Public health lessons from the Ebola crisis: America’s healthcare stumbles

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Ebola relief / Photo: European Commission DG
Ebola relief / Photo: European Commission DG

MONTGOMERY VILLAGE, Md., October 15, 2014 — News of yet another American Ebola victim has dominated the news today. The fact that America’s sophisticated health care system has shown such serious chinks in its armor is of concern to all of us.

Those chinks began to show up from the appearance of the first Ebola patient on American soil. A Liberian national, Thomas Duncan, came into a hospital in Dallas — the Texas Health Presbyterian Hospital — exhibiting symptoms of Ebola. He informed the receiving staff at the hospital of the fact that he came from Liberia. This information was ignored. He was sent home with antibiotics.

Why wasn’t Duncan hospitalized and quarantined immediately, and precautions taken to prevent the spread of the infection? Cynics would say that because he was from a foreign country and without health insurance, he received a different standard of care than he would have otherwise.

Four days after Duncan was sent home, he reappeared at the hospital in worse shape. He was then hospitalized, but not before having to wait in the emergency room with other patients. According to media reports, he was not immediately given the proper treatment, a fact that may have contributed to his demise a few days later.


It gets worse. Since Duncan died, two of the health care workers who took care of him have been diagnosed with Ebola.

The head of the CDC claimed that the first healthcare worker infected had not used proper protocol when donning and taking off protective equipment. In a subtle way, this put the blame on the person and not the system. The second healthcare worker diagnosed had, after the death of Duncan and the Ebola diagnosis of the first nurse, flown to Cleveland and back to Dallas. One has to wonder about her judgement. She has been transported to a specialized hospital in Atlanta.

The nursing organization National Nurses United has responded that nurses are subject to managerial orders and have little leverage until there is a crisis. They have complained that decisions are made or heavily influenced by people not usually trained in epidemiology. The nurses have criticized the lack of training in epidemic response.

This is what should be expected from the management of for-profit hospitals. When nurses are training, the health corporations don’t make any money.

The Centers for Disease Control (CDC) has been put on the spot for not taking prompt action when the first patient was diagnosed, and even earlier, when the crisis in West Africa began to unfold. However, primary responsibility for responding to a public health emergency belongs to the local health departments and the states, not federal agencies. Their ability to exert primary authority in these cases is diminished by their narrow legislative mandate. In general Federal agencies are reluctant to be perceived as usurping local Health departments authorities.

In related news, an NBC news crew led by medical correspondent Dr. Nancy Snyderman broke a voluntary quarantine to go to a restaurant to buy soup. They had been to West Africa reporting on the Ebola outbreak. Their voluntary quarantine was made mandatory. So far, though, quarantines of people exposed to Ebola generally remain voluntary.

Republicans have started to blame President Obama for the crisis, again claiming that his lack of decisiveness has made things worse. However, Obama has taken action by mobilizing the military to try to contain the health crisis at the source. He has also directed the CDC to assist local governments in their planning to prevent a more deadly outbreak.

Several things were made clear by the comedy of errors of the last few weeks:

  1. Volunteer quarantines are not effective;
  2. The CDC has to be given more authority and should exercise it decisively;
  3. Health professionals have to be trained to respond appropriately to epidemics like Ebola;
  4. In a for-profit health system, we can’t trust accountants to act like epidemiologist;
  5. Did I say that quarantines have to be made mandatory?

Finally, the fact that President Obama’s father is from Africa does not make him responsible for Ebola.

 

Mario Salazar, the 21st Century Pacifist, is a ardent supporter of a public, not for profit, health system like the ones in France, Germany, Sweden and other social democratic countries. He is in Twitter (@chibcharus), Google+ and Facebook (Mario Salazar).

 

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  • Monique DC

    Mario, I was wondering about the profit status of the two hospitals (the one in Dallas that botched the initial diagnosis and the one in Atlanta). I would not be surprised to see the profit motive at play sadly.
    And the people who do not honor the quarantine status (both the news crews and the nurse) were most irresponsible – in my opinion. The CDC did have a press conference explaining that when they stated a breach in protocol happened at the Dallas hospital, that this was terminology they consistently used in their management of infectious decisions – and not a judgment on the individuals involved I suspect (as the head of the Nurses Union has stated often of late) that the hospitals considered an email to be sufficient training. NOT EVEN if they tracked the people who actually read it.
    The bottom line is that I believe the US cultural theme of Exceptionalism seems to be at play here. People are scoffing at the concept of a quarantine (which should be mandatory) as something that “doesn’t happen here”).
    I would also think that all the persons who are being “monitored” for possible infection should be put on “no fly, no mass transit” lists until after the potential incubation period. We have the technology to do this and it should be done.

    • 21st Century Pacifist

      Monique,
      I agree with all you say. It is still difficult to understand why T. Duncan was not hospitalized immediately. It appears to me that unsinsured patients are not treated equally.

      • Mad Doc

        As far as I’m concerned, the issue of whether we have a right to enforce quarantines on people who are at risk is akin to sequestering a jury during a well publicized trial. No one asks the jury for their consent.
        The case of people who are engaged in humanitarian aid can be handled by requiring the workers to sign “pre-consent” forms. I would assume that people who volunteer to help in these situations – knowing the risks they face from the disease – wouldn’t object to being quarantined in order to protect their community upon their return.
        If I had my way, the conditions of the quarantine should be as less onerous as possible. After all, these people are not criminals. A military base might be best situated, or adaptable, to handle the situation.

  • Mad Doc

    I’m curious about something. What is the incubation time for a person who has been exposed to Ebola? Nowhere in the news stories about people breaking quarantine, have I heard how long the quarantine period is. To put it another way – If you and I have lunch together, and I later learn that you had Ebola, how long should I be without symptoms before we can be confident that I don’t have the virus in my system, and that I haven’t spread it to others? I may have missed a discussion and explanation of this, but it seems to me that the media has also been remiss in an opportunity to inform and educate the public.
    I do think that their should be enforced quarantine rules for people returning from voluntary Ebola work in Africa – even if they are not showing obvious symptoms.
    If a foreign country will not screen passengers before allowing them to board a commercial flight to the United States, (I’m thinking about the Liberian man) then we should refuse to accept flights from that country. People who are travelling into and out of these regions for humanitarian reasons should be transported in military aircraft.

    • 21st Century Pacifist

      Doc,
      I heard on TV, and it sounds logical, that if a person wants to travel really bad, he/she will find a way. We can’t rely on foreign governments to keep us safe. We have to check people out when they arrive. Thank you for your comment, hope you are doing fine.

      • Mad Doc

        Mar,
        The problem with checking them out when they arrive is they have already flown on an airliner full of people. Assuming we know who to check, are we to hold everyone on the plane until we get the results? If we don’t hold them, and the person we check turns out to be infected, the rest of the passengers will have dispersed around the country creating that many more potential exposures. It is better to identify the risk before that person boards a plane that will enter this country. If the countries of origin refuse to cooperate, we should refuse to allow flights from that country to land in the U.S.
        Of course there is no fool proof way to keep someone out who wants to enter. We can only do the possible. The possibilities at this time are far more manageable than they will be if a full blown outbreak were to occur on our soil.