Ebola hits home [Editorial]

Our view: A case in Dallas shows just how easily the deadly disease can spread to America — and fall through the cracks of our health system

October 02, 2014

"This is not West Africa," Texas health commissioner Dr. David Lakey said Wednesday at a news conference designed to dispel Texans' (and Americans') fear of an Ebola outbreak after a man there was diagnosed with the disease. "This is a very sophisticated city, a very sophisticated hospital." The subtext: All those gruesome photos you're seeing of people dying in the streets in West Africa — that's something that happens over there, to other people, not here, not to us. But what the events of the last few days have shown is that it's exactly that kind of hubris that puts us most at risk, and that for all the sophistication of the U.S. health system, it only takes a simple lapse to create the conditions for a broader outbreak.

According to news reports, Thomas E. Duncan, a 40-year-old Liberian national who was visiting relatives in Dallas, went to the emergency room at Texas Health Presbyterian Hospital on Sept. 25 with a complaint of fever and abdominal pain. A nurse, following a checklist, asked whether he had recently visited West Africa. He told her he had. "Regretfully, that information was not fully communicated," a hospital official said Wednesday. Mr. Duncan was then sent home with antibiotics — useless against the Ebola virus. (Of course, they would also be useless against the "low-grade common viral disease" the doctors thought he had.) He returned on the 28th, and by then he was reportedly vomiting profusely — a real worry since Ebola is spread through contact with the bodily fluids of an infected person. In the days when he was symptomatic and home, he had primary or secondary contact with scores of people, including five schoolchildren and the medics who transported him to the hospital. Now Texas health officials have put Mr. Duncan's family under mandatory quarantine and are monitoring as many as 100 people.

Texas officials are right that this incident is theoretically containable using the kind of measures they are now employing. In Guinea, Liberia and Sierra Leone, the West African nations where the outbreak has hit hardest, the disease spread first in remote, rural areas and was already well established before the public health systems there became fully engaged in the effort to combat it. What the case in Dallas represents is more akin to the experience in Nigeria, where a quick and overwhelming response by officials appears to have contained an outbreak sparked by the case of a single traveler, the New York Times reported Tuesday.

Nigera, the most populous nation in Africa and already a center of international health efforts to check polio and HIV, had significantly more resources and infrastructure than the region where the Ebola outbreak is worst, and the United States, of course, has vastly more resources than Nigeria. The public health community here, led by the Centers for Disease Control, has been spreading the word to health care workers nationwide to be on the lookout for the signs of Ebola. We have sophisticated facilities for isolating patients, no lack of protective gear for health care workers, and the means to accelerate production of experimental drug therapies to treat the disease.

But what the Dallas case emphasizes is that all our wealth and technological prowess is useless if health care workers don't get the basics right. It's mind boggling that the information about Mr. Duncan's travel was not "fully communicated" to the doctor who initially assessed him and sent him home, but it's also inexcusable that the doctor didn't ask more questions about the patient's history. Given reports that four days before leaving Liberia and 10 days before going to the hospital in Dallas, Mr. Duncan had helped carry a woman who was dying of Ebola, it's hard to imagine that he was not fearful that he was infected when he first began to show symptoms. Did the medical team who examined him take time to think about the person in front of them or just the list of symptoms on his chart? Such lapses are sadly all to common in the American medical system. At a time of a global health crisis, they can be disastrous.

Public health officials say they hope this case will serve as a wake-up call to the health system. We certainly hope that is the case. Many major hospitals (including the Johns Hopkins and University of Maryland systems) have been making extensive efforts for weeks to prepare clinical workers to recognize and properly react to potential Ebola infections, but a case could present anywhere, including small, stand-alone clinics now common in drug and discount stores.

More broadly, this case needs to serve as a wake-up call that the international community's efforts remain inadequate to control the Ebola outbreak in Africa. Even with stepped-up aid from the United States and other nations, international health officials now estimate that 1 million or more Africans could become infected. If that proves to be the case, more infected patients will inevitably show up in the United States, Europe and elsewhere — and more mistakes like those made in Dallas will be sure to follow.


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