by Todd Pollock, MD
Dallas County Medical Society President
It is days before the deadline and I am staring at this month’s President’s Page that seems meaningless in light of recent events. The first patient to develop Ebola in the United States walked into a Dallas hospital. A little over two weeks later, that index patient, Thomas Eric Duncan, has died and two nurses who cared for him were diagnosed with the disease. I feel compelled to put aside the essay I was working on and discuss this crisis. Never mind that by the time this goes to press, many of the unknowns will be known. Many of the burning questions will have been answered, and new questions will have arisen. We will learn a great deal when we dissect this experience, but I offer some contemporaneous observations.
Dallas has not been under such scrutiny since the Kennedy assassination in 1963, and I suspect that the nerves of the city and of the country were equally raw at that time, although for much different reasons. The World Health Organization calls the current African Ebola outbreak the “most severe, acute health emergency seen in modern times.” Until Sept. 28, Ebola was just a frightening disease in West Africa that we saw on the nightly news. But modern air travel makes Africa a plane ride away and makes the question of Ebola in this country not “if” but “when.” And that “when” is “now” as Mr. Duncan presented to the ED at Texas Health Presbyterian of Dallas on Sept. 28. Paraphrasing a hearsay quote of a THD administrator (who was paraphrasing Humphrey Bogart), “Of all the hospitals in all the world, he had to walk into ours.”
I remember first learning of Ebola in Richard Preston’s 1994 book “The Hot Zone,” which was based on true events. For some reason, just the name, Ebola, evokes fear. The first known infection occurred in 1976 deep in the jungles of Zaire near the headwaters of the Ebola River for which it was named. As with many viruses, Ebola jumped from its animal host to man where the jungle met society. Over the years, outbreaks would spring up periodically and remit spontaneously, likely due to the isolation of the affected villages. This most recent outbreak has gotten out of control in West Africa, killing more than 4,500 people to date. WHO projects this number to grow exponentially unless the virus can be effectively contained and controlled. Containment efforts to prevent spread outside of Africa have been hotly debated. Specifically, the controversy centers around screening methods, travel bans and mandatory quarantines of travelers from those affected West African countries.
Big-Picture Lessons We Have Learned to This Point
Our biggest enemies are ignorance and fear.
Margaret Chan, general director of the World Health Organization, said that “fear of infection has spread around the world much faster than the virus” and that 90 percent of economic costs connected to the virus “come from irrational and disorganized efforts of the public to avoid infection.” Many examples of this can be seen in Dallas. We have seen patients cancelling appointments and surgeries. Concerns have been generated about using public transportation, air transportation, and even ambulance transportation. We have seen children turned away from schools because their parents work at Presbyterian Hospital. DART stations shut down because a commuter became ill. Ambulances and airplanes have been taken out of service and cruise ships turned away from ports. The cure for this irrational action is factual information.
The media must remain responsible in its reporting.
In a situation like this, the media should be our greatest ally in satisfying the public thirst for information. Fact-based reporting is helpful in allowing the community to understand its risks, avoid infection and, we hope, quell fears. Unfortunately, 24-hour news and the competition created by the great number of news sources have left the public to sort out good information from the abundance of poorly sourced material, misinformation, speculation, and half-truths. We have seen too many examples of the media second-guessing and finger-pointing in the name of investigative journalism. We have seen dramatic on-camera reporting worthy more of an Oscar than a Pulitzer. This has resulted in an atmosphere of unwarranted public fear, distrust and irrational behavior.
Fortunately, some in the media have recognized the importance of their role and made efforts to spread fact-based information. John McCaa and WFAA launched the “Facts, Not Fear” campaign to promote dissemination of scientific information and to fight fear mongering. Efforts like this should be commended. I also found several of Jacquielynn Floyd’s columns in The Dallas Morning News to have a refreshingly level-headed message. To other members of the media who are committed to responsible journalism, I commend their efforts, as well.
Physicians, hospitals and public officials must maintain the public’s trust.
