“We must always tell what we see. Above all, and this is more difficult, we must always see what we see.”
Help me understand something.
The virulent Ebola virus which once seemed forever vicious, yet aloof in the heart of Africa, is now here in America. On a federal, state and local level, government, public health and medical authorities are grappling with what we know and what we don’t know about managing this virus’ impact on a person and its threat to a society. As I described in my previous post, On Ebola, Uncertainty & Imperfection, we can be commended for what we understand about this disease, but we should be quite chastened about the many things we don’t understand.
Recognizing that there is uncertainty, let us consider what we think we know about Ebola. For this, I am going to draw upon the latest information from the United States’ Centers for Disease Control’s website.
– CDC FACT: Ebola is most reliably transmitted through exposure to blood or body fluids (urine, sweat, feces, vomit, breast milk, semen), contaminated objects and animal vectors.
BUT…while not commonly considered airborne, the CDC says “if a symptomatic patient with Ebola coughs or sneezes on someone, and saliva or mucus come into contact with that person’s eyes, nose or mouth, these fluids may transmit the disease.”
AND the CDC declares that “Ebola on dry surfaces, such as doorknobs and countertops, can survive for several hours; however, virus in body fluids (such as blood) can survive up to several days at room temperature.”
– CDC FACT: Ebola, once recovered from, is no longer transmissible.
BUT…the CDC recognizes that the virus can be found in semen for up to 3 months after infection so abstinence or condom use is recommended.
– CDC FACT: Ebola symptoms can include fever, headache, muscle pains, weakness, diarrhea, vomiting, abdominal pain and hemorrhage with most symptoms emerging between 2-21 days after exposure to Ebola
BUT…the CDC admits that”diagnosing Ebola in a person who has been infected for only a few days is difficult, because the early symptoms, such as fever, are nonspecific to Ebola infection and are seen often in patients with more commonly occurring disease.”
So the updated CDC website confidently pronounces what it deems a fact about Ebola only to outline exceptions or contradictions to that very same fact. Now, as I reasoned in my previous post, embracing uncertainty and dealing with this crisis honestly is essential to engendering trust and forging a reliable plan going forward. Honesty and candor is always a good step towards recognition of our limitations and, simultaneously, tempering us from becoming overconfident in our comprehension of this disease. Medicine, again, is an uncertain and imperfect field comprised of “best evidence” and “consensus understanding”. This is part of any institution compromised of fallible human beings with incomplete understanding. It is simply our human condition… But it is what we do with this incomplete understanding that really matters. And when fallible public health meets self-serving political aims…watch out.
So let’s consider the events which led an isolated index case of Ebola to become a larger public health concern. Then let’s consider how the government and health care authorities have responded to these events.
In early October, two nurses involved in the care of America’s first Ebola-afflicted patient, Thomas Eric Duncan, at Texas Health Presbyterian Hospital contracted the disease while wearing the recommended personal protective gear for handling an Ebola patient (gown, gloves, mask, and eye shield). Though their infection was hastily described but the CDC as a “breach in protocol” there has yet to be described the protocol that was, in fact, breached. Coincidentally, the CDC has since upgraded its personal protective equipment (PPE) requirements to include a PAPR or N95 mask, double gloving, impermeable gown, impermeable apron and calf-high boots as well as a systematic “donning” and “doffing” protocol with a partner. In the wake of the two nurses becoming infected, the Texas officials obtained pledges (potentially enforceable by state authority) from nearly 100 exposed health care workers to enact self-imposed quarantine for twenty-one days during which time they would avoid public transportation and gatherings. Duncan’s apartment mates were put under state-enforced quarantine. After one of the infected nurses, Amber Joy Vinson, flew to Ohio, 132 passengers were asked to call the CDC for monitoring and next steps.
In the wake of these developments, in response to the unfolding Ebola epidemic (including the diagnosis of New York City’s Doctors Without Borders, Dr. Craig Spencer) and in the absence of a West African travel ban, several states including New York, New Jersey, Illinois and California have enacted mandatory 21 day quarantines for returning health care workers from Ebola-afflicted West Africa. Furthermore, Secretary of Defense Chuck Hagel has ordered a 21 day quarantine for all soldiers returning from similar regions in West Africa. A military spokesman, Air Force Colonel Edward Thomas, simply said,
“At least initially, we think this conservative approach is the right one,”
Read that again. And again.
But what has the Federal Government and the Centers for Disease Control had to say? How have they led? What precautions have they taken?
