|Ebola: Lessons Learned the Hard Way
||[Oct. 14th, 2014|12:36 pm]
We could start with the worst: those who rouse panic largely for their own gain: to make money, to get elected to or stay in public office, to get their faces on the front pages or a chance at being a talking head on TV, to raise the ratings of their network, TV station, radio station, blogsite, Twitter feed, etc, etc, etc. But that bunch don't learn lessons--they simply take any problem, magnify it, and declare that it's someone else's fault (for the past six years, Obama's fault) and add it to their repertoire to bring up when they move on to the next problem they can get a little publicity out of. So I restrain myself from adding my personal "Worst of the Panic-Raisers" list and move on to the lessons. They're more important, and so are the reasons we're learning them the hard way instead of easier ways.
Lesson One: A stitch in time saves nine. If you want to get classical about it, the "stitch in time" is a subset of that hoary old virtue called Prudence, the foresight virtue. It's noticing early stages of something, thinking out the "What if this goes on?" and how the problem might be alleviated and future worse outcomes prevented--and then doing something about it. It's one of the least common virtues, because it requires expending time and energy and resources on something that hasn't happened yet. That's not something we humans are good at, especially if the time, energy, and resources involved are our own, and not someone else's.
Ebola is not a new health threat; sporadic small outbreaks have taught those who worked where it was that a) it could be contained and b) how to contain it. Its mode of transmission and its potential to spread from nation to nation have been under discussion for decades. The ability of people incubating a serious disease to move globally before their disease becomes evident, thanks to the speed of modern travel, is not new and has been under discussion for even more decades. Ebola specifically has been talked about in medical journals as a one of a number of serious health threats. But...Ebola was "over there" in Africa, the outbreaks were small, and the proposed costs of preparing for its arrival "here" (meaning outside Africa) seemed far too high to spend much time, energy, or money on actual preparedness.
Individuals, medical centers, and governments all chose to ignore the loose stitches in the fabric of global health (inclding a lot more than Ebola) in favor of saving time, energy, and money for other problems. Hospitals did not review their admittance procedures. They did not train staff. They did not stockpile the supplies needed. They did not foresee the need for special handling of Ebola-contaminated trash. Governments did not ensure that clear guidelines were issued, nor did they fund additional research into what it might take to mitigate the threats. Nor did they send assistance to the affected countries the current outbreak occurred, to help contain it. The medical staff who did go were volunteers, not representing their governments, and thus without a clear pipeline to the medical and political establishments back home. Their experience--crucial to setting up protocols to deal safely with the same disease elsewhere--was not transmitted clearly.
In the U.S., states were alloted "disaster" funds after 9/11, and four high-containment treatment units for especially dangerous diseases were in fact set up, one in each of four states (Maryland, Georgia, Missouri, Nebraska), but the use of funds was up to the states themselves and no provision was made to assign all patients with a particular disease to one of them. Two--in Georgia and Nebraska--have been used so far for Ebola patients. One of those, in Nebraska, was considered an unnecessary waste of taxpayer money until they had an Ebola case.
Lesson Two: Hubris kills. The countries remote (they thought) from Africa that also had "modern" medical systems felt secure and comfortable in their medical superiority: their hospitals full of equipment, their staffs well-trained to Western standards, their generally well-fed and healthy patient populations, their reliance on someone else to screen arrivals for signs of any dread disease. Maybe "those people" couldn't deal with Ebola outbreaks--after all, these were poor countries, patients already had compromised health, medical personnel were few and they lacked all the medical bells and whistles a richer country takes for graned. If an Ebola patient showed up out of Africa, the superior medical skills, equipment, and supplies of the receiving hospital would instantly recognize and abate the threat to others, and probably the patient would survive, thanks to advanced care. There was no need to seek out and learn from those who cared for Ebola in Africa, because the greater resources in wealthier countries made their experience irrelevant.
