Where would Ebola’s CFR line be on this graph?
We are in uncharted territory with the Ebola virus disease (EVD). The last time we had a plague that was this deadly was the Black Death in the 14th century, when there were only 450 million people in the world. That pandemic killed 30% to 70% of the population. There is no benchmark for EVD, which kills 3 out of 4 people it touches, and is emerging into a global population of 7 billion.
(Ulgiati, Ascione, Zucaro & Campanella, 2011, Fig. 1) Emergy-based complexity measures in natural and social systems – Emergy flows plateau in modern Rome as an example of a high-transformity system
This pandemic signifies a turning point for society in response to peak oil, highlighting the problem of globalization for a planet of 7 billion people. We have lost control of a deadly outbreak, and our responses to its exponential growth are linear at best, ensuring that this plague will most likely spread further. Many in first world countries think we are immune to plagues. How might transmission of EVD change as it moves from a low-resource or low-transformity setting in West Africa to resource-rich (high-transformity) countries? How might the battle against this epidemic change as it breaks out into different environments?
World views in transition
Media pundits have labeled recent world events with the words “perfect storm.” The use of this term suggests a rare and unusual event that comes once in a lifetime. But the term also suggests that our world view is incomplete. First world views of society are dependent on the preservation of infinite growth. When we lack the world view to explain a new phenomenon, especially when denial is a reason, our brains may assemble responses that displace our fears, or blame the situation on powerful control from the top, and not a global system in transition during descent. We lack the systems view to explain predicted outcomes of descent. But crises not only sharpen one’s focus; crises also restructure dysfunctional paradigms.
Margaret Bourke-White, Louisville, KY, USA, 1937
Public health has gotten a free ride in the fossil fuel era, as everyone’s socioeconomic status, including sanitation, clean water, and healthy, safe food improved. That process of rising socioeconomic status during the last 200 years occurred because of fossil fuels, but because fossil fuels have been ubiquitous, we did not see it. Rosling’s video from Gapminder on 200 Years That Changed the World identifies the trend, but misses the cause. His plots could be better expressed by plotting life expectancy against global per capita fossil fuel use. Our first world exceptionalism is a function of fossil fuels and the hierarchy of complexity and not some special character trait.
In energy descent, the energy basis for our public health basis will decline. Maintaining public health in local communities will need more effort and resources, especially in response to disasters from the larger scale. But Americans in particular will no longer have the resources to act as the world’s healthcare provider or police officer. The world’s population growth has created a situation where top-down control during a crisis is not possible.
High resource versus low resource systems
The epidemiological triangle consists of host, agent, and environment. The future of this epidemic will be dependent on the different environments that it travels to, as well as host factors in different countries, and agent factors as the virus mutates. EVD has only affected low resource healthcare systems historically. What might be different in a high-resource (high-transformity) system which might make combatting this disease easier or harder?
The epidemiological triangle
Pandemic factors related to the agent, the virus, include the relative infectivity, in terms of the R0 (R-zero or R-nought) and Case Fatality Rate (CFR). The R0 of this disease is relatively high for a disease that is not considered very contagious, estimated at between 1.4 and 2.0, which is higher than seasonal flu, for which there is some population immunity. The CFR is somewhere between 70 to 80%, which is twenty-fold greater than the death rate of flu. Though epidemiologists claim that this disease is not very infectious, we have my heroes and heroines, Médecins Sans Frontières (MSF) walking around in cobbled-together moonsuits with no exposed skin, but who are still getting infected, either in hospital settings directly, or indirectly through the community. Are the ethics of new drug trials for EVD different when the disease is currently killing 3 out of 4 victims?
Host and environmental factors that might speed transmission in first world countries are related to a high-transformity system that loses control. High mobility is one of the biggest cultural factors of a high-transformity system. A high-transformity system could potentially create a larger R0, since there is a larger ecological footprint, with highly mobile imports and exports, reliance on services, and a 3-day shelf-life for goods. Americans have to shop to survive, and economic growth is our main imperative. We must work to keep our economy and wall street humming–shutting down the economy is unthinkable to most.
