The New Neo

This is one of the saddest things I’ve ever read. It’s an account of how patient zero, Thomas Eric Duncan, contracted Ebola in Liberia. But more than that, it’s a story that’s all too typical of the tragedy of this disease so far in Africa, where it’s ravaged villages and cut a swath through families and friends who try to help sick people, sometimes without even being aware that Ebola is the disease they have.

It also makes it clear that we don’t really know whether Duncan knew what killed the 19-year-old pregnant woman he’d helped, or even that she had died at all.

Here’s the sort of thing I mean by “sad”:

Within weeks, everyone who helped Williams that day was either sick or dead, too ”” victims of Ebola, the virus that is ravaging Liberia’s capital and other parts of West Africa, with more than 3,300 deaths reported.

The disease is spread through direct contact with saliva, sweat, blood and other bodily fluids, and all those who fell ill after helping Williams had touched her. She turned out to have Ebola…

As 9-year-old Mercy Kennedy sobbed along with neighbors mourning news of her mother’s death, not a person would touch the little girl to comfort her.

Mercy’s mother had helped to wash the pregnant woman’s clothes, and had touched her body after she died at home when no hospital could find space for her, neighbors said.

On Thursday, little Mercy walked around in a daze in a torn nightgown and flip-flops, pulling up the fabric to wipe her tears as a group of workers from the neighborhood task force followed the sound of wailing through the thick grove of banana trees and corn plants.

“We love you so dearly, yeah,” one man wearing rubber gloves told her from a safe distance. “We want to take care of you. Have you been playing with your friends here?”

With Mercy’s mother dead, neighbors fear it is only a matter of time before she, too, shows signs of the virus, and they want to know which other children may have come into contact with her while she was fetching water.

Aside from the pathos, there’s interesting information there. “All those who fell ill after helping Williams had touched her.” Ebola is spread by “direct contact” and not simple touch—meaning that body fluids must come in contact not just with unbroken skin, but with mucus membranes (including nose or mouth), broken skin, or eyes. These people did not nurse Williams in an intimate manner (although some may have). Nor is it alleged she vomited in their faces or bled on them, although I suppose that’s possible. Most seem to have merely touched her, probably getting smaller bits of virus on their hands (from virus that was on her from her own body fluids, perhaps including sweat) and then almost certainly touched or rubbed their eyes, noses, or mouths.

We touch our faces, including rubbing our eyes, many times a day. Not a good habit when Ebola is rampant.

There is little question in my mind that Duncan, Dallas’ Ebola patient zero, knew he most likely had Ebola when he got sick, and particularly as he got sicker. His first trip to the hospital, and their negligent (perhaps even criminally negligent) failure to admit him then, is one of the most perplexing, frustrating, and infuriating parts of the whole story.

It seems, though, that once he got very sick, he may have made a belated (and perhaps unsuccessful) effort to avoid infecting others directly [emphasis mine]:

Two days after he was sent home from a Dallas hospital, the man who is the first person to be diagnosed with Ebola in the United States was seen vomiting on the ground outside an apartment complex as he was bundled into an ambulance…

“His whole family was screaming. He got outside and he was throwing up all over the place,” resident Mesud Osmanovic, 21, said on Wednesday, describing the chaotic scene before the man was admitted to Texas Health Presbyterian Hospital on Sunday where he is in serious condition.

It seems likely, from the details I bolded, that the man and his family knew the score and they were terrified—otherwise, no one would be screaming just because a man was vomiting. Nor would someone ordinarily go outside to vomit; the person would stay inside and use the bathroom. It seems pretty clear to me that Duncan’s move outside was an effort to not have so much contact between the people in his family and his body fluids. But of course, his move potentially exposed the neighbors, although not unless someone acted so strangely as to go up to investigate what he had produced.

And the ambulance crew is a whole different story. Did anyone—the man himself, or anyone in the family—try to convey the actual situation to them? My guess is that they didn’t, perhaps in part out of fear that the crew would refuse to transport him if they knew. The situation is right out of a horror movie.

