Oct 14 2014

Ebola and Human Error

It has been fascinating, and a little scary, to watch the first ever Ebola epidemic from the comfort of my Connecticut environs – about as far from the epidemic as you can get. Two thoughts keep coming back to me. The first, as this epidemic progresses and the CDC and WHO keep advancing their predictions about how bad it’s going to get, is this question: are we witnessing the unfolding of a major epidemic or even pandemic? Are we going to look back at the second half of 2014 and wonder how no one recognized how serious this is going to get?

Of course, I do not want to overstate the situation, stoke unnecessary fears, or come off as sensationalist. So I, like the CDC, will point out that the probability of a pandemic is extremely small. Unlike West Africa, most industrialized nations have a robust healthcare infrastructure and we’ll be able to deal with an outbreak before it gets out of control.

But this leads me to my second thought – how did it get so bad in the first place? The story is essentially a story of human error. The current epidemic represents a failure at many levels. This is not about finger pointing, but recognizing human limitations and frailty.

By all accounts the current Ebola epidemic is overwhelming the governments and the infrastructure in West Africa where it is still spreading, and in fact increasing geometrically. The world is reacting, some have charged, too late to this crisis. In fact, an Ebola rapid response infrastructure should have been in place, ready to squash any outbreak in its infancy.

I guess we were made complacent by past experience. Ebola has always caused small local outbreaks. When I first heard of a new Ebola outbreak, months ago, I assumed (probably like everyone else) that this would be yet another typical small outbreak, and it hardly caught my attention at all.

Now we’re launching a massive effort, but the disease may be growing faster than our efforts to stem it. The fire is already spreading out of control, it’s too late to install sprinklers.

The culture in West Africa is partly responsible. There is widespread superstition, distrust of government and outsiders (with good reason), and paranoia. In Guinea, for example, 8 health care workers, trying to treat the Ebola epidemic, were killed with clubs and machetes by villagers who believed they were spreading Ebola.

There are also reports that people who are sick often do not show up to treatment centers, for fear that they will simply be quarantined and left to die.

Victims are often not buried properly because of local burial customs. Funerals are therefore a very dangerous place to be.

There are also reports of profound individual failures. I wrote previously about an herbalist who may have been solely responsible for the spread of the epidemic to Sierra Leone by promising an herbal cure for Ebola. All she succeeded in doing was luring infected people across the border, spreading the infection, resulting in her own death from Ebola.

There is now also the case of the Liberian man, Thomas Duncan, who did not disclose his contact with Ebola victims, entered the US, and then was diagnosed with Ebola in Texas (and has subsequently died). A nurse caring for Duncan has now also contracted Ebola. The CDC reports that this must be due to some breach in protocol.

The assumption was that US hospitals have the training and equipment to deal with a virus like Ebola, but then the very first case diagnosed in an American hospital (so not counting health care workers who contracted Ebola in Africa and were brought home for treatment) resulted in a failure to prevent spread.

Ebola screening has now begun at JFK airport, and is likely to begin at other international airports.

Here are some updated Ebola statistics from the CDC.

Total Cases: 8400
Laboratory-Confirmed Cases: 4656
Total Deaths: 4033

And some good news:

Nigeria and Senegal have not reported any new cases since September 5, 2014, and August 29, 2014, respectively. All contacts in both countries have now completed their 21-day follow up, with no further cases of Ebola reported.

So it is possible to contain the virus’s spread in West Africa.

Conclusion

Whenever events like this unfold I always sense conflicting imperatives from officials responsible for dealing with the crisis. On the one hand they do not want to stoke fears and panic. So they reassure the public that we are dealing with the crisis and everything will be fine.

On the other hand, they have to convey the seriousness of the crisis so that proper resources will be allocated to dealing with it, and the public will take it seriously and do their part. This is serious, but don’t panic.

Further, it is essentially the job of those responsible for the crisis to prepare for it being much worse than it probably will be. Better to overprepare then to underprepare by even a little. We saw this with the H1N1 epidemic a few years ago. It was not as bad as projections predicted, and then the public criticized the CDC for being Cassandras. But that is their job.

Trying to write about the Ebola epidemic in a balanced way, I understand how difficult this can be. I don’t want to overstate the situation, but I don’t want to minimize it either. The fact is, the probability of a pandemic is very small. Outside of West Africa, you are probably safe and have nothing to worry about.

