By Roy M. Poses, MD, Clinical Associate Professor of Medicine at Brown University, and President of FIRM, the Foundation for Integrity and Responsibility in Medicine, a not-for-profit organization (NGO) designed to raise awareness of external threats to the core values in health care as the first step toward addressing them. Originally published at Health Care Renewal.
The Ebola virus epidemic in West Africa continues to grow, and now appears to be the worst known epidemic of that disease to date. In the US and Western Europe, press reports are now raising concerns that the disease could spread there. For example, CNN, in an article entitled “Ebola Fears Hits Close to Home,” was a section headed “Could Ebola spread to the US?” An ABC article was entitled, “How the US Government Could Evacuate Americans with Ebola.”
Reasons for fear of spread are the increased mobility of people made possible by air travel, and the lack of specificity of early symptoms of Ebola, so infectious people may not realize the dangers their travel might pose. A US citizen with Ebola was on his way back to the US via several connections, and made it as far as Lagos, Nigeria before becoming too ill to travel further (per CNN). Making the fears worse are the high fatality rate of Ebola, the current epidemic included. According to Vox, the current outbreak is the Zaire subtype of the virus, with an expected mortality rate of 68%. Finally, there is no known effective treatment or vaccine for the Ebola virus.
Economics, not Science the Reason for Lack of Medical Options for Ebola
The reason there are no vaccines or treatments available for Ebola does not appear to be the scientific difficulty involved in developing them. Vox also published a discussion for the economic genesis of the problem:
Researchers have devoted lots of time to building a vaccine that could stop the disease altogether — and according to Daniel Bausch, a Tulane professor who researches Ebola and other infectious diseases, they’re making really significant progress.
Bausch says that the obstacle to developing an Ebola vaccine isn’t the science; researchers have actually made really great strides in figuring out how to fight back against Ebola and the Marburg virus, a similar disease.
‘We now have a couple of different vaccine platforms that have shown to be protective with non-human primates,’ says Bausch, who has received awards for his work containing disease outbreaks in Uganda. He is currently stationed in Lima, Peru, as the director of the emerging infections department of Naval Medical Research Unit 6.
The problem, instead, is the economics of drug development. Pharmaceutical companies have little incentive to pour research and development dollars into curing a disease that surfaces sporadically in low-income, African countries. They aren’t likely to see a large pay-off at the end — and could stand to lose money.
Prof Bausch elaborated,
These outbreaks affect the poorest communities on the planet. Although they do create incredible upheaval, they are relatively rare events. So if you look at the interest of pharmaceutical companies, there is not huge enthusiasm to take an Ebola drug through phase one, two, and three of a trial and make an Ebola vaccine that maybe a few tens of thousands or hundreds of thousands of people will use.
Of course, that assumes that this outbreak, like previous ones, will remain relatively confined, at least to Africa.
The 10/90 Gap
So the implication is that had things been otherwise, those in developed countries now worried that Ebola could spread their way could have been reassured by the availability of a vaccine, or other treatment.
The irony, if that is the right word, is that we do not have an effective treatment or vaccine for a viral disease that is relatively easily spread, and could likely rapidly kill nearly 70% of those infected. Yet in the last months, we have been arguing about how the use of an extremely expensive treatment for another viral disease that is difficult to spread, and may kill a few percent of its victims over up to 20 or 30 years after infection.
I am referring, of course, to Sovaldi, the recently announced $1000 pill for hepatitis C. Hepatitis C does affect a lot of people, including relatively affluent people in developed countries. As we noted previously, though, the majority of people infected with hepatitis C will never have serious medical repercussion from it. Small proportions of patients will eventually develop severe liver disease, including cirrhosis, liver failure, and liver cancer, and may die from the disease. (See the report by the Center for Evidence Based Policy). Yet the treatment is being promoted for all patients with hepatitis C, most of whom could not benefit from treatment. Furthermore, the evidence that treatment will actually prevent bad clinical outcomes, cirrhosis, liver failure, liver cancer, and premature death, is weak (look here). Yet considerable money was devoted to developing multiple hepatitis C treatments, with the expectation that huge amounts of money could be made from selling them.
This is an example of the 10/90 gap.
