On Sept. 24 of last year, Thomas Eric Duncan, a Liberian national who had come to the United States to visit family, became ill and went to the emergency department of the Texas Health Presbyterian Hospital in Dallas. He was examined and evaluated and, although he had a high fever, was diagnosed with nonlife-threatening sinusitis and abdominal pain and sent home with a prescription. Four days later, he returned to the hospital in an ambulance, with the same symptoms, although they were more severe. He was subsequently tested for and proved positive for Ebola fever, which had broken out in West Africa earlier in the year. The hospital contacted the Centers for Disease Control, initiated high-level infection control procedures, and moved Duncan to the intensive care unit after all other patients in the ICU had been relocated.
He died at the hospital on Oct. 8. And all hell broke loose.
The hospital was excoriated by some critics for not admitting Duncan when he first sought care. When two nurses who had treated him tested positive for Ebola fever, the criticism escalated. Both nurses were transferred to hospitals with extensive experience in treating infectious disease, and both recovered, as have all U.S. health care workers but one who had contracted Ebola. Only Duncan and Martin Salia, M.D., a physician who was originally from Sierra Leone but was a permanent U.S. resident, and who was caring for Ebola patients in Africa, have died of the disease on U.S. soil.
Within a relatively short time, federal authorities mandated that anyone arriving in the United States from West Africa by plane be questioned at the airport about exposure to the disease. The federal government also named Ron Klain, an attorney with ties to the Obama administration, who at the time was president of the holding company of AOL, and who had no experience with infectious disease, as its "Ebola czar."
There were widespread calls in this country and others to ban all flights from West Africa; this move was deemed unnecessary. In October, the CDC issued new guidelines to providers regarding treatment of patients suspected of having Ebola. Governors in several states demanded mandatory quarantine for health care workers who had recently returned from West Africa. Kaci Hicox, R.N., a nurse volunteer who had cared for patients with Ebola in Africa, was ordered quarantined by Maine Governor Paul LePage; she defied the ban and it was overturned by a judge in November. Craig Spenser, M.D., a volunteer who had also recently treated Ebola patients in Africa, returned to his New York City home in October, visited with his girlfriend, rode the subway, went bowling and showed symptoms of the disease shortly thereafter. He was treated at Bellevue Hospital Center, recovered, and was discharged in November. Both he and Hicox were widely criticized for risking the health of other people by not isolating themselves.
Any of these actions can be debated, and they all were. I am not an epidemiologist, and I am no expert on Ebola fever. However, my gut instincts tell me that if there is any chance that you have been exposed to a deadly communicable disease, you should isolate yourself and immediately seek medical advice.
On the political front, the Klain appointment was inscrutable to me at the time, and still is. His appointment was temporary, and he has returned to the private sector.
Overreaction or Caution?
But just as it is a fact that one is not going to contract syphilis from a toilet seat, one is not likely to contract Ebola on a subway. The infection comes from major exposure to the bodily fluids of patients with the disease, who expel gallons of them. Spenser was not symptomatic at the time of his outings, and Hicox was not infected.
Concern spread swiftly. When I arrived in Cambodia in November, I was required to fill out a questionnaire about where I had been and if I had a fever. I guess that was to screen out the thousands of West Africans who were trying to enter Cambodia (sorry about the sarcasm, but I mean, really). On the other hand, there are hundreds of nongovernmental service groups active there, and it was entirely possible that someone who had been working in Africa had been reassigned and needed to be screened. I did find it interesting that I was asked no such questions when I arrived in Thailand a day earlier.
These clinical issues will continue to be discussed, as they should be. But what I have chronicled so far were, for the most part, reasonable responses to the potential spread of a very dangerous virus (with the possible exception of some political posturing in an election season).
I still wonder if the epidemic had broken out in, say, Sweden, whether the response would have been different. More than one racist website exhumed the tired old "send them back to Africa" garbage, but I don't think racism was in play in most cases. It should be remembered that one of the two nurses who were infected in Dallas was African-American, and the other was Vietnamese-American. I didn't hear any calls for them to be sent anywhere other than to hospitals with expertise in treatment of the disease.
It's some of the other events that should trouble us.
The Onset of Hysteria
A hospital laboratory technologist who thought she might have come in contact with a specimen from Duncan voluntarily isolated herself in her cabin while she was on a cruise. The authorities of the school district where many of her fellow travelers on the cruise — students and teachers — worked and studied told them not to return to school when they arrived home. Nigerian applicants to a Texas college were rejected because they lived in West Africa; the Ebola outbreak in Nigeria had been controlled very quickly, but I guess the college didn't get the word.
