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Ebola patients are real people, deserving of more

31 July 2014

In writing two pieces on governmental response to Ebola, I’ve read a lot about the Ebola outbreak in West Africa. I’ve been particularly interested in firsthand accounts, including news stories sharing the perspectives of doctors treating patients, people who have recovered from Ebola, and, of course, journalists‘ interpretations of how people are responding to the epidemic. They’ve all been really interesting. Sometimes, though, the statements by doctors have gotten under my skin. Many of the characterizations of the people who are themselves navigating the deadly outbreak fail to appreciate the greater context and are downright ethnocentric (e.g., this).

Then, I read this, which has single-handedly restored my faith in international medical personnel treating those suffering from Ebola. Dr. William “Billy” Fischer II, a doctor from UNC-Chapel Hill, went to Gueckedou, Guinea — what is considered the epicenter of the current Ebola epidemic — in late May to work with Doctors without Borders/Médecins sans Frontiéres. UNC collected and edited his emails home to give people an idea of the situation. Billy’s emails are moving. Here are a few excerpts:

June 2, 2014


Today was a pretty tough day – one of the first two patients I admitted on May 30 died.  I walked into his room and he was on the floor half naked surrounded by bloody emesis and diarrhea.  I put him back in bed, bathed him, and put fresh clothes on him and as I finished he died. 


It’s pretty emotional to bathe a 27-year- old man who was incredibly strong and rendered completely helpless. His sister is next door and will likely die in the next hour. This is all in front of the other patients in the room, many of whom are family members or neighbors. The despair is suffocating.



June 3, 2014


Unfortunately we also have an 18-year-old woman who is 5 months pregnant, has Ebola, and malaria. I thought being 18 was tough – I can only imagine being pregnant, infected with a near uniformly fatal virus, having malaria, and being in an isolation zone treated with people in space suits. The clinical course of pregnant woman with Ebola is not good, to say the least, and unfortunately she began having contractions overnight and we “helped” her deliver a non-viable fetus this morning. Miserable.



June 4, 2014


Part of what makes Ebola so devastating in addition to the manner in which people die, is that this virus wipes out families.  It penalizes those families who are close and transforms tradition into transmission.  The 18-year-old pregnant woman that I wrote about yesterday died.  After delivering she continued to hemorrhage despite oxytoxin and uterine massage.

When her husband was told about this he responded with, “ma vie est fini” (“my life is over”). Ebola has killed his mother, his mother-in-law, his wife and their unborn child.  I worry that when the fight leaves a person the body is quick to follow.  Similarly, when a woman died last week, her mother, who was also a patient and improving, soon followed. I’m not sure that there is anything worse than dying with despair after watching your child die.

Despite all this suffering there are moments of hope.  There is one older man, who, as soon as I walk in, starts doing calisthenics to demonstrate his clinical improvement.  I can’t help but smile and he has started doing them when he sits outside and we walk by – he is the first person I look for when I arrive at the isolation center.  Another younger man has started to do well and I anointed him team leader for his room.  He has embraced this role brilliantly by helping the other patients in this room encouraging them to drink and helping to translate Kissi into French for me.  

And this is the one that broke me down into tears:

June 8, 2014


As the reality of my departure nears I can’t help but feel some sense of guilt—guilt for not having done more, faster, and better. But I think this feeling emanates from the fact that I can leave and the patients in this epidemic can’t. Last night we admitted a young boy who was transported with his mother from Kueldou. They had been locked in a house for four days because they were symptomatic. Unfortunately the delay in presentation was significant as only the boy was admitted because his mother died in transit. A 9-year-old boy sat next to his mother as she died. Now he sits in the isolation ward alone.

His father and brothers walked the 25km today to the isolation ward as the family’s village has rejected them and reported that the father may have symptoms. The MSF team sent a car to pick them up but the father refused to ride given what happened to his wife.

