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.