2014-08-13

Ebola 2: Hubris, credulity or too much of good heart may kill you. Likely hidden vectors of ebola transmission

3.0.6

Let's talk about the unexpected benefits of being paranoid, stereotypical, egoistic, conservative and mistrusting of the authorities. It's a question of life and death.



As I have written here before, there are cases where the more compassionate you are when faced with a contagion, including treating the current ebola virus disease (EVD), the sooner you die and the more misery you bring on the people you are trying to help. 
The ugly instinct of self-preservation, often rearing up during such epidemics, is a proven evolutionary springboard for the other paleomammalian emotions of revulsion, mistrust and separatism (and worse). But sometimes it is these "bad" atavistic tendencies which save your life, the life of your close ones and your neighbours.

God! Was it you who set things up during this and other epidemics so as to decimate mostly the good guys? I strongly suspect so.

Brave Dr Khan
Let's talk ebola facts first. 

Meet Sheik Umar Khan, a national hero of Sierra Leone in their fight with ebola virus disease during the 2014 EVD outbreak, a person whom I admire, who among other brave health professionals gave up his life in this fight.
Consider, however, that the meticulous infection mitigation measures which Dr Khan always employed, eerily similar to the rightly celebrated case of another medical hero Matthew Lukwiya, 14 years before, did not protect him from catching this ebola virus
 
It's doctors, nursers and other carers 
who often are key contagion nodes in the EVD

In my opinion, such selfless doctors died, rightly shocking their fellow workers and their countrymen, and taking with them other doctors, nurses and patients to their graves, due to the wrong procedures employed, coupled with the dire lack of resources.

As I wrote in the other EVD posts here, fully trusting medical authorities is sometimes deadly dangerous. It brings death of you (the doctor), your colleagues, and your heretofore uninfected patients, which is even more tragic.

Analyze these bolded fragments from an interview with Dr Khan when he was still alive and kicking, yet probably already infected and asymptomatic:


“I make sure whenever I am going into the isolation unit I am in my full protective clothing, and I make sure my nurses are all in theirs” he said to me. “I even have a mirror in my office” he went on which he said served as his policeman which he salutes before getting into action to save lives. He looked at himself in it to be sure there were no openings to his protective clothing.

All his colleagues told me he was very meticulous with protecting himself. [Politico]

She resumed duty at the hospital on the 21st of July, while Patrick Sawyer was admitted at the hospital on the 20th. He was her first patient. She was one of the nurses that nursed him. She was pregnant and so her immune system was weak, which made it easy for her to contract the disease. On that first day which was a Monday, she was having some pregnancy symptoms, but I just encouraged her to go because it was her first day at work. Sawyer was her first patient. The next day, Tuesday, she didn’t work on Sawyer. Wednesday and Thursday, she was off. Then on Friday, Patrick Sawyer died. They didn’t know he had Ebola, it was three days later that they realized it was Ebola" he said. [Source]

[Professor David Heymann] told The Independent: “There has been a lack of international cooperation as to the recommendations of what needs to be done [to stop the disease spreading] – and much greater collaboration is needed.
“But at the same time its false to say that border controls can stop infections from spreading – you can be not showing symptoms or even travel when you have symptoms and keep them hidden, as has happened with doctors in the past.” [The Independent]

There are data that go back several decades—over several outbreaks—that suggest when you have individuals that have recovered from Ebola virus infection they may still be shedding nuclear material [genetic material from the virus which could potentially help spread it] in semen in males and vaginal secretions in females and also, potentially in urine. [USA Today]

And thus likely also on their hands etc. after they take a pee. 

So here is the smoking gun, the additional likely vector of Dr Khan's infection:

Dr. Khan: Indeed yes, they no longer have Ebola and in fact as a matter of fact these are people I embrace myself on the day of discharge because don’t forget the stigma about Ebola with some people you have to give them certificates so that by the time they return to their villages people will understand that they are no more suffering from the disease and they are free to interact with the population.

Politico: Are you concerned that Ebola in Sierra Leone and even the Mano River Union of Sierra Leone, Liberia and Guinea is spiralling out of control as Medecines Sans Frontiers has said.
Dr. Khan: Well I wouldn’t say it is out of control. Rather because as I am seeing it, I can speak for Sierra Leone.