Secure in their assumption of superiority, politicians evaded the need to fund forward-thinking ways to deal with what was (as the best medical advice said) the inevitable arrival of new, serious diseases from overseas and instead bragged on having a wonderful health care system. Secure in their assumption of superiority, government agencies assured themselves (and the public) that their country's existing medical structures would respond promptly and correctly should Ebola appear...without running any checks to see if that was true. Secure in their assumption of superiority, and pressured to cut costs, hospitals shaved preparedness activities to the bone, or simply eliminated them. Public education on unfamiliar diseases (like Ebola) was left to sensationalist media with agendas not based on the public welfare: movies, television programs, talk radio, etc. with the result that most of the public knew only that it was a scary African disease and could kill a lot of people really quickly.
We know now how well that worked. In spite of the fact that the current outbreak has been in the medical news since early last spring, and in the regular news at least since July, hospitals did not immediately leap into action to train staff on the techniques needed for dealing with an Ebola patient. Nor did most of them update their admissions and triage protocols to make detection of Ebola more likely and contamination of other patients and staff less likely. Certainly they were not paying attention to the exact ways volunteer staff in the affected outbreak area went about their work, and why. So when an actual Ebola patient showed up, the systems supposedly in place turned out to have large gaping holes. In Texas Health Presbyterian Hospital, where Mr. Duncan died, his initial ER diagnosis was "sinusitis" and he was deemed "not sick enough" to be admitted.
In both the US and UK, the shock of finding out that superiority wasn't as superior as had been thought shook public confidence in medical systems, and medical staffers' confidence in themselves. In a few clinics where someone showed up stating he or she might have Ebola, staff refused to come near them and clearly did not know what to do. Some clinics and hospitals experienced staff shortages due to staff concerns. Nursing organizations complained that they hadn't had proper training and the protective gear now shown wasn't even available where they worked...yet nursing organizations, just like medical societies, had access to information about Ebola years before. With no automatic referral of Ebola patients to the specialty units, including safe transport from their current location to such a unit, Ebola patients could--as Mr. Duncan did--appear at hospitals completely unprepared to recognize or care for someone with Ebola. When hubris is shown up as hubris, when those smugly certain they had a situation under control find they didn't--the resulting shock can render existing systems unstable--individuals no longer know what they know, since they've just found out it wasn't as much as they thought. And in that situation, individuals may perform worse than they did before, not better. Any chaotic situation means people at risk. THPH closed its Emergency Department (reasons not stated)--so where will sick people in its area go now? Ebola is not the only killer: where will people with malaria, heart attacks, strokes, TB, and trauma go?
Lesson Three: Privatisation is no guarantee of quality performance. Despite claims by conservative politicians that the United States has the best health care system in the world, this crisis (and others ) have shown that the health care system here is deficient in the main goal of any health care system: enabling a healthier populace. At enormous cost, the U.S. has accepted a health care system that enriches insurance companies, pharmaceutical companies, for-profit hospital groups, medical equipment manufacturers, etc, while failing to provide adequate basic health care to large segments of the population. We have all the shiny--all the machines, all the specialists, all the big hospitals, all the extras--anyone could hope for, but we do not have a sound basis for a good health care system: access for every citizen, regardless of income, to swift, accurate diagnosis and treatment, and to the underlying necessities of a healthy life: access to clean air, clean water, sufficient healthy and uncontaminated foods, decent housing, space for children and adults to exercise safely, quality education, and meaningful work. That's why the basic health statistics in the U.S. have slipped year by year so the only thing we're #1 in is the cost of health care.
Lack of universal access results in the early stages of both communicable and so-called "lifestyle" diseases going undiagnosed and untreated because many people do not have the money to pay for discovery and treatment. When Mr. Duncan appeared in the Emergency Room of Texas Health Presbyterian Hospital--a black, foreign, uninsured person--staff saw that, not the possibility that he had Ebola. Emergency Departments in most hospitals lose money--it's where poor people go, who don't have insurance or money for illnesses that people with resources go to doctors' offices for. The ER is a drain on other hospital resources and thus there's pressure from hospital administrations to get the non-payers out of there fast. THPH, like all privately owned hospitals, had a bottom-line responsibility, and bottom-line priority is always a risk to quality patient care. A hasty misdiagnosis of Mr. Duncan led to endangering not only his life, but the lives of staff, other patients, and those who contacted him outside the hospital, including his own family. THPH isn't a monster: It is an average hospital, representative of how many hospitals are run, in a national health care "system" that does not put public health or the health of individuals (if they're poor, especially) first. Privatisation privileges profit, the bottom line, over patient welfare. In any nation that values private enterprises, the tension between private and public agendas must be monitored with care.
