Friday, September 26, 2014

Distributed doctoring

UPDATE: Prepositioning medicines won't work very well. They will deteriorate in the heat and humidity (want to bet the bottles won't be opened from time to time?). You would have to re-distribute regularly--possibly annually.

One of my favorite scenes in the movies is the engineers around the table in Apollo 13.

I wish I had a team of engineers and nurses.

Ebola is, of course, out of hand in Liberia/Guinea/Sierra Leone now. The centralized medical centers were overwhelmed and eviscerated. They are trying to open secondary centers. USAID is trying to bring in ebola management kits to distribute to the villages.(*) The kits aren’t quite complete enough but they have the right idea.

Treatment has to happen at the extremely local level: village or neighborhood. Without that presence people don’t buy into the system, and in any event there’s nowhere near enough beds even if you could transport everybody to the hospital without infecting another half dozen people on the way.

There are not enough doctors or nurses. There won’t be. All you have available is family members, with advice.

Cell phones are widely known and used, and though smart phones aren’t nearly as common as the candy-bar models this can help spread the word among the skeptical. But this is just the start.

Here’s the challenge: given local resources (in the slum or in the village), how can we arrange for medical care while minimizing the risk of ebola infection to others?

A few features seem to be inevitable. Homes are crowded, so the patient needs to come out of the home and stay in a more isolated setting. One member of the family will be taking care of the patient—so the isolation area needs to have room for pairs. The caregiver has to assume that the patient has ebola, and so buckets of bleach water have to be available.

The patient probably doesn’t have ebola, so the kit is deficient. It should also have malaria suppressants and vermifuge and some anti-diarrhea tablets and some rehydration salts and maybe a few other things as well. The average caregiver will have no idea how to use these things. I’ll get back to that. (Tylenol might be more dangerous than it is worth unless the kit has only a little--that's a judgment call.)

The slums should have readier access to bleach, plastic bags, gasoline, cloth, and other useful items. The village will have more space to put an isolation building—the slums are horribly crowded—and better sewage disposal. Neither one has useful medical advice.

Engineers and Nurses:

Can one kludge procedures using cloth, plastic bags, and bleach that will let you clean a sick patient without exposing your own skin to ebola? How much bleach residue can someone with diarrhea stand, since you have to bleach the cup he drinks from? How can you use cloth and whatever to hold someone up enough to drink? What sorts of procedures can you use to wrap the dead (bearing in mind that whatever he was lying on is wet and contaminated) that won’t put you at excessive risk?

Can you make a decent mask with available cloth? How many do you need to have on hand if you have to keep soaking old ones in the bleach?

Can you make disposable bedding from leaves and branches (in season)?

What is bleach going to do to skin infections?

How much cloth is one person with the runs going to need?

If the patient is bed-ridden, what can one use for a bedpan?

If the patient is not bedridden, how can one kludge a latrine in the slum? Since the waste is potentially deadly (even without ebola), this isn’t a trivial problem.

Other ideas and questions--straw men and otherwise.

Beef up those medical kits. I’m assuming the information pamphlets are cartoons, since most people can’t read. The medicines need to be brightly and distinctly colored so they can tell them apart easily. Probably everybody has worms, so dosing everybody in the village on general principles is probably harmless and might increase overall health.

Create medical teams that just answer cell phone questions. You need a lot of them, because there will be a lot of questions and a lot of languages. Their job is not to provide care but to explain how to use the souped-up medical kits. They in turn will not be doctors or nurses; they’ll be working mostly from scripts. If they get stumped they call for advice from medical central (which might not even be in the country). Not all villages will have a cell phone to call with. Can't solve that problem here.

The circulating education teams have to demonstrate all the details of all the procedures. This means that it will take a long time to finish a circuit. Folding cloth to make a support or an impermeable mitten is something that needs to be practiced a little. So long as one person gets it, the team has to rely on that person to train the others as needed since they can't stay for too long. Cartoons are all very well, but there’s no substitute for trying procedures out yourself (even cartoons aren't as clear as their creators dream). The teams will have to resupply the medicines from time to time. Some villages can only be reached by a few day’s walk. Some slums are dangerous.