A long time ago, in 1998, I was invited to Forum 2 of an organization called the Global Forum for Health Research The GFHR was an organization dedicated to overcoming the “10/90 gap”:
Less than 10% of the worldwide expenditure on health research and development is devoted to the major health problems of 90% of the population
Yet the 10/90 gap is probably getting worse. In the US, our health care has now been heavily influenced by advocates of neoliberalism, or economism. Health care is now largely run by generic managers trained in business schools, with no specific training or expertise in health care, and doubtful loyalty to its values. Current business school dogma emphasizes the primacy of economic efficiency over all other goals (look here), to maximize “shareholder value,” which usually practically means maximizing short term revenue, to the immediate advantage of shareholders sometimes, but nearly always to the great and immediate financial advantage of paid managers and executives. The emphasis on short term revenue uber alles helps explain how we have multiple expensive hepatitis C drugs, and no Ebola drugs or vaccines.
The real irony is now that some very well paid managers may be worrying about the possibility of contracting Ebola whose transmission was facilitated by our increasingly global economy, globalized in part due to the advocacy of those advocating neoliberalism and economism.
Summary
Unfortunately, the fortunes of the Global Forum for Health Research seem to have faded. It went into sudden decline in 2010, and was subsumed into COHRED, the Council on Health Research for Development. The last Global Forum meeting was in 2012, although there seem to be plans for another next year. Meanwhile, multiple international organizations. including Medicins Sans Frontieres, established a Drugs for Neglected Diseases initiative, although its progress seems to be slow (see Pedrique B, Strub-Wourgaft N, Some C et al. The drug and vaccine landscape for neglected diseases (2000-11): a systematic assessment. Lancet Glob Health 2013; 1: e371. Link here.).
In my humble opinion, as long as much of the health care system is run so as to put short-term revenue ahead of all else, a manifestation of financialization encouraged by the generic managers who run so much of health, partly in their own self-interest, and by business schools promoting the shareholder value theory, we will not make much progress on the 10/90 gap. Ironically, the realization that even rich generic managers may no longer be protected from some of the deadliest diseases that used to only afflict the poorest people in the world may have an effect on this problem.
As I have said before, true health care reform would put in place leadership that understands the health care context, upholds health care professionals’ values, and puts patients’ and the public’s health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty.
But this sort of reform would challenge the interests of managers who are getting very rich off the current system. So I am afraid the US may end up going far down this final common pathway before enough people manifest enough strength to make real changes.
35 comments
Comments are closed.
omg they might lose money. well, that settle that.
People should realize that as we sit here we are enabling the world’s largest control fraud. The current troika of pending free trade agreements seem to endorse a new way of looking at the value of drugs. These new FTAs seem to me to enshrine “what the market will bear” as the entitled price, so literally the worse a disease is, or the wealthier the sufferers are the more money the manufacturer and the supply chain seems to now be entitled to. There is no such thing as a concept that people who make less should be able to get those drugs too, by any means, as far as I can tell.
By not speaking up, (despite the fact that there has been no coverage in major media of them) people in the United States, in particular, are now being seen as signifying their agreement to these three FTAs and their implicit rejection of unprofitable, efficient, fair public health care and its preference for affordability and egalitarianism. After all, the Americans are getting rich off of all this, right?
Thank you for this comment. Some of us have tried to speak up, by circulating information about the so-called FTAs, writing letters to newspapers, and calling and visiting our Congress critters. The negotiations continue. When people do congregate and protest, and on the rare occasions that the MSM take note, the numbers participating are reported as wildly lower than is actually the case, so our voices are discounted and marginalized. Meanwhile, the negotiations grind on.
It’s not as if we have a representative democracy, and the only semblance of a free press is at blogs like this one. If you have suggestions for how we could more effectively make ourselves heard in this system, I’m sure many of us would like to hear them.
@mellon & Carla,
Well, one of the issues of living in a so called “capitalist” society is that capital has to make money or a profit and that you can actually make more profit from a non-existent threat or disease than from a real one – this is explained clearly in Jaques Paretti’s latest documentary: The Men Who Made Us Buy, which is the follow-up to his other two exposes, namely, the men who made us fat and the men who made us thin. Now Statins for heart disease and blood pressure control are a case in point, and as the Lancet Journal has pointed out, these drugs may do more harm than good – but by clever marketing, specifically inventing an actual disease and sub-set of diseases Big Pharma, particularly in the USA can make huge wallops of money from a gullible public and corrupted health care system.
