The predicament of patients with suspected Ebola – Authors' reply
Authors: Eugene T Richardson, Mosoka P Fallah, J Daniel Kelly, Mohamed Bailor Barrie
Journal: The Lancet Global Health (2017)

We thank Thomas Mayrhofer and colleagues for offering their threshold model as an explanation for patients' aversion to accessing Ebola facilities during the recent Ebola outbreak in west Africa. We agree that this threshold model provides a rational and more elegant explanation of patients' avoidance of ill-equipped and poorly sanitised holding centres; however, such an explanation was not the goal of our Comment.1Richardson ET Barrie MB Nutt CT et al.The Ebola suspect's dilemma.Lancet Glob Health. 2017; 5: e254-e256Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar Instead, we aimed to produce a reductio ad absurdum2AristotlePrior analytics. Hackett Publishing Company, Indianapolis1989Google Scholar of rationalist approaches to understanding behaviour during the Ebola outbreak. Our argument was that these approaches reproduce an ideology of individualism that maps poorly onto our understanding of care seeking during the outbreak. By hypostasising individual autonomy and assuming perfect information, rationalist paradigms perniciously normalise the perception that clinical outcomes are a result of patient choice, rather than a result of intentional underdevelopment of health systems3Rodney W How Europe underdeveloped Africa. Bogle-L'Ouverture Publications, London1972Google Scholar coupled with the historical prioritisation by colonial medicine and its legacies (including contemporary humanitarian aid) of containment by isolation.4Greene J Basilico MT Kim H Farmer P Colonial medicine and its legacies.in: Farmer P Kleinman A Kim J Basilico M Reimagining global health: an introduction. University of California Press, Berkeley2013Google Scholar Hence the absurdity of our suggestion that a rational decision for patients with Ebola virus disease might be to deliberately infect themselves with malaria, which Robert Colebunders and colleagues correctly recognise as facetious. Furthermore, our ironic reflections on terms such as “rational” and “superspreader” are a call to recognise and interrogate the categories of thought that are instilled by our training as scientists, clinicians, and public health professionals.5Good BJ Medicine, rationality and experience: an anthropological perspective. Cambridge University Press, Cambridge1993Crossref Google Scholar Colebunders and Felicity Fitzgerald and their colleagues also question whether we overestimate the potential for nosocomial Ebola virus transmission. In contrast with the low nosocomial transmission rates that they cite in Freetown, our experience in rural areas—which are so much more poorly resourced than the capital that they are deemed internal colonies6Zack-Williams B Diamond mining and underdevelopment in Sierra Leone—1930/1980.Africa Development. 1990; 15: 95-117Google Scholar—revealed, at times, much less effective infection prevention and control than in the metropole. For example, upon arrival at a rural district hospital in November, 2014, we entered wards crowded with corpses, pools of infectious vomit and excreta, and large amounts of contaminated personal protective equipment. Patients with suspected Ebola virus disease were admitted on clinical grounds because samples, if they were taken, took several days until results were attained; nine (100%) of nine nurses working there contracted Ebola virus disease. Additionally, it was not uncommon for several patients with suspected Ebola virus disease who were vomiting and had diarrhoea to be transported over great distances in a single ambulance. Thus, for the absurdist exercise presented in our Comment, we did not feel that it was far-fetched to posit that a quarter of negative individuals exposed to a similar field of risk could have become infected. Even so, the purpose of our Comment was to counter the notion that is useful to think in terms of “Ebola suspects” and their ostensible options, while reminding us to question whether the fetishisation of isolation over treatment was “an institutionalized form of non-assistance” that resulted in “a high number of presumably avoidable deaths”.7Ebola: a challenge to our humanitarian identityA letter to the MSF movement. December, 2014http://www.liberation.fr/terre/2015/02/03/parfois-le-traitement-symptomatique-a-ete-neglige-voire-oublie_1194960Google Scholar As such, our suggestion of the term “PPE [personal protective equipment]-bereft care-nexus” refers to a pragmatic re-description8Rorty R Philosophy and social hope. Penguin Books, London1999Google Scholar of the “Ebola suspect”, in an attempt to provide a more adequate vocabulary for outbreak containment by decolonising humanitarian illusions of bounded subjects.9Mbembe A On the postcolony. University of California Press, Berkeley2001Google Scholar To extend the re-description even further, we suggest viewing Guinea, Sierra Leone, and Liberia as one large West Africa Ebola Holding Unit (WAEHU) for high-income and upper-middle-income countries around the world, with the implication that the focus on local statistics—including the often cited 70% mortality rate of Ebola virus disease10Agua-Agum J Ariyarajah A Aylward B et al.WHO Ebola response teamWest African Ebola epidemic after one year—slowing but not yet under control.N Engl J Med. 2015; 372: 584-587Crossref PubMed Scopus (140) Google Scholar—makes it difficult to distinguish the outbreak from its origins in transnational relations of inequality.11Richardson ET Barrie MB Kelly JD Dibba Y Koedoyoma S Farmer PE Biosocial approaches to the 2013–16 Ebola pandemic.Health Hum Rights. 2016; 18: 115-128PubMed Google Scholar A 0% case-fatality ratio in repatriated white American clinicians was achieved outside the WAEHU, which should remind us that such re-descriptions of outbreaks are necessary if we want to integrate power12Mayer J The political ecology of disease as one new focus for medical geography.Progress in Human Geography. 1996; 20: 441-456Crossref Scopus (143) Google Scholar into an understanding of disease dynamics. We declare no competing interests. The predicament of patients with suspected EbolaWe appreciate Eugene Richardson and colleagues' framing of the Ebola suspect using the “Ebola suspect's dilemma” heuristic.1 Nevertheless, we disagree with some data used to inform their argument. For instance, the authors (presumably facetiously) mention that “a rational decision might be to deliberately infect yourself with malaria” on the basis of data showing that patients with plasmodium parasitaemia and Ebola virus disease who received anti-malarial treatment had 20% increased survival compared with a group infected with Ebola virus disease only. Full-Text PDF Open AccessThe predicament of patients with suspected EbolaWe have concerns about both the accuracy and underlying rationale of Eugene Richardson and colleagues' Comment1 about the “Ebola suspect's dilemma”. The authors quote a nosocomial infection rate of “around 25%” for individuals admitted to Ebola treatment facilities without Ebola virus disease. However, two previous papers document rates of 3%2 and 7%.3 In our previous study4 of over 1000 children admitted to Ebola treatment facilities with suspected Ebola virus disease, only three (0·5%) of 630 children who tested negative were subsequently readmitted with a positive test, all of whom had lost a parent to Ebola virus disease before their first admission; therefore, they were more likely to have acquired Ebola virus disease in the community than nosocomially. Full-Text PDF Open AccessThe Ebola suspect's dilemmaIn 1950, Merrill Flood and Melvin Dresher of the RAND Corporation developed a theoretical model of cooperation and conflict, which was later formalised by Albert W Tucker as the prisoner's dilemma.1 This model represents a situation in which two prisoners each have the option to confess or not, but their sentencing outcomes depend crucially on the simultaneous choice of the other (figure).1 Fittingly, it has become the paradigmatic example of individual versus group rationality and is an often used heuristic when conveying introductory social theory to students. Full-Text PDF Open Access