High-tech medicine alone cannot protect U.S. from Ebola – we need to get the basics right

October 1, 2014

Handout of the Aeromedical Biological Containment System before being fitted into a Gulfstream III aircraft

On Tuesday, The Centers for Disease Control and Prevention confirmed that a second healthcare worker in Dallas tested positive for Ebola. The next day, the health authority issued a statement saying that the nurse travelled by air on October 12, the day before she reported symptoms.

The nurse had been caring for the now deceased Liberian Ebola patient, identified as Thomas Eric Duncan, who arrived in Dallas, Texas, from Liberia on Sept. 20. He didn’t develop symptoms of Ebola until four days later. On Sept. 26, he went to the emergency department at Texas Health Presbyterian Hospital complaining of fever and nausea. Though he told a nurse that he’d traveled to West Africa, where an epidemic of Ebola has broken out, he was diagnosed with a “low-grade, common viral disease” and sent home with antibiotics. Never mind that antibiotics shouldn’t be prescribed for viral infections like the common cold — why was he sent home?

The U.S. healthcare system is the most sophisticated in the world. It is also byzantine and inefficient, and those systemic flaws may have allowed a patient with a deadly virus to slip through the cracks.

As a doctor, I know that healthcare providers sometimes don’t get basic things right. We don’t spend enough time talking to patients to understand their stories, their worries and why they’ve come to see us. We often don’t communicate well with our patients and with the other providers involved in their care.

A general view of the Texas Health Presbyterian Hospital in Dallas

Medicine is among the most hierarchical of workplace cultures. This is great for issuing orders and making sure they’re obeyed, but can mean certain team members are valued and listened to more than others. Nurses function as patient advocates, for example, but physicians often dismiss their concerns.

Even among physicians, hierarchies abound. Infectious-disease specialists, experts in diagnosing and treating diseases like Ebola, (full disclosure: I am one) are the least-well-paid doctors in the United States — even though some may have more years of training than, say, a generalist. Those of us who go into the field have reasons other than compensation for doing so.

Though a news report quoted a hospital official as saying Texas Health Presbyterian Hospital was “well prepared” to care for a patient with Ebola, it was unlikely that an expert in diagnosing and treating diseases like Ebola was asked to examine the patient in Dallas before he was sent home. That oversight, if true, would expose a serious — and dangerous — shortcoming of a system that assigns different values to different doctors.

There is another reason why the patient may have been sent home. America is a society enamored with technology. This helps explain the public’s continuing fascination with new drugs and vaccines as the best way to fight Ebola. In medicine, this love of technology has partly encouraged the overuse of laboratory and radiology testing at the expense of doctors taking the time to talk to their patients. Some physicians even seem to have forgotten how to perform a thorough physical exam.

But even  ZMAPP, an experimental drug for the treatment of Ebola, is no substitute for a thorough physical exam and following public-health basics — what CDC director Dr. Thomas Frieden has called “tried-and-true public-health interventions.”

Simple and low tech as these practices may seem, they make for the bigger difference in outcome — fewer people getting sick. Unfortunately, public health departments and the CDC, which are responsible for the unglamorous, seemingly mundane tasks that keep us safe from outbreaks like Ebola, have sustained substantial budget cuts over the past several years, reducing their effectiveness.

Burial team prepare to enter the home suspected Ebola virus victim in FreetownWhether Ebola infects others beyond the Dallas patient and the two nurses who treated him is a good litmus test for our high-tech health system. Ebola is still spreading in Liberia, Sierra Leone and Guinea, which all have primitive health systems. But in Nigeria, where almost 900 people were exposed to Ebola and 20 were diagnosed with the disease, the outbreak has been stamped out. In Senegal, more than 60 people were exposed to a single Ebola patient — and no one came down with the disease.

The Dallas patient was isolated within four days of becoming sick. But not before possibly exposing a dozen or more to the deadly virus, including the two nurses who have since fallen sick. If further cases of Ebola develop in Texas, this will only serve to highlight the systemic problems in the world’s most expensive and sophisticated medical care system.

PHOTO (TOP): The Aeromedical Biological Containment System is shown in this undated handout photo provided by the Centers for Disease Control (CDC) in Atlanta, Georgia, August 1, 2014. REUTERS/CDC/Handout via Reuters

PHOTO 2: A general view of Texas Health Presbyterian Hospital in Dallas, Texas, September 30, 2014. REUTERS/Brandon Wade

PHOTO 3: A burial team wearing protective clothing, prepare to enter the home a person suspected of having died of the Ebola virus, in Freetown, Sierra Leone,  September 28, 2014. REUTERS/Christopher Black/WHO/Handout via Reuters




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Says a response to my Sciencemag.org comment:
So what happens when influenza season hits, perhaps with a particularly virulent stain, just as a handful of patients in the USA also get Ebola at the same time?
And what if, for all public perception intents and purposes, the symptoms mimic each other? Then watch American people go into panic mode — a scenario that’s not that many weeks away.

CRS_DrPH Rudy Haugeneder • 36 minutes ago. In fact, Ebola virus disease (EVD) does exactly mimic seasonal influenza in its early stages. Fever, malaise, aches etc. That is why we will have such a problem this flu season, there is likely to be a patient load-up at hospital ERs of flu cases, and they will all have to be evaluated as if they were Ebola. In bioterrorism prevention, we call diseases like EVD “influenza-like illness” or ILI for short. It won’t be pretty.