On the other hand, the epidemic is still in a phase where it is exceeding our prior projections, and we are still escalating our response in order to contain it. How draconian will containment measures have to get before the epidemic is over?

Thrown into this is the factor of human error. This is a variable that is difficult to predict, and we have already seen irresponsible decisions on the part of individuals foil our best efforts at preventing spread. In the end I suspect this will be a story of human error more than anything else.

35 responses so far

35 Responses to “Ebola and Human Error”

  1. thequarkon 14 Oct 2014 at 10:41 am

    The news also his the narrative of Ebola possibly becoming airborne — which there seems to be disagreement on how possible this is (see the snopes article: http://www.snopes.com/medical/disease/ebolaairborne.asp as well as this LA times piece: http://www.latimes.com/nation/la-na-ebola-questions-20141007-story.html#page=1).

    I’ve been struggling with the question: Should the CDC’s preparedness extend to these unlikely situations? On the one hand, finite resources suggest we prepare for the clear and present danger, but on the other hand, there could be sufficient scientific disagreement (unless the LA times article is misrepresenting the consensus) to warrant use of the precautionary principle.

  2. RCon 14 Oct 2014 at 11:37 am

    The meat of the LA Times article seems to be two scientists basically saying “We don’t know” and “It hasn’t been tested”… I think the article is a bit inflammatory.

    It does mention that ebola virus is found in the sputum, and that droplet transmission is suspected (there are a couple of cross-species studies that show the virus moving across air gaps), but droplet transmission is not the same thing as airborne transmission – something the article seems to gloss over.

    Viruses changing their method of transmission is basically unheard of. I think this is mostly a case of the news media knowing that exaggeration gets more hits.

  3. locutusbrgon 14 Oct 2014 at 1:21 pm

    @ the Quark
    After doing some generalized research through a medical data compiling service and a search of available medical databases from a medical school library. I have found essentially what the CDC has been saying about conversion from contact to airborne pathogen. Meaning that it becomes very easily passed like-> IE: measles which is spread through the air..
    1. It simply has never happened with any disease ever, they either have the capacity or they don’t. Although theoretically possible -highly unlikely. End stage disease can produced aerosolized droplets, that is very different from lets say… measles(very hardy virus) which persists floating in the air in enclosed spaces (like elevators) for hours.
    2. Ebola zaire strain(this current disease) has an extremely low mutation rate. That makes it even less likely that ebola will suddenly mutate into a dangerous “airborne” version.
    It also probably means that we will eventually have a vaccine for it, just no help right now.

  4. locutusbrgon 14 Oct 2014 at 1:29 pm

    Also Steve
    I agree with the difficult nature of having this discussion. It has become almost daily conversation and sometimes panicky discussions. The news media is lapping it up. I think to the detriment of understanding. Adding in the recent political dimension rearing up in the news and we have media gold and public health nightmare. IE: People showing up to the ER with flu like symptoms convinced they got ebola from the game at meadowlands stadium in NJ. I am already seeing the trickle of that now in the ED.
    You are an exceptionally calm and rational medical professional/commenter. that history means… If you’re showing even minimal concern that may cause even greater consternation. That said I think you held a good balance.
    It kind of funny but it was more reassuring when you didn’t address it.

  5. steve12on 14 Oct 2014 at 3:41 pm

    Is it possible that the virus has mutated in some way that makes it more virulent, (though not airborne)?

    I’ve had a reaction against the alarmism that makes be feel like I’m echoing cable news, but this outbreak is a huge outlier in lives lost. Given that the health infrastructure and health related behaviors haven’t changed markedly in West Africa (or at least not markedly for the worse, right?) what accounts for this?

  6. Kawarthajonon 14 Oct 2014 at 3:57 pm

    “Thrown into this is the factor of human error. This is a variable that is difficult to predict” – I think that we can predict very accurately that human error will happen, as it has already happened, and it will have negative consequences for this epidemic.

    I have to say, as a non-medical or public health person, that I am increasingly alarmed by the news of this outbreak. Part of the problem lies in the fact that the WHO and MSF keep predicting the number of new cases, only to find out that the number is way higher than predicted. We were told early on that this outbreak would fizzle out after a few hundred patients contracted the disease, then over a thousand, 10,000+, then 100’s of thousands and now over a million! Clearly they have no accurate way of predicting the outcome of this epidemic (as discussed on the SGU), but it will be a big killer this year and next. Each time I hear a news story about the outbreak, the news is bleak, the action taken too late and the health systems are being overwhelmed.