Lesson Four: Fear is faster than facts. Biology makes us sensitive to threats--if you don't notice the lion, you get eaten. But away from the very plain threats of lion, tiger, flood, fire, humans are generally bad at analyzing the relative danger of threats. Which is more dangerous, your forty-minute commute, or Ebola in your state? Which is more likely to kill you within the next 12 months? The commute, of course. But you're a good driver--you're sure of that--and it's a familiar route, and it's not scary. Ebola is scary...your imagination, faster than a speeding bullet, leaps the tall buildings of likelihood in a single bound and you are convinced that Ebola is the big bad lion crouched to spring. If you have certain personality traits, anyone trying to give you the facts about Ebola will strike you as a fool or a tool of some conspiracy (involving the government, of course) and you will reject the facts in favor of nursing your own particular fear. You will be helped in this by the ignorant and ambitious fear-mongers who are eager to push you towards other actions or opinions for their own reasons. If you're detached from the fear, it's easier to see them work---they use Ebola as a tool in their argument for "closing the border" or "ending waste in Washington" or any other political or economic end.
It's hard not to react to the efforts of others to engender fear--we're social animals, and we are affected by others' emotions. But panic is not a good basis for action. It's impossible to think when panicking, and hard to think when scared at all. Yet when a threat is not imminent (the lion is two miles away, not about to spring at you) taking the time to ascertain the facts (that lion is two miles away and there's not another lion any closer) and act on facts, not fear, produces better results. Most of us know that, when nothing scary is going on. But the requirement of rational action--stopping to learn the facts, to think clearly, to act accordingly--takes time, and can feel as if "nothing's being done" and something should be. Learning not to panic, but think--that takes training (and it helps if it starts in childhood.) In most situations (there are exceptions and learning to tell the difference is important), slowing down to think improves the chance of a better outcome. Is this threat immediate? Is it a day away? A week? A month? Next door? Down the street? Across town? Hundreds of miles away? If it's a threat you know little about, if it's really a new threat, something no one anticipated, then accept that the facts won't be known for awhile (nobody has all the facts) and ignore those who want to throw their favorite conspiracy theory onto the new emergency.
Two more ancient virtues help: temperance, the habit of, and ability to, control your emotions and desires, and courage/fortitude, the habit of not giving in to fear and panic.
Lesson Five: Change takes time. A system cannot change in an instant. Either you take the time to notice that your pants have a few stitches gone in the seam, and take the time then to fix it, or when it's an obvious and embarrassing split, you take more time to fix it then. Medical care systems are made up of "paper" as well as people, drugs, machine, and buildings: they are made of protocols, routines, habits. I have read a clear description of the protocols used in one hospital in Liberia for treating Ebola patients: that does not mean I could perform it, put on and take off the protective clothing without contaminating myself. I don't have the right habits; I don't have the right background of training and experience that builds the right habits. (Six years in EMS wasn't enough, and that was thirty years ago anyway.) Moreover a systerm reacts to any change with other changes--some of them difficult to predict, and discovered in practice. Systems that work tend to stabilize and then to protect that stability (whether it's what you wanted or not.) To change an existing system's way of working requires careful analysis and firm goals--and the willingness to put in the time, energy, and money necessary to overcome the system's inertia. Behind one missed diagnosis--or one successful diagnosis--lies a whole system. If making critical diagnoses of rare conditions is a priority, then time, energy, and money must be spent to make that one rare diagnosis possible.
