Ebola, fate, and appropriately assessing risk.

There has been a lot written about Ebola lately, and lots of talk about it, and fear about it, in the halls of the hospital and clinics where I work, and I would guess lots of other places also. I don’t have any expertise in Ebola, and don’t claim to know what should have been done, or what “we” should be doing going forward, but it is clear that there have been mistakes, or at least major miscalculations, made by the WHO and the CDC and other government agencies. Some of this may be the result of cuts in funding over the last many years, some the result of emphasis on bioterrorism rather than the impact of infectious agents that get transmitted the regular way (“Failures of Competence”, Joe Nocera, October 18, 2014) but has been both sobering as well as a vehicle for administration opponents to attack it. Of course, the attacks may be justified, but there is no reason to think a previous administration would have done better.

First, it is critical to point out that the real problem, suffering, and crisis is in West Africa, in Liberia and Sierra Leone, and Guinea. In countries with little infrastructure and few resources and in the cases of the first two, relatively recent histories of devastating civil wars. The concern about Ebola in the US (so far two home-grown cases, both in nurses who cared for the Liberian man in Texas) needs to be seen in that context. Those countries that are severely affected need major resources, both human and financial, and need them fast. An excellent video analysis of the issues was recently done by Laurie Garrett on a webinar called “The Ebola crisis: the best and worst case scenarios from here”. Thankfully, there is some recognition of the need in these countries among those who are seeking to make political hay of this crisis; my own Senator Jerry Moran has joined others, particularly other Republicans, in calling for closing off flights from the affected countries, but proposes to exempt health workers. Of course, this misses the fact that it is easier to screen folks coming from those countries than people who first travel to other countries and then fly to the US.

What does interest me about the whole discussion in this country around Ebola is the degree to which it illustrates two common flaws in the way people think about problems. One, obviously at play in the case of Ebola, is the fear of the new, unfamiliar, and scary, especially when hyped up by the media. Thus, for example, the reluctance of both patients and staff (encouraged by their families) to come to work in our clinic during the period that a patient at our hospital was being ruled out for Ebola (he didn’t end up having it), even though it is in a separate building and the patient was three layers of isolation deep. This fear is stoked by events such as the revelation that the second nurse to come down with Ebola had been allowed to fly from Texas to Ohio and back on a commercial airliner (although it could just as well be cited as evidence that anyone, working in a hospital or not, might be at risk).

The second is that people often find it easier to worry about, to get worked up about, problems that they are at low risk for but that they cannot do anything about, even when they are not doing what they could do to prevent problems for which they are at much greater risk. I have written in the past about a prototypical patient obsessed by breast cancer, a condition for which she was in fact at no increased risk, who was not doing anything about problems she could act on such as uncontrolled hypertension, cigarette smoking, and unprotected sex with multiple partners. Indeed, my point was that if she was worried about those last three, people would expect her to do something about them since she could – she could take blood pressure medication, stop or cut down on her smoking, and use protection when having sex. But those might be hard. Worrying about breast cancer, something that there was nothing she herself could do to prevent (doctors could order mammograms, at too young an age and far too frequently, but she wouldn’t have to do anything) was, in this sense, easier. Both of these logical flaws were highlighted by comments from the chief medical officer of my hospital, early in the isolation of the possible Ebola patient: “If 20,000 people were dying of Ebola there would be riots in the streets. But every year an average of 22,000 Americans die of influenza, and people still don’t get their flu shots”.