A passenger on a flight from Dallas to Chicago became airsick, vomited and was ordered to stay in the plane's bathroom for the rest of the flight. A New England schoolteacher who had visited the Dallas area was sent home for 21 days. An airport security employee who, while wearing gloves, patted down one of the nurses who subsequently tested positive for Ebola was told to leave work and stay home. Syracuse University withdrew a teaching invitation to a Pulitzer Prize–winning photographer who had been documenting the Ebola epidemic in Africa.
And as a health care journalist who receives many press releases a day, I can tell you that the attempted profiteering and exploitation regarding the threat of Ebola was nothing short of disgusting. I was bombarded with solicitations to write stories about miracle cures or to interview physicians who "knew the truth" about the disease. It got to the point where I didn't even want to look at my email inbox.
Perhaps the most appalling incident was when pundit Ann Coulter condemned Kent Brantly, M.D., a Christian missionary volunteer who had cared for Ebola patients in Africa and contracted the disease (he has since recovered and has donated plasma to other Ebola patients), as a "narcissist" for trying to treat patients in "disease-ridden cesspools" like West Africa. She suggested that he should instead spend his time converting Hollywood moguls to Christianity.
(If Coulter studied history, she might have been aware that New York City was once a "disease-ridden cesspool," and that it was pulled out of that plight only through the efforts of the physicians and nurses of the city's public health department and the work of activists such as Lillian Wald, who also fought for civil rights for African-Americans.)
There were many more inappropriate responses to the minor appearance of Ebola on our shores. It was yet another example of what I call health care hysteria. And it isn't new.
A Sorry History
In the mid-14th century, the Black Death — probably a tragic co-epidemic of bubonic and pneumonic plagues — broke out in Asia (likely in China) and spread via the flea-ridden rats that traveled on both maritime and land trade routes.
There are indications that during various wars at the time, the corpses of people who had died of plague were heaved across enemy lines, thus spreading the disease. Returning soldiers, sailors, traders and others brought the plague to Europe. Although estimates are highly speculative, it is generally thought that at least 75 million people may have died; at the time, that was a significant proportion of the populations of Europe and Asia. Cities such as London and Paris may have lost half their residents.
The plague was all the more terrifying because no one knew how it spread; the vector, a bacterium known as Yersinia pestis, which is carried by fleas that bite rats and other rodents, was not identified until 1894 (it eventually was named for its discoverer, Alexandre Yersin).
Short of that knowledge, the people of medieval Europe soon fell into health care hysteria. Christian extremists who came to be known as flagellants roamed through the countryside, beating themselves with whips until they drew blood, because they believed that the plague was God's punishment for sinners.
And in an unfortunate but time-honored tradition, one of the most common responses was to blame Jews. They were poisoning the wells. They were spreading the disease intentionally. Although discriminating against Jews was hardly new, those gripped by the hysteria pointed to the fact that Jews were less affected by the plague than other groups. That many Jews were isolated in ghettoes and therefore were less exposed to the disease did not matter. They were murdered in France, Spain, Flanders and elsewhere, and 900 were burned alive in Strasbourg, France, in 1349, even though there was no plague in the city. Pope Clement VI tried to stop the killing, but to no avail. Eventually, the epidemic ran its course, and the killing of Jews stopped. For a while, anyway.
To this day, in England, many villages decorate their wells with flowers in the spring and early summer, in recognition of the fact that the water did not kill their forebears.
Influenza and Its Effects
At the end of World War I, a severe strain of influenza broke out worldwide (seemy column for Hospitals & Health Networks Daily, "In the Shadow of the ‘Spanish Lady," February 2005, available from Health Forum or on my website, www.emilyfriedman.com), due to a combination of circumstances: war, displacement, famine, malnutrition and the concentration of many young people in military and refugee camps. This particular strain was most virulent among 20- to 40-year olds, and it killed 40 million to 50 million people in less than a year.
Hysteria occurred again. Attempts at vaccination — and, granted, early vaccines were not the safest treatments on the planet — sometimes proved deadly (although many of those who claimed that vaccination was the real cause of death also blamed aspirin and other drugs that could not have been responsible). Phony remedies were peddled, with the inevitable fatal results. Public health nurses — truly heroic professionals — in some cities in the Northeast were criticized or even attacked and accused of spreading the disease. This influenza, which likely was a mutated variant of what we now call bird, or avian, flu, disappeared as quickly as it had come.
