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Guinea

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Exponential Ebola

Here are two good things about the Ebola virus. It is unlikely to mutate into a version that can spread through the air, as some other viruses have done. And people who have been infected by Ebola cannot pass it on to others during the incubation period (between two and 21 days). Only when they develop detectable symptoms, notably fever, do they become infectious to others, and only by the transfer of bodily fluids.

Here are three bad things about Ebola. The “bodily fluids” that can transmit it include even the tiniest droplet of sweat: just the slightest touch can pass the virus on. The death rate for those who become infected is 70 percent. And the US government’s Centers for Disease Control warned recently that we could have 1.4 million cases of Ebola by January.

Since the number of known cases so far is only around 7,500, that suggests that the number of new cases is doubling approximately every two weeks. This is called exponential growth: not 1, 2, 3, 4, 5, 6… but 1, 2, 4, 8, 16, 32…. If you put one grain of wheat on the first square of a chess-board, two on the second, and keep doubling the grains every square, there are not enough grains of wheat in the world to get you to the 64th square.

Exponential growth always slows down eventually, but the question is when? A vaccine would slow it down, and the British pharmaceutical giant GlaxoSmithKline already has one under development, but it is still in an early stage of testing. Human volunteers are now being given the vaccine to check for unforeseen side effects.

If no serious side-effects are found, the vaccine will then be given to health workers in West Africa. A process that normally takes years is being compressed into mere months, and ten thousand doses of the vaccine are already being produced (for the health workers). But it will be the end of the year before we know if it actually gives a useful degree of protection from the virus.

If it does, then millions of doses would have to be produced and injected into the people of Liberia, Sierra Leone and Guinea, where Ebola is already an epidemic – or tens of millions of doses if the disease has spread by then to more populous countries like Ivory Coast, Ghana or, worst of all, Nigeria, which has 175 million people.

Until and unless a vaccine becomes available in very large quantities, the only way to stop the exponential spread of Ebola in the affected countries is to isolate the victims, a task that is very difficult in mostly rural countries with minimal medical facilities. Liberia with 4.2m people, had only 51 doctors and 978 nurses and midwives at the start of the crisis, and some of those have already died or fled.
You don’t need to find and isolate everybody who gets the disease to break the exponential pattern. Just isolating 75 percent of them as soon as they become infectious would drastically slow the spread. But at the moment, in the three most affected countries, only an estimated 18 percent of the victims are being taken to treatment centres (where, of course, most of them will die).

This is why the most important intervention so far has been the dispatch of 3,000 US troops to Liberia, with the primary job of creating seventeen large tent hospitals and training 500 nurses to work in them. Britain is providing 200 new hospital beds in its former colony of Sierra Leone, with 500 more in the next few months. Cuba has sent 165 health workers, China has sent 60, and France has sent various teams to help its former colony, Guinea.

But with the exception of the American aid to Liberia, it is all woefully inadequate. Nine months after the first case of Ebola was confirmed in Guinea, we are still playing catch-up, and playing it badly. Why is that? Aren’t the developed countries also at risk if the virus continues to spread?

Well, no, or at least their governments don’t think so. Even without a vaccine, they are confident that their health services can find and isolate any infected people quickly and prevent Ebola from becoming an epidemic in their countries. They are probably right, and so they see the limited help they are sending to West Africa as charity rather than a vital self-interest. But they may be wrong.

As Professor Peter Piot, who first identified the Ebola virus in 1976, said in a recent interview with Der Spiegel, “I am more worried about the many people from India who work in trade or industry in West Africa. It would only take one of them to become infected, travel to India during the virus’s incubation period to visit relatives, and then, once he becomes sick, go to a public hospital.

“Doctors and nurses in India often don’t wear protective gloves. They would immediately become infected and spread the virus.” Then you would have Ebola on the loose in a country of more than a billion people, millions of whom travel abroad each year. All hope of confining the disease to Africa and driving it back down to almost nothing, as was done in previous outbreaks, would be gone.
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To shorten to 725 words, omit paragraphs 4, 5 and 6. (“Exponential…people”)

The Economics of Infection

Ebola is a truly frightening disease, with a fatality rate as high as 95 percent (although the death rate in the current outbreak in West Africa is only 55 to 60 percent).

