Ebola and “the French Disease”

Jim Moore

The origin of AIDS

By comparing the degree of variation among samples of HIV 1 group M (the virus responsible for the pandemic), we can estimate how long it has been since the original variant existed; that gives us a time for the most recent common ancestor (TMRCA) of between 1908 and 1920 (depending on which recent analysis you like). For group O (which has not spread far), the TMRCA is a few years later, about 1920 to 1926. Put in the error estimates for these dates, and the range is about 1903 to 1948. Group N, with fewer than 20 patients known, is thought to have originated between 1948 – 1977 and the range for group P (2 patients) spans more than a century.

By comparing HIV 1 with different strains of SIVcpz and SIVgor (simian immunodeficiency virus of chimpanzees and gorillas), we find the closest match for group M comes from chimpanzee groups in SE Cameroon, just over the border from RP Congo (“Congo Brazzaville” to distinguish it from the Democratic Republic of Congo [DRC], ex-Zaire, ex-Belgian Congo). Group O appears to be derived from SIVgor, most likely someplace in southwest Cameroon. That discovery involved collecting thousands of samples of ape feces from all over Africa and screening them for SIV, a prodigious project overseen by Beatrice Hahn. And a recent paper in Science makes a good case that for HIV 1 group M, after initially becoming established in someone in northern RP Congo/SE Cameroon, the virus traveled down the Sangha River to Kinshasa (personally, I don’t think they can meaningfully separate Kinshasa and Brazzaville at this stage) around 1920, where it was maintained at a low prevalence until about 1960 when the pandemic began.

Do the same exercises for HIV 2, and the two epidemic groups (A & B) most likely originated around 1940 – 1945 (1924 to 1959) from SIVsm (sooty mangabey) someplace in or near Ivory Coast. Like HIV1 group M, the virus seems to have travelled from its point of origin (sooty mangabeys in the Tai Forest, Ivory Coast, have the closest SIV matches to both groups) to where they caught on and eventually became pandemic (Guinea-Bissau, where the war of independence seems to have facilitated the process).

Now here’s the thing: people in both areas have eaten primates, and so been exposed to SIVs, for millennia. And as a sexually transmitted disease, well, sex has been going on for even longer. Massively increased promiscuity in the context of commercial sex workers in rapidly urbanizing and poor populations? That’s more a twentieth century thing, starting early in the century but really taking off after World War Two and ongoing today. Furthermore, in around 1960 disposable plastic syringes became widely available and, in poor areas, were often reused and/or easily available to traditional healers and charlatans, making unsterile injections more common. And of course travel by trains, cars, and planes has increased through the 20th century (with an important caveat that in parts of Africa such as the DRC, many railroads and roads weren’t maintained after independence and fell apart post–1960s).

So exposure to SIV has been going on for millennia, and “the usual suspects” in terms of STD risk factors became important early in the 20th century but increased dramatically (and have remained high) since the late 1950s, and despite that the only strains of HIV that have “caught on” all date from around 1920 – 1945. What is missing?

The French Connection

Those places, those times: French Equatorial Africa and French West Africa. There are SIV-carrying primates in many parts of Africa, under various colonial powers at various times, but all four zoonotic HIV strains happened under the French. Bad luck?

It is impossible to be sure, but I have argued that for HIV 1 the catalyst was the combination of two things. First comes the unbelievably brutal treatment of Africans in both French Equatorial Africa (FEA) and the Belgian Congo, resulting (among other things) in labor camps where men were overworked, malnourished, and provided with women as a matter of policy to keep the workers – well, “happy” is probably not the best word, but you get the idea. The second element was the effort to cure smallpox and sleeping sickness through aggressive diagnosis/treatment/inoculation campaigns using traveling “mobile clinics” that had inadequate equipment for the scale of the job they were doing. For example, one sleeping sickness expedition in 1916 into what is now Central African Republic diagnosed/treated more than 89,000 people with just 6 syringes (the number of needles isn’t recorded). Over more than a decade, these mobile clinics, pioneered by Dr. Eugene Jamot, reached – and injected – millions of people. The importance of sterile equipment was well understood, but the logistics (I speculate) would have been prohibitive. The campaigns represent a major humanitarian effort that saved many lives, but the combination of widespread use of unsterile needles and stress-induced immunosuppression could not have been better designed for adapting a virus to new hosts.