I'd thought that for somebody in a village with ebola a trench filled with leaf bedding would be useful, but since there won't be a diagnosis (probably ever) I don't know if this would be suitable. For a one-off treatment site it might be OK for easing cleanup.

If a man dies you need to bury or burn his contaminated clothing and bedding. This will be a bit of a sacrifice, and in the rainy season (like right now) difficult. How long can you soak a filthy shirt in bleach before it is safe enough for someone else to inherit?

If the people intensely dislike the smell of chlorine bleach on the departed one, maybe perfume would help mask the smell, and also mask the fact that the person hasn’t been bathed as thoroughly as custom demands.

Sometimes liquid latex is available from rubber trees—can that be used to make cloth less permeable?

In the slums, the city is going to have to clear some areas out to make room for isolation buildings and latrines. This will make people angry. If you compensate those whose houses were razed, the neighbors will be angry that they didn't get a share. Money allocated for compensation will leak away before it gets to the people. You just have to deal with the anger somehow.

This will need lots of volunteers with working knowledge of tribal languages. You can probably find some in churches.

The isolation buildings don’t have to be any fancier than anything else in the area—in fact it is probably a bad idea to have them be too good since there will be squatters in the slums. The shelters have to keep the rain off, fresh air in (insofar as there is any), and the patients out of the draft and separated from each other. Latrines outside, places for paraphernalia where the caregiver can keep an eye on them so they don’t get stolen (the slums are slums). There need to be a lot of these shelters, since a caregiver will likely have other obligations to other family members and can’t spend 24/7 at the isolation building—so these can’t be far from home.

What kind of landscape is needed for siting an isolation building?

Try to recruit burial team members from the slums. You may have to pay by the body or they might not show up.

Water is a problem--too big to solve on a useful timescale for stopping ebola.

UPDATE 27-Sep: See this story about makeshift protective gear.

SIEGEL: That kind of gear and information is in kits that will soon be distributed by the U.S. government in Liberia. But as NPR's Nurith Aizenman reports, the home health care kits come with mixed messages.
NURITH AIZENMAN: Here's what's in these kits...
NANCY LINDBORG: It's a bucket that contains a sprayer, which is used for disinfectant, rolls of bags for capturing any infected garments or items, gloves, a gown, a mask, soap, chlorine.
AIZENMAN: Nancy Lindborg is a top official at USAID. She says the agency's plan is to distribute the kits to 400,000 households across Liberia. The first 50,000 kits are arriving next week. And here's the question - can these kits help slow this outbreak?
Kits like this have been distributed in previous Ebola outbreaks, but never on this scale. Dr. Daniel Bausch is an infectious disease expert with Tulane University and the U.S. Navy. He's advising the U.S. government on the current Ebola outbreak, though he's not working directly on the home kits.
DANIEL BAUSCH: In previous outbreaks, the question was is it better to try to take care of people at home with these sorts of kits or should we really focus on getting people into an Ebola treatment units? But that's not an option now.
AIZENMAN: There are very few treatment centers in Liberia. So people are taking care of their family members at home. They don't have a choice. President Obama is promising to build 17 new treatment centers with a total of 1,700 beds. But that's going to take time.
BAUSCH: Until we can do that, I think that we have to be honest. And we have to offer people what protections and what care we can even though it's far from ideal.
AIZENMAN: But USAID says that the kits are not meant to be used to provide treatment. For instance, they don't contain Tylenol for fevers or rehydration salts to help replace fluids lost through vomiting and diarrhea. Officials say the most important item in the kit is an information pamphlet telling people how to protect themselves. Dr. Bausch says that while using items in the kits like gloves or surgical gowns won't completely protect the family members and friends of someone with Ebola, every little bit helps.
BAUSCH: If we can cut down - rather than having five infected people from a sick person in a home, if we can cut down to three, obviously that's a good thing.

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