Now, despite capitalisms supposed wonders, we have a huge amount of misdirected and malinvestments of capital, which is actually supposed to not happen, but seems to happen frequently, suggesting capitalism is mightily flawed – which most of us posters on NC seem to know is a most accurate picture shall we say.
So, here’s the crack, they, that is big pharma, spend billions on finding drugs, testing drugs, marketing of drugs and creating unreal diseases for drugs. Regrettably some of the biggest killers go unchallenged, particularly those that are of an exotic nature from far away non-temperate climes.
Most of the most beneficial drugs we have in our armoury, be they preventative or treatments, have actually come from the public commons, be this our universities, the military, or persons who believe in humanity rather than huge profits. As way of an example, if HIV was only an issue in Africa it would not have attracted much attention, which is also true of Ebola. However, once a disease gets out of its natural environment and begins traversing the world into the West, things change rapidly, mostly prompted I hasten to add by government, rather than the private sector and Big Pharma.
here’s the good news, by focusing its attention on rich mens disease, Big Pharma, like capitalism itself, is digging its own grave, for eventually one of these new emergent diseases is going to be airborne and kill in equal measure rich and poor alike. And whilst we have several strains of Ebola, the latest of which is less virulent and has a longer gestation period until the disease expresses itself, the question arises if another Ebola strain mimics the longer gestation period but kills more than 90% of those infected, i.e., a disease that can be spread by a few individuals to millions of people globally before the medical authorities know what has hit them – think SARS, but with a three-six month timeline before it kills the host.
Just my two cents worth, but all these FTA’s make my blood boil, plus it seems greed trumps common sense continually, which means its greed that will ultimately be humanities downfall unless we can curb this particular excess.
+1 And thank you for your work.
This being a lefty blog it will be mood disorders central. FWIW I think the basic social critiques of such blogs are mostly right, but there’s a whole phenomena that goes on: where everyone will point fingers and blame every nearly powerless (or at the LEAST (self) PERCEIVED powerless) other person for the state of things. Very few ideas of how to concretely change anything (and not just what changes might be desirable) Better to talk about when there is a protest, when there is a city policy improved, etc.
And no we don’t have a representative democracy (except to some degree on the local level) or a free press.
The scariest thing is the lack of development of new antibiotics. With new antibiotic-resistant bugs turning up everywhere, that will come back to bite us in the ass very soon.
Do not worry, there are plenty of people trying to develop new antibiotics, including big pharma. It is just tough to find an antibiotic that does not also harm humans.
Hepatitis C is much more prevalent than this post lets on. In particular, the late boomers have the largest exposure, a combination of blood infusions, drug use, the sexual revolution, etc.
Solvadi came on the market when it did to take advantage of the pig in a python of hepatitis c cases among the baby boomers. The cdc has actually suggested testing all Americans born between 1945-1965 for hepatitis c as many Americans are not even aware they have it. The current rate of infection is estimated to be just shy of 2% of the population.
That this post downplays the risks of hepatitis c is alarming.
Having been involved with pharmaceutical development at a company that worked on both an HCV vaccine and drug treatment, Poses makes a good point. He did not say the rate of infection was low. He said the incidence of actual symptoms—real suffering was low. In fact, there is evidence that in the great majority of those infected with HCV never suffer any harm. And it’s not that easy to get HCV.
I was diagnosed with hep C about ten years ago and got the interferon-ribavarin treatment for 24 weeks. At the time I was fortunate enough to have great insurance. The total cost of treatment including drugs, liver biopsy, ultrasounds, etc., ran about $33,000. My out of pocket cost .was something on the order of $300.00. I live an hour from the Mayo Clinic so that’s where the local doc sent me. Funny thing is, on my last visit I was presented with an overdue bill out of pocket bill of approximately $150. Despite at that time of having already been paid in excess of $30,000, Mayo balked at keeping my appointment unless I wrote a check for the $150 right then on the spot.
BTW–according to Mayo and the CDC, hep C is not transmitted sexually unless your sexual practices involve the exchange of blood. My wife of 30 something years was not infected.
But the gist of this article is spot on. Although the virus can eat your liver, it usually takes decades before it becomes sympomatic. Just another sad tale of our for-profit medical industry.
If the disease is so benign then why were you treated? Because the disease is not benign.