Fortunately, the 3 other siblings do not have symptoms but I’m concerned it’s only a matter of time as the father walked 25km with one of the children tied to his back exposing him to potentially infectious sweat. The estimated 21-day incubation period of Ebola complicates contact tracing given that people can theoretically be symptom free for 3 weeks following exposure. Since we can’t hold the family in the isolation ward for 3 weeks we can only test them now and formulate plans to follow them in case they do develop symptoms.

When the 9-year-old was brought into the treatment facility he barely had a palpable pulse. When I met him he was weak, in pain, but incredibly stoic and most awfully alone. With fluid resuscitation we were able to get a pressure and with that a chance. His clothes were soiled and so we brought a new outfit for him. After some effort I got him to smile and in that smile I found false hope.

With Ebola you can’t have a good death. You are isolated from your friends, your family, your home. You are cared for by people whose primary focus is on stopping transmission from infected to susceptible and from patient to provider rather than comfort and cure.

These people often die without the comfort of a human hand, without seeing someone’s full face or even just knowing that a loved one is near. I think of all the death notes that I’ve written in the United States and the bulk of them usually include the sentence, “they passed away peacefully with family at the bedside.”

I didn’t get a chance to write that for this little boy. Despite the hope that his smile brought me, he died overnight. In the void of darkness he converted to hemorrhagic shock with massive vomiting of blood and I’m told he bled out on the floor of the isolation ward.

I can’t help but think about what his last days were like – being locked in a house with his mother by his family and his community out of fear; then watching his mother die in the back of a pick up truck, being placed in an isolation zone staffed by foreigners in space suits, and finally vomiting blood alone.

I am troubled that I’m not better at this – that I haven’t figured out a way to implement more advanced healthcare infrastructure that would allow us to save more. When this epidemic is over I am sure there will be more time for reflection but now there are more patients and more chances to help.

There are real people suffering from Ebola. Fathers, children, pregnant women. They are scared and the majority of them will die. The resources to stop Ebola are stretched thin. If you read more of Billy’s emails, you’ll note how few medical personnel there are. In Liberia’s capital, they’ve run out of space in the hospital for people suffering from Ebola.

If you are moved, I urge you to make a donation to Doctors without Borders — they’re supplying equipment and medical staff to multiple regions affected by the outbreak. And, judging at least from Billy’s perspective, they’re doing good work.

why I think the fatality rate in the current Ebola epidemic suffers from undercounting

30 July 2014

Two days ago the World Health Organization (WHO) released its most recent update on the Ebola situation in West Africa. Here are the numbers.


One debate about Ebola numbers has been about journalists’ use of a particular statistic: the fatality rate from Ebola. In the worst epidemic ever, 90% of those reported infected died from Ebola (and this is the rate you’ll see cited in many of the news stories about Ebola). The chart of fatality rates since 1976 shows a range from 25-90% for any epidemic with more than one reported Ebola case. This helpful image of Ebola fatality rates created by Brett Keller excludes epidemics with fewer than 30 deaths:

Analysts debate whether using the 90% fatality rate is an effort to dramatize the disease outbreak. According to the WHO’s recent report, the fatality rate is at roughly 56% (divide 672/1201) for reported cases in the current epidemic. So some analysts are reporting this lower figure, citing it as more accurate. But Carl Bialik at FiveThirtyEight points out that the fatality rate in the current Ebola epidemic is just an estimate:

…there are several reasons to interpret the reported death toll as very preliminary; some reasons mean it might rise from here, while others mean it might fall.

He offers four reasons why the fatality rate is a moving target. In brief:

  1. The outbreak isn’t over — there are still many people who are sick and likely to die. Even with no new cases, as the disease runs its course in those already infected, the fatality rate will go up.
  2. False positives (meaning suspected or probable not yet confirmed cases of Ebola that will eventually be ruled as not Ebola) temporarily inflate the number of people infected, making the overall ratio of deaths to infected seem lower than it really is.
  3. Some people may never get tested for Ebola because they recover. Some Ebola symptoms are also symptoms of other diseases (e.g., malaria, flu, etc.) and so these people could self-diagnose as having something else. Those with more severe symptoms might be more likely to seek treatment.
  4. People who die from Ebola without diagnosis will eventually be counted in WHO statistics.

