledge of TLRs is very, very much a nicety in Liberian medicine, and not of much practical use. It was about then that I realized I needed to tailor my lectures to my audience mighty fast.) At other times I had to come to grips with my own ignorance of what constituted common pathology in a place like Liberia. Here in the US, the condition of bronchiectasis is mostly limited to patients with Cystic Fibrosis, treated with repeated courses of antibiotics, and its progression is followed by serial Cat scans; there the diagnosis is made by taking a whiff of putrid breath from someone with a chronic productive cough.

Throughout my brief stint there, my host was Dr. Borbor. I can't speak to his impression of me, but I liked him from the start. He was smart and funny, in his element during morning rounds when teaching his interns and residents. It took me time to size up some of the trainees owing to culture shock, but by the end of the first week it was clear to me which of the housestaff Dr. Borbor thought had real potential, and it was equally clear that his appraisals were unsentimental and reflected high standards.

I have only one picture of him, taken in a car when we were driving around Greater Monrovia so I could get a feel for the place outside the walled compound of JFK. This picture was taken of an old Ministry building (Health? Defense? I can't now recall). A good portion of the driving that day was done in the West Point neighborhood that has become representative of the threats and challenges that this epidemic poses to Liberia, and the rest of the world should it get outside of West Africa.

The conversation that day centered around the challenges of not merely providing medical care in such a resource-limited place, but simply living in such an environment. Ebola is only the most extreme example of the hurdles that people in West Point must face in order to live, work, and love just like anyone else in the world wants to do. We spent a good amount of time talking about how such a neighborhood gets power (the quick answer: pirated from transmission wires and then "sold" by the owners of the pirated lines; families who consider purchasing such power think in terms of whether they can afford to have a single light bulb on in the evenings). In these conversations, I came to see that Dr. Borbor had a considerable grasp of problems well beyond medicine that his country faced, and somehow he not only remained undaunted by political and economic difficulties that most of us would consider hopeless, but he maintained a sense of humor as well.

All of this is to give you a sense of the man that I came to know and appreciate, and was hoping to meet again soon, but that's not the most important point to know about Abraham Borbor. What is critical to know about him, as well as his colleague, Dr. Samuel Brisbane, who also died of Ebola one month ago, is that these men formed the backbone of Liberian medicine. (Dr. Brisbane was out of the country most of the time I was there and so my meetings with him were brief.) Both of these doctors had somehow managed to not only stay alive during the civil war, when scores of their comrades either were killed or fled, but they stayed at their posts, continuing to care for patients when a place like JFK had no supplies or anything resembling what we would think of as the infrastructure required to run a hospital. Basically, they had a building, and they had their wits. And Dr. Borbor didn't leave, even though he was among the rare Liberians who had enough means and connections that he could have done so. There aren't words for that level of dedication.

At JFK, which prior to the outbreak was regarded as the central teaching hospital for all of Liberia, Drs. Borbor and Brisbane were the department of internal medicine. If tomorrow I were to be killed in a car accident, whatever the personal loss my death would be to family and friends, in professional terms my absence would hardly register as a blip in American medicine. There are twenty trained specialists who are capable of doing what I do on a daily basis just at my institution, and there are at least a half-dozen other infectious disease doctors also working in the area, either in private practice or at the other major hospital across town. And these doctors constitute just one subspecialty within the broader umbrella of internal medicine. In Massachusetts--a state with roughly a comparable population to Liberia--there are thousands of doctors, plus perhaps a similarly sized group of PAs whose clinical responsibilities often overlap with doctors. At JFK, one of the central places for residents to be given advanced training, Abraham Borbor and Samuel Brisbane constituted the internal medicine faculty in its entirety.

Their loss cannot be so easily replaced. I am sad to have lost a colleague for whom I had much affection. But I am devastated for the future of Liberian medicine. Their loss will reverberate for a generation.
--Billy