For a while, it seemed the U.S. Ebola crisis might be calming down. But it was unrealistic to think we had seen the last case of ebola in the United States. Now, with yesterday’s diagnosis of Dr. Craig Spencer, recently returned to New York City from treating Ebola patients in Guinea, the situation is back and more public than ever.
Even before Dr. Spencer’s diagnosis, when we were only dealing with the fallout from the first Ebola patient to be diagnosed in this country, it had already become necessary to take a hard look at the depth and breadth of the institutional rot that had been revealed. Who would have thought the arrival of one ailing Liberian could have uncovered such unpreparedness and incompetence within our health care system? On the national and the local levels, from prevention to diagnosis, from crisis intervention to communication to containment, the deficits appear to have been greater than even the most cynical among us might have imagined.
Each line of defense was breached, one by one, in ways that have seemed frighteningly careless. Our Maginot Line failed to protect as promised. Through it all there were repeated attempts to reassure us, but as the problems mounted, those confident assurances were exposed.
Health authorities did not lack warnings or time to prepare. Ebola has had outbreaks in Africa for nearly four decades, and the current epidemic in East Africa, the largest by far, has caused worldwide alarm for several months. As long as people were allowed to arrive in this country from Ebola-ravaged areas of Africa, it should have been glaringly obvious that the entry of a patient into the U.S. was a strong possibility and would present unique and serious challenges. We needed to address the issue as if it would happen, and to have stout defenses in place already.
A commonsense first line of defense is a travel restriction. Instead, the administration, for political reasons — chose to rely on the screening measures in place in African airports to prevent the exit of people who might have Ebola. These efforts were designed to identify those at high risk of recent exposure, as well as those who were already beginning to exhibit symptoms. But the screening depends on self-reported questionnaires and temperature-taking to detect the presence of early disease. Obviously, this system is porous — and U.S. officials knew this. The questionnaires are susceptible to ignorance or lying, and a fever can be foiled by Tylenol, inadequate equipment, or poorly trained screening personnel.
Because of those obvious vulnerabilities, authorities must have assumed that the measures would fail as a first line of defense, and that someday a patient would walk into a U.S. emergency room exhibiting symptoms of Ebola. That being the case, plans for this eventuality should have been comprehensive, detailed, and communicated clearly and urgently to every hospital in America, and accompanied by training.
It is obvious now that this did not happen, and that preparations were desultory and marked by a strong sense of denial. Even knowing of the flawed screening measures, the administration seemed to believe it almost certainly wouldn’t happen here. This attitude seems to have filtered down through the system.
Dr. Gary Weinstein, the doctor at Dallas Presbyterian who ended up treating the first three U.S. ebola patients, reported that his first reaction on hearing that the hospital had a probable Ebola case was: “That can’t be.”
When Thomas Eric Duncan arrived in the emergency room of Dallas Presbyterian on the evening of September 25 for his first visit, his symptoms plus his travel history ought to have put everyone on high alert. That diagnosis doesn’t appear to have occurred to anyone, although Dallas has a large enough Liberian community that such a possibility should have been given prior attention.
And so the second line of defense failed as miserably as the first had. Duncan was sent home to worsen. By the time he returned to Dallas Presbyterian in an ambulance he was vomiting, highly contagious, and ultimately beyond the reach of Western medicine.
By the time he died, two nurses caring for him had been infected, which represented a failure of the third line of defense: protection. The gear the medical staff had been given to wear was inadequate, as later admitted by the CDC. How could the CDC have gotten the protection wrong? They seem to have cut-and-pasted the WHO standards without reflection on their appropriateness:
Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, said those caring for an Ebola patient in Dallas were vulnerable because some of their skin was exposed.
The Centers for Disease Control and Prevention is working on revisions to safety protocols. Earlier ones, he said, were based on a World Health Organization model in which care was given in more remote places, often outdoors, and without intensive training for health workers.
If that weren’t bad enough, the fourth line of defense was breached: monitoring.
The CDC unaccountably failed to demonstrate the excess of caution needed when trying to prevent a further spread from a very small at-risk group into the general population. Duncan’s stepdaughter Youngor Jallah, a nurse’s aide who had cared for him up to the point of his hospital admission, had been exposed to Duncan’s body fluids without any protective gear. Once it was determined that he had Ebola, caution should have dictated that she be quarantined by public health officials until the 21-day incubation period was over. Instead, the CDC told Jallah that she could continue to go to work as a nurse’s aide as long as she was monitored for temperature changes.
Jallah herself decided that wasn’t good enough, and she chose to stay home until the full period was up.
Next, after nurse Nina Pham had been diagnosed with Ebola after caring for Duncan and running only a mild fever, the CDC failed to sound the alarm when another of his nurses, Amber Vinson, began to run a similar low-grade fever. Shockingly, when Vinson reported her fever symptoms to the CDC by phone as instructed, the person she spoke to there was reduced to looking up the answer on the CDC website and erroneously cleared her to board a commercial flight home.
If we couldn’t get expertise or honesty from the authorities, could they at least demonstrate common sense? Apparently not; some of the most simple and seemingly obvious approaches, such as keeping the number of hospital workers interacting with Duncan to the minimum necessary, were never implemented. Nor did the hospital or the CDC appear to have considered something as obvious as sending Duncan to a facility where the personnel were already experienced in dealing with Ebola, as had happened with previous American Ebola patients who had been flown back from Africa for treatment. Instead, the CDC apparently thought it would be a fine idea to let an inexperienced local hospital get on-the-job training with the very first Ebola patient to be diagnosed here:
Initially the CDC’s plan was to let patients be treated in place at major hospitals. The idea was that these institutions would gain experience that would be essential in the event of a larger outbreak.
And what of the newest patient, Dr. Spencer? Another commonsense rule would be a mandatory 21-day quarantine for any health worker arriving here after treating Ebola patients in Africa, particularly since conditions and equipment there are often subpar. Instead, Dr. Spencer was allowed to “self-quarantine,” which apparently does not mean “quarantine.”
As of this writing, it appears that the current plan is to treat Dr. Spencer at Bellevue, a hospital that has only very recently been designated as a center for Ebola care. Are we to imagine they are as knowledgeable at Bellevue about treating Ebola and protecting their staff as hospitals such as Emory, which have far more experience with Ebola as well as specially designed biocontainment units?
Why not err on the side of caution while the numbers are still small?
Both Nina Pham and Amber Vinson appear to be doing well and will almost certainly survive. Hopefully Dr. Spencer will take a similar trajectory, and none of the Bellevue health care workers inolved in his treatment will catch the disease. And perhaps this scare will knock some sense into the CDC and convince it that the threat of Ebola in America is real, and that rigid defenses must be in place immediately and permanently.
But don’t count on it. The CDC, and perhaps the federal government as well, will probably never regain the trust of the American people after their failure to protect in the most basic and obvious of ways. The legacy of the Ebola scare is a deep and profound skepticism about the ability and even the desire of the government to prepare for crises, to meet crises when they come, to prevent crises from worsening, and to communicate the truth about the inherent risks to the American people.