First, I haven’t heard of people suffering from Ebola that mend on their own. (Anyone have more info on this?)

But more importantly, I think it’s most likely that there will be an undercount of deaths and that the fatality rate will be an underreport. Bialik is confident from his conversation with a WHO spokesperson that eventually people who died from Ebola without seeking treatment will be counted. I am not so confident.

With some communities fearful and suspicious of clinics treating Ebola, it is no doubt there are Ebola cases going unreported. As these people die from Ebola (the fate for many of them), what incentive do their families have of alerting health authorities after-the-fact? How could health authorities posthumously test a suspected Ebola case — especially following burial?

my shero

14 July 2014

DON’T: Tone-police. Does she sound enraged, impatient, and bitter? Is she not being especially nice to all the people who have Tweeted at her to explain sexism, ask her how to solve sexism, or otherwise undermine the things she is saying? Too bad. You wouldn’t be nice either if you lived in a system which consistently conspired to remove your authority and devalue your work. No matter what happens, you are not the victim in the situation — do not re-center conversations on yourself and your needs and emotions by pestering angry women to talk more nicely to you.


Did she hurt your feelings? You’ll live. Ditch the passive aggressive “fair enough” and “I was merely trying to” and “as you wish” and all of this, leave her alone, and consider your obligation to be part of the solution to a system that has harmed her and made her angry. If you think women, particularly women who are public figures, should feel an equally-important sense of obligation to make you feel good about yourself while they are under stress, congratulations: You are part of the problem.

That is just a snippet from the very excellent guide: “But WHAT CAN BE DONE: Dos and Don’ts To Combat Online Sexism,” by Leigh Anderson.

HT @WilHMoo.

coolest paper I’ve read this week

7 June 2014

In India, Muslims face significantly lower child mortality rates than Hindus, despite Muslim parents being poorer and less educated on average. Because observable characteristics would predict a Muslim disadvantage relative to Hindus, previous studies documenting this robust and persistent pattern have called it a “puzzle” of Muslim mortality. This paper offers a simple solution to the puzzle in the form of an important sanitation externality. Most of India’s population defecates in the open, without the use of toilets or latrines, spreading fecal pathogens that can make children ill. Hindus are 40% more likely than Muslims to do so, and we show that this one difference in sanitation can fully account for the large (18%) child mortality gap between Hindus and Muslims. Building on our finding that religion predicts infant and child mortality only through its association with latrine use, we show that latrine use constitutes an externality rather than a pure private gain: It is the open defecation of one’s neighbors, rather than the household’s own practice, that matters most for child survival. The gradient and mechanism we uncover have important implications for child health and mortality worldwide, since 15% of the world’s population defecates in the open. To put the results in context, we find that moving from a locality where everybody defecates in the open to a locality where nobody defecates in the open is associated with a larger difference in child mortality than moving from the bottom quintile of asset wealth to the top quintile of asset wealth.

That is the abstract for “Sanitation and health externalities: Resolving the Muslim mortality paradox,” available here.

HT @alanna_shaikh.

leaving before the fat lady sings

27 May 2014

I’m about to board a plane home out of Blantyre, Malawi. When I originally scheduled my trip to observe Malawi’s elections, I expected seven days following Election Day would be sufficient time for the electoral commission to tally and announce the results. While that might have been true for previous elections, this one had turned out to be… special. 


Photo of today’s front pages in Malawi’s two major daily newspapers.

I’ll be following updates from the states when I land, but if you want to keep tabs on the ever-changing situation, I recommend following some folks on Twitter: Boni Dulani, Blessings Chinsinga, Levi Kabwato, and MEIC_2014. (Apologies for not linking directly, I’m composing this on my phone.)


Malawi’s election saga continues

25 May 2014
Malawians queue to vote at Namadwe polling station in Thyolo District on May 20, 2014. Taken by Kim Yi Dionne. All rights reserved.

