Ebola - Where are we? I did not think that we would be faced with so little believable information on this terrible viral infection called Ebola. the media and public panic surrounding the Ebola epidemic in West Africa have brought this quote to the forefront of my mind this past week. Since the first documented small outbreak in 1976 in Zaire and in Sudan, there has been 70 small epidemics of Ebola over the last several decades, but the previous episodes occurred in smaller areas that were easier to isolate and control the epidemic, This disease makes people sick by causing dehydration and severe lung congestion. Two days to three weeks after contracting the virus, the patients show fever, sore throat, muscle pain and headaches. Then, vomiting, diarrhea,and rash usually follows, along with decreased function of the liver and kidneys. At this time, generally, some people begin to bleed internally, Death, if it occurs, is typically six to sixteen days after the first symptoms occur. As of October 14th, 9,216 suspected cases resulting in the death of 4,555 have been reported. First, let me share my personal view of the Ebola crisis in West Africa. It is a tragedy in all senses of the word for Guinea, Liberia, and Sierra Leone. As a wealthy country and as global citizens we have a moral obligation to assist in the control of this outbreak and to help these countries build/rebuild their health and economic infrastructure after the devastation wrought by this disease. If the moral argument does not do it for you, remember that we have self-interest here, too. We benefit domestically from increased control of the disease in Africa and fewer cases found and treated in the U.S. We have been affected by misinformation and reassurances that have not been correct. And I guess that is part of our problem. We give airtime to sensationalism. Loudmouths and others who have no apparent background in the science or epidemiology of Ebola. We live in fear of Ebola as an “unknown unknown.” We don’t know what we don’t know about it, but any disease that is fifty percent fatal sure sounds scary. I think that people hear “Ebola” and have a similar visceral reaction to anthrax, bioterrorism, or SARS. Our own ignorance and insecurity leave us vulnerable to overreacting to sensationalism and fear-mongering which are so prevalent in our internet-based culture. Headlines like the UN warning of a “nightmare scenario” where Ebola “could become airborne” (when in actuality the article quotes the source as saying that this is an extremely unlikely event that would be a nightmare). Panic can lead to the emptying of a police station, or parents keeping their children home from school. At this point, it seems that a patient with Ebola infects about as many patients as one with hepatitis C. This does not mean that it is similar to hepatitis C, but it is only transmissible by someone who is showing symptoms (no symptoms = no transmission). Fear and ignorance make it difficult for us to understand the true tragedy of the disease. Right now, there are thousands of people dying of this disease in West Africa. The reason they are dying is that there were not enough beds or providers to care for ill patients before the outbreak started, and now that inadequate infrastructure has been overwhelmed. There are not enough beds, gloves, clean water, nor basic sanitation. Beyond Ebola, thousands more people are dying from lack of treatment of malaria, lack of prenatal care, inability to access other basic medical care, and malnutrition. Back at home fear and ignorance make it difficult to sort through the myriad of news on the TV, radio, newspaper and Internet to try to get accurate information. Here are my answers to a few questions I have heard bandied about: Q. Is Ebola transmissible by the airborne method or not? A. No — there is no evidence of this, and it unlikely to mutate to become airborne. Q. Do we need to care for patients in a biosafety level four type of center? A. The New York Times details changes in recent guidelines, but even with the changes, I think that we should still be able to safely care for Ebola-infected patients. Q. What is the incubation period? A. 21 days at most, but most people develop symptoms earlier (8 to 10 days). I have my own set of worries about our domestic response to Ebola. I worry that patients feared to be infectious will be unable to get care, leading to possible spread of disease. I worry we will miss other diseases: Malaria and typhoid fever are far more likely in a returning West African patient than Ebola. I worry that our immigrant and refugee communities will be stigmatized for a misperceived role in spread of disease. And I worry that when this crisis is over, we will continue to poorly fund our scientific institutions that lead to a better understanding of illnesses like Ebola. We physicians have responsibility and culpability here as well. As a Primary Care Physician, I am one of the first people (after my ER colleagues) to see someone who is sick enough to need to be admitted to the hospital. I have a responsibility to my patients to ask appropriate questions to get to a diagnosis as quickly and efficiently as possible. As physicians, we need to be able to recognize and manage what is most likely, what could kill the patient, and what could have an impact on public health, and then we need to prioritize our work-up and interventions. We live in an increasingly mobile and interconnected world — one in which we can travel between any two points in the world within the incubation period for any infectious disease. I assume that we will continue to see more cases of Ebola that are diagnosed here in the U.S., so we best be prepared to manage both the patients and the fear/ignorance (both our own and that of the broader public). Remember that two of the most important questions to ask someone as part of a history and physical are, “Where were you born?” and “Where have you traveled?” In the previous 3 months, 36,000 people flew out of the three countries where the epidemic is centered, and thru screening 77 people were detained due to symptoms of illness, but after investigating none of those 77 ill people were infected with Ebola, most has Malaria. In medicine, it is not the known unknowns that I worry about; these are manageable. We recognize a gap in our knowledge, and we order tests or call in help by getting consultants involved. It is the unknown unknowns that should be more scary for us. I would like to think this was the case in Dallas that led the patient to be sent home from the ER on September 26th despite showing symptoms of Ebola and telling staff there that he had returned from Liberia. I do not think that patients expect us to know everything, but I do think they expect us to know our limitations, recognize red flags, and know when to ask for help. So, for all my colleagues who work in health care, I have a few requests: 1. Remember the social contract that we agreed to as doctors, nurses, and other providers. We cannot abandon patients who are suffering in the midst of this crisis. Some of the comments out there come uncomfortably close to the stigma and fear around the HIV epidemic in the 1980s and 1990s, with health care providers refusing to care for patients with AIDS. 2. Be a voice of reason amidst hyperbole and sensationalism. Do not underestimate or overestimate the seriousness of this epidemic, both in Africa and here in the U.S. Consider calling your congresspeople to encourage decent funding for scientific research. We are seriously underfunding all areas of research across all disciplines. In medicine, this includes infectious diseases like Ebola, but also noninfectious ones like ALS. 3. Be aware of your own limitations and gaps in knowledge. Take steps to address these gaps, whether it is more learning, or a consult to a colleague with experience in the area. 4. It is OK if you do not know everything about Ebola, and it is even OK to be scared of it. But learn about it, learn how to prevent spread, and find out what your hospital would do if you have a patient with it. Running out the door is not a morally viable option, and remember that it is far more likely that the patient has something else
Posted on: Mon, 20 Oct 2014 06:17:00 +0000
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