America doesn't have an Ebola epidemic, but it's been infected with a whole lot of fear-mongering, finger-pointing and downright nonsense lately. Politicians, in particular, have unleashed a whirlwind of irresponsible speculation and policy prescriptions with no basis in reality.
Senator Rand Paul is telling reporters that you can catch Ebola at a cocktail party -- an unlikely prospect, unless if, for some reason, you manage to make contact with the bodily fluids of someone who's actively sick with the disease. Todd Kincannon, the former general counsel and executive director of the South Carolina Republican Party, declared that the "immediate humane execution" of U.S. Ebola patients would somehow save lives. Lawmakers on both sides of the aisle continue to push for travel bans, despite experts' warnings that they could make the crisis worse. And a vocal contingent of conservatives is convinced that the threat of an infectious disease from West Africa warrants sealing the U.S.-Mexico border -- an enormously expensive and probably impossible to execute solution, as Salon's Simon Maloy points out, for a problem that doesn't even exist.
Here are the problems we're actually dealing with: a worrisome amount of misinformation, and a U.S. health system that's increasingly showing its flaws. Two health care workers charged with treating the first Ebola patient in the U.S. themselves became infected with the disease, and no one's really sure how it happened. It probably didn't help that, as some nurses at that hospital allege, “there was no advanced preparedness on what to do with the patient. There was no protocol. There was no system." The Centers for Disease Control and Prevention, while not responsible for the hospital's policies, admits it regrets the way it initially responded to the case. No one's quite sure, either, how the second health care worker to become infected with Ebola ended up on a commercial flight just one day before she presented with a fever; the CDC acknowledges that shouldn't have happened, either. The director of the National Institutes of Health, meanwhile, said we'd probably already have an Ebola vaccine, if it weren't for budget cuts.
It's clear we need to begin a more constructive dialogue — about what Ebola is and what it is not, about the humanitarian crisis unfolding in West Africa and how much of a threat it actually poses to the U.S., and also about the legitimate ways in which the U.S. health system isn't prepared for Ebola, or some other, even worse public health threat.
Yesterday morning, two weeks after the first case of Ebola was diagnosed in the U.S., Salon spoke with Arthur Caplan, director of the Division of Medical Ethics at NYU Langone Medical Center, about his take on the lessons we can take away from our sometimes hysterical, not always effective response -- and about the system-wide changes he believes are needed to ensure we do better, going forward. Our conversation has been lightly edited for clarity.
It’s been a high-profile couple of weeks for the U.S. health system, with what's being portrayed as some pretty major screw-ups: the Dallas hospital letting the Ebola patient go, two health care workers getting sick, and the CDC admitting it would have done things differently. Before we get to some of the more out-there political accusations, what can we say really has gone wrong, and how serious were those missteps?
You know, it's still hard to say what went wrong. That things went wrong, we're pretty sure -- but why, I still don't think we know [what], exactly. For example, I don't know if someone took a porous history of the gentleman who came in with Ebola, I don't know if there was a failure in the handoff from the nurse to the doctor, I don't know if the electronic medical record didn't let them enter in the right information, or flag it in a way that was important. I don't even know if the guy was sent home because he didn't have insurance, which is a problem in the U.S. health system still -- in places like Texas particularly. So there could be many reasons for that single error that we haven't heard. And I think we need to hear about it. I get a little angry when I hear people saying "privacy" -- I think privacy, in an epidemic, has to yield to getting a straight story. And I also worry that liability fears are preventing a straight story from coming out.
Most of these problems I think that we're seeing are also occurring because we're trying to act as if every hospital in the United States can be "Ebola-ready," and I think that is a very unwarranted assumption. There are plenty of hospitals in the United States that can't deal with an Ebola patient. They don't have practice with isolation; some of them are hospitals that are set up to care for veterans and are in nursing-home mode; some of them are specialty children's hospitals. What we need to do is focus on a few hundred hospitals that have a lot of experience and are quite capable of dealing with Ebola patients, or anyone else who's got a highly infectious disease; make sure they're trained, and following the same set of policies; make sure they're practicing -- putting on their equipment, taking it off -- and stop pretending as if an Ebola patient can go anywhere in the United States and be managed.
So then what do you do when a patient unexpectedly shows up at a hospital, like Texas Presbyterian, that might not be prepared?
The other arm is, we need to train EMTs, police, fire -- in association with each one of those hospitals -- to go get that patient when they're identified. So I'm a little nervous that training hasn't been done. It's not that we don't have Hazmat teams and so forth. But you want to prepare them for managing a patient rather than a chemical spill. And I think the way to go is to set up a network of transportation, a kind of quick response -- which we have. We have ambulances that can get almost anywhere in a few minutes in most parts of the country, and certainly in most parts of the country where an Ebola patient is likely to pop up. We can do it.