I do not know the relevant history of French West Africa (FWA) so am cautious about saying the same thing happened there with HIV 2. However, it is worth noting that in 1931 Jamot was held responsible for the accidental blinding of hundreds of people being treated by one of his subordinates (sleeping sickness was treated with an arsenic derivative, and the subordinate apparently tried out a higher dosage, with disastrous results). With a cloud over his reputation, Jamot shifted from FEA to – Ouagadougou, in FWA. There he took charge of the sleeping sickness campaign, again with mobile clinics and again treating thousands of people under difficult conditions over several years before his health deteriorated.

About 20 years between the origins of HIV 1 in FEA and HIV 2 in FWA, and about 15 years between the onset of Jamot’s work in FEA and his move to FWA. Very circumstantial, but it gives one pause.

Why belabor the French?

Eugene Jamot was a genuine hero, and while colonial support for the mobile clinics wasn’t all humanitarian (there were concerns about the loss of [forced] labor if too many died), I am sure the people involved were doing their best to help other people in need. It might seem mean-spirited to point the finger of AIDS at them.

Well, here is one reason. A recent article in Science by Faria et al. examined the history of HIV 1 group M, concluding that the virus arrived in Kinshasa in about 1920 where it barely kept up with population growth until about 1960, when it began rapidly spreading in the pandemic we see today. It is valuable and interesting work. The actual origin of the virus is not their focus, but they summarize it thusly:

After localized transmission, presumably resulting from the hunting of primates, the virus probably traveled via ferry along the Sangha River system to Kinshasa. During the period of German colonization of Cameroon (1884 – 1916), fluvial connections between southern Cameroon and Kinshasa were frequent due to the exploitation of rubber and ivory. (page 58)

German colonization? Well, yes; the Germans were in Cameroon up until 1916 (when French/Belgian forces that had traveled up the Sangha in 1914 finally drove them out; Jamot was a medical officer with the expeditionary force). But traffic on the Sangha River didn’t end in 1916, and most of it was between Brazzaville/Kinshasa and the French towns of Ouesso, Nola, and Carnot anyhow. Why specify the “period of German colonization”?? I do not KNOW, but I note that (1) there is no other mention of any colonial power in the Faria et al. article, and (2) of the 14 authors, 6 are affiliated with institutions in Belgium or France (the rest, UK and USA). It looks to me like there may have been a bit of whitewashing going on there, and using a scientific article to blow historical smoke in our eyes gets my dander up.

AIDS and Ebola

Here is a better reason for acknowledging the likelihood that AIDS got its start as an unanticipated consequence of underfunded, understaffed humanitarian efforts to deal with infectious diseases in equatorial/west Africa: history can repeat itself. To ignore ebola in West Africa is not an option, and half-measures have whole risks.

Further reading

The puzzling origins of AIDS (2004). Jim Moore. American Scientist 92: 540–547. pdf

The early spread and epidemic ignition of HIV–1 in human populations (2014).
Nuno R. Faria, Andrew Rambaut, Marc A. Suchard, Guy Baele, Trevor Bedford, Melissa J.Ward, Andrew J. Tatem, João D. Sousa, Nimalan Arinaminpathy, Jacques Pépin, David Posada, Martine Peeters, Oliver G. Pybus, and Philippe Lemey. Science 346: 56 – 61.

Some other material of mine on HIV origins

Further note: Readers of this blog will avoid confusion by noting that this Jim Moore is not the Aquatic Ape Jim Moore. Same name, different guy.

“Here’s the bottom line. Patients can beat this disease. And we can beat this disease. But we have to stay vigilant. We have to work together at every level — federal, state and local. And we have to keep leading the global response, because the best way to stop this disease, the best way to keep Americans safe, is to stop it at its source — in West Africa.”