The CDC has NOT recommended quarantine of the highest risk asymptomatic patients, but rather to “pay attention to your health”. In fact, ignoring this advice, recently infected Dr. Craig Spencer knew his risks and proceeded to eat out, ride the subway and go bowling. It has also come to light that he lied to health officials about his activity (claiming self-quarantine) until his metro card and credit card proved that he in fact went out about town. Let’s also not forget Ebola-exposed NBC chief medical correspondent Dr. Nancy Snyderman who violated quarantine for some takeout and subsequently required police surveillance to enforce it. And Maine nurse Kaci Hickox, quarantined due to her West African medical work with Ebola patients and her questionable reliability and trustworthiness per officials who interviewed her, is determined to break her quarantine saying,
“I’m not willing to stand here and let my civil rights be violated when it’s not science-based.”
And the President? He held a high profile East Room ceremony thanking health care workers who have been going to West Africa. In his speech, he criticized the state quarantine policies saying,
“Policies that would avoid leadership and have us running in the opposite direction and hiding under the covers…it makes me a little frustrated.”
“And when [these workers] come home, they deserve to be treated properly. They deserve to be treated like the heroes that they are.”
“We will respond with common sense and skill and courage [and not with] fear, hysteria and misinformation.”
“It’s critical that we remain focused on the facts and on the science.”
“I put those on notice who think that we should hide from these problems…That’s not who we are , that’s not who I am, that’s not who these folks are. This is America and we do things differently.”
And Dr. Tom Frieden, Director of the CDC?
“If we turn [America health aid workers] into pariahs instead of recognizing the heroic nature of the work they’re doing, [then they may be less likely to identify themselves as health workers – and thus go unmonitored – and] less likely to go help [Africa] in the first place.”
“[The CDC’s guidelines] are based on science.”
Ah. I see.
Science. Facts. That’s what this is all about, right?
Well, if that were the case, the government would see that it’s own experts are having difficulty with science and facts. They are not entirely certain about the exact mode of Ebola’s transmission (reassuring that there is no airborne element only to say there may be an airborne element), how safe Ebola-exposed inanimate surfaces are, how long a person may conceivably be infectious before symptoms and after cure, and how easily the early symptomatic manifestations of Ebola may be missed or discounted.
Not only that, our scientists have proven that they have not been organized. Remember, the Ebola conflagration in West Africa began in February, 2014 – AND reared its head in numerous African outbreaks in previous years – so it is not entirely a surprise event. The CDC has not initially advised well on personal protective equipment and the necessary operational infrastructure for hospitals to handle Ebola cases (while making assumptions and disparaging remarks when problems occur). What is more, as discussed above, the government’s own voluntary quarantine program has proven inadequate time and again in keeping people in the necessary isolation.
So I would reason that, upon closer inspection, “science and facts” are not necessarily the government’s strong suit.
Now once again, I will grant you, we need to accept uncertainty and imperfection. But it is vitally important that the actions emerging from our uncertain footing are deeply prudent. An over-reaction may be inconvenient for a time, but appropriately judicious (Pace, Kaci Hickox). And aggressive measures can always be dialed back as firmer facts emerge. But an under-reaction cannot be made up for – especially when it comes to a lethal infectious disease. Once the genie is seriously out of the bottle…it is not going back in.
That is why the President and Director Frieden’s notion that following a prudent approach (such as targeted quarantines) in the beginning uncertain stages of an epidemic would, in any way, disrespect international aid workers or denigrate their work is utterly irresponsible. Apparently, in these authorities’ eyes, it doesn’t disrespect military personnel who have had similar exposure and now are in an enforced 21 day quarantine. The President’s paraded argument is an unseemly non-sequitur and represents base political opportunism that addresses a self-serving end while leaving the true public health concern of a disease’s further communicability neglected and unaddressed.
I will say again what I said in the last post: It is okay – in fact, preferable – to admit what we don’t know. It is okay – in fact, understandable – to have missteps and imperfections in the execution of a major policy. But wouldn’t it be wise to own our shortcomings and take the advice of Air Force Colonel Edward Thomas?
“At least initially, we think this conservative approach is the right one.”
Ebola is a vicious disease that is now a reality on American soil. We must do everything we can to embrace humility, exercise prudence and proceed with caution and due diligence lest we fall victim to the irrationalities of political correctness, ideology and opportunism draping themselves in the glowing mantle of “science and facts”.
I think I am starting to understand.
When Ebola, public health and politics collide, watch out.
For great pieces on Ebola, please read:
Pascal Emmanuel-Gobry’s “Did the Archbishop of Monrovia Blame Ebola on Gays?”