We Should Have Seen This Coming

That is all that needs to be said about the recent Ebola crisis in the United States.  Not a crisis of infections, but a crisis of missteps, over-reaction and ignorance brought on by a complete lack of foresight.  We should have seen this coming.

It is no secret that US hospitals have an infectious disease problem.  We have a rampant epidemic of C-diff MRSA, and other antibiotic-resistant infections that are acquired in hospitals.  We tolerate a background of hundreds of thousands of these infections, which result in longer hospital stays, more intense medical procedures, and, in some cases, death for these patients. Up to 30 percent of these infections are acquired in the intensive care unit.

Efforts to reduce these infections have not yielded good results.  Decreases are often seen in hospitals that establish intensive efforts to raise the awareness and supply incentives and goals for staff to do better.  But these efforts vary from hospital to hospital and are often short-lived, as there are no federal requirements for hospitals to address the issue. Thus, despite an awareness of the problem, the number of hospital-acquired infections remains unacceptable.

Knowing this, it is difficult to understand why the US health care system did not prepare itself more effectively for an Ebola patient.   This would mean much more intense care to identify such patients, to limit public contact with the patient,  and more intensive cleaning and disinfecting procedures plus the use of specialized equipment, including proper protective suiting for health care workers.  Ramping up all of these procedures, and keeping them elevated and at top of mind is essential to contain an outbreak of any infectious disease, but somehow, many hospitals did not do this for Ebola.

Granted, there are some hospitals where cutting edge, state-of-the art readiness is embedded in the hospital DNA.  For example, had Mr. Duncan gone to another Texas hospital, say Baylor, he might have been identified right away as being at risk for Ebola, isolated and given appropriate therapy from appropriately protected health workers.  The system would have worked, and Ebola would have been contained.  Public confidence in our system would be maintained.

But because Dallas Presbyterian Hospital was not prepared, they began a series of missteps and  unfortunate actions that started a snowball of distrust and ultimate, caused the US citizenry to lose confidence in the health care system. This perceived failure caused the public to act irrationally and become subject to rumor, political manipulation and panic.

In my opinion, CDC was just as at fault as the hospital.  Instead of checking to see if hospitals were preparing for Ebola, the CDC made blanket statements filled with false assurances.  No Americans need to be concerned about Ebola, was their blanket message to not only the US population, but to the world. Americans have the best health care system, we are so much more prepared than the West African countries, our hospitals will nip this disease right in the bud.  They said this without any real knowledge of actual preparedness the ground.

I rarely use or tolerate the use of the words "Ivory Tower."  But they have hardly ever been  more appropriate. The CDC was so disconnected with hospitals that it didn't know what many of them had not distributed a single word on Ebola to the staff; that most of those that did merely sent out an email with a link to CDC guidelines but never ensured that patients read them; that most hospitals had not held hands-on Ebola training; and that many of them did not have appropriate protective gear in stock; nor had they followed through to ensure that they had appropriate waste collection and transportation procedures.   Indeed, the CDC later found that their guidelines were inadequate for the situation, even if followed to the letter.  The real problem with the CDC is that they didn't check out the situation on the ground, thus giving false assurances which, when they didn't pan out, shook the public's confidence in the US public service's ability to prevent an Ebola outbreak.

I can understand the bigger picture that the CDC was, perhaps, trying to convey.  It is true that West Africa has a devastating situation going on, and that with our vastly stronger health and communication infrastructure, the US  is not facing an outbreak on anything even approaching that scale.  The problem with the CDC is that their optimistic public face was not matched by the behind-the-scenes reality.  And when the Dallas fiasco revealed the true situation "behind the curtain," the public immediately lost faith in the health care system that it was relying on to keep it safe.

Matters were not helped at all when a nurse and a technician with potential exposures, instead of staying put during their incubation period, decided to take air and boat travel, putting others at risk.  This not only drew their own judgement in question, but caused the public to doubt that state and local health officials could keep control of the situation.