[My comment: alas, the doctor was so wrong here. I know that hindsight is always 20-20, but he should have been alerting foreign media non-stop about the epidemiological danger resulting from the corrupt government not giving him enough resources. As another reporter noticed separately, Dr Khan was too reticent. Modesty kills here, too]

Politico: Well if you say it is not out of control, in under a month scores of people have been killed in Sierra Leone alone and most of them in the last two weeks. That gives one the impression that it is out of control.
[I love the reporter's questions here!]

Dr. Khan: In Sierra Leone,…usually when you have an initial outbreak you have cases coming in…the education we are giving our people will determine whether the situation is out of control.

Politico: Well you say a lot of those who died are women but also many of them who have died so far are health workers. Are you concerned that nurses are succumbing to this Ebola outbreak. Just behind you there inside the Isolation Ward, I understand there are five of your nurses admitted there for Ebola. Does this concern you?
[Very sensible, hard-hitting questions, Politico!]

So yes all what I am saying is there with our health workers somebody has to be vigilant, keep up your guard and make sure we all adhere to the universal precautions. 
[Implying that "it is their fault" ? Please, doctor - they did not even have enough gloves or chlorine in the end. It is the administrators', that is the Liberian government's fault]

Don’t forget the disease of itself is not airborne. That’s why I am proud. I am not afraid of working. It is all about contact, it is all about bodily fluids. If
"Body Fluids only": the poor doctor must have believed in this
we continue the same universal precautions then we could be in the better position to save ourselves. 
And if you are afraid of it you will take the maximum precautions which I am doing. If you neglect you don’t take your life important then you will ignore most of these personal protective equipment and you wouldn’t do things correctly. So having that at the back of my mind I make sure whenever I am going into the isolation unit I make sure I am in full PPE…I make sure they are on, make sure my nurses are all in the same PPE. In fact if you go and watch at my dressing room you would see what we call the mirror. The mirror here is the policeman. Even if you’ve certified me that I am okay I will look at myself again objectively, without somebody looking at me and telling me I am fine So we have that at the back of our mind. We are mindful of those facts making sure all things are deposited. If you look right above maybe it’s a bit not here, you will see the incinerator with smoke. So that tells you all those disposals are being taken care of. [Source: Politico SL]

Another reporter wrote this, when the doctor was still around:
His fight against Ebola has immortalised him. Yes I know he is still alive and will live for many more years. 
[No such luck. He died shortly afterwards, the poor soul]

But someone should tell him that the nation is praying for him. He deserves the prayer of all of us and for more reasons than one.
[Prayers to God do not help, remember: the more you pray, the more trusting and less careful you become. Sad, but that is the low-life God that we have to deal with here...]
And he is in God’s heart. With the blessing of the Holy Month of Ramadan, it shall be well with you, doc. You will return and we shall discuss this and laugh about it. Just lie on your side. [Source]

After death, he was lying on his side indeed, unceremoniously dumped in a mass grave, see the photo below and read this local reporter's harrowing testimony. 

Other field reports:


Fifty meters away from an Ebola treatment center I observed with awe how our nurses are risking their lives in saving those of suspected patients. With no protective gears on the nurses could be seen inspecting and taking medical history and details of suspected patients. According to some nurses I contacted, the area in concern was labeled a ‘low risk” area-they told me ‘they are mere suspects’.
Where these nurses unaware of the averse risk they have endangered themselves and that of their relatives and families? I keep asking myself. Do they really know how virulent Ebola is far? I wonder that. And as if to add some spite I keep receiving picture downloads of how our medics dress during the burial of an Ebola victim. I am yet to see them donning biohazard mask when conducting such burial-even those who buried late Dr. Khan didn’t wear biohazard mask. Perhaps someone may have told them that Ebola is not airborne and so a biohazard mask is not necessary. That could be the greatest medical fallacy in recent time. [Source
And one more voice from the frontline that ebola may be airborne and that hospitals contribute to spreading it by operating according to the official WHO guidelines:

And beyond these public health activities is the lack of the appropriate logistics in containing the virus. Are our nurses fully equipped to handle suspected as well as confirmed Ebola cases? We need not to callously look over this question just like but an introspective, nuanced and objective analysis is really needed here.
Let’s start where we should in the first place: of course the death of Dr. Umouro S. Khan-most hyped about as the country’s leading virologist and Ebola researcher. It is imperative we start there and keep asking ourselves: Did Khan do anything wrong professionally to warrant him losing his life to this dreadful Ebola. Was he a careless medical doctor? [...]
Kenema Government Hospital is a Biosafety Level 2 research center and its location in fact has compromised the public health safety of the entire nation. Located in the heart of Kenema Township with a population of loosely 520,000 or more, the Lassa fever laboratory is high public health risk for Sierra Leone. [Source]
Ebola burial:
reality on the ground


More about airborneness. Do you remember this quote from the CDC July 2014 guidelines, quietly removed from their website now?:

[...] all persons, [...] who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. [archived source]

Here is my other post more about the CDC and their real internal Biosafety Level 4 containment operations when ebola is at stake. Such precautions should be universal.

Also, do you know how clued-in First World doctors, who survived ebola outbreaks, treat such artifacts as medical notes, taken afterwards in a separate room, after donning off the PPEs? Read this:

Some methods avoided taking any objects out of the filovirus [that is: ebola etc.] disease ward: Clinical notes were recorded by memory once outside the ward (n = 6 interviewees); clinical notes were dictated to a HCW on the other side of the fence (6); clinical notes were held up at the fence and then photographed (5), manually copied (2), or entered into a laptop computer (1) by a HCW standing outside the fence.
Other methods avoided taking paper forms out of the filovirus disease ward but involved taking other objects out after disinfection: Patient records were photographed inside the ward with a digital camera wrapped in a plastic bag, which was disinfected by chlorine before taking it out (1); a designated laptop was used inside the ward for data entry, sprayed with chlorine solution, and taken out at the end of the day (1).

Methods used in BSL-4 Laboratories in Europe

Methods included data transfer via fax, Internet, telephone, or voice activated dictation machine. In developed countries no paperwork was removed from isolation areas. Source


Now, let us go back to Africa.


Dr. Mohamed A. Vandi at the Kenema Government Hospital said: [...]"This is an excellent hospital with the required equipment to handle such cases. Dr. Khan and his team are working hard to save lives in Sierra Leone," he said.

[AllAfrica]


She added, “You are asking, ‘Who is next?’ ” In all, some 22 workers at the hospital died.
The nurses and doctors here had banked on their experience treating Lassa fever, another deadly disease that causes bleeding. But Ebola is of a different order, and they had never seen it before.
With the first cases, the nurses simply used their Lassa goggles. Ebola demands a far more protective face shield. They also used “light gloves,” Ms. Sellu said. Now, she puts on two layers of heavy-duty rubber gloves. The inadequate initial precautions had fatal consequences, even for the revered young doctor who headed the Lassa unit, Dr. Sheik Umar Khan.
“Such a careful man, always saying, ‘Don’t do this, don’t do that,’ ” Ms. Sellu said. “That is the mystery.” Dr. Khan died on July 29, a huge blow to the nation.
[Source]


Health Care Settings. Without trained staff, isolation units, personal protective equipment, and strict infection control, hospitals have become “amplification points” for spread of EVD, placing health workers at significant risk; approximately 140 African health care workers have been infected, with 80 deaths.10 The high risk incurred by workers, often with inadequate salaries, has compounded a severe human resource shortage. There are numerous ethical dilemmas, such as whether health professionals have a duty to report to work without adequate personal protective equipment.
[source]



July 26 -- Brantly and Nancy Writebol, a missionary serving as a personnel coordinator for SIM, another medical missions organization, are confirmed as having Ebola, according to Ken Isaacs.
“He [Brantly] is such a meticulous physician. He does everything almost to perfection. I just couldn’t believe that he had gotten it,” Furman recalls. [Source]

Also, you can harbour and infect with ebola even when you are not symptomatic, that is when you do not have any fever

Firstly, there always are some "ebola Marys*", that is asymptomatic carriers.
 
The Ebola virus, which has caused deaths from high fever and bleeding in African outbreaks, can also infect without producing illness, according to a new finding by African and European scientists.
The possibility of asymptomatic infection was only suggested in earlier studies, they said in last week's issue of The Lancet, a medical journal published in London. Now they said they had documented such infections for the first time. They found that the Ebola virus could persist in the blood of asymptomatic infected individuals for two weeks after they were first exposed to an infected individual. How much longer the virus can persist is unknown.
[Source]

 

During both outbreaks we identified some individuals in direct contact with sick patients who never developed symptoms.