One thing that keeps stunning me is the incredible negligence—in my mind amounting perhaps to criminal negligence—of the hospital. If Duncan had been admitted on the first go-round it would have still been a big story and a distressing one, but nothing like as awful a situation as what actually has transpired. More than anything else in the entire tale, the hospital’s failure undermines anyone’s lingering faith in the ability of our health care system to get this thing right and to protect us adequately.

And yet there’s been little focus on how the snafu happened. The statements by hospital official Mark Lester are totally inadequate as an explanation. I have been unable to find a full transcript of Lester’s statement that includes reporters’ questions to him (they seem to have been inaudible in this transcript of his press conference), but here’s the relevant section. Note how relatively unconcerned Lester appears to be, and how he defends the hospital’s decision by saying that Duncan’s symptoms weren’t “typical at that time yet for Ebola.” Ah, so they have to wait until symptoms are full-blown to admit someone? And even if the staff failed to realize that the patient had come recently from Liberia, wasn’t it obvious that he was an African national? Was no one interested in that fact at all? Or was it too un-PC to have noticed and paid attention?

INAUDIBLE QUESTION)

LESTER: A checklist was in place for Ebola in this hospital for several weeks. And Dr. Ed Goodman (ph), to my right, had led the implementation of that. That checklist was utilized by the nurse who did ask that question. That nurse was part of a care team. And it was a complex care team taking care of him in the emergency department.

Regretfully, that information was not fully communicated throughout the full team. And as a result, the full import of that information wasn’t factored into the clinical decision-making. The overall clinical presentation was not typical at that time yet for Ebola. So as the team assessed him, they felt clinically it was a low-grade common viral disease. That was the presentation.

(INAUDIBLE QUESTION)

LESTER: He volunteered that he had traveled from Africa in response to the nurse operating the checklist and asking that question.

(INAUDIBLE QUESTION)

LESTER: I can’t answer that question because that’s one piece of information that would be factored into the entire clinical picture. The clinicians did not factor it in. So it was not part of their decision-making.

(INAUDIBLE QUESTION)

LESTER: I — that’s a question that’s really not in my domain.

(INAUDIBLE QUESTION)

LESTER: We are carefully assessing that now. And that is being investigated. So we are investigating it. I can’t give you specific information. We will look very carefully at that.

QUESTION: Sir, would I – would I call that a misstep, would you not?

LESTER: I would call that not factoring all the information among the team that was present so that all the information wasn’t present as they made their clinical decision.

QUESTION: Was there any (ph) expressed any information that this person (INAUDIBLE).

LESTER: That information was not obtained when the patient was in the emergency room.

QUESTION: But do you know that now?

QUESTION: (INAUDIBLE QUESTION) you name is, sir?

LESTER: Oh, I’m Dr. Mark Lester…

Lester won’t even call it a “misstep.” This culture of failure to take responsibility is so widespread as to be a sort of epidemic in and of itself. Or maybe a pandemic.

Lester never answered the questions I have for him:

What is the usual protocol of the hospital for “factoring in” such information? What is the “full decision making” process? How is it that you think this information failed to get conveyed? Who was in charge of the discharge decision, and did that person even speak to the nurse who had questioned the patient and received the information? Has this protocol been changed to correct this problem? Has anyone been fired or disciplined? Have you reviewed other protocols to see where they might be lacking? Who sets these procedures?

[ADDENDUM: Liberia is planning to prosecute Duncan for lying during an airport screening when he was asked if he’d had contact with an Ebola patient. If Duncan dies, however (which for many reasons I hope does not happen), I assume the suit would be moot.

The article mentions, however, that when Duncan helped the ill woman into a cab, he allegedly thought she had a pregnancy-related illness. This is possible, because she was nauseated or vomiting and was in fact seven months pregnant. Although pregnancy-related nausea tends to occur much earlier in pregnancy, it would certainly not be hard to believe that Duncan may not have realized she had Ebola. Of course, if he later got the news that she had died, that would be more difficult to argue.]