Posted by RudyHaugeneder | Report as abusive

An uncontroled society is unwanted so a little threat will cause panic. In the long run we will loose ‘the battle’ as life as a whole has ‘to struggle’ with all kind of medicines ‘to survive’. The stronger a medicine is the better protection a virus will make to survive.

Posted by henkkorbee | Report as abusive

A better way would be to quarantine anyone who travelled to West Africa. Now would be a good time to convince the public the urgent need to build a GitMo for Ebola suspects. If they came in contact with innocent citizens, they too can be thrown inside Ebola GitMo for a period of not less than 21 days. After the Ebola scare, these facilities could be used as GitMos for other kind of suspects too.

Posted by CorporateStiff | Report as abusive

Just shoot the Ebola suspects to contain the virus.
Killing a few to protect Millions (Citizens and Money) can always be justified in America.

Posted by CorporateStiff | Report as abusive

The article is written as if anyone, any place, any time, is ready for Ebola or any disease like it. There isn’t, none of those places exist. Some anarchist can criticize the USA for not being ready for third world horror but, then, certainly the third world isn’t ready for it either.

Posted by SixthRomeo | Report as abusive

Celine, thanks for reminding us that the first step in any solution is to listen to the problem first to be able to identify it, before we can define it, much less resolve it.

Posted by StevenMitchell1 | Report as abusive

Remind me of something Ronn Torossian once wrote on http://www.huffingtonpost.com/ronn-toros sian/

Posted by jayzon | Report as abusive

No one seems to be questioning why in the State of Texas, a low income person has to seek treatment at an ER. Seems to me that an emergency room is the worst place for a comprehensive diagnosis of a disease that can mimic so many others. I myself have been misdiagnosed in an ER and I don’t question the staff’s competence – when I went in they were dealing with an out-of-control mental patient and someone who had fallen from a ladder. Why didn’t Mr. Duncan have a general practitioner to go to?

Posted by CGROVE | Report as abusive

[…] US healthcare system is the most sophisticated in the world,” writes Celine Gounder, an infectious disease specialist, for Reuters. “It is also byzantine and inefficient, and […]

Posted by US Ebola ‘blunder’ stokes anger – News | Report as abusive

Since inflammation is such an issue with this disease, I imagine that panicked people will be trying to get the most powerful antioxidants at the stores, but watch out for vitamin E because it thins the blood, and this is a bleeding disease. If you feel you must take an antioxidant, make sure it is the type that does not thin the blood.

Posted by Gosseyn09 | Report as abusive

This story spoke at length about the lack of time doctors talk with patients. This isn’t the doctors fault. It’s ALL about our insurance system and how every second is precious. This sadly in turn diminishes the quality of care doctors can provide since their employer is screaming, “See more patients per hour!” While my doctors are great, I do see a chronic lack of REAL interaction thus Ebola could be easily overlooked. Perhaps it’s time we plan ahead for ourselves? Neither medical care nor our government has the resources nor the manpower to solve a problem this massive in scale if/when this pot boils over.

Posted by bobinmo | Report as abusive

I would be curious to know if Mr. Duncan had health insurance and paid a co-pay to go to the hospital? Anyone with insurance with a sizeable co-pay does not go to the hospital willy nilly.

I bet he had no insurance and listed no means of income and was treated for free. These kind of patients go to the hospital for a cold and hospitals tend to dismiss their aches and pains unless obviously serious and shoo them out of the hospital as quick as possible.

Posted by Butch_from_PA | Report as abusive

Celine, thanks for reminding us that the first step in any solution is to listen to the problem first to be able to identify it, before we can define it, much less resolve it. Thanks for reminding us that consistently applied behavioral fundamentals are always the most effective foundation, to any technological use.

Posted by StevenMitchell1 | Report as abusive

Why would a hospital prescribe antibiotics for a “low grade, common viral disease”? It’ s completely against protocol unless theres’s a secondary bacterial infection

Posted by molly123 | Report as abusive

Remember, he’s a traveler FROM Liberia. It is very unlikely he has health insurance that’s recognized in the United States.

Posted by Burns0011 | Report as abusive

No amount of listening to a patient is going to help when said patient is a liar, as was Mr. Duncan for not telling Liberian officials and Dallas hospital staff about his contact with a pregnant women who apparently died from ebola the day after he helped her. However, he did explain to Dallas hospital staff that he’d recently arrived from Liberia, which fell on deaf ears to everyone at the hospital. It isn’t the doctor so much as the first person to have contact with a patient who needs to listen and sound the alarm before the doctor begins the examination.

Posted by twistoflime | Report as abusive

What exactly is the point of the article? That doctors make mistakes? That mankind, and medicine in particular, are hierarchical? Duhhh. And as all people are not created equal (US Constitution aside….), neither are doctors and so not Ebola (or pandemic flu) cases will be caught. I didn’t need this article to tell me this fact. Clearly, while the US is not a 3rd world country, it is vulnerable to pandemic and this seems clear without statement. In the end this seems like it will end up as a “foot race” between prevention and spread of the disease. This is not the first time the foot race has played out, and depending on when in history we look, from the Black Plague to TB – the results have been quite different.

Posted by Subwavelength | Report as abusive