    It seems to me that it is likely that people will begin contracting it in other countries, as West Africans flee to get away from the epidemic. It could then spread to other countries nearby and then the spread will continue to other countries and so on (I know that Nigeria managed to contain it, but there will be more travelers bringing it to the country). It could be transmitted patient to in the US, as well as Europe, Australia and Canada (there are potential ebola patients in isolation about 80km from my home in a small city hospital, as well as a couple hundred kms away in a larger city). What if this disease travels to China or India, where people live in incredibly crowded circumstances? I get that culture, economy and health care systems play a role, but having lived in China and India, I seriously doubt they could contend with an outbreak of the disease. (BTW, China is a heavy investor in the West African countries that are experiencing an outbreak, making a transmission via travel highly feasible.)

    I apologize for my alarmist remarks, but several health agencies have been predicting global pandemics for decades. I think they thought it would be a type of flu, but it could just as easily be Ebola. Should I stop by the drug store on the way home from work to pick up masks, bleach and gloves?

  7. Kawarthajonon 14 Oct 2014 at 4:19 pm

    Looking to the future, WHO’s Director of Strategy Christopher Dye said that “this is a bit like weather forecasting. We can do it a few days in advance, but looking a few weeks or months ahead is very difficult.”

    http://www.aljazeera.com/news/africa/2014/09/ebola-cases-may-reach-14-million-next-year-2014923163038427875.html

  8. Elizabeth.Hazelon 14 Oct 2014 at 4:27 pm

    I really enjoy your blog and had a couple of comments on some points in this article.

    You mention that West African culture is responsible for the epidemic. First off, what is West Africa? It’s 17 countries, thousands of languages and ethnicities. It’s not a monoculture. Also many of the scenarios you describe above would happen in the US given that scale of epidemic. You’ve written about superstition and paranoia in the US against scientific institutions before – the anti-vaxx movement for instance. I don’t think we can say that it’s West African culture that has allowed this epidemic to occur. The catalysis is lack of hospital infrastructure and a poor health system. It’s difficult for health workers from the US to imagine a hospital in a resource poor setting. Not only are gloves, goggles and masks scarce but often there is no clean water, poor sanitation disposal and sporadic electricity. There aren’t nearly enough beds or doctors to treat patients and this was before the epidemic. We are very unikely to see what is happening in Liberia in the US.

    However, it is very likely that the US will see more ebola cases although our health system has the capacity to isolate them and halt the epidemic. Airport screenings are a step in the right direction but will not be effective due to ebola’s long incubation period. A person may pass through security infected (although they wouldn’t be infective) because they are not symptomatic. We should be prepared for the eventuality of more US cases and the risk will continue until the epidemic is stopped in West Africa.

    It is good news that the spread has been contained in Senegal and Nigeria but the situation is much different in Guinea, Sierra Leone and Liberia. Senegal had one case. Nigeria had 20. I don’t think we can look to them as a model for the three endemic countries. It may not be possible to contain the spread there. We can only hope for an effective vaccine. And health systems development work as shown us that having a vaccine isn’t enough, getting the vaccine to everyone in a country with a weak health infrastructure will be challenging.

    Finally, the airborne issue. There is a chance that the virus could be spread through droplets, coughed or vomited. However that is not the major route of transmission. The CDC and MSF have been following up on 1000s of cases in W. Africa and they are all due to close contact: family members, burial attendants, health workers. There are no “unexplained” cases where droplet transmission was the only probable route. It could be occurring but it seems to be rare. There is no evidence of another virus drastically changing transmission or “becoming airborne”. That doesn’t mean that it couldn’t happen with ebola, only that we have no reason to think it would. Maybe sharks would sprout wings and fly around eating everyone. Sure, anything is possible but we really don’t think that would happen.

    I’m faculty at JHSPH in the International Health department. JHSPH just had a symposium on the Ebola virus today. The recorded webcast is here http://www.jhsph.edu/events/2014/ebola-forum/webcast.html. It was very interested and also terrifying.

  9. Steven Novellaon 14 Oct 2014 at 5:16 pm

    That human error will occur is predictable. The exact nature of that error cannot, and so preventing it is difficult.

    From what I am reading there is nothing really new about this strain, but that may not be the final word.