CDC Update page for the West African outbreak.

Ebola Update from Dr. Anthony Fauci, infectious disease chief at the National Institutes of Health (NIH).

More here from the Whitehouse.

The health workers I know tend to run into burning buildings or jump into frozen lakes and such to rescue people, so I can’t see that happening. Apparently it has been an issue in Spain and in West Africa. I can’t explain Spain, but things are so dismal in West Africa that it is not at all unexpected. But what about in the US?

So far there doesn’t seem to be an issue according to Barnett’s research, but he cautions that continued willingness to work with Ebola patients here is not assured. In an earlier study, Barnett and colleagues found that one-third of workers at a large U.S. urban medical center would be unwilling to respond to a severe infectious disease outbreak.

“An individual’s personal perception of the importance of his or her work during the response phase and his or her sense of confidence in performing this role effectively, are among the most powerful determinants of willingness to respond,” notes Dr. Barnett. “Our research also suggests that familiarizing health responders with laws and policies designed to protect their wellbeing in an emergent infectious disease event is important for bolstering response willingness,” Barnett adds.

Barnet notes that for training to be effective it must provide clear guidance on infection control protocols and instill a clear understanding of outbreak response duties. I asked him about the domestic side of this, about training of health workers regarding in relation to thier behavior or decision making when they are off duty. This seems to have arisen as an issue with the second Ebola-infected worker in Dallas, who took an air flight after starting a fever (if reports are accurate) and before diagnosis as having the disease.

“Preparedness and response trainings on emergent infectious diseases need to cover not only work-related protocols,” he told me, “but also address behavioral elements outside of the healthcare setting in the interest of public health. To date, there’s essentially been no research or ‘environmental scan’ on the extent to which such trainings actually encompass behaviors and practices outside of the health care workplace. However, this type of training on precautionary measures outside the workplace is essential. It needs to be imbedded into trainings and harmonized across healthcare institutions to ensure consistency.”

UPDATE: The second infected health worker will be transferred from Dallas to Emory.

This is a second health worker, who reported in with at fever on Tuesday. The worker is one of the 76 who had been self monitoring, who were thought to be most likely beyond the most likely period for infection.

(This might be a good time to point out that while the CDC uses 21 days, which is probably usually good, one study showed that a small percent of individuals might develop the disease after 21 days following exposure.

Yesterday, Tom Frieden, head of the CDC, noted “CDC Director on Ebola: ‘Even a Single Infection is Unacceptable'” Also, yesterday, Dallas nurses complained about the situation at the beginning of the treatment period for the Index patient who died there.

There was a briefing in Dallas.

During the briefing, it is confirmed that this new patient was involved in care for the Index patient.

We’re a great hospital, we always have been, we want to get this right, we fell really bad, we’re doing fine, etc. etc. (that was the hospital representative)

Teams have swooped in and started cleaning common areas near the new patient’s apartment, neighbors have been or are being interviewed.

The patient lived alone and with no pets. Inside cleaning and cleaning of the car will happen later today.

Question for hospital rep: Does a second case indicate systematic institutional problem. Answer: No. We know what we are doing and handling it and we are looking at everything.

Was this person a nurse? We won’t tell you that.

Question: When did this patient come forward and get a blood test in relation to yesterday’s press conference? Answer. Hipaa.

Question: There are three isolation rooms at the hospital. What will you do when you fill up? Answer: Working on that. Also, there are actually is more room than that, a little.

Question: Timeline? Answer, got confirmation about 1:00 AM. Then we started doing stuff, press release at 4:00.

Question: Allegations from the nurses?? Answer: I can’t comment. We have the proper protected gear.

Question (breathless): Are steps being taken to isolate the other workers? Answer. There are 75 hospital workers. They are asymptomatic, the are not contagious. Please try to avoid community panic with those questions (I paraphrase, he didn’t say that). When people get symptomatic they report in, like happened twice, the system is working.