Host and environmental factors in first world countries that might slow transmission include less density in housing such as nuclear families, better public health, sanitation, water, and nutrition, more healthcare providers, and better handwashing. The case for handwashing as protection in first world countries is arguable—we have the means, but do we do it?
Breaking the Chain of Infection
Our high-transformity healthcare system is probably the biggest problem with community/hospital preparedness. The two imported EVD patients at Emory Hospital reportedly created 40 bags of medical waste per day. Logistics of caring for patients with a deadly illness would snarl routine care in unimaginable ways–probably one reason sick healthcare providers are returning to different flagship hospitals experienced in infection control, for trial runs with the process. The chain of infection involves six different steps which all need to be attended to, and in a high transformity environment, those issues expand. Perencevich illustrates this problem when he discusses PPE, saying “over-protection does not equal protection,” which also applies overall, to the relative protection of high resource availability. In an era of a shrinking emergy basis, especially in complex hierarchies such as hospitals or cities, a sudden pulse of disorder from the larger scale such as a pandemic may create just as much chaos, if not more, as it does in a low-resource system. Over-protection in one corner of the system does not make us safe from gaps in the chain of infection in other segments of the situation where less control exists. Even if we are assiduous in hospital settings, once EVD lands by air and gains a foothold, transmission might occur in other concentrated community settings where infections spread, such as cities, schools, prisons, and military operations. We are in uncharted territory here, and how this plague unfolds in other countries remains to be seen.
In a low-resource system, waste is minimal, with infectious mattresses as one of the most complicated waste disposal problems. Contrast the 40 bags of waste per patient day in a hospital in Atlanta with the low-resource system for personal protection devised by Fatu Kekula, a nursing student of Liberia who made her own PPE with trash bags and kept her family alive. Kenyan and Malian hospital workers have made their own local alcohol handrubs from sugar cane. In a low-resource system, adaptation to a disordering pulse may be easier as people are more likely to be inventive, independent generalists, not as psychologically or physically reliant on a highly specialized hierarchy of goods and services. Frieden illustrates the problem of waste, suggesting that even in a low-resource setting,
“to pick up one body you might need nine full changes of PPE [personal protective equipment]. Four for the people to put the corpse onto the truck. One for the person to spray them down so they don’t get infected. And then again four to take them off the truck” (Frieden, Sept. 29, 2014).
In a high resource setting, how many more changes of disposable PPE would be required in order to comply with standards and maintain safety for this one task alone, for the multiple specialties involved? And many high-transformity systems are automated. What additional disinfection requirements would be needed with those, and how much equipment would simply have to be discarded (and where)? EVD in a high-transformity setting quickly slides down a rabbit hole of receding compliance and expanding demands on resources. High-transformity healthcare systems will need to adopt lower-transformity methods such as reusable or resterilizable equipment fairly quickly in order to keep up with this epidemic over the longer term.
In a model run by the Mobs lab, the US had similar risk of introduction as Nigeria, based on the assumption of flights creating relatively virtual neighbors, depending on your connections.
EVD introduction to the US is probably more likely by plane than by boat, as a boat allows time for the disease to emerge. A recent model suggested that an 80% reduction in air travel would slow the introduction of EVD to the US, but not stop it. We won’t reduce air travel by 80%
Because it’s bad for business, and we can’t reduce air travel by 100%, because we live in a society with a 3-day shelf life—shutting down any sort of commerce is inconceivable.
because it’s bad for business, and we can’t reduce air travel by 100%, because we live in a society with a 3-day shelf life—shutting down any sort of commerce is inconceivable to most, and is also political suicide. In another run of the same model, the US had similar risk of introduction as Nigeria, most likely based on the assumption of direct flights creating virtual neighbors. The volume of infection in other countries eventually makes its way everywhere, through the wonders of modern air travel. The Black Death took 8 years to spread to Europe through eastern trade routes–camels are slower than airplanes. I am getting a good geography lesson as I watch the news and see suspected EVD patients popping up in obscure parts of the world.
Host and environmental factors that impact fitness include genetic, cultural, systemic, and behavioral factors. Genetic fitness of the population is enhanced when there is less medical rescue, and less high-tech medicine resulting in patient sub-populations with immunosuppression or other genetic vulnerabilities. There is also the issue of increased background radiation as the result of various nuclear accidents. The radiation background in many countries has increased in the last 65 years, especially post-Fukushima.