    What is new is that the outbreak reached a city. That increased the outbreak by orders of magnitude, overwhelming the infrastructure. (BTW – this outbreak is now officially an epidemic). Previous outbreaks were isolated to the sticks.

  10. Steven Novellaon 14 Oct 2014 at 5:21 pm

    Elizabeth. I wrote that the West African culture is “partly” responsible. Other factors are important as well, such as too little infrastructure, which I also mentioned.

    I know this is many countries, languages, etc. The commonality, however, is a generally low level of scientific literacy and reliance on local customs and superstition. I never suggested this was unique or implied other parts of the world are immune. I am simply relating what the health care workers have been reporting – containing the virus has partly been challenged by local beliefs about the disease and its spread which are wrong and often unscientific, and resistance to changing burial practices which are not safe.

  11. Robneyon 15 Oct 2014 at 12:42 am

    Elizabeth,

    Would you be as equally sensitive to a generalised statement about ‘Western Europe’, a region of the world composed of many nation states, regional cultures and languages. Or would you agree there are enough commonalities between Western European countries that some generalisations can be made despite the many national differences?

  12. Robneyon 15 Oct 2014 at 12:54 am

    I wonder what the anti-vaccination groups’ stance would be if a vaccination became available for Ebola?

    If it was proven safe, effective and was cheap to manufacture and easy to administer, would they object to West African people being vaccinated? Would they take it themselves?

    I’m not saying that to make cheap points. I’m genuinely curious what their position would be. I think it would be very bad PR for them if some anti-vaccination groups opposed a vaccination that could potentially save hundreds of thousands of West African lives.

    But really, that’s what they already do so I wonder if that hypothetical scenario would cause any introspection on their part.

  13. Stormbringeron 15 Oct 2014 at 1:15 am

    I have two concerns about the spread of Ebola; First is the movement of people in the upcoming holiday season. There are millions of people that travel to Mecca over the next month. If someone that was in West Africa, attends this pilgrimage, and then becomes symptomatic. Some of the customs like washing the feet before entering the mosque could allow the virus to spread.
    While the above could be bad I think the worse case would be if it was spread to Indonesia or India. With what I see from documentaries the living conditions are tight, little medical care available, and low sanitation conditions in some areas.
    What would happen if someone became an unaffected carrier.

    Steve since this virus is present in the saliva could a test be developed that uses a mouth swab to detect the virus before a person is symptomatic?

  14. grabulaon 15 Oct 2014 at 2:11 am

    Robney, that’s a good question. I suspect the adults would get them under the idea that they didn’t have to worry about ‘catching’ autism. I dread to think they would leave their children at risk but they’ve shown an irrational behavior already, I’m not sure what would change that. As they are sort of doing now I suspect they would ride the herd immunity as much as they could.

  15. grabulaon 15 Oct 2014 at 2:12 am

    I hit submit prematurely (happens when you get older). What I was getting at is that we assume as rational individuals that a more extreme situation would call for an exception to the rule however I don’t think the irrational behavior they show now would be budged much by something like that.

  16. Jared Olsenon 15 Oct 2014 at 4:52 am

    Not to make light of this terrifying epidemic, but if this is the way in which we deal with a virus that has relatively low communicability, and we in fact know how to prevent it from spreading, I don’t have much confidence in our ability to prevent a pandemic of a highly virulent virus
    that may pop up in the future.

  17. Steven Novellaon 15 Oct 2014 at 7:21 am

    Robney – at least some of them would say: The vaccine doesn’t work. This is all Big Pharma exploiting the situation to make money. Drink their special herbal tea blend and clear up your chakras and you will be able to resist the virus.

  18. Jared Olsenon 15 Oct 2014 at 7:49 am

    I wonder if they’d start marketing that on their supplements, with the ubiquitous “MAY help with symptoms of Ebola…”?
    Could they morally and legally sink so low?

  19. seandon 15 Oct 2014 at 8:56 am

    So far as the airborne route goes there’s a pretty slam-dunk appraisal of that one here: http://www.rectofossal.com/airborne-arse/ – love the ‘Giant Muslim Spiders Bringing Ebola to UK’ newspaper headline!