By the way, the are not coming in to work.

Perspective:

On preparedness of the hospital. There is evidence that the Dallas hospital that treated Thomas Duncan was not prepared to handle an Ebola case, and initially, nurses were not well protected. It is also clear that the clean, crisp, rapid response we may have expected from the CDC was not there. However, it is probably the case that that hospital is now managing the two cases they have properly, and that the monitoring program for other contacts is good.

To me, this means that the repeated, near universal statement by the US health community that the US can handle Ebola was overstated. Let’s take a look at the overall problem. I previously divided the Ebola exposure problem into several phases. Here is an updated version of that:

1: An infected individual arrives in the US, becomes (or already is) symptomatic, and is not yet admitted to a hospital. At this point we rely on that person’s decisions to seek treatment. There can be several hours to several days of time of potential exposure, but even so, the person is ambulatory and less symptomatic, and probably is an infection risk but a low(ish) one.

2: The infected individual either becomes very sick and is brought to the hospital or self admits. At this point there is a risk of infection to other people at the hospital including other patients and hospital workers, as well as ambulance drivers, etc. During this second phase it is up to the hospital to quickly identify a possible Ebola case and isolate the patient, and start safe procedures for care. In the case of the Index patient in Dallas, this took several days (and the patient was sent back into Stage 1). This inadequacy conflicted with what the public was being told by experts. However, now that the very first actual case of Ebola emerging in the US happened, and those who were not expected to mess it up did mess it up, everyone is on their toes and the chances of a repeat of that are lower. The CDC has also developed an improved method of addressing this (their ready teams).

3: The infected individual is in an isolation unit and being cared for. At this point it is up to the hospital and the health workers to minimize the chance of infection of others, and those at risk are, theoretically, the health workers. In the case of the Index patient at Dallas, according to nurses who worked there, the risk of infection of health workers was not minimized fully at least initially, and it is even possible that risks beyond the care staff continued. Eventually, we assume this was fixed. But, the fact that two health workers have been infected does amply demonstrate that whatever was going on was not adequate, though at this point we don’t yet know in what way, or when, things were done improperly and we need to take the word of the same hospital and health system spokespeople that earlier assured us that things are fine. Since the system representatives have yet to fully acknowledge there were inadequate procedures or care, and describe that inadequacy openly, we really don’t know. I suspect they really have cleaned up their acts, because they are strongly motivated to, but we are starting to see the edges of an Orwellian response where information is being cleaned or withheld, sometimes under cover of HIPAA rules.

1: During the first three stages, exposure of others may happen, and those individuals need to be identified and managed. Individuals who do end up being infected during that period are now in Stage 1, but if there is an effective monitoring program, stage 1 is very short (hours?). Because the system is ready for secondary cases, stage 2 is minimized (or does not even exist), and the patient is now in Stage 3. In the case of Dallas, we can guess that the two patients who have cycled into Stage 1 (both health workers) are in Stage 3 and Stage 3 is being done properly.

At a later time, if there are too many additional cases, the revamped and updated Stage 3 response may break down again due to lack of isolation facilities. The authorities seem to be aware of this possibility.

We don’t have a lot of control over what happens during Stage 1 for newly arriving patients, though the system has demonstrated that it can handle Stage 1 for those of known risk who are in a monitoring pool. But for the system to be like various spokespeople claimed it was, a great deal of effort has to be put into training, procedure, and dispersal of equipment. Dallas demonstrates that for a hospital that should have been ready, this was not the case. But, the CDC response, of having ready teams (like we learned from movies and literature to be how the CDC operates, in fiction!) should make the transformation from inadequate response to adequate response more likely if there are other cases.

Many thousands of people in West Africa have gotten Ebola, about half have died. Our problems here in the US are tiny. But, everyone is concerned about the possibility of spread outside of West Africa. One consequence of the small leakage that may occur being handled poorly is a stricter response in the form of travel restrictions. This would have multiple negative consequences. The Dallas Index patient got past the system, but the international travel problem is being tightened up a little (we have no idea if that is adequate). If infections beyond Stage 1 continue to happen, as they have in the US and Spain, people will demand a closure of borders. And, perhaps, that is what should happen.