In early February 1976, a soldier in Fort Dix, N.J., died of what seemed to be no more than a bad cold. A dozen of his fellow soldiers had the same symptoms. Subsequent examinations found they had contracted a form of influenza that became known as "swine flu," which researchers said was related to the deadly 1918 avian virus. President Gerald Ford convened a group of experts and ordered expedited production of an effective vaccine; the goal was to vaccinate all U.S. residents. Vaccine production was plagued by various problems, but by October, inoculation began.
By December, about a quarter of the U.S. population had been vaccinated, but reports of Guillain-Barré syndrome were beginning to come in; this paralytic condition is associated with both influenza and vaccines that combat it. The firm that manufactured the vaccine had demanded, and been granted, immunity from lawsuits, an action that has been widely criticized.
The vaccination program was suspended in December 1976. In the end, 500 people contracted Guillain-Barré syndrome, most likely from the vaccine, and at least 25 died. The swine flu never infected anyone outside of Fort Dix, and the only person to die of it was the one recruit.
HIV and AIDS
The story of the emergence of human immunodeficiency virus (HIV), which causes AIDS, does not need to be retold in detail here, given that it has been the subject of hundreds of books, articles, and both documentary and fiction films.
Although the date of its appearance in the United States will likely never be pinpointed, it is known that a young man in St. Louis, Mo. — perhaps a sexually abused child or a prostitute — died of the virus in 1969. Deaths linked to HIV in Europe were traced back to the 1950s, and others were later identified as occurring earlier in Africa.
The first reports in the United States, involving gay men in New York City and Los Angeles, were published in 1981. And again, all hell broke loose. The people who were most affected did not constitute the most popular crowd in town in many places, and the newly inaugurated Reagan administration made it clear that it was not particularly concerned (for which President Reagan later apologized).
The combination of an ostracized patient population — which soon came to include not only gay men, but also prostitutes, injectable drug users and people with promiscuous sex lives (and some patients who had received HIV-tainted blood transfusions, although they were not attacked as the others were) — and a truly awful disease led to yet another onset of hysteria. A surgeon working for a large health care system said she would not operate on patients with HIV; the system, to its everlasting credit, sent the word out to every single employee: "You don't want to treat these patients? You don't work here anymore." Health care professionals in some settings sought to treat AIDS patients only while wearing hazmat suits.
The insurers really went to town on this one. I recall that one California carrier instructed its agents not to issue policies to any man who was a florist, an interior decorator or a performer in the arts. All I could think of is that whoever issued the order should have been required to spend some time in a gay longshoremen's bar on the San Francisco waterfront so he or she could get over the stereotypes.
Anyway, because of the profound courage of people from Gay Men's Health Crisis in New York to then Surgeon General C. Everett Koop, M.D., and the research expertise at the Pasteur Institute in Paris and elsewhere, the United States, over the years, has, for the most part, managed to control AIDS well enough that it is now a largely chronic disease, albeit a horrible one. As far as I know, less than a dozen Americans now die of AIDS per year; just my luck that a few years ago, I knew two of them. Many other countries have also done well; even poor little Cambodia has the lowest new infection rate in Southeast Asia, as well as a maternal-to-fetus transmission rate of almost zero. And if some other countries in that region would be willing to put a brake on the revolting sex tourism trade, especially activities involving pedophilia, even better results would soon be forthcoming.
So what can we learn from all this? Each of these epidemics is unique, of course, but there are still overall lessons to be learned. The general ones, I think, are:
Leadership at the top is necessary. Until Koop became surgeon general, most Americans could not have named who held that office if a gun were held to their heads. How many of us have paid proper homage to then Surgeon General Luther Terry, who, 50 years ago last year, issued a report saying that smoking could kill you? At the time, cigarette manufacturers were running ads with endorsements from physicians alleging that tobacco was good for you! Until last month, we had gone for years without a surgeon general, and I don't know how our new one, Vivek Murthy, M.D., will fare, given his belief that gun control is a public health issue and the conservatism of the new Congress.
All of that being as it may, this country — like all countries — needs coordinated, qualified leadership when an infectious disease outbreak occurs. The bugs don't heed election cycles, partisan politics or competing power silos. They just do their thing, and it's difficult to combat that when no one is in charge.