Human beings are not perfect isolated organisms living in ziplock bags but rather complex beings with less than perfect lifestyles. I really think its a disservice to downplay hepatitis c as this post does especially for readers who may be unfamiliar with the disease.
Match for that straw? The point of the post:
Nobody’s arguing that human beings are perfect isolated organisms in ziplock bags.
My argument is solely with this statement which undermines the rest of the post:
“….the majority of people infected with hepatitis C will never have serious medical repercussion from it. Small proportions of patients will eventually develop severe liver disease, including cirrhosis, liver failure, and liver cancer, and may die from the disease.”
Which portions of that statement are false?
There’s about 200m estimated infections of HPC. If 0.1% of them develop serious medical problems, that’s 200,000 people.
Over a quarter of liver cirhosis cases in the world are thought to be caused by HPC.
There has been less than 5000 deaths from all Ebola outbreaks (i.e. not an individual infection or a few) combined IIRC (althought there has been more deaths than that)
Until this year, there’s been less than 1000 infections diagnosed per year since 1974 when Ebola was first identified.
The article uses Ebola since it’s a nice scarecrow. If you really wanted to limit Ebola, it’d be actually much more cost effective (for everyone, but most importantly for the affected) to get the fact that it spreads by touch/bodily fluids across the population and get the population to act in line with that (which admitedly is not trivial, since it would in some parts meaning changing burial customs..). That means working with local priests and (*gasp*) witch doctors (well, “traditional healers” in the PC speak). Which is what MSF is now trying to do.
If you want to make an impact, I have two different diseases for you – HIV in Africa and tuberculosis worldwide. Especially TBC, as it’s bug is by its nature very resistant to all current antibiotics.
So, the claims are correct….
Statement may or may not be false, I suspect it’s correct. Using Ebola and HPC as two cases proving it right though is at best misguided, as Ebola is not a major health problem of the world population, and HPC is definitely a more major problem. My 0.1% was an attempt at an conservative guess. Even at that guess (and doing some quick reading on this, it’s more likely that the problems are with percents, not tents of percents of infected) there’s a magnitude more of serious health problems with HPC than there was ever Ebola diagnosed patients.
My objection is not that we’re misallocating medical resources. We are. My objection is that using a case which is plainly wront even though nicely emotionally tinted doesn’t help the case, especially when I believe there are cases that can sell the case better.
did you leave out, or was it too much of a conspiracy to mention that many of the (male) individuals in that cohort may have been infected when they received innoculations prior to engaging in military service for Vietnam. Many, at the very least, contracted it during that timeframe from the use of airgun style vaccine tools, which were used to inoculate many people en masse without proper sanitation between uses (actually, the problem is supposedly that there is no real way to sanitize the entire unit, and blowback blood and tissue become lodged in the tool).
or is that simply an internet rumour? reading on Vietnam Vet message boards, many of them seem to have it and can vouch that they did not engage in any of the risky behavior that would’ve landed them with it. nevertheless, their doctors usually rack it up to ‘lifestyle’ reasons. The common denom-the airgun injector. they used these on students in schools at that time as well, so…*tsk.
http://www.hepatitis.va.gov/patient/faqs/air-gun-vaccinations.asp
http://www.va.gov/vetapp05/files5/0531165.txt
There is a battle to be fought over research dollars spent , but you choose to do so in a way that’s problematic.
I think the comment above about Hep C may cover the problem but here is WHO discussing Hep C which is responsible world wide for 350,000 to 500,000 deaths a year.
The same is no where near the case for Ebola although its fatality rate is higher:
http://www.who.int/mediacentre/factsheets/fs103/en/
This outbreak may see a 1000
Pitting one deadly disease against another is a bad idea.
I would also caution against believing we are close to a cure for Ebola. Drugs need ti be tested as discussed here:
http://m.huffpost.com/uk/entry/563340
That is a separate ethical concern from whether pharma should be doing the testing.
Until the research is done , it may or nay not be right around the corner
I agree with Poses generally. The private system won’t pay attention to diseases where there is no market for a premium treatment.
I disagree with the statement about an Ebola vaccine implying we’re near an effective preventative or cure. “Great strides” in “non-human” primates are still light years from real human trials in terms of science as well as funding. A better example is TB.