Timing of infections vis-a-vis the Index patient

Ebola is thought to manifest in as little as four days after exposure, with most cases showing up prior to 17 days after exposure, but as late as 25 days, using very liberal estimates of exposure time. The Dallas Index patient, Thomas Duncan, was cared for in the hospital staring on September 25th, and died on October 8. The most recent secondary infection was identified last night, so let’s round up and say that was 7 days after possible exposure. If we assume for the moment (we have no basis for this, this is a rough guess) that the first half of that care period was as suggested by nurses being handled inadequately, and the last half was managed well, to split the difference, perhaps the most likely period of exposure ended around the second of October. So, perhaps today is about two weeks post dating likely exposure. So, a roughly optimistic guess would be that the chances of another health worker ending up with Ebola is not small for the next three or four days. A fully pessimistic estimate is that we have ten or so days over which this could happen. Stay tuned.

-Patient Zero was left for several hours in a place with up to seven other patients, not in isolation. When a senior nurse attempted to insist he be moved to an isolation unit she was met with “hostile” responses.
-Blood samples were transported through the hospital tube system instead of hand carried.
-Nurses were not entirely covered with protective wear. The gear they had left their necks exposed. To remedy this they were told to wrap tape or gauze (not sure) around their necks.
-People were going in and out of isolation areas without protective equipment.
-Medical waste was not properly handled, with hazardous waste piled nearly to the ceiling as there was no plan to dispose of it.

The hospital has not responded.

From as story in Science:

Stephan Becker is tired of waiting. The virologist at the University of Marburg in Germany is part of a consortium of scientists that is ready to do a safety trial of one of the candidate vaccines for Ebola. But the vaccine doses he’s supposed to test on 20 German volunteers are still in Canada. Negotiations with the U.S. company that holds the license for commercialization of the vaccine…have needlessly delayed the start of the trial… “It’s making me mad, that we are sitting here and could be doing something, but things are not moving forward,” Becker says.

… it’s inexplicable that one of the candidate vaccines, developed at the Public Health Agency of Canada (PHAC) in Winnipeg, has yet to go in the first volunteer’s arm, says virologist Heinz Feldmann, who helped develop the vaccine while at PHAC. “It’s a farce; these doses are lying around there while people are dying in Africa,” says Feldmann,…

At the center of the controversy is NewLink Genetics, a small company in Ames, Iowa, that bought a license to the vaccine’s commercialization from the Canadian government in 2010… Becker and others say the company has been dragging its feet the past 2 months because it is worried about losing control over the development of the vaccine. But Brian Wiley, vice president of business development at NewLink Genetics, says the company is doing all it can. “Our program has moved forward at an unprecedented pace,” he says. Even if it took another few months, “we would still be breaking a record in terms of getting this into patients.” Wiley says the holdup is “the administrative process”: agreeing on a protocol, getting collaborators to sign the right contracts, securing insurance in case something goes wrong.

Marie-Paule Kieny, a vaccine expert and WHO assistant director-general, disputes that NewLink is dragging its feet. “We have so far been able to resolve issues along the way, to get moving as fast as possible,” she says.

…

A stock of the Canadian-developed VSV vaccine is stored at PHAC in Winnipeg. The Canadian government owned 1500 doses, 800 to 1000 of which it has donated to WHO; the rest are owned by NewLink Genetics.

Scientists say WHO’s vials could have already been shipped to the research centers planning to do phase I trials. One such trial is scheduled at the Walter Reed Army Institute of Research in Silver Spring, Maryland; other studies, by a consortium that includes WHO and Becker, are on the drawing boards in Hamburg, Germany, in Geneva, and at sites in Kenya and Gabon. PHAC is ready to ship the doses “at a moment’s notice,” a representative says.