And it also didnt matter that the CDC is actually not actually in charge of health in the states, that the state public health service should take the lead.  The public's perception is that the CDC takes care of it all.  The fact that Republicans, ever seeking a way to cast aspersions on President Obama, who was leading the effort to provide funding for West African Ebola care, laid the blame at the federal level.  American citizens thus perceived the Ebola crisis in the US was being led by the President and the CDC, and they were not advised of their mistake. The CDC continued to appear on national television saying there was nothing to fear.    Republicans continued to stoke the fires by conjuring up images of Ebola-infected Muslims sneaking over the Mexican border to blow themselves up in crowded shopping centers.

In reality, those who are involved in health care know, or should know, that the risk of a wide-spread epidemic of Ebola in the United States is low, even given the missteps that occurred (or despite them.)  However, the average person in the United States is not a specialist in epidemiology.  In fact, the average American learns very little about health as they go through school, and those who attend college can skip the health-related electives.  Much of what Americans learn about health comes from word of mouth, from friends and family.  We might visit a doctor about a specific complaint, where we get information about that specific complaint and little else.  Indeed, a vast amount of what Americans find out about health is fed to them through television advertisements for products and pharmaceuticals.  Right now you would think everyone has erectile dysfunction, a-fib not caused by a heart valve problem, and bladder control issues.  We have a public health service that is focused on treatment, and not prevention, and that is a bigger subject than can be dealt with in this blog.

What also became very apparent from this episode is that the CDC did not look at the two realities in the United States and West Africa and think, there but for our infrastructure go we. Without the infrastructure enjoyed by the United States, we  have much of the same response to Ebola. Every household, indeed almost every person has a telephone in the United States, so that we can be notified of where to go and what to do.  We have the internet so that we can look up and receive accurate, timely information on infectious diseases and our risks.  We have hospitals with many beds serving every community.  We have hundreds of highly trained doctors and nurses.  But take these away and we are just like those facing Ebola in Liberia or Sierra Leone.

We have the same suspicions and fear.  Many citizens, and even health care professionals have fled Ebola in West Africa..  Many people with sick loved ones are afraid to take them to hospitals because so many die there. Contact tracers have to search houses to find the sick, and many are driven away by mobs of angry people without knowledge of how important contact tracing is to containing the outbreak.  In the US, no one wants to go to Dallas Presbyterian Hospital. Angry groups of people gather on the streets and wonder why no one is telling them anything .  People run in and out with space suits on. Television crews appear on the street corners.  Newspaper reporters refuse to broadcast from inside Dallas Presbyterian Hospital, and network television anchors described themselves as "scared."

Why is it that those who have compassion on those in West Africa who flee from Ebola and hide the sick but have no tolerance for Americans who are just as afraid? Just because the United States is more powerful as a country doesn't mean that the population is super human.  It doesn't mean we are more educated on health than those of other countries.. Obviously, people were scared, no one was in charge, and those with Ebola exposures seemed to be running about the country (or the world) at will.  The fact that these are health professions who "should" know better gives us all an idea of the knowledge of the general population.In fact, it seems  presumptuous, arrogant and somewhat stereotypical  to think that Americans are somehow inherently able to handle an Ebola out break better than West Africans, especially if you don't know whether the structure that gives them an advantage is actually in place.

I think that some people thought that any attempt to deal with American cases would distract attention and resources that should be directed toward Africa.  It is true that there would be no threat to the US if the Ebola outbreak were contained in Africa.  However, the greater need does not negate the lesser need.  We needed to pay attention to both.

So in the end, we had to transfer the Ebola patients to one of four hospitals that have proven they can take care of Ebola patients without causing further infections.  The final straw was the appointment of an Ebola czar, followed by a plan to have the military step in and ensure that hospitals follow correct procedures if there is another Ebola case.  This is unacceptable, and embarrassing.  The Republicans should feel an even deeper shame for taking advantage of the situation to further their political aims.  This cannot be forgiven.

No truer words have been spoken than those of the character Kay in "Men in Black".  "A person is smart. People are dumb, panicky, dangerous animals and you know it."  The failure of leaders in our health care system to understand this led to widespread panic over three cases of Ebola.  I wonder if they have learned any lessons here that can be applied to future threats, such as SARS, which, unlike Ebola, is airborne and easy to catch.  Surely we can see that coming.