Time: Staff must be educated, and a single half hour to three hour training session with someone talking, a handout, and some slides is not enough. Where behaviors need to be changed, only practice works...and the practice cannot be just rote, but intelligent, responsive practice. Variations on the presentation of an emergency build a depth of skill in personnel that repeating the same exercise over and over does not. If the behaviors are rarely used, then they must be practiced frequently enough to maintain the skills, which takes time from other duties.
Effort: Planning and executing change is not easy, and exercises to break one habit and make another are difficult and often frustrating. As the change begins to take hold, the unanticipated consequences show up, and must be dealt with. People experienced in systems design and management in real-life systems are often hard to find (not everyone who claims that skill has it.)
Money: To institute and maintain change in a system requires money--both to initiate it and to maintain it, as it requires staff time beyond existing duties. In the case of medicine, it also requires maintaining an inventory of supplies that may not be needed except at long intervals. Changes in protocols may also require money--if, for instance, it become standard to transfer patients with a given disease to a specialty center, then some entity must pay for that transport.
Is it possible to ensure that every hospital in the world will be able to recognize and handle a case of Ebola without transmission to a staff member or other patient? Probably not. Is it possible to ensure that every hospital in the United States will be able to do so? Maybe, but unlikely. Is it possible to ensure that every 300+ bed hospital in the United States can follow a simple protocol that identifies the probability that someone has Ebola, and take the correct steps to protect staff and other patients from contamination while awaiting more expert assistance? Probably...but not by next week, or next month. Too many hospitals, too many different organizations involved, and no central authority to enforce a common standard. CDC can give advice, but has no power to compel compliance with its advice, besides being underfunded and understaffed. Political forces in the US--anti-science, anti-regulation, anti-government--mitigate against any effective national policy.
The light bulb has to want to change. Does this lightbulb? Too early to tell.
Lesson Six: Everything is connected to everything else. A disease outbreak in one country affects people in distant countries--even before someone with a disease arrives, it spreads panic, it changes individual goals, it impacts governments' policies.
A hospital's desire for a business award affects its policies and procedures in its Emergency Department. Fear affects whether an apartment complex will provide space for someone related to a patient with a certain disease.
Some connections are unreasonable, but they still have an effect--they're still "real" in a psychological sense: they change behaviors. When a Texas politician wants to spend money "closing the Mexican border" instead of improving hospitals' response to sick people--that's not smart, but it is a connection in his mind between "foreigners" and "disease." (His grasp of the overall disease burden in this state and where it comes from is...minimal.)
There is no bunker deep enough, no ivory tower high enough, no wall stout enough, or weapons system powerful enough to keep what happens "there" from affecting life "here." We are part of a larger system, like it or not: we are being changed even as we attempt to create change. That's how systems work. This is not the same world--physically, socially, psychologically, scientifically--that I was born into and grew up in, and it won't be the same as it is now when I am a decade older, when my son is the age I am now.
Because everything is connected to everything else, every person is connected to every other person, and what one group does, another reacts to. To reach the best possible future requires understanding that, and accepting that reality, and then trying to act in ways that make things better for the system as a whole. Knowing that good intentions don't ensure good outcomes. Knowing that these outcomes are definitely not desirable, but uncertain about which good ones are even remotely possible. This is a very hard lesson, since so much is not known abourt the best route to the best outcome even in one field. It's not as simple as "wash your hands before eating and after using the toilet, eat five or more servings of vegetables a day, get x minutes of exercise daily." But it is possible (though not easy) to learn to think past one's own net worth in dollars, past one's own social or professional standing, past where to go on vacation next time, or how to afford the tuition at the community college while raising your kid on minimum wage. It is possible to be aware of the connections and of being part of something more than one household or town or county or state.
Our choir director often says, when we're slightly out of synch, "WILL it to be together." And then we are. Because, I think, we're aware then, for sure, that we can't just read the music and sing the notes in the right order for the right duration...each interpreting that individually. We have to sing together. We have to be willing to sing together, more than insisting on our individual "rightness." If we are willing to admit the connections, willing to "sing it together," better outcomes are possible.