FINDINGS: 11 of 24 asymptomatic individuals developed both IgM and IgG responses to Ebola antigens, indicating viral infection. Western-blot analysis showed that IgG responses were directed to nucleoprotein and viral protein of 40 kDa. The glycoprotein and viral protein of 24 kDa genes showed no nucleotide differences between symptomatic and asymptomatic individuals. Asymptomatic individuals had a strong inflammatory response characterised by high circulating concentrations of cytokines and chemokines.



INTERPRETATION: This study showed that asymptomatic, replicative Ebola infection can and does occur in human beings.

Here is another, British this time, nurse who had been happily hugging ebola survivors, before he quickly fell ill with ebola himself:
William Pooley hugging local people
who have recovered from Ebola in Sierra Leone
Recovered, but ...




Fever considered as
a sine qua non for an ebola diagnosis - wrong!
Secondly, you can be so weak, in the death throes already, that, unintuitively, you do not have elevated temperature and your ebola tests show nothing. 

Yet the official ebola triage criteria, see the official advice to the right, assume it, it reads: "Case definition: FEVER +" everywhere. 

This workflow is consistent with the (misleading) guidelines given by the WHO in their operating procedures given to Liberian hospitals
A  person  can  incubate  the  virus  without  symptoms  for  2-­-21  days,  the  average  being  five  to  eight  days  before  becoming  ill.    THEY  ARE  NOT  CONTAGIOUS  until  they  are  acutely  ill. 
Only  when  ill,  does  the  viral  load  express  itself  first  in  the 
blood  and  then  in  other  bodily  fluids...

[source

Listen, WHO: they bloody can be contagious before they become gravely ill, without any symptoms, and sometimes even after the symptoms subside and after they are declared free and safe to return to their communities with a clean bill of health!

A man had arrived late one night, panting and with abdominal pain. During the previous few days, he had been treated at two private clinics, given intravenous fluids and sent home. The staff did not suspect Ebola because he had no fever. But fever can diminish at the end stage of the disease. The man died two hours after arriving. Tests later showed he had been [tested] positive for Ebola.  Untold numbers of health care workers and their subsequent patients had been exposed to the disease.
The resulting unsuspected cases, appearing at hospitals without standard infection control measures, worsened the spread in a “vicious circle,” Dr. Mardel said.
[Source]

The latent period before symptoms appear tends be around 8-10 days. It is therefore likely that in the coming couple of weeks the cases will rise, from contacts of the previous patients, and our work and lifestyle will need to change to meet the challenges this brings.
[source]

The fact remains that there seems to be two types of Ebola patients - the well and the unwell. I was ready for the pitiful sight of grown men weakened and dying, to see people wilted from profuse diarrhoea and external bleeding. And of course I saw those haunting sights, but I also found groups of young people sitting around talking and eating together, listening to the radio and playing cards. This was the other face of Ebola, the surviving class.
[source]
Want some more?

Officials said Thursday that a man working for the Economic Community of West African States [infected by Patrick Sawyer] recovered from an Ebola infection without treatment [after running away], but that his doctor [who also ran away] died last week from the virus. Source

That is: yet another reckless ECOWAS official, Nigerian this time, fell ill, infected God knows whom including one doctor dead by now, and lived to tell the tale. (Read my update about this vile case of his Liberian ECOWAS colleague here.) 
Speaking of the patient, Chukwu said, "One of them is a primary contact of the index case (Mr. Patrick Sawyer). Even though presently he does not have EVD but further laboratory tests indicate that he had suffered EVD."

Some of the necessary ebola tests: are all performed at
In plain language: there was a FALSE NEGATIVE ebola test which caused God knows how many new infections, after official denials. Read more about false negatives in my other post here.

"The more time you give a virus to mutate and the more human-to-human transmission you see," she says, "the more opportunities you give it to fall upon some [mutation] that could make it more easily transmissible or more pathogenic."...
The virus has been spreading through human-to-human transmissionnot through humans eating infected bush meat (wild game) as was first thought. Source

Let's analyze the sad story of Dr Patrick Nshamdze, the Hospital Director.

I reconstructed the key dates here:


2 July - Patrick Sawyer's pregnant sister died in JFK hospital of ebola, infecting staff and her infamous brother, who were not aware of her illness.