But for a clinical trial to start, regulators require information about how the vaccine was manufactured, and that resides with NewLink Genetics, which has been slow to release it, people familiar with the negotiations say. …

…

Part of the problem may be that NewLink is a small company, with about 100 employees, that has concentrated on immunotherapies to fight cancer in recent years. The Biomedical Advanced Research and Development Authority—a U.S. government agency tasked with speeding up the development of emergency drugs and vaccines—recently sent two staffers to Ames to help NewLink file documents needed by the U.S. Food and Drug Administration, a U.S. government representative says. “Our engagement of outside help has nothing to do with our competence, but with the urgency around this matter,” Wiley says.

Those who are taken ill and die of Ebola are the victims of a natural disaster, until paperwork, incompetence, greed, or some combination of those delays an international response by weeks time. After that, it is something else.

UPDATE: I’m adding this here because it is my current post on Ebola. Thomas Eric Duncan, the person who became symptomatic with Ebola in Dallas, had died at the Texas Health Presbyterian Hospital (according to news alerts).

A nurse’s assistant in Spain caring for Spanish nationals returned with Ebola from West Africa contracted the disease, gaining the dubious distinction of being the first person to be infected with Ebola outside of that disease’s normal range in West Africa, Central Africa and western East Africa. There is speculation that she contracted the disease by contacting the outside surfaces of her own protective gear, which is exactly what I’ve speculated to be a likely cause of infection in health care workers. This is not certain, however.

Members of her family and others, including additional health care workers, are in quarantine. There is evidence that the hospital procedures were inadequate to keep a lid on Ebola in this context, and nurse’s unions and others are protesting and demanding change.

Meanwhile, the Spanish government has claimed that there is “scientific evidence” that dogs can transmit Ebola, so Excalibur, the nurse’s family dog, will be euthanized and incinerated. People have gone to the streets to safe the dog.

So, can dogs get, or transmit if they get it, Ebola? Short answer: Yes, and probably not. Here’s my thinking on this, and some information.

1) Pick a random species, or to make it easier, pick a random mammal, and test to see if it can transmit a disease known in humans. It is unlikely to be the case because diseases are to some degree adapted to exist in certain hosts, and host vary, well, by species. So it seems unlikely.

2) On the other hand, Ebola seems to be able to infect a very wide range of mammals. Ebola resides in multiple species of fruit bats (though maybe not uniformly or equally well). A range of mammals seen to be suitable intermediates between fruit bats and humans. The mammals known to be able to harbor Ebola are diverse. It isn’t like only primates can be infected. So, it seems quite possible.

3) On the third hand, I’ve never heard of dogs being addressed as an issue in the current crisis in West Africa or during prior outbreaks. One would think that if dogs were a concern this would have been mentioned by someone some time.

4) On the fourth hand, dogs in Central Africa are less likely to be house dogs, hanging around with the family on the couch, and more likely to be working dogs that spend all their time outdoors. A Spanish family pet may have hung around on the sick bed with an ill individual. I don’t know about dogs in West African cities. By the way, you have to go look to see what the story with dogs there is, and it may within that context. I’ve noticed that westerners tend to have a rather monolithic view of how humans “elsewhere” (especially the “third world”) relate to their dogs, based on a concept we hold of them, not based on actual knowledge. How dogs fit in with humans from place to place and time to time varies.

5) I’ve read a good amount of the peer reviewed literature on Ebola and I can not recall anything about dogs.

5) But … A quick check of Google Scholar did come up with one study. From the abstract:

During the 2001–2002 outbreak in Gabon, we observed that several dogs were highly exposed to Ebola virus by eating infected dead animals. To examine whether these animals became infected with Ebola virus, we sampled 439 dogs and screened them by Ebola virus–specific immunoglobulin (Ig) G assay, antigen detection, and viral polymerase chain reaction amplification. Seven (8.9%) of 79 samples from the 2 main towns, 15 (15.2%) of 14 the 99 samples from Mekambo, and 40 (25.2%) of 159 samples from villages in the Ebola virus–epidemic area had detectable Ebola virus–IgG, compared to only 2 (2%) of 102 samples from France. Among dogs from villages with both infected animal carcasses and human cases, seroprevalence was 31.8%. A significant positive direct association existed between seroprevalence and the distances to the Ebola virus–epidemic area. This study suggests that dogs can be infected by Ebola virus and that the putative infection is asymptomatic.