  20. Steven Novellaon 15 Oct 2014 at 9:39 am

    Called it: http://io9.com/the-anti-vaxxers-are-spreading-ebola-conspiracy-theori-1645815265

  21. wmadon 15 Oct 2014 at 10:23 am

    My only real concern with Ebola in the US is that we have a quite a few superstitious and paranoid people as well. Every day, I hear anything from “the government created Ebola as a form of population control,” to “Big Pharma unleashed this to increase profits.” That sort of talk is extremely problematic because it could ultimately lead to the same patterns emerging here that have happened in Africa; that is, people will avoid “mainstream” doctors in favor of the unregulated ones and avoid being formally diagnosed until the disease has progressed to such a point that they have no other choice.

  22. daedalus2uon 15 Oct 2014 at 10:57 am

    One of the early factors in this outbreak was a local traditional herbalist who claimed she could cure ebola. She couldn’t, died from it herself, and her quackery allowed and facilitated a lot of the initial spread.

  23. GlobalCitizenon 15 Oct 2014 at 12:30 pm

    My understanding is that once you are infected with the current strain of Ebola in West Africa you are immune from further illness. If so why is it that MSF and other organizations in West Africa not asking survivors of Ebola (health workers as well as lay individuals) to work with these infected individuals as they would not have to use protective equipment etc. Am I missing something?

  24. Dianeon 15 Oct 2014 at 1:23 pm

    @Steve12

    It is important to remember that this outbreak is happening in an unusual place. Ebola comes from the Congo region and almost all previous outbreaks have been in central Africa, mostly in the Democratic Republic of the Congo, 2000 miles away. Central Africans (both medical professionals and ordinary people) have learned the hard way what to do and what not to do in an ebola outbreak. The typical Congolese person is much better informed about how to protect themselves from ebola than the typical Liberian. So the medical and public health professionals in west Africa are not only trying to stop a disease they themselves have little experience with, they are having to educate the population at the same time.

  25. RickKon 15 Oct 2014 at 6:53 pm

    I too am a resident of Connecticut, but I’m also a daily rider of the NYC subway. I’m not nearly as comfortable about this outbreak, primarily because of the potential of intentional dispersal of the virus.

    Ebola can live on a dry surface for hours and a moist surface for days. And as the infections in U.S. healthcare workers proves, it can spread even when faced with active protection measures. I haven’t thought through all the details, but it certainly seems like there are several low-effort, low-tech ways to transport the virus into a crowded western city, particularly by someone willing to sacrifice their life for the cause.

    I’m not wearing a mask and gloves during my commute, but I’m far from confident that the U.S. will avoid a tragic outbreak.

  26. leo100on 15 Oct 2014 at 8:01 pm

    Is there any truth to this, this is pretty scary if this is true.

    http://www.inquisitr.com/1541821/ebola-is-airborne-university-of-minnesota-cidrap-researchers-claim/

  27. LDoBeon 16 Oct 2014 at 2:28 am

    leo100

    The article you’re referencing is an exaggeration of the original source found here: http://www.cidrap.umn.edu/news-perspective/2014/10/cdc-deploy-ebola-response-team-help-hospitals

    What it seems to be saying, as I understand it, is that full body gear is recommended when treating late-stage patients with a liklihood of generating a ton of fluid droplets. For instance someone who has coughing fits that are so bad that they could hawk a throat oyster in your eye.

    This isn’t airborne transmission like the flu or common cold, it’s literally small droplets of liquid landing on the mucous membranes (eyes, mouth etc) of healthcare workers.

    Also, precautions for healthcare workers are much more extreme than those for average Joe public, because healthcare workers are in much more risky situations for exposure.

    Here’s a direct quote from the actual original source article:

    “Though Emory officials are on board with CDC recommendations, he said, it made operational sense to have the workers wear the extra gear to avoid having to wipe the sweat off their brows or risk their eyewear fogging up in the Atlanta heat.”

  28. Bruceon 16 Oct 2014 at 4:03 am

    I have a very strang thing happening on my facebook pages with my friends in Zimbabwe. Some are claiming that the Ebola spread is a western conspiracy (Big Pharma etc.) to make the african goverments spend money on experiemental/useless drugs. Other people are up in arms that some of the drugs are being given to westerners but not africans… I am not sure if they think Ebola was created by the west or not, but the rumour mill is in full swing.

    I am due to go back there for Christmas holidays, and while making sure I have the relevant insurance in case it is declared a no fly zone, I am pretty confident that southern/central african countries are better educated on the disease and if it were to creep south it would be contained (much for the same reasons Diane has mentioned above).

