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Ebola, not gone or forgotten at Global Health Day

Yale Medicine Magazine, 2015 - Spring

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Ebola no longer dominates the headlines, but lessons from the epidemic remain relevant, according to speakers at the annual Global Health Day held this spring. Disease outbreak patterns change along with human behavior, said Majid Sadigh, M.D., director of the Global Health Program at Western Connecticut Health Network/University of Vermont School of Medicine. The take-home message from the event, sponsored by the Office of Global Health and the Department of Internal Medicine, was this: If the health care community remembers these Ebola lessons, the world’s citizens will have a better chance against known and unknown infectious diseases.

Sadigh, a former associate professor of medicine at Yale, returned to campus for Global Health Day to share his experience of fighting Ebola on the frontlines in Liberia last summer. In his grand rounds lecture in Fitkin Amphitheatre, Sadigh showed a photo of shacks and children playing near Meliandou, a village in Guinea that is considered the epicenter of the 2014 West African Ebola outbreak. “You can see there is a road,” Sadigh said. “All you need to remember about Ebola is that it needs a road.” During the height of the outbreak, American news media, along with the public, worried that the Ebola virus, which is tens of millions years old, had somehow morphed to become capable of aerosol transmission. But years of extensive research had never hinted at that possibility, Sadigh said. “It was human behavior, not the virus, that changed,” he said.

A medical professional may show up laden with high-tech medical supplies, as he did in Liberia, but Sadigh explained that doctors and nurses need to understand the local culture. “Whatever intervention you want to do, you have to respect the culture,” Sadigh said. “Imagine if I believed strongly that that if I do not wash the body of my father who died, then my father will not get to the other world,” he said, referring to local traditions of washing the dead. “His soul will hover over the village, and will bring sickness, poverty, and a miserable life to my family members,” Sadigh said. He also recalled the difficulty of communicating with patients in Liberia. Some spoke English, but because of syntax and organization, even English communication sometimes needed translation. Sadigh also discovered that, culturally, it is not desirable to show or discuss pain, thus making one of the crucial symptoms of the virus difficult to record. Some patients waiting for their test results were so dehydrated that Sadigh and his colleagues sometimes added food dye to the water to make it look like medicine so they would be more likely to drink it.

Sadigh said he also understood why some health workers could get infected with the virus—no one in his group did—given the elaborate 22 steps necessary to don and doff personal protective equipment (PPE). During PPE training, healthcare workers were instructed never to raise their hands above their shoulders. But this protocol could break down in the 100-degree weather and humidity, Sadigh said. “It’s hard to see behind foggy glasses if you are checking the right box,” he said. Medical record maintenance was also a struggle since papers couldn’t leave a zone if they were suspected of being exposed to Ebola. “So, then, two hours later, when you are outside of the tent and exhausted, you are trying to remember, ‘Oh, did Patient 3 have abdominal distension?’” he said.

Despite the dire situation, Sadigh said, the team shared a deep camaraderie. In another photo of his team of doctors, nurses, and health workers at the Buchanan Ebola Treatment Unit, everyone was smiling. Sadigh pointed out that this team represented a workforce now not only willing, but able, to confine and treat outbreaks of infectious disease. “Next time we will be very ready to serve,” he said.

Tracy Rabin, M.D., HS ’10, assistant professor of medicine and assistant director of the Office of Global Health, and Gerald Friedland, M.D., professor of medicine and epidemiology, discussed the quandaries of disease control during a discussion that took place later in the day at Park Street Auditorium. Rabin directs a program that sends medical trainees to work in a resource-limited hospital in Uganda, and brings Ugandan junior faculty and students to Yale for clinical training. Friedland directs a program targeting extensively drug resistant tuberculosis in rural South Africa. Friedland shared his experiences with the HIV/AIDS epidemic in the 1980s, just months after the first case study had been publicly recorded. In his Bronx hospital, Friedland saw that most doctors, nurses, and other staff carried out their duties responsibly, some heroically. But some refused to care for patients with HIV/AIDS, a product of the fearful nature of the disease, fear of transmission, and stigma related to their unprofessional views about the patients affected. Apart from health care workers themselves, the responsibility for patient care also rests ultimately with the institution, Friedland said. “Hospitals and clinics must educate their health care workers and provide a safe work environment for those placed in the path of epidemics by the nature of their work.”

In the day’s final talk, Mark Rothstein, J.D., Herbert F. Boehl Chair of Law and Medicine at the University of Louisville School of Medicine, discussed some of the missteps around the country as hospitals and health care workers struggled with the disease and a national panic ensued.

Unlike in other countries, hospitals and clinics in the United States are not governed by a national health ministry, Rothstein pointed out in his presentation, “Lessons of the Ebola Quarantine in the United States.” Under the U.S. Constitution, public health is not a power of the federal government. Instead, the responsibility falls to states and local governments, Rothstein said. As a result, rules on quarantine vary widely. But what the four Ebola cases in this country should teach us is that quarantine needs to be tailored to the disease and health status of the individual, or a community could run the risk of wasting resources, as did officials in New York City. They spent close to $21 million to trace the movements of a doctor who tested positive for the Ebola virus.

The Centers for Disease and Control and Prevention (CDC) erred by assuming that all hospitals were prepared to treat Ebola patients. “That was a silly idea,” Rothstein said. An October 2014 study of infectious disease directors at 1,000 hospitals across the country found that only 6 percent felt they could handle an Ebola case. All cases should have been redirected to hospitals prepared to handle such rare situations, like Emory University Hospital, in Atlanta, he said. Another mistake was the failure of public officials and the media to appreciate the public’s reaction to information. Headlines fanned the flames and increased concern unnecessarily, he said. Governors like Andrew Cuomo of New York and Chris Christie of New Jersey did not help by having a “race to the bottom in terms of public health policy,” Rothstein said, referring to increasingly aggressive quarantine—and counterproductive—policies. Public officials have an obligation to focus on the known science, Rothstein said. “Our country has a very short memory and shorter attention span,” he said. “Now is not the time for complacency because we are only a plane ride away from our next public health disaster.”

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