This selective concern is a form of determinism, the topic addressed by Konika Banerjee and Paul Bloom in “Does everything happen for a reason?” in the NY Times, October 19, 2014. They discuss the idea of fate, that things happen that were destined to happen, that experiences of adversity which coincidentally lead to positive outcomes (the man hospitalized for injuries as a result of the 2013 Boston Marathon bombings who falls in love with and marries his nurse) are “meant to be”. They note that while this is most common in people who are religious and believe that God determines everything, it is still a very common belief among atheists. It is an attractive idea, but it is a mis-reading of chance. That is, people pay attention when things seem to fortuitously happen, or a coincidence facilitates something you wanted to happen. (E.g., yesterday morning I heard a part of a 1981 song on the oldies station but couldn’t remember its name; amazingly, when I turned the station back on in the evening, it was playing again! Fated? No, just Rick Springfield’s “Jesse’s Girl”.) We forget how often things do not happen, but remember when they do. Banerjee and Bloom write:

Not everyone would go as far as the atheist Richard Dawkins, who has written that the universe exhibits “precisely the properties we should expect if there is, at bottom, no design, no purpose, no evil, and no good, nothing but blind, pitiless indifference.”

Deists, like Thomas Jefferson I heard yesterday (also on the radio, but NPR this time), believed that the world was so ordered that there must be a creator, although they rejected the detailed instructions that many of their contemporaries took from the Bible or other religious texts. However, the random nature of events, as suggested by Dawkins or by Stephen Jay Gould (“Full House: The Spread of Excellence from Plato to Darwin”) accounts for these just as well.

The same issue of the Times contains a more medically related piece, “Why doctors need stories”, by Peter D. Kramer. I like stories, and I use them a lot (see above for a couple); they make things come alive, tie abstract events to actual lives, create examples in the experience of individual people of phenomena that are harder to understand when we look only at populations. But they can be misused; my story about the woman who was more worried about breast cancer than her smoking or high blood pressure is meant to be an example of how people can choose which facts they believe and which they ignore. It doesn’t prove anything, certainly not that most people act this way, or don’t. It does (I hope) get your attention. We have to be careful how stories are used; “I knew someone who had an abnormal Pap smear and she didn’t do anything and it went away”, while consistent with our most current knowledge about the early course of abnormal Pap smears in young women, is not a valid argument for you to not do anything. Stories tell what they tell; the lessons learned and conclusions reached are up to us.

Banerjee and Bloom end their piece:

If there is such a thing as divine justice or karmic retribution, the world we live in is not the place to find it. Instead, the events of human life unfold in a fair and just manner only when individuals and society work hard to make this happen. We should resist our natural urge to think otherwise.

And, no matter what we think about Ebola, we should get our flu shots.

Ebola, risk, and the public's health

My friend Allen Perkins received a text from his college-student daughter asking if she should be worried about the Ebola virus. His reply, discussed in “Ebola virus and the dread factor” in his excellent blog, “Training Family Doctors” was “Are you considering moving to west Africa?” This was wise and profound fatherly advice, based upon an understanding of the epidemiology of disease. While is it obviously a serious problem in West Africa (particularly Liberia, Sierra Leone, and Guinea), it is not in the United States. Many other things are much more of a threat in the US, including, as Allen points out, “death from bee stings” (100 per year in the US).

Ebola might someday become a significant problem in the US, but it is unlikely and is not now. Many other health problems are. College students like Allen’s daughter should be sure that they have all their recommended immunizations for diseases that can be prevented by vaccine, including HPV and meningococcus, a very serious and often deadly cause of meningitis that can become epidemic where young people live together in close quarters, like college dormitories (and army bases). Yet, many do not receive these immunizations for reasons that range from passively not getting it done (less of a problem in schools where it is required) to having beliefs, or having parents who have beliefs, that vaccines are dangerous and should be avoided (in some cases this can trump school requirements). They are, by the way, wrong. The net benefit far outstrips the risk. Having your child get meningococcal meningitis and die or have serious brain damage, or get cervical cancer, is not something you want.

But focusing on conditions over which we have little or no control, rather than the ones we do, is fairly epidemic in this country (and likely others). Dr. Perkins focuses on the “dread factor”, about how news reports (not to mention thriller movies) whip up fear about these diseases. On the other hand, mostly what we can do is fear them, while the diseases which we individually might be able to have an impact on would require us to have to maybe do something hard: change our diet, start exercising, stop smoking, not drink so much or at the wrong times. I have written in the past about a patient who had a terror of breast cancer, a disease for which she was not at an increased risk based both on her youth and lack of family history. On the other hand, she did not seem particularly worried about the health risks of her uncontrolled high blood pressure, smoking two packs of cigarettes a day, or having unprotected sex with several different men.