Public health needs more support. My longtime joke — which isn't particularly funny — about public health is that most municipalities, counties, states and even the federal government grossly underfund public health departments because the success of these agencies is in the absence of problems. Then someone gets Escherichia coli from a slice at the local pizzeria and everyone goes ballistic about why the public health department wasn't monitoring the mozzarella. Our public health agencies need more funding — and more respect.
News coverage and political decisions come and go, but viruses and bacteria are forever. As I write this, Ebola fever has faded from the headlines, like the poor kidnapped little girls in Nigeria and a dozen other important stories whose outcomes we may never know.
But health care leadership in this country, from the White House to the local hospital, has to be prepared. There will be another outbreak of something, somewhere. People travel on airplanes and in every other form of conveyance; violence and war displace hundreds of thousands of human beings; dehydration, malnutrition and other conditions allow people to become vulnerable to opportunistic infections; many countries' health care systems are inadequate; valiant volunteer clinicians go to where they're needed. Infections come with a global community. And aside from politics and religion and racial bias and everything else, the fact is that these infections will sometimes land in American hospitals. This one did.
A Few Suggestions
So, I will end with a few suggestions for health care professionals, health care systems, hospitals and other care settings that may well one day find themselves on the front lines.
Combat fear and hysteria. It's no secret that the American public is not crazy about its politicians just now, and some political leaders are more than glad to exploit a situation like Ebola. Calm, informed communications from local health care providers about, as Bob Dylan wrote, what is real and what is not, may make the difference between another outbreak of hysteria and a reasonable, disciplined reaction to an infectious threat.
As a young friend of mine — and trust me, he is no bleeding-heart liberal; his politics make Rush Limbaugh look like Bernie Sanders — said recently, "Calm down, folks; more people have been married to Newt Gingrich than have died of Ebola in the United States."
Be informed. No one working in health care these days needs something else to do, but we all have to stay informed about infectious diseases to some extent, so we know that what we are telling people is accurate and helpful.
Advocate for public health. Hospitals and health systems all over the country are partnering with public health agencies and others to improve the health of local populations; part of that work should be to support and advocate for public health agencies and their employees. We all have to work together on this, because we are all at risk.
Support clinician volunteers. I think one of the saddest aspects of the Ebola hysteria has been the attacks on volunteers who have selflessly gone overseas to help people in dire need. Are there issues here? How much time have you got? The elite in some of the countries hardest hit by Ebola and AIDS and other plagues are richer than many of the folks on Wall Street, yet their nations' health care systems are pathetic. As most of my readers know, I spend a lot of time in Cambodia, and if it weren't for nongovernmental charities and volunteers from around the world, there would be a whole lot more Cambodians dead from completely treatable disease than there already are. Yet some people in the country's elite have a net worth in the hundreds of millions — if not more.
I can't change that. But I can support those people who try to save lives in such places. We should not treat them as pariahs when they come home.
Think upstream. At least in the case of Ebola fever, if we do not want to be at risk in this country, one obvious measure is to do something about the situation in West Africa. They are turning the corner: Nigeria has contained it, Liberia is close to doing so and Guinea has at least reopened its schools. These nations face tough challenges, ranging from unsafe cultural practices regarding the dead to grossly underfunded health care systems. But we, who are privileged to have the health care system that we do — regardless of its many problems — might try to think more globally about contravening infections in less fortunate places, if not for the sake of those who are suffering there, then for our own sakes.
Know your limitations. The CDC has begun to designate hospitals as qualified to receive patients with deadly infectious disease. This process is only starting, and we will have to see how it goes; the politics of health are complex. The leaders at one hospital told me that although they are proud of the designation, it's costing a heck of a lot of money to make sure that their infectious disease unit is what it needs to be. As of this writing, 46 hospitals have been designated. I am sure there will be more. I hope they will avail themselves of the expertise of the hospitals that have treated patients with Ebola, so that we don't have to reinvent the wheel.
And I sure as heck hope that the hospitals that have faced such challenges will share what they have learned with their sister organizations.
None of us — individuals or institutions or systems — is good at everything. Sometimes the best thing to do is safely transfer the patient to a provider with greater expertise. We have to know, as Kenny Rogers sang, when to hold 'em and when to fold 'em, to protect our patients and staff members. Infections are the enemy, not our fellow caregivers. If there were ever a situation in which we are all in it together, the outbreak of serious infectious disease is it.
This article is dedicated, with great respect, to all of those who have cared for patients with Ebola fever and other infectious diseases, here and abroad, and especially to those who lost their lives doing so.
Copyright © 2015 by Emily Friedman. All rights reserved.