On October 15, the second case of Ebola transmitted in the United States was confirmed in Texas between patient Thomas Eric Duncan and a health worker. Even more frightening, perhaps, is the sequence of events leading up to the transmission, and the many questions it generates about the preparedness of the US in responding to public health emergencies.
Six days after Duncan arrived in the United States – having passed a screening for fever at a Liberian airport – his symptoms progressed and he sought care at a Texas hospital, where he was promptly sent home with antibiotics.
The hospital claimed his early discharge was the fault of the electronic health record (EHR) for not communicating the patient’s travel history, but soon issued a correction saying his history was “available to the full care team…there was no flaw in the EHR.”
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No matter who or what is at fault for letting Duncan fall through the cracks, we cannot let this huge breach in protocol happen again.
More than a week later, and several days after the patient was confirmed to have Ebola, the apartment at which he was staying with four individuals remained unsterilized. The quarantined family had the responsibility of arranging clean bedding until a waste management company agreed to clean the apartment. When they arrived, contractors wore no protective equipment and used power washers to sanitize – a practice which is likely not the most effective method of treating infectious surfaces.
And then, on October 12, the CDC confirmed that a nurse who had worn full protective gear while treating Duncan had contracted Ebola due to a yet unknown breach in protocol. On, October 15, another nurse who treated Duncan was confirmed to have the virus, showing symptoms just one day after boarding a commercial flight returning from Cleveland to Dallas.
These events point to several issues in the US public health infrastructure: who is in charge when high-stakes infectious diseases spread? How should the US prevent diseases originating in other countries? What can we learn from this case to prevent other errors in the system?
First, we need to decide who, or which agency, is in charge when a public health emergency occurs. Larry Copeland, a reporter at USA Today, agrees. Currently, the CDC provides assistance and guidelines to states and educates providers about how to prepare for Ebola. The choice to enact these protocols and successful operation of these procedures remains with the states. The CDC also issues guidelines to prohibit practitioners who have treated Ebola patients from boarding commercial flights. Separately, the Department of Homeland Security controls issues of air travel, including providing guidance to airlines and calling for symptom screenings at high-profile airports.
So there is no single entity leading the public health response to Ebola. While the CDC may fall into this role, it is up to individual hospitals and practitioners to respond promptly and effectively. Unfortunately, in Texas, several errors – including sending the patient home while infected, delaying sanitation of the patient’s apartment, and developing two more confirmed cases – showcase how disorganization in public health can lead to unfavorable outcomes.
And how should the US prevent diseases originating in other countries? Experts agree that closing borders of West African countries would worsen the crisis. Unfortunately, the issue of Ebola as it relates to air travel has become politicized by conservatives, prompting CDC Director Tom Frieden to speak out strongly against a travel ban. Conservative Republicans have even attempted to relate Ebola to anti-immigration reform by claiming that migrants from Central America could bring Ebola through the southern US border (despite the fact that no outbreak of Ebola has ever occurred in Latin America).
In a press conference, Dr. Frieden assured that strong core public health functions could stop the spread of Ebola. Although the CDC and public health workers successfully tracked close contacts of Duncan and isolated those at high risk, those steps could not stop the first incorrect diagnosis or the spread to front-line health workers – arguably the most important role in stopping the epidemic.
The implications of public health slipups cannot be understated. We need to start a conversation about the relationship between federal, state and local public health authorities. We need to simplify and communicate protocols to hospitals and ensure that providers and communities are enacting preparations for infectious diseases. Valuing the field of public health as much as we do individual appointment-based care is essential to stopping an epidemic. We need to organize authority and mobilize an informed and efficient workforce to improve the preparedness of the US health system in responding to public health emergencies.