  29. BillyJoe7on 16 Oct 2014 at 7:48 am

    A slightly scary encounter:

    I had one degree of separation from a man who had just arrived here from Nigeria with flu symptoms. He passed the infection onto this two kids and I came into contact with his kids. When I enquired further, his wife told me that he had left Nigeria after it was pronounced free of Ebola and so I was probably okay. Probably? Anyway, as if turned out, the man and his kids got better and I never got the virus.

    I hope that’s as close as I ever get.

  30. Jared Olsenon 17 Oct 2014 at 4:40 am

    BillyJoe-

    “Slightly”?
    I can think of a few stronger modifiers I would use..

  31. Nitpickingon 17 Oct 2014 at 7:34 am

    @Kawarthajonon, China has handled far more communicable diseases than ebola just fine, notably SARS. One thing they’re good at is exerting rigid control of situations.

    Steve, two nurses now. According to media reports, Texas Health Presbyterian Hospital Dallas didn’t institute infection control measures until two days after Mr. Duncan was admitted. That, I think, explains why the two nurses got infected.

    Carl

  32. Elizabeth.Hazelon 17 Oct 2014 at 9:58 am

    @ Stephen – Thanks, my point would merely be that weak hospital infrastructure is considered the primary reason for the epidemic spreading this far. Cultural reasons come into play but I think it’s important to make this distinction. If there were adequate beds and resources in Liberia, the cultural practices wouldn’t matter since most people could be isolated and treated.

    @ Robney – I don’t think I’m being overly sensitive on this issues. I don’t think it’s controversial that our society is Eurocentric. Many people might not even be able to name a West African country, much less understand the complex and diverse culture. One West African country – Nigeria – probably has more ethnic and cultural diversity that all of Western Europe.

    I’m not trying to nit-pick here but I think if we’re going to understand why the epidemic has spread so far in West Africa, we need to understand a little more about the area and be clear when discussing it.

    And I’m also annoyed that my family is freaking out because I just got back from South Africa. South Africa is as close to Liberia and Norway is!

  33. Kawarthajonon 19 Oct 2014 at 8:40 pm

    # Nitpickingon 17 Oct 2014 at 7:34 am
    “@Kawarthajonon, China has handled far more communicable diseases than ebola just fine, notably SARS. One thing they’re good at is exerting rigid control of situations.”

    Not true. They are very good at taking rigid control of information, but there are many horrible diseases that are endemic to China, including the Bubonic plague, typhus and HIV to name a few. Health care for rich, connected Chinese is fantastic. Your average Chinese citizen has substandard care, if they get any effective medical care at all. Cities like Beijing and Shanghai are crowded to the breaking point with illegal migrants from the country. Millions of these people live in horrible, crowded and unsanitary conditions, where diseases are rampant. They would be excellent places for Ebola to spread.

    As for SARS:

    “Despite taking some action to control it, Chinese government officials did not inform the World Health Organization of the outbreak until February 2003. This lack of openness caused delays in efforts to control the epidemic, resulting in criticism of the People’s Republic of China from the international community. China has since officially apologized for early slowness in dealing with the SARS epidemic.[15]”

    http://en.wikipedia.org/wiki/Severe_acute_respiratory_syndrome

  34. RickKon 23 Oct 2014 at 10:53 pm

    Well, now I’m even more concerned. Someone has been riding the NYC subway with Ebola. Getting too darned close.

  35. AmateurSkepticon 24 Oct 2014 at 4:43 pm

    Adding Perspective

    From the CDC:

    Heart disease: 596,577
    Cancer: 576,691
    Chronic lower respiratory diseases: 142,943
    Stroke (cerebrovascular diseases): 128,932
    Accidents (unintentional injuries): 126,438
    Alzheimer’s disease: 84,974
    Diabetes: 73,831
    Influenza and Pneumonia: 53,826
    Nephritis, nephrotic syndrome, and nephrosis: 45,591
    Intentional self-harm (suicide): 39,518

    Other sources:

    In 2010, there were 19,392 firearm-related suicides, and 11,078 firearm-related homicides in the U.S

    Unintentional fall deaths: 27,483

    Motor vehicle traffic deaths: 33,783

    Unintentional poisoning deaths: 36,280

    Perhaps a hard drinking, overweight smoker can help me figure out where to insert Ebola (or terrorism, for that matter) into this list.

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