You mentioned easing up on privacy restrictions. What sort of things, specifically, are you talking about? Because with the Texas patients, everyone who may have had contact with them was alerted and monitored...
Well, we don't need patient names, but we do need information on where somebody has been.
The public needs to know that we're doing contact tracing. We need to know why somebody was told to go on a plane, if they were told that it's okay to travel with fever. We need more information, in other words, than we'd normally [need]. If I go to the doctor, nobody needs to know where I've been. It doesn't matter, it's my business, they don't have to track me through a taxi or a subway. But I think we do need that information about Ebola patients. Partly it will reassure people that it's hard to get the disease -- they won't come down with it if they just sat next to somebody who wasn't symptomatic on the subway.
We need more information about the errors, as I said. We could use a little more information about how quarantine is working: what does it mean, how do they get food, what happens in the kind of incident that you saw when the NBC reporter came out of the house -- why did that happen? What was she told? If someone does come out of the house, what happens? Are the cops going to shoot them dead? Are they going to tase them, are they going to tackle them in a moon suit?
So there's a lot of normal information -- I come out of my house to go to the supermarket, that's private. I come out of my house having been exposed to Ebola, I need to know what the response was and I need to know what the response is going to be.
So some kind of publicly available, very detailed list of standards and policies.
Would it be reasonable to expect that we could have had that ready?
By now, yes.
I'm going to ask you a question: if you were sitting on a plane, and there was a guy who looked like he might be from Africa -- he was wearing a dashiki or something -- and he threw up, what would you do?
I think I'd be wary of vomit in general...
But would you move away? Would you call the flight attendant?
I'd definitely move away and call the flight attendant.
And if you call the flight attendant -- because I've been asking them, having had the joy of flying a lot in the past two weeks -- they tell me they haven't had any specific training on Ebola. A couple of them said they have biohazard equipment on the plane. I ask them if they've practiced with it, they said no. So that's what I'm talking about. We have a campaign for terrorists that says "If you see something, say something." We need an Ebola public education campaign.
How do you do that without inciting panic? Is there a danger of being overly cautious, in that it could creep into the realm of racial profiling?
Well, I think you have more panic if you don't do anything. Listening to my neighbors, they seem pretty panicked already. So I don't think that's a problem. I would say, you know, people didn't panic over the idea that it could be a bomb in every trashcan. They just look around and watch. So I think it can be done, I'm not worried about that. I think those flight attendants, train conductors, people who run the mortuaries, they all ought to have a little special information, too, about what they're supposed to do.
There is a huge danger of stigma: we saw it with AIDS in the early days. We need to be sure people know what to do if they see something since we don't want everyone crossing the street to avoid contact with anyone who looks "African."
There's a very, very small chance of there being an Ebola outbreak in the U.S. But seeing what's happened with this, should we be concerned about the United States' ability to handle another, perhaps containable epidemic or another public health scare?
Yes, we should. We have starved the public health system, both in terms of research and ability to respond. We need a rapid-response capability, both here and in overseas locations where outbreaks occur -- there is no equivalent of the Special Forces to send, no boots on the ground kind of thing. There was no one to send to Guinea when Ebola first broke out: there was a lot of begging for help, but there wasn't like a standing volunteer force that said, "Yep, okay, they need us, and we've practiced and we've been to other places, we can get there." I think also we're seeing a lack of coordination, because everyone's talking about the CDC. The whole Texas thing is run by the Texas Health Department. The CDC is an advisory group. They don't have any authority. Is that a good system? I don't think so.
Would you say we're mostly just lacking in funding right now? Are there ways to reprioritize some of our health spending?
Well here's a health funding problem: there's a big lobby -- I just watched them march around -- for breast cancer. There's a lobby for Alzheimer's. There's a lobby for Parkinson's. There's even a big lobby for ALS. There's no lobby for Ebola. There's no lobby for pandemic flu. There's no lobby for West Nile Virus. So it's clear that the way our funding works is to respond to political lobbying, and we need to make sure that money is put aside to handle infectious disease, plagues or scourges that don't have any lobby because they haven't happened yet.
It would seem like right now, with all the attention Ebola's getting, there'd be more fundraising. Do you have any theories for why that's not happening?
Because I think the way the funding is structured, it moves to where the disease lobbies are, and where congressmen hear from constituents about their desire to cure this or that. And again, despite fear of Ebola, I'm not sure there's any group or organization that's doing that. In fact, I'm sure there isn't. And so in an advocacy demography, Ebola's kind of a lost orphan. It doesn't fit into the usual geography for generating money.