Good points. And the question is how do we test the efficacy of a vaccine to prevent ebola? It is especially hard to do vaccine trials in Africa because some the conspiracy theory nuts convinced a large number of people that AIDS was initially spread through other vaccine campaigns.
here’s a piece describing hardships on funding even location for these BSL 4-Labs (let alone their ri$k)
http://www.thestar.com/news/insight/2013/03/22/winnipegs_national_microbiology_laboratory_prepares_for_next_big_outbreak.html
“In 2009, a former employee smuggled 22 vials out of the lab, including ones containing non-infectious Ebola material (he was caught at the U.S. border and arrested). Incident reports also document occasional fluctuations in air pressure and, in one instance, an employee accidentally poked with a needle handling non-infectious material.”
http://www.thestar.com/news/world/2014/07/09/ebola_outbreak_not_right_for_testing_experimental_vaccines_drugs_experts.html
“But the only way the world will learn if Ebola and Marburg vaccines and drugs work is by using
them in an outbreak — a reality rife with ethical concerns and logistical problems.”
from 2012 (i imagine today we have enough exposed people to bypass the ethical conundrum) …”Testing an Ebola vaccine is tricky, because the disease is so deadly and rare. With measles or hepatitis, there is already a widespread population infected, so scientists can test the vaccine in those individuals. But with Ebola, one would have to expose humans to the virus to get a large enough sample, something that could never happen ethically.”
http://www.livescience.com/24829-ebola-vaccine-study.html
http://www.livescience.com/24829-ebola-vaccine-study.html
I see this article as bringing up the theme of ‘mission finance’ in the medical realm. We need to get financialization out of it so these decisions can be made more on their medical worthiness than their cost. Much of this basic R&D is already part of the public interest and the pharmaceutical companies or other parts the medical field shouldn’t be lavishly reimbursed while people go untreated.
With the explosion of the field of molecular genetics we are seeing the potential for a lot of individual based cancer treatment. We are also learning a lot about infectious disease.
We have such a broken medical system it’s hard to address these big issues when we can’t even provide basic care in a reasonable way to our population. We need to start thinking in terms of a good public health system again instead of for-profit healthcare.
I think Mariana Mazzucato, author of Building the Entrepreneurial State is making some good strides here.
http://ftalphaville.ft.com/2014/07/18/1901312/mission-finance-starting-to-think-big-again/
Mission Finance: starting to think big again – Mariana Mazzucato
“”Success in the past required companies that were willing and able to invest in long-run areas, and a confident ‘entrepreneurial state’ willing and able to take on the early, capital intensive high risk areas which the private sector tends to fear. Indeed, today this is becoming even more necessary with record hoarding rates in the private sector, and many companies choosing to spend more on share buybacks than on R&D.
The iPhone is a good example. This chart shows how every technology that makes it so smart, traces its funding back to a mission-oriented public agency in the US government which likes to pretend it believes in the free market when actually it has been one of the most interventionist in history.
The emphasis since the Global Financial Crisis on cutting public debt (even though it was private debt that caused the crisis) has inevitably affected the budgets of the very state agencies that have been responsible for creating both the direct and indirect types of investments needed to catalyse the technological revolutions of the past.
In the US, ‘sequestration’ has put close to one-third of the US public R&D budget ($130bn per year) at risk. In Europe, the ‘fiscal compact’ (which requires member states to have fiscal deficits that are only 3 per cent of their GDP) is putting pressure on countries to cut spending on areas like education and R&D. Spain—a critical case—has cut publicly funded R&D by 40 per cent since 2009. In the UK, while the government has ‘ring-fenced’ the science budget, in real (inflation-adjusted) terms, this has meant a 15 per cent cut.””
Ebola is a fairly rare disease so it may not even be worth the cost of developing a vaccine. Less than a thousand people have died in Africa from the Ebola epidemic, compared to an average of 23700 deaths yearly in Africa from rabies, according to the World Health Organization. People who get good supportive care are also much more likely to survive Ebola – the death rate goes down from 90% to perhaps 25%.
It would save far more lives per year to spend the money on bringing the quality of rural African hospitals up to par with the developed world. In many places you are expected to bring your own sheets, hypodermic needles, etc to the hospital, and sanitary standards are very low. Ebola is spreading around the hospitals because of poor hygiene.