It is Mental Health, America!

So many theories are going around about the recent killings in California by a disturbed young man who was purportedly seeking revenge for a number of things he was feeling about life.  These theories range from “this is the legacy of the NRA” to “this is what happens when we hand out drugs to people” to “this is what men do when women don’t respond the way men feel they are entitled to.”  My own theory about this killing and many of the other mass killings that have happened in the past few years is that our understanding of mental health issues is just abysmal, and this latest event shows that we are not making progress.

We as a country need to figure out how to better understand how the brain works, what is going wrong with the brain when mental illness develops, how to diagnose and scale mental illness, how to better predict outcomes, how to better treat mental illness and, most importantly, how to influence society so that mental illness is seen for what it is—a set of disorders that are caused organically or as a result of an injury that needs to be diagnosed and treated.  And within the context of this societal understanding of mental illness, we need to both protect the privacy of the patient and the safety of the public.

A tall order?  You better believe it.  Mental illness is not something we can tackle easily.  It is both complex and time consuming.  We have not had the will to address mental illness as a nation since Rosalynn Carter made it her special project during the Carter Administration. 

Yesterday, I was struck by the number of groups that had latched on to the latest mass murder and started using it for their pet gripes—gun access blamed on the NRA, pursuit of control of women, and our propensity to hand out drugs with serious side effects to youth.  I believe these are red herrings and side shows. 

Access to guns by the mentally ill is only a sidebar to the main problem here.  This is still an issue that could be addressed through a background check.  But we do not yet have the information we need to provide accurate guidelines on which mental illnesses can lead to violence, or to measure patients's propensity toward violence on any scale.  Privacy is very important right to most Americans, and with more advanced science and knowledge  we can better sort out those whose mental illness carries a potential for harm.  We are far from this.

Another thing I noticed in my readings about the recent events was the number of cartoons and comments that called the mentally ill “whack jobs,” “nut cases” and “loonies.”  This is certainly not helping and it is thinking that harkens back to the Middle Ages.  I can remember when people talked in whispers about a cancer diagnosis, and kept it so quiet that even close family members didn’t know.  We have a long way to go before mental illnesses, even mild depression, does not carry a social stigma.  This hampers treatment and it also drives the need for stringent privacy laws.   

It is doing absolutely no good to sidestep the issue.  We need to realize that the only thing the last 10 or 50 or 100 of these incidents have in common was that the perpetrator was mentally ill.  Many of these were getting treatment, and that alone should tell us a lot.   Our mental health system needs help.   What makes us so unwilling to acknowledge that it is mental illness that is driving this mass murder train? 

  

I am not a mental health professional, but even I can see that there is something wrong here that isn’t being addressed.  Maybe we are willing to put up with 6-year old children being mowed down in their classrooms, students murdered in their apartments, and movie goers being sprayed with bullets as just background noise.  Many of us don’t really know what to do about it.  Most of us feel distanced and powerless.  We need a mental health champion.  More than that, we as a nation need to wake up to the 800 pound gorilla in the room.   Because I hear a lot of things about these killings, but I sure as heck don’t hear anyone calling for a new focus on mental health.

Climate Change: Does This Have to be the Way the World Ends?

I have been thinking I wanted to put a small sheet of facts together about climate change to show some people who refuse to believe it is happening, and then I thought, what is the use?  The people I would hope to convince with mere facts would toss them aside like popcorn.  "Don't muddy the waters with facts, I want to bask in the clear waters of denial" is the mantra that these people breathe daily.

When people didn't understand thunder in ancient days, they made up plausible stories to explain it.  Bowling pins crashing around sounded like thunder, so explaining the sound by imagining sky god Thor going bowling. Then they weren't scared, they didn't have to go out and investigate, and they didn't have to worry about it.

This is the same reaction I see among those who deny climate change.  If they are worried in the least when they hear about it, on the next cool day they feel assured that it is all someone's imagination.  And if it snows, they can even laugh at those who believe that the earth is heating up.  And once they have made this connection, they don't have to worry about it any more.