Around 8 July - Nshamdze contracted ebola and was asymptomatic for a week.

15 July - Nshamdze got sick. Nobody suspected a case of ebola in a doctor, so he kept on working and infecting staff and patients.

18 July - negative (false) ebola test. Nshamdze kept on infecting colleagues, as "science is always right". *

29 July - the doctor was tested again, with a positive result.  He was relieved of his duties, transfered to another hospital.

Official burial site of ebola victims
in a Liberian neighbourhood
1 August - Nshamdze was dead.

Around 3 August - the doctor's body is hastily deposited in this dump of a shallow watery mass grave, see the actual photo of their burial ground here:



* Press reports with details: 

“Based on this result, the other sisters and brothers decided to nurse him back to health. Despite their treatment, he progressively began to show signs and symptoms that were typical of Ebola [...]
But he was also in denial and because of that, did not show the true outcome of the first test that came out positive. But, how a negative result was pronounced that came back two weeks later as positive is still a puzzle that Liberians are trying to piece together
[...]
Sources tell FrontPageAfrica that after the result came back negative, the Catholic brother told his colleagues that all was well and they kept caring for him because they felt he was suffering from a heart disease that was his known medical condition. It was when a second test was done on him that came out positive after he tried to leave the country while critically ill did his colleagues begin to cut off contact with him but it was too late. He died on August 2, 2014 and the death roll continued after that. [source]

Among the corpses deposited there is that of the late Dr. Patrick Nshamdze, 57, who expired on August 1, 2014.  He was a Cameroonian and the Chief Administrator of the St. Joseph’s Catholic Hospital in Congo Town, Monrovia. 
Others include: Vivian Pewe, 24; Joyce Paul, 28; John Forkpah, 27; Musu Johnson, 39, Sister Shalor, 35; Gerald K. Kollie, 45; Joe Gbozeh, 50; Mercy Dahn, 35; James D. Paul, 35; Joy Moses, 58; Augustine Jalo, 45; Isatu Joe, 20; Mamie S. Kparteh, 29; and Edward K. Brown, 63; Lusu Fayia, 60; Hawa Sirleaf, 24; Krubo Carter; 17, Korpo E. Kollie, 25; and Kollie Klemie, 60; among others. [source1 source 2]

So for around 2 weeks he himself was unwittingly infecting other carers, because of his denials:

“They had trusted us and our ability to manage the Ebola response; we cause all of them to be infected. After serving this country for over 40 years and saving thousands of lives, is this the way we could repay them. As the ambulance made its way out of the deserted hospital with the first badge of two nuns, I became too overwhelmed with sorrow. The ambulance was returning for four of them, including a medical doctor. How could we have disappointed them.” Source

The new patients sometimes arrive eight to an ambulance, those with suspected cases and those with probable cases all mixed together. We've given the ambulance drivers basic PPE to distribute to patients, but they're afraid to get close enough to hand it out.
source


Four men sit on plastic chairs waiting to be tested for the disease. Surrounding them are confirmed Ebola patients, walking around the packed dirt square getting exercise. One man collapses on the ground, unable to walk and appearing near death. Leaning against the wall is a woman who just died.
Those admitted to the unit who don’t have Ebola will surely catch it. Those already diagnosed with the disease are just waiting to see if their bodies will fight it off. 
...
No physical contact with the patients was allowed. If a patient collapsed, they would have to wait until someone in proper gear was available to help.
...
Behind the triage tent was the isolation ward, where patients were waiting to die or survive. The scene was apocalyptic. I asked the security guard if he was scared. "No," he replied. If an Ebola patient comes near him and tries to touch him, he runs. He showed me where he once knocked down the fence running to escape. source

The issue of personal safety and that of his colleagues was a concern for Will [the British nurse]. But the possibility of becoming infected just did not seem like an option for him. He assured me at one point that "the PPE that we wear protects you against Ebola, full stop really. If you wear it and you don't make any mistakes and everything is done properly then you will never catch Ebola when you are working." 
He also said that he did not take the same risks that his colleagues had taken. "I operate very differently to local nurses. A simple example is that it's very normal for staff to eat onsite in a moment of going in and out of the ward. I don't do that. So I'm protected by circumstance in some ways and also I'm a lot more afraid than the local nurses so I take more precautions." [source]
And then he caught ebola.