But, but, markets always work. This must be the result of some regulations that need to be repealed. :-)
With 20,000 to 30,000 preventable childhood deaths _every day_ due to poverty, it is difficult to work up any sympathy for treatment of boutique diseases when increased available worlwide health care would both catch and manage much of it.
http://www.examiner.com/article/economics-of-ending-poverty-0-7-of-gni-is-all-it-takes
By boutique do you mean “poor” or “rich”?
“Boutique” was a poor choice of words. I did mean any minimally prevalent affliction, though, of course, those they afflict, both rich and poor, justifiably have their immediate health at concern. If you would read the article, you would find that the UN Millennium Goals for 2015 include increased health care. All it takes is $.
That word “Economism” is new to me but it certainly belongs here. Now that the world has become captive to the business model then we do indeed have Economism: where research and development for the public good is only undertaken when it is sure of producing a profit. When everything is financialized, then the financiers call the shot.
We should not be surprised.
Imagine if 99.9% the commentary about the state of the horrendous highways in so and so location was about the quality of vehicle repair shops available instead having a conversation about fixing the roads. This is what is going on in the Western world vis a vis health care.
The solution to all of these problems lies in spending what resources [a society can garner] on prevention/health, not on disease. You beat disease by preventing it. Mankind can only outsmart the microbial world for so long, until these critters take advantage of our decreased resistance and enter our species to the addendum of past life-forms on the planet.
No, imagine if the comments were related to the actual problem … cash bribes given to politicians! Can you imagine what it’d be like if the PUBLIC funded the elections rather than Pfizer et al. I’m 76 and won’t have to tolerate this “voter stupidity” much longer, but my grandkids will have to likely suffer through an armed rebellion. All while the corrupt D’s and R’s watch on.
One has little control of the collective, but a great deal of control over the self.
As the answers rarely lie in tweaking the former, the collective always manifests its power to the advantage of the sociopaths who captain it.
“Could Ebola spread to the US?”
It already has, and not by accident but rather as a deliberate act of will.
Sure, “we know how to safely handle such patients here”, but given that even the most advanced medical facilities in the world cannot do so with 100% safety, where was the “upside v downside” calculation which should be a v ital part of any potential public-health-impacting action such as flying active Ebola cases back to the U.S.?
Allow me to offer one — Because of the asymmetric nature of time’s arrow the upside here is certain, whereas on the downside we need to consider a range of possibilities:
o Upside: A tiny number of patients have their survival odds bettered by way of expensive high-tech “support” treatment.
o Downside: At the milder but higher-probability end of things, the quarantine is breached. That carries a high risk of at least a major public-health scare. At the worse end, what if the current outbreak strain turns out to be more easily spread than previous ones? (If not via the dreaded airborne route, perhaps via aerosolized fluid droplets). What if it has an unexpectedly long survival time on non-living surfaces?
It was grossly irresponsible of those flying in such patients to not at least provide some kind of tangible (and publicly discussable) public-health impact statement before doing so.
Sorry but Dr. Poses is just plain wrong. There is nothing liberal or even remotely free market about the health care system in the US or in the majority of the western world. There is no competition to speak of between different forms of health care (i.e. allopathic, naturopathic, homeopathic, etc) nor among different health care providers. What exists is a cabal of policiticians and regulators who in return for political contributions or lucrative positions work to eliminate any threatening competition for insurance and pharmaceutical companies as well as allopathic health care providers.
No in relation to the situation with ebola, it’s not even true that there presently exist a cure. It’s been known for at least the last 10 years that one can use one of the forms of MMS (i.e. chlorine dioxide diluted in water, or 28% solution of sodium chlorite, or calcium hypochlorite in water -> hypochlorous acid or chlorine dioxide in water) to easily treat ebola. In fact, the Red Cross did a trial of it on malaria in Uganda and had a 100% cure rate in 2 days! But then because it is seen as a major major threat to big pharma (because you can easily make the stuff in your kitchen for pennies) it has not only been suppressed and the red cross denies that they even did the trials!?! In any case if you google ‘red cross mms uganda’ you can see the video yourself of the trial that was done. So here is something that can cure a multitude of diseases for pennies and can be used in places like africa to help people for practically nothing and it is being suppressed and/or ignored, even by the people who are spoken about in this article who profess to want to help people in the developing countries. That’s the reality!
Contracting ebola… contracting means outsourcing, outsourcing means profit… BUY BUY BUY!!!