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Ebola in Dallas Texas: Is our response adequate?

First, let’s look at the situation in West Africa, because that is way more important than anything going on in the US right now. The WHO has said two things about this. First, if there is not a full intervention, there may be hundreds of thousands or even millions of cases of Ebola several months from now (cumulatively). Second, with full intervention they can stop this epidemic.

What is full intervention? They say that full intervention is the development and manufacture of an effective vaccine, and the deployment of that vaccine to a very large percentage of the affected population.

Putting this another way, the current response has been inadequate, and while it can be improved, it can’t be made adequate. Things are pretty bad, are going to get enormously worse, and there is little hope for any other outcome, unless full deployment of a vaccine that does not exist over the next six months is realistic.

Now let’s look at the US. Public health officials and public health experts have been saying the same thing for months. Don’t worry about an Ebola outbreak in the US. We can handle it. We know what we are doing, and we have the systems in place to take care of this. So just don’t worry.

I’m going to tell you now why this is probably both true and untrue.

It is probably true at the large scale. We are not going to have an outbreak of Ebola in the US that involves hundreds of people getting the disease. Probably not even dozens. But, it is not true that we have the capacity to fully handle Ebola coming to the US in the way most people assume this is meant. It is very possible for Ebola to some to the US and make a bunch of people sick with about half of them dying. How many is a bunch? Five, maybe eight, something along those lines, but possibly a few times, in a few places, adding to a couple of dozen. (Totally guessing here, feel free to make your own guess.) That may not happen at all, but given the current situation it is absolutely possible. However, it is not necessary. If our public health system was truly able to handle an Ebola intrusion, the only people who would have Ebola in the US would be those who arrive with it, and possibly a very small number of additional people, not a bunch. In other words, unless changes are made, the inadequacy of our system, said to be fully adequate, will allow several people in the US to become ill, some will die, over the next year.

Here is why.

First, consider the travel problem, which is probably the smallest part of this. When Patient X came to Dallas with no Ebola symptoms, he was almost certainly not a risk. But he did get on an aircraft with the disease, and took a long trip the US. If this event happens 100 times over the next several months, how many times will the patient become symptomatic on the plane, possibly exposing others? 10% of the time? 5%? 20%? Hard to say, but often enough that over the next several months hundreds of travelers and airline workers will be exposed, but, the chance of them contracting the disease is low. So, with the current expanding outbreak and current policies, a very small number of people may get Ebola in a system that claims to be totally able to handle it. That’s small change compared to what is going on in West Africa, and it is probably the least of our worries here in First World Land.

Second, we have the problem of reporting and identification. Patient X became symptomatic and then for something like a day did not seek medical help, during which time various individuals were potentially exposed. Again, since Ebola is not airborne, the chances of them getting the disease is low, but it is real. The problem is that when people get sick, there is almost always going to be a window of time from a few hours to a couple of days during which the most prepared health care system in the world has no control over what happens because the person does not show up at a hospital or clinic. There may be no way to avoid this, but the risks can be reduced. If the West African epidemic continues members of the communities that overlap between the US and West Africa will be at risk, albeit low risk, of exposure to those who travel back and forth on a regular basis. What needs to happen is that those communities take special care to address this issue internally. All it is going to take is one or two Americans catching the disease from a person living part time in West Africa to shut down air connections between the two regions. If we want to avoid this, there needs to be self-monitoring in the communities.

Third, we have the unconscionable thing that happened in Dallas. A patient who had been in Liberia showed up with Ebola like symptoms in a hospital and was sent home. Holy moly. Why did that happen? Well if you’ve been recently in the hospital for anything that required testing and such, you may already know. Hospitals and clinics, but especially emergency rooms, are run like those steak houses that became popular back in the 1980s. You arrive at the steak house, and a nice person with a big smile seats your group. Then a server comes over and takes drink orders. A second server brings the drinks. A third server comes by for your meal order. A fourth server brings the appetizers, and a fifth server brings your meal. Eventually somebody comes by with the check. (Remember those?)

In an emergency room, there will probably be a physician taking care of you but all the tests that are run are done by different individuals, if there is some kind of treatment you need, the person who cues you in on that (tells you how to take the pill or use the device they are going to give you) is different still. The person who checks you out is different still. What is the possibility that a concern you address to the physical will be responded to by that physician later during your visit? It depends on how fast the person who check you out and sends you home arrives on the scene. Maybe 50–50.

That is probably how Patient X was let go with Ebola. The system has too many places to break. How likely is that to happen again in other emergency rooms or clinics in the US? Not zero.

So, the bad news is that our system does not really put the lid on Patient Zeros that may show up in clinics or hospital, reliably. The system we have been assured would not allow an outbreak probably won’t allow an outbreak, but it may well allow dozens of people to be needlessly exposed, among whom some may contract the disease.

Now here’s the good news. It is said (though the information is spotty) that between 80–100 people who may have had even minimal contact with Patient X are being checked twice a day for fever, and a smaller number are being looked at more closely, even quarantined. The several schools attended by some kids Patient X had contact with are being sterilized. And so on. Frankly, this is more than necessary, but that’s irrelevant. If you only have a few tiny “hot zones” (in this case, one, and not that hot) an abundance of caution is not overkill. If over-cautious reactions eventually emerge whenever an Ebola patient shows up in the US, the larger scale outbreak will be avoided. But the handful of people initially at risk will not be safe by virtue of our system.

Perhaps that is unavoidable, but I think most people will look at the Dallas event and say that sending the patient home clearly should not have happened, and now every hospital and clinic in the country will be extra cautious. Like, remember that one time a surgeon accidentally amputated the wrong leg, and after that one time, it never happened ever again anywhere?

What, you don’t remember that? Hmm… me neither.

(Also, consider this: Imagine implementing the level of caution now being implemented in Dallas in the affected areas of West Africa? Can you imagine implementing this only half way, or a quarter of the effort? That would a) stop Ebola and b) be impossible. That is why the outbreak continues there. We have a lot to be thankful here in the US.)

Conclusion: The communities that have regular interaction with the affected countries are already in many cases somewhat organized as communities. These communities need to develop humane and thoughtful ways of making sure travelers are properly watched after. Everyone who works in any clinic or hospital has to double check what they are doing and not mess up again. The initial conditions that led to the current situation in Dallas are going to become more common over time.

And, remember, so far everything in Dallas is under control, but it will take 27 days to be sure (the incubation period is about 27 days, despite the “21 day” number you keep hearing). Also, while Ebola can manifest in an infected patient as quickly as two days after exposure, it is more typical to show up 8-10 days later. So the first week to 10 days of October is a fairly likely time, perhaps, to see a second case in Dallas, if there is in fact, further infection.

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