The governments of Liberia, Guinea, and Sierra Leone were fairly well non-existent and the civil society non-existent with brutish chaotic lifestyle. The governments were corrupt and ineffective to deliver even the most basic oversight and public health policy.
So this is used to explain why Ebola thrived here of all places.
But Ebola has always existed in such places, it almost seems to a prerequisite for the disease as the flint of winged bats or "bushmeat" strikes the steel of corruption and poverty. Yet all other outbreaks in areas just as chaotic did not reach such a terrible number as this Ebola outbreak.
This outbreak was so obviously different from all Marburg and Ebola outbreaks in the past that it is heard this was a terrible more dangerous (if that was possible) unique strain of Ebola.
The civics in the three Ebola countries were basically nonexistent, and what did exist was chaotic and corrupt, but so too 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. 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?
The CDC offers a good starting point to find this deadly difference. They reduce the disease to the standard epidemiology math - which is robust and effective in all outbreaks. However
the models were surprised with the outcome and provide, now 9 months later, "corrections". The corrections were that more people attended health facilities to begin with than "reported" and there were more contagion than the models estimate in general.
The 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 what was to be changed 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 doesnt make sense. But this doesnt jive with the the drop in cases to the recent lows. The original model says that if 70% of those infected do find either quarantine or a hospital bed will end the outbreak, effectively speaking. This is a link to the CDC 3 factor model, easily made available since September of last year. It is a straight forward but elegantly designed Excel 10 spread sheet and allows the three factors to be directly changed and "what ifs" applied. Changes which are required to reach to the swift ramp up that did occur shown above. 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. 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 standard sanitation and procedures and 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 person 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 die alone.
This means 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.
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 risky in the initial treatment if Ebola. 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 near suicidal care. Many of the healthcare workers died and become part of the 30% infection rate in the general public. This catastrophic failure in 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 can be 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, "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.
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 and their general incompetency. The model provided by the CDC can provide "what ifs" that suggests that the difference in this Ebola outbreak was the MSF. Chaos and lack of regulatory oversight did exist in Liberia, Sierra Leone and Guinea, but this allowed MSF to apply such near 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 and turbo charged the spread of the disease, more often than not via the initial health 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 to save the poor savages in Africa, and yet they had to provide the low standard health care that they do I guess to make ends meet - proof is in the numbers.
The WHO is apparently going through a re-organization and one of their first tasks is to force a general licensing and oversight over such organizations like MSF.
'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 the MSF caused this Ebola outbreak.