It could get much worse. If Ebola successfully made the jump to a more prosperous, densely populated country like Nigeria, whose citizens travel all over the world, the current 800 recorded deaths could become 8,000, or 80,000, or even more. And the worst of it is that there is no effective vaccine or treatment for Ebola.

Let me rephrase that. There is no approved vaccine or treatment for Ebola. There are candidates, some of which have shown promising results when tested on non-human primates. But they haven’t gone through the full testing process that is necessary before they are approved for human use, because nobody was willing to pay for it.

The normal procedure in the United States, home to more than half of the world’s major drug companies (“Big Pharma”), is that basic research for new drugs may be paid for by government grants or even by private philanthropy (like Bill Gates’s $200 million donation for research on a malaria vaccine), but the work of bringing the drugs to market is left to the commercial companies. All too often, they simply can’t be bothered.

It costs hundreds of millions of dollars to take a drug through the whole approval process and put it on the market. That’s worthwhile if the drug will then sell at a high cost and be used regularly over long periods of time: a drug that fights “rich people’s diseases” like cancer or heart disease, say, or even something like Viagra.

But a one-shot vaccine that would mainly be used by poor Africans will never make a profit, so it is ignored.

Galvanized by the panic over Ebola, the National Institutes of Health in the United States has now scheduled phase one trials of an Ebola vaccine on human subjects for next month. But there are two more phases after that, and the earliest a vaccine could be approved for general use is next July. And even in this emergency, it’s public money, not Big Pharma, that is funding the research.

The problem goes much wider than Ebola and other tropical diseases. It extends, unfortunately, to the antibiotics that vanquished the bacterial infections that were once responsible for about 25 percent of adult deaths.

The last new class of antibiotics, carbapenems, was approved in 1980. Since then, nothing—even though the usefulness of existing antibiotics is rapidly eroding as resistant strains of bacteria emerge.

That’s a big threat, but antibiotics are still not big money-makers, as they are used for relatively short periods of time to fight some specific infection. So no new type of antibiotic has been developed by Big Pharma for more than three decades.

A minimum of 23,000 people in the United States died last year of infections that would once have been easily ended by antibiotics; in the European Union the total was 25,000.

There are some measures that would dramatically slow the spread of antibiotic-resistant bacteria. Far fewer prescriptions should be written for antibiotics, and doctors should be monitored to ensure that they are not over-prescribing. Patients must complete any course of antibiotics that they begin, and report that they have done so. Over-the-counter sales of antibiotics in countries like China and Russia must cease.

Above all, it should be a criminal offence to feed antibiotics to animals just to make them grow faster and bigger. (That is where 80 percent of the antibiotics consumed in the United States go at the moment.) And even when all that has been done, the rise of antibiotic-resistant bacteria will continue, though at a much slower pace. Bacterial resistance is an evolutionary process that can only be slowed, not stopped.

So we desperately need new antibiotics, and there are none forthcoming. Without them, warned Dame Sally Davies, chief medical officer for England, “Modern medicine would quickly go out of the window.”

Almost all surgery, including things as commonplace as caesarian sections and hip replacements, and most cancer treatments as well, involve a significant risk of infection that must be controlled by antibiotics. As Prime Minister Davd Cameron told The Time”: “If we fail to act…we are cast back into the dark ages of medicine, where treatable infections and injuries will kill once again.”

Yet Big Pharma will not fill the gap, for those companies are answerable to their shareholders, not to the public. The case for direct state intervention to finance the development of the vaccines and antibiotics that the commercial sector neglects is overwhelming. And very urgent.

The West African Curse

11 December 2009

The West African Curse

By Gwynne Dyer

There have been political horrors in other parts of Africa, like the genocidal former regime in Rwanda, the current regime in Zimbabwe, or any Congolese regime you care to name. But the worst regimes in Africa seem to arise along the stretch of tropical coastline between Ghana and Senegal.