There have been some others "solutions" proposed: John Boehner just asked the White House to consider a ban on travel from stricken African countries, then we have Scott Brown and other Republicans arguing that we should close the U.S.-Mexico border because "Ebola-infected terrorists" are apparently a threat. Is there any logic to those ideas? Or are they just completely skipping over practical solutions?
Well the "close the U.S.-Mexico border" is kind of hilarious, because no one's been able to close the border from the plague of drugs that kills a lot of people, so I don't know why we'd be all better at it tomorrow morning. There are no direct flights here, as far as I can figure out, from Sierra Leone, Guinea or Liberal. There are some direct flights to England and France, but people have to come here indirectly. So if you're going to close those routes... I think it does make sense to take temperatures and get good contact information from those coming from impacted nations, but there's no need to ban them.
So for politicians that are demanding action, what are some more reasonable approaches to preventing more Ebola cases in the U.S. that they can be calling for?
Spend some money -- more money than we're spending. Go to West Africa with more aid and equipment, and try to get the epidemic under control. If we don't get it under control there, pretty soon no one's going to be able to fly anywhere, so to speak -- cases will leak out, is my point. And what's on the ground there, as far as I can see, is not sufficient to turn the epidemic around yet.
Is there a place for the U.S. to be playing a leading role in that?
Well, you certainly can be working with the World Health Organization, the usual NGOs, but I think here it's "U.S. Does It." It's a little bit like ISIL: you can build a coalition, but we have to take the lead.
So far as preventing public panic back in the U.S., you've written about the need for a Surgeon General -- which is held up in Congress right now thanks to the pro-gun lobby. What kind of role would such a person play in situations like this? How would it be different from the CDC director’s role?
It would mainly be public education things that the CDC director's trying to handle. The Surgeon General is the U.S. health educator. Without that role, it's harder to get messages across about what to do if someone seems sick, or this is what's going to happen if you get sick -- it's not that they have mighty authority to impose policies, but they are really the bully pulpit, the nation's educator. And to not have that, in the middle of an Ebola outbreak, I think everybody in Congress should be impeached if they don't get a Surgeon General in there.
It's this funny dynamic, where the CDC is both telling people not to worry, trying to get out good information, and then also being held to task for these high-profile cases -- is that one of the things that's contributing to the public fear?
I do think that is a problem. It creates distrust. The fact is, we're going to get 10 or 20 more Ebola cases. The CDC should say that; the media should be ready for that. They're not going to pose any big threat to anybody if we have the right speciality transporters and specialty hospitals to take care of them. But there are very likely to be more. For example, just sending 3,000 U.S. troops to Africa to try and deal with the outbreak is likely to get one or two people who get infected somehow, who then expose some others, and that's why I say you can't go around saying "everything's okay, it's completely under control," because then you have that drip, drip, drip of individual cases, somebody wanders out of quarantine, and it just makes people think, "I can't trust you, because look, the epidemic is continuing and you tell me everything was okay." What's more honest is to say, "we can get 10 or 20 more cases, but don't freak out, we've got the system to manage them."
It seems like there needs to be a balance between panic and complacency. If we keep getting cases and the attention completely goes away, then not only are we not addressing some of these major issues in the U.S. health system, then we're probably not doing much to help West Africa, either.
Absolutely agree. So in a weird way, you don't want to let people let their guard down and then not pay attention to these big gaps in funding, infrastructure and centralized control that you need in an epidemic. Those are still problems if pandemic flu comes back, or if some nasty bug crawls out of somewhere.
There's a lot of unfounded fear -- most people aren't going to get Ebola -- but in my experience, at least, it's all anyone can seem to talk about. Do you have any ideas for how we can kind of rechannel that interest toward more productive conversations?
I think having more religious leaders, high school assemblies -- take it out of the medical and put it into the general culture, talking about public health, about what are the threats that are out there and what we need to respond. If you just keep it inside a health framework, I don't think you get the dialogue you want. So town halls, more congressional hearings, more state legislative hearings. I'd like to see more media "forum on Ebola" kind of things instead of just talking heads wondering about who's flying where.
What's the least productive talk that you're seeing right now?
It's that border control thing. Taking temperatures, controlling the borders, that's just very tough to do in this world where you can get air connections all over the place and still show up. And if you don't get on top of the epidemic while it's still in West Africa, if it still increases and increases, then there will be leakage of cases to Europe, Asia, the United States and the rest of the world. So target one is still stopping the epidemic, not worrying about who's coming in here.