Most of us can see that this is not logical, and maybe even snicker a little about her poor decision making. But it is only a little extreme. Many, perhaps most, of us, could do a better job of eating right, of exercising, of not smoking or drinking excessively (which for many people is “at all”). If not Allen’s daughter, many of her classmates are at much greater risk from going out and getting drunk on a weekend night, increasing their risk of motor vehicle accidents, sexual assault, poor judgment in choosing voluntary sexual encounters, and long term habituation for those with a predilection for or family history of alcoholism, just for starters. But taking action to prevent such bad outcomes is hard, requires effort, and often means not doing things we like in the short term, such as eating tasty-but-unhealthful foods, drinking with friends, smoking when we are addicted to nicotine, driving when we (or the driver) is only a “little drunk”, or having to do unpleasant exercise. Or it can conflict with our self-image: wearing a bicycle or motorcycle helmet, eschewing doing things that our friends are doing. Worrying about things that we can do nothing about, like breast cancer or Ebola, may be a little irrational, but it is in some way comforting because if the bad thing happens we are an innocent victim.

In addition, there are actions a society can take, that could make even more of a difference from a public health, population health, point of view, saving more lives, but these require political will. Sadly, this is often more lacking than individual will. Guns are the prime example; many state legislatures and legislators make it a point of personal pride to advocate for there being no restrictions at all on what kind of guns (e.g., automatic weapons) and ammunition (e.g., armor piercing bullets) people can have or where they can carry them (everywhere, open or concealed). Helmets and alcohol regulation are other areas where opportunity for prevention is often missed. Car safety has been increased by car and highway redesign and tobacco has been increasingly regulated (against the opposition of the industry, it should be noted, in both cases) for the benefit of public health, but many opportunities remain.

Indeed, expanding health coverage to all those below 133% of poverty by Medicaid expansion continues to be opposed by those who want to be seen as against Obamacare. This may be irrational from a public health point of view, but in many states it is rational, if offensive, for being re-elected. The most unjust and inequitable part of it all is how the effects of poor public health policies most affect the most vulnerable, poorest, least empowered people in our society, or indeed any society. Public health education campaigns tend to focus on diseases that have well-funded advocacy groups and affect the majority population; a recent qualitative study of African-American women found that they were very aware of the threat of breast cancer, but hardly at all of stroke – a disease statistically more likely to affect them.

Speaking of public health, it is gratifying to see some newspaper coverage of Ebola that is not sensationalist or scary. “U.S. Colleges See Little Risk From Ebola, but Depend on Students to Speak Up”, by Richard Pérez-Peña in the NY Times, August 30, 2014, addresses the small but real risk that may affect colleges from students who have (unlike Allen’s daughter) actually traveled to West Africa. Even better is “Leadership and Calm Are Urged in Ebola Outbreak” by Donald G. McNeil, Jr., which presents a rational, thoughtful, public health approach, and discusses public health strategies which have been used in the past in major crises and are beginning to be implemented in West Africa. These strategies center around the use of local, respected experts who can effectively communicate with the people in their countries, rather than international aid agencies. The goal is to help people to utilize appropriate prevention and protection measures rather than panic. Again, as in the case of the other personal behaviors described above, this can be hard for people, especially when it contradicts cultural and religious values (such as how the dead are buried). But having voices who are local, who understand the culture, and have both medical/public health credentials and individual credibility, is extremely important. Of course, unlike the Ebola “scare” articles, these were both on page 8 of the newspaper, but have a more prominent position on that day’s Times homepage.

So what are the lessons? Understanding risk is not always easy, especially when an epidemic with a hugely high mortality rate threatens.  Doing something is harder than not doing anything, and it can thus be tempting to worry more about the things that we can’t do anything about rather than those we could reasonably take action on. The same is true for public health issues that need to be addressed at a societal level.

And, of course, it is always the most vulnerable who suffer the most.