I’ve not looked further at the literature. This study suggests, unsurprisingly (see point 2 above) that dogs can harbor the virus. However, they don’t seem to be symptomatic. Therefore, spread from a dog seems unlikely. I would think the dog could be kenneled for a few weeks, rather than being put down.

The Ngram is above. Note that I have smoothing set to zero, which I recommend, and I’ve got the date set for early on in the use of the term so pre-disease uses are more visible.

The two interesting instances I wanted to show you are ..

1) An Okapi at the Paris Zoo named Ebola, allegedly the first captive born Okapi to survive in a zoo.

The other is a bit stranger. Have a look:

See the yellow highlight? This (and the Okapi picture) are screen grabs of what Google Books give you when you search for a word or term. Here, “China” in funny Gothic looking script was recognized by the scanner as “Ebola.” You can kind of see how that would happen. Not really. But it happened.

The confusion caused by this misconception is further enhanced in a more subtle way. Since the Hollywood version of Ebola (or some other similar disease) indicates that it is dangerous because it becomes airborne, we see constant claims today on the Internet that Ebola must be airborne because it is out of control in West Africa. And, of course, we see claims that it is only a matter of time before it becomes airborne. But an examination of the disease from an evolutionary perspective suggests that this is extremely unlikely. It is almost as though people have to believe that Ebola will eventually become airborne (or already is) to take it seriously. It wont’ become airborne. You must still take it seriously.

So that is the first area of confusion, about what Ebola is and what it does and does not do.

To this confusion, by the way, we may add the already mentioned hyperbolic reaction to Ebola, often of a rather tin-hat variety and the equally incorrect hyperskepticism that has made claims like Ebola is not that big of a deal because it is not malaria. That is also demonstrably false.

The second area of confusion is what is normally done when something like Ebola shows up in the US, as it has in Dallas, Texas. The Hollywood and Literature version is that a big silver truck shows up at the site, people with protective gear jump out of the back, individuals are taken away to Level 4 containment facilities that are handily available nearby, the site is sterilized using high tech devices (or imploded or burned down with flame throwers?), and if there are a lot of possibly infected people, everybody is quickly rounded up and moved in large green trucks to a containment camp run by the Army, with Morgan Freeman in charge whom you think at first is a nice guy but turns out to be evil.

Well, some of that is sort of happening, but slowly and clumsily and with no has-mat suits and no containment camp. As I write this I’m watching the live briefing on Ebola in Dallas. We have just learned that pretty soon some guys are going to go over to the apartment where the family of the patient lives. They will do the laundry when they get there because there might be Ebola kooties on the sheets and pillows. The CDC went grocery shopping for them, and they are being told they can’t leave. So in a way this is a little like what Hollywood says would happen, but with much, much lower production value and pretty much as a post-hoc set of reactions rather than a clear plan always in place just in case.

We are also learning at the news conference that there is not a current plan for where to take a second or third Ebola case. No playbook in place. Having said that, the authorities are confident that they can handle the problem.

None of this is surprising. After all, fiction is fiction. That’s why they call it fiction. What is also not surprising, but disappointing, is the low level of thought behind the questions the press are asking, and the highly unprofessional approach taken by some reporters. Pro tip: Don’t ask only dumb questions, or questions that have already been answered, then be all mad and stuff when the press conference ends sooner than you thought it should.

More on Ebola:

• Two Ways Hollywood and Literature Have Confused The Ebola Problem
• Ebola in Dallas Texas: Is our response adequate?
• Ebola Will Not Become Airborne And Here Is Why
• Has the Ebola Death Toll Surpassed Malaria in West Africa?