Think globally, act locally?
Crises delineate the problems, focus the issues, and crystallize intent. What is the solution to deadly, global pandemics either now or in the future? Is the answer global health teams to rescue impoverished societies, more high-tech healthcare for everyone, or high-tech vaccines for every mutating strain of virus or cures for bacterial infections? No—we cannot continue with more growth and high-transformity globalization of society in the face of waning oil production, not in a world of 7 billion, especially when a deadly plague is spread globally for lack of vinyl gloves. A call for high-tech PPE to cool or monitor healthcare providers illustrates this conundrum. When privileged westerners have air-conditioned PPEs and computerized heart rate monitors, or are evacuated to safety when they fall ill, but the community cares for victims without gloves, the inequities continue to accumulate in the war against a plague.
Pieter Bruegel the Elder, 1563, The Tower of Babel. In this painting, Bruegel depicted the transformation of nature into an urban hierarchy through the hubris of man, which was then destroyed by God. Breugel modeled the tower in the painting on the Rome Coliseum.
A thermodynamic principle explains the quandary—a proposed 5th thermodynamic law of Transformity states that “You shorten the cumulative length of the game the more you steal.” We build hierarchies of complexity if there is surplus energy available. Those hierarchies of complexity include high-transformity items like computerized heart rate monitors for Americans’ PPE. By doing so, however, and contributing to increasing inequities, we shorten the length of the game by exposing the hierarchy to instabilities such as plagues. Are urban centers, which were created by surplus fossil fuels, more dangerous in plagues, especially in descent?
TR Frieden April 2010, 100 (4) AJPH Genetics is at the top of the pyramid, while environmental medicine is at the bottom.
Political leaders are already talking about global health teams, more funding for vaccine research, and what we will do when the next pandemic hits. This leap in thinking past the crisis at hand seems to be a form of denial and displacement anxiety, in a similar protection of the psyche as Americans’ focus on climate change as our biggest threat. We deny and displace our broader worries about society onto a specific focus that is a distant potential threat in the future. Prevention in the form of contact tracing, surveillance, and local quarantine appears to be the way to combat this disease, but surveillance only works if we can move past denial and irrational or panicky behavior. If an outbreak isn’t prevented locally, it could get out of hand quickly.
But with waning fossil fuels, the answers to resilience in general lie in relocalization and simplification. We need to ask ourselves, “Does my action further new relocalized society or does it further the old growth regime? Does my action work to improve socioeconomic status at the bottom of the pyramid, or serve to make inequities worse through a taller pyramid?”
In addition to basic personal preps, including gloves, masks, and bleach, my global action is to give to MSF, as I cannot bear to see caregivers without gloves. But mostly my actions will go towards volunteering at the local community level to strengthen local community preparedness, since I believe in relocalization. I signed up for the American Red Cross this week, in response to a comment by Sally Sellers, RN, in an earlier post.
“I’m currently working on my MSN and conducted a field community preparedness project this past summer in response to climate change threats. What an eye opener! I became a Red Cross volunteer to get a first hand look at Orlando’s preparedness . . . it is a total illusion. A wing and prayer is what we’ve got. Here we are a metro-city of more than a million strong and 4 . . . count them four…nurse volunteers for the health services for central Florida. Since my project the Red Cross has actually cut back and reduced paid staff state wide due to lack of funding. This might not be so bad but the surrounding counties have cut their employees who would serve as shelter operators and have instituted plans to rely on the Red Cross volunteers! One county even cut its #311 county wide emergency call system for lack of funds.”
The answer lies in a smaller society, with simpler, basic healthcare for everyone—less healthcare, but we can hope that everybody gets some, resulting in healthier communities and society. Nature will take care of the smaller society, as wars beget famine and pestilence which beget wars.
Didier Pittet, expert on handwashing, on the multi-cultural complexity of changing handwashing behaviors, which requires a “multimodal behavior change strategy. . . . One must dare to disagree. . . Clean hands save lives.”
Header Art: Triumph of Death, Peter Breugel the Elder, 1562. Interestingly, Breugel’s painted the Tower of Babel a year before he painted Triumph of Death.