It reminds me of this discontinued medical practice: 
For example, there used to be a belief that patients who had bacterial sepsis did much better if you gave them high doses of steroids. Now we know that these may be detrimental instead of beneficial. We know now since we’ve done the studies. [source]

Given that proper ebola tests, which can take days, are so unreliable, these "medical checkups" at the airports are theatrics. 

Screening of passengers at points of entry (arrival or departure) is costly and expected to have very limited impact because it is very unlikely to detect any arriving person infected with EVD. This is particularly true for EVD with its incubation period of 2 to 21 days and symptoms that are not specific. As part of this, the use of thermal scanners that rely on the presence of ‘fever’ in arriving passengers is costly, unlikely to detect any arriving person infected with EVD and is not encouraged. [WHO report from April 2014]

Worse still, these cursory checks are sometimes wrongly treated by the authorities as a clean bill of health, see the Patrick Sawyer's case, who himself, and his sister, incidentally were treated in the very same hospital, closed by now.

One ex Sierra Leonian provides an interesting take on another possible vector of infection: walking barefoot. Although he is living in the USA now, he speaks from experience: a sad story of his childhood is told in his contribution. 




Are you convinced by now that God is devious?  If not yet, read another MSF field
Ebola God aka Kali, by Jade Needles
report to see how vicious, scheming and cunning she gets during this EVD outbreak.

Or maybe it is the opposite? Nature is merciful and wants to kill us, the Earth's parasites?

Let us savour again Preston's prescient take on ebola and similar viruses:

"In a sense, the earth is mounting an immune response against the human species. It is beginning to react to the human parasite, the flooding infection of people, the dead spots of concrete all over the planet, the cancerous rot-outs in Europe, Japan, and the United States, thick with replicating primates, the colonies enlarging and spreading and threatening to shock the biosphere with mass extinction. Perhaps the biosphere does not "like" the idea of five billion humans. Or it could also be said that the extreme amplification of the human race, which has occurred only in the past hundred years or so, has suddenly produced a very large quantity of meat, which is sitting everywhere in the biosphere and may not be able to defend itself against a life form that might want to consume it. Nature has interesting ways of balancing itself. The rain forest has its own defenses. The earth's immune system, so to speak, has recognized the presence of the human species and is starting to kick in. The Earth is attempting to rid itself of an infection by the human parasite. Perhaps AIDS [and now Ebola] is the first step in a natural process of clearance."
Preston: The Hot Zone, 1995

  1. Maintain humanity under 500,000,000 in perpetual balance with nature.
  2. Guide reproduction wisely — improving fitness and diversity.
  3. ...
  4. Be not a cancer on the earth — Leave room for nature — Leave room for nature
Georgia Runestones, 1980

Humans have overpopulated the Earth and in the process have created an ideal nutritional substrate on which bacteria and viruses (microbes) will grow and prosper. We are behaving like bacteria growing on an agar plate, flourishing until natural limits are reached or until another microbe colonizes and takes over, using them as their resource. In addition to our extremely high population density, we are social and mobile, exactly the conditions that favor growth and spread of pathogenic (disease-causing) microbes. I believe it is only a matter of time until microbes once again assert control over our population, since we are unwilling to control it ourselves. ... We need to make a transition to a sustainable world. If we don't, nature is going to do it for us in ways of her own choosing. By definition, these ways will not be ours and they won't be much fun. Think about that.
Eric Pianka, 2006
”[Disease] will control the scourge of humanity [...] We’re looking forward to a huge collapse. [...]  We’ve grown fat, apathetic and miserable, ... [we are a] fat, human biomass[...] AIDS is not killing off the surplus human population fast enough[...] Ebola [is needed] to kill 5.8 billion of the world’s 6 billion plus humans.
Eric Pianka, before being reported to and interogated by the FBI, 2006



We may thus not need evil God (whom I believe more and more to be Kali, the Destroyer) or another Ted Kaczyński to restore environmental balance via simplification, the Coming Anarchy. We can count on Mother Nature herself to heal the Earth, getting rid of most of us, humans: the infectious and self-destructing vermin that cruelly pollutes her.

Verbum sapienti sat est.

Read my other ebola posts, to find out about other subterranean developments in this long-overdue process.

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