I am very proud of the actions of everyone at Texas Health Presbyterian Dallas who bravely and professionally carried out their duties in the face of this frightening situation. But, despite valiant efforts to be prepared and close adherence to CDC protocols, we cannot deny that errors were made. It is easy to play Monday morning quarterback, but we should not have to apologize for the fact that we don’t have a lot of practical experience with this situation. Unfortunately, PR mistakes by the hospital hurt public confidence. Putting out information before details are known breeds mistrust. Confidence is built through forthright honesty. Errors and mistakes are more readily accepted when presented in an up-front manner. Over the last several years, the admission of medical and surgical errors has been promoted as a best practice that should be communicated along with appropriate apologies. Hospitals have championed this concept. They need to take their own advice.
Unfortunately, many efforts made to calm fears only led to public doubt and concern. This occurred when what was said conflicted with actions taken. For instance, the public was told that passengers on airplanes that carried an asymptomatic, exposed person had no chance of catching the disease. Yet, these planes were taken out of service and deep cleaned, often multiple times. Similarly, the apartments of the infected nurses were treated like a hot zone, but the neighbors were told they were not at risk. Although I understand that these efforts were made to be extra cautious and to be reassuring to the public, the conflicting message created suspicion and distrust.
Public officials and trusted community leaders should be committed to comforting the public through fact-based comments. This is not a time for these trusted individuals to advance speculation, fear mongering or politics. Community leaders who publicly blamed Mr. Duncan’s initial ER discharge and fatal outcome on his race and insurance status made absurd allegations that generated unnecessary and unwarranted fear.
Healthcare officials must remain unified in action and voice.
When mistakes are made, the media begins its unrelenting probing for blame, and those involved have a natural defense of pointing fingers. This unproductive exercise drives a wedge between agencies, organizations and individuals. No one stands alone in these complex situations and everyone has their roles. Breakdown of cooperation invites disaster, and an inconsistent message will further public mistrust and fear.
Physicians’ actions must be based in science, not fear.
As healthcare workers, we are on the front line of patient care, and when a disease as horrific as Ebola potentially is in our community, it is normal to fear for the safety of our staff, our families and ourselves. It is imperative that we base our actions and words on science and not fear. We are role models in matters of health, and our patients listen to what we say and watch what we do.
We must learn from our experiences, both triumphant and tragic, and make changes when appropriate.
In light of the infection of two healthcare workers who cared for Mr. Duncan, the CDC has changed some of its protocols. This has generated criticism from the media, leading to the undermining of public trust. But we cannot let this criticism derail us from what we always have done — advancing medicine through careful examination of our successes and our failures. We all share the experience of M&M conferences or the like, wearing our failures on our sleeves but coming out the better for it. The public must understand that Ebola is a disease that never has been on our soil, that few physicians in our country have seen a case, and that a relative few physicians in the world have any significant experience in treatment. Additionally, we cannot let our pride get in the way of admitting error and need for change. The head of the World Health Organization said, “Hubris is the greatest danger to the wealthy countries.” As usual, we must face our errors head-on, determine what we did both right and wrong, and make changes as indicated.
We must hold up as heroes those whose professionalism placed the care of the patient above themselves.
We all owe a great debt of gratitude to the paramedics, nurses, lab techs, janitorial staff, and host of others who selflessly cared for those stricken with Ebola. We also must appreciate the first responders, the ER staffs and office staffs who interact each day with the public, never knowing if they may be dealing with the next Ebola victim. The nurses who contracted the disease while caring for Mr. Duncan deserve our deepest praise and our most heartfelt prayers for recovery. Those who cast blame on these individuals should be ashamed.
DCMS plays an important role in health-related issues of our community.
DCMS has been actively involved in the Ebola situation from the beginning. Our members have played roles in everything from directly caring for the victims at Presbyterian Hospital to participating in the development of a regional medical disaster plan. We have manned the Dallas Emergency Command Center and given counsel to city officials and schools. One of the stated goals of the society is to be the “definitive source of healthcare information in North Texas.” To this objective, DCMS has been a key source of fact-based medical information to city officials, the media and the public. A page on the DCMS website* provides up-to-date information and references. Our members have participated in interviews, town hall meetings, and social media Q&As. We all can be very proud of DCMS and its members for meritorious participation at every level as Dallas navigates this frightening and potentially disastrous ordeal.
This post first appeared as the President's Page in the October 2014 Dallas Medical Journal.