Sierra Leone, Liberia and Ivory Coast have all lived through nightmarish civil wars after long-ruling dictators died or were killed and junior officers seized power. Gambia has been ruled for the past fifteen years by a former army lieutenant who now imports witch doctors from Guinea to hunt down the witches who he believes are trying to kill him. And now Guinea has fallen into the hands of the junior officers.

It’s the classic pattern. For fifty years after independence, from 1958 to 2008, Guinea was ruled by just two “big men”: Sekou Toure for 26 years and then Lansana Conte for another 24. They and their cronies stole all the money, of course, while over 90 percent of the mineral-rich country’s 10 million people continued to live on less than a dollar a day. But at least they lived in a relatively safe and orderly poverty.

Then Lansana Conte died late last year – and within hours a group of young officers broke into the main television station to announce that they were taking over the country. Their leader was an army captain called Moussa “Dadis” Camara, who promised to hold free and fair elections by 2010. He also promised that he would not to run for the presidency himself.

Sensible promises, because before 2008 nobody except his own family and his junior officer friends had ever heard of “Dadis” (as he calls himself). He has no experience or qualifications relevant to running a government. But a presidential palace is a nicer place to live in than a barracks, and the pay and perks are much better, too. The experience kind of grows on you, and eventually you ask yourself: why leave?

If a general had taken power after Lansana Conte’s death, he might have kept a promise to hand power over to a democratically elected civilian president, for generals already have comfortable houses, limos and lots of stolen money. However, generals usually don’t have direct command of troops.

That’s why it’s so often the junior officers who seize power in Africa: they have the troops, and they are not much constrained by traditional ideas of military discipline. They seize power because it’s the only way to change their own lives for the better – and they generally start to quarrel among themselves after a while, because they have already broken all the traditional bonds of hierarchy and discipline.

Guinea has now moved on to the next stage of the process. “Dadis” began talking about running for president himself last August. “I have been taken hostage by the people, a part of the people, with some saying that President Dadis cannot be a candidate and others saying President Dadis has to be a candidate,” he told Radio France Internationale in an interview. In a burst of frankness, he added that if he did not stand for election, another military officer would take over the country.

At that stage, Dadis probably had still had the backing of the other young officers. They were doing very nicely too. Why would they complain so long as the supply of girls, drink and drugs kept flowing? But then the civilians got involved.

Various political groups that had opposed Lansana Conte for years now saw democracy being stolen from them again. They held a rally in Conakry’s sports stadium in late September to protest against Dadis’s presidential plans. Lieutenant Abubakar “Toumba” Diakite, another member of the military junta and the head of the presidential guard, was sent to deal with them.

He did so by massacring them. His soldiers slaughtered 157 people and raped dozens of women inside the stadium. Twenty women were kidnapped and videotaped for several days while they were being raped and tortured. It is possible that “Toumba” exceeded his instructions. The reaction certainly exceeded his expectations.

The junta denied it all, but the evidence was overwhelming. The African Union, the United States, the European Union, and the West African economic group Ecowas all imposed sanctions on the junta, with Ecowas president Mohamed Ibn Chambas saying bluntly that Guinea’s military rulers were using state power “to repress the population….If the military junta has its way it will impose yet another dictatorship on them”

The United Nations sent a mission to investigate the massacre, raising the possibility that the International Criminal Court might bring charges against junta members for crimes against humanity. So Dadis apparently concluded that it was time to throw Toumba to the wolves.

On 4 December, Dadis went to the barracks where Toumba’s troops are based in Conakry. It was not a wise move, because Toumba shot him in the head and went on the run. Dadis was flown to Morocco for emergency surgery, and the remaining junta members chose “General” Sekouba Konate to act as front man in his absence.

If things run true to form, the final step in this tragedy will be for Toumba to start an insurgency in the interior, plunging the country into a long and horrible civil war of the kind that has ruined several of its neighbours. This part of Africa seems cursed.

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To shorten to 725 words, omit paragraphs 6, 7 and 12. (“If a general…discipline”; and “The junta…them”).

Gwynne Dyer is a London-based independent journalist whose articles are published in 45 countries.