But what the ancients, and the modern naysayers forgot, is the lightning.

We have to deal with the lightning.  No matter what we think of the thunder, lightning is another story.  It is scary, it is hard to understand and it is out of our control.  The best we can do, these nonbelievers say, now or in ancient days, is to close our eyes and ignore it and pretty soon it will be gone.

In ancient days, the citizenry did just that.  Whether by hunkering down, trying to hide, seeking shelter, and lying flat, they learned the ways to protect themselves from lightning.  Today, we use some of the same methods to deal with evidence of climate change--ignore it, deny it, wait for it to pass--but the lightning in this case is not just electric current in a passing storm, it is myriad problems associated with climate change that range from heat waves to pestilence, from drought to floods.  These problems create lasting damage--and have the potential to grow worse with each passing year.

Unfortunately, many of us in the United States do not care what happens outside of our realm.  If flooding occurs in Bangladesh, or polar bears begin to starve when the ice melts, we click our tongues and if we think at all about it, we think about how glad we are that we aren't Bangladeshians, nor are we polar bears.  We do not make the connection that the cause of these two tragedies are global in nature.  The same heat that is melting the arctic ice is the same heat that is contributing to the rise in sea level, that affects not only Bangladesh but all who inhabit coastal regions.   That means us, particularly the 60 percent of the US population that lives on the East Coast. In 2013, the National Oceanic and Atmospheric Administration declared that the Atlantic Coast of the United States was the most at risk from climate change-related sea rise.

Even on the verge of this calamity, the cold snap that hit most of the United States this past winter has driven many of the climate change deniers back into their comfortable fact-free zone. And anyway, they rationalize, if the worst, happens, I'm safe.  My family is safe.  We will just move, or purchase more heat in winter, and we could hire someone to shovel our walks, or clean up storm damage in summer.

Famed climate change author and activist Bill McKibben, in a 2013 speech, said something that has stuck with me since.  He listed the dangers the United States is facing as its share of climate change, including super storms, floods, increased heat wave and asthma deaths, drought, and increased vector-borne illness.  And he confirmed--yes, he confirmed the nay-sayer's position.  The US is smart, he said, and the world is smart.  It can figure out how to adapt  to these things.  However, he continued, climate change is not going to stop at blows we can absorb.  It is the things that we cannot adapt to that we need to be worried about.  "We must prevent that to which we can not adapt," McKibben said.

"That to which we can not adapt."  Those words are very scary.  Climate change is moving on, even if we are not.  If naysayers in the US continue to stall, to make excuses, and to deny climate change, our goose is going to be, literally, cooked.  The temperature of the Earth's atmosphere is already at the point of our being able to absorb the blow.  Some say it is way beyond that.  But I like to have hope.  Many scientists say that by making drastic changes now, we can stop climate change before this occurs.    So why are we still standing around, wringing our hands and twiddling our thumbs?    As we continue to put off any action to save the world, I have to think that T.S. Elliot predicted our response in his poem, The Hollow Man.  You know how that ends.

Republicans, Here is What America Wants

Republicans, This is what America Wants
I saw a really interesting discussion yesterday with a whole host of Republican leaders and they were tripping all over themselves to try to explain what happened this election.  They all blamed demographics, and even the interviewer agreed that the republican leadership needed to look at themselves--all white men except one white woman--and that they needed to be more diverse as a group.
But my view is that the Republican's ideas, and not their looks, are the problem.  It won't be any better to have a Black, Asian, or Hispanic Republican spouting the rhetoric we have heard over and over again during this election cycle.  So Republicans, here is some advice:
1)  America is diverse, and each factor by which we are diverse also has diverse elements,  so stop trying to lump everyone in an ethnic group together and thinking that there is one thing  that you can offer that will get all of their votes. 
2)  Stop thinking that Republicans are the arbitrars of who is patriotic.  Americans of all ranks and walks of life can be patriotic, and the measure of patriotism is not whether a person adheres to the Republican Party Platform.
3)  Stay out of the bedroom.  Most Americans can handle these issues themselves. No one is asking you to do what they are doing, so just don't do it.  But dont try to prevent others from doing it.
4)  Walk the walk.  If you want to espouse your views, make sure you live up to your views.  Nothing turns out worse than someone who is caught being a hypocrit.  Don't condemn others if you have skeletons in your closet, they will surely come out. 
5)  Please dont act like you are the only ones who believe in God.  There are a variety of interpretations of the Bible and what the word of God means. You don't have a lock on it. 
6) Realize that many people who have done well financially and socially come from poor families and backgrounds that wouldnt necessarily predict their success.  The reason they can do this is that this country offers opportunity for all.  Restricting opportunities and failing to encourage and help people from these groups is actually NOT the American way.