[ADDENDUM II: Duncan’s nephew says he had to call the CDC to get his uncle admitted to the hospital.]

[ADDENDUM III: Much more, worth reading, here.

Stunning, shocking stuff.]

…came to this country from Liberia knowing he had been closely exposed to an Ebola patient in his home country [hat tip: Artfldgr].

Mr. Duncan, the first person to develop symptoms outside Africa during the current epidemic, had direct contact with a woman stricken by Ebola on Sept. 15, just four days before he left Liberia for the United States, the woman’s parents and Mr. Duncan’s neighbors said.

In a pattern often seen here in Monrovia, the Liberian capital, the family of the woman, Marthalene Williams, 19, took her by taxi to a hospital with Mr. Duncan’s help on Sept. 15 after failing to get an ambulance, said her parents, Emmanuel and Amie Williams. She was convulsing and seven months pregnant, they said.

Turned away from a hospital for lack of space in its Ebola treatment ward, the family said it took Ms. Williams back home in the evening, and that she died hours later, around 3 a.m.

Mr. Duncan, who was a family friend and also a tenant in a house owned by the Williams family, rode in the taxi in the front passenger seat while Ms. Williams, her father and her brother, Sonny Boy, shared the back seat, her parents said. Mr. Duncan then helped carry Ms. Williams, who was no longer able to walk, back to the family home that evening, neighbors said.

Terribly tragic and terribly negligent. Mr. Duncan must have realized he was at risk, and yet he came here knowing that (perhaps his motivation was to get treatment here, rather than die there). He apparently told the Dallas hospital on his first visit there that he had come from Liberia, and yet somehow that information “was not fully communicated throughout the whole team.” Did he manage to “communicate” the fact that he’d been so closely exposed to a dying Ebola patient, or did he leave that detail out?

There is so much fault here—Duncan, the hospital, the CDC, the government—that it’s hard to know who to blame first.

Deeply, deeply, deeply disturbing.

In the early 90s I wrote a research paper on HIV and contact tracing. Initially, I had assumed that HIV would be treated in the same way as other diseases spread by sexual contact such as syphilis, and that contact tracing would be a big part of the approach to controlling it.

I was wrong. How very wrong I didn’t discover until I started researching the paper. I interviewed public health authorities, and grew increasingly stunned by the answers they gave me. Those time-honored methods had been jettisoned, and why? There were a number of reasons, but the main one was politics. Gay rights groups had the public health people frightened of doing anything to limit their sexual habits, and many of the public health people didn’t even need intimidating because they had already internalized the idea that the rights of patients to absolute privacy should be the paramount consideration.

An even greater consideration than keeping people from dying, which was the almost invariable result of HIV infection back then.

Commenter “Wolla Dalbo” has some questions the CDC should be asking itself. Remember, the Ebola patient in the US went to the Dallas hospital with symptoms and was sent home only to return again several days later, much sicker. Wolla wonders:

The CDC director gave the impression that, when he was contagious, the patient only had contact with his family members, who were the ones most likely to have been infected with Ebola. But, what about that first hospital visit?

How did the patient get to and from the first hospital? Did his relatives drive him, or did he use a cab or public transportation? We weren’t told.

Did our Ebola carrier sit for any length of time in a busy public waiting room, where countless patients, visitors and staff came in and out? How about a smaller waiting room? How about all the medical personnel who he came into close contact with, the people he passed in the hall, and did he use the bathroom at any point? Did he do any visiting or eating out?

None of these questions were even mentioned.

There are many more questions that haven’t been touched on, including ones I asked in yesterday’s post: why, given the fact that the man had just come in from Liberia, which is a hotbed of Ebola, was he treated and released? Why was he not quarantined and tested?

In fact, why is the technique of quarantine not used more in this situation, including for the man’s family? Is it a case of some patients’ rights thing trumping all else? Or is simple incompetence at work? Or is it considered too expensive or bothersome to quarantine people? It would be a lot more expensive and bothersome if we have an Ebola epidemic—expensive in