Malawians queue to vote at Namadwe polling station in Thyolo District on May 20, 2014. Taken by Kim Yi Dionne. All rights reserved.

Now five days after Malawi’s tripartite election should have ended, there is still no official declaration as to who won the presidential race. Unofficial results and a parallel vote tabulation project Peter Mutharika of the Democratic Progressive Party (DPP) has won, and he was trailed by Lazarus Chakwera of the Malawi Congress Party (MCP), and then current President, Joyce Banda of the People’s Party (PP).

Both Banda and presidential candidate Atupele Muluzi of the United Democratic Front (UDF) have held press conferences proclaiming massive irregularities in the vote counts. Banda’s press conference was perhaps the most surprising – it was the first time I heard a sitting president allege that the opposition has rigged the vote. She mentioned in particular the problems the Malawi Electoral Commission (MEC) was having in transmitting vote counts from the constituencies to the tally center headquarters in Blantyre. Interestingly, the government-run media house, Malawi Broadcasting Corporation (MBC), did not air her press conference live. Shortly thereafter, MBC’s Director General, Benson Tembo, was put on forced leave (he has since been reinstated).

MEC [originally] stood by their counting process, saying though their electronic data capture system’s problems required them to do a manual tally, their counts were still consistent with the tallies made in the constituencies.

Then, yesterday afternoon, President Banda held a press conference saying that in her position as the president, she was nullifying the elections and ordering fresh elections to happen in 90 days. (She claimed she would not be a candidate in those fresh elections.) Banda asserted she had the power to nullify the election results under Malawi’s constitution (at first she cited Section 82(2), and a later press conference corrected herself by citing Section 88(2)). Section 88(2) reads:

The President shall provide executive leadership in the interest of national unity in accordance with this Constitution and the laws of the Republic.

After seeing many on Twitter cite this section of the constitution, I pointed them to what is said in Section 88(5):

The President and members of the Cabinet shall not use their respective offices for personal gain or place themselves in a situation where their material interests conflict with the responsibilities and duties of their offices.

It was obvious Banda was grasping at straws to try to block a Peter Mutharika presidency. Perhaps she is concerned that once he’s president, he will use his power to make things difficult for her, as she was the one who pursued Peter Mutharika for treason after the death of his brother, former President Bingu wa Mutharika.

No constitutional or legal scholar believed Section 88(2) gave Banda the power to nullify elections. Only hours after Banda’s press conference, Malawi’s High Court set aside Banda’s order that MEC stop counting votes. Counting resumed.

Then, last night, MEC announced they would do a manual recount because of some serious anomalies. (The recount would cover all three elections: presidential, parliamentary, and local government.) The anomalies include having vote tallies that exceeded the number of registered voters in certain constituencies. Malawi’s electoral law requires an announcement of election results by MEC no later than eight days after the election. Even if we consider May 22 the end of the election (because of delays, some polling stations did not complete voting until May 22), the official declaration by MEC of election winners would be required by May 30. I am confident MEC won’t declare official winners by then. They say it will be less than a month. I’ll just leave you with what Blessings Chinsinga has to say about that:

when politicians monitor how you respond to their handouts

24 May 2014

photo (1)

Political scientists who question the efficacy of the exchange of goods for votes point in particular to the problem of monitoring: if a politician gives someone something in exchange for their vote in the era of secret ballots, how can that politician know the citizen actually voted for him?

A Malawian politician offers a great example of a workaround to this problem. From Thursday’s copy of The Nation, I bring you the story of MP candidate in Rumphi West Constituency, Jane Kabogodo Gondwe. Gondwe made a donation to a local health center (beds, mattresses, a drip stand, trolleys). Once she figured out she was losing the race for MP, she went back to the health center to take all of her donations back.

Gondwe gave a large donation, meant to benefit a group of people. Alternatively, she could have given small handouts to individual voters. Monitoring individual voters is hard. Keeping tabs on whether a larger group of people have supported you is much easier — and if they fail to hold up their end of the bargain (at least as you see it), you can just go and take your large donation back.


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