More on Limbaugh and Men in Politics

I am not finished with my thoughts on Rush Limbaugh and his horrible attack on the Georgetown student over the birth control issue. 

First is his ignorance.  I noted to my husband, and was glad to see that Rachel Maddow picked up on it as well, that Rush Limbaugh's rant indicated his ignorance of women's reproductive process.  The fact that he thought that prescription on birth control for women is only expensive if we have a lot of sex means that he doesnt understand that birth control pills are taken only once a day, not before or after every episode of intercourse.  And the fact that he doesnt seem to understand that women's birth control is a prescription drug, not an over-the-counter medication, and therefore deserves to be covered under any insured person's health plan that includes prescription drug coverage, doubles his ignorance.

Secondly, the fact that Rush Limbaugh added the suggestion that the student film her sexual episodes is not only grotesque, it is an attack on women.  It is this type of intimidation that riles me most.  If women want to have sex, and use birth control, now, they must film the episodes and post them on YouTube.  This shows exactly the type of person Rush Limbaugh is.  The fact that he added this bit shows that intimidation of women is high on his arsenal of ways to keep women "in their place." 

Third, Limbaugh's apology is as phony as a three dollar bill.  It is clear to me that he only apologized after his sponsors started taking flight, and kudos to them if they mean it and stay away.  His apology was no apology--it was a feeble and unbelieveable attempt to state that it was the choice of words, and not the context, intent or message that was despicable.  The fact still remains that Limbaugh chose to call Ms. Fluke hate-filled names, and that was not merely a choice of words.  The fact that Limbaugh linked women's birth control with promiscuity was deliberate.  The fact that he further demanded to see the videos was not a poor choice of words but a reflection of how he thinks.  The apology that Limbaugh should have made would have been for thinking these mysogenistic thoughts and then putting those thoughts into words in an attempt to cast aspersons on Ms. Fluke and all women who demand fair and equal treatment. 

Fourth, it bothers me tremendously that Rush Limbaugh and others of his ilk have such a large stage in America today.  Sure, he is an entertainer, but most people believe he is a serious politician.  His job is to make outrageous statements and to stir the pot in order for people to tune in to his fireworks.  Many see Limbaugh as "giving it to the liberals."  Many of them are willing to accept his outrageous positions, no matter how extreme.   But do politicians have to be held in his sway?  Cant the republicans repudiate him as a sideshow?  I believe George Will is correct--Republicans are afraid of Rush Limbaugh.  Note how late and how hesitantly those few that repudiated his comments actually did so. 

I hope this attack on women from Rushbaugh, which was only half-heartedly repudiated by republicans will serve as a warning to those in our country who believe women's rights are safe.  First is the ignorance, secondly, the intimidation and character assassination, third, the failure of fair-minded individuals on the right to speak up--all these show that women's rights are not entrenched--they were hard won, and the fight to keep them still goes on.  If this doesnt serve as a wakeup call to voters in this election year, I dont know what will.

Tornados and Limbaugh

My heart goes out to the people who lost loved ones/homes/pets/livelihoods in the tornado outbreak in the midwest.

I hope that the outburst by Rush Limbaugh made this week costs him dearly.  Im so pleased that the four sponsors withdrew their support of his radio show, but am very disappointed that it took that for him to cease his attack.  What is wrong with people who listen to Rush Limbaugh? 

In other good news, its growing season in Virginia, and time to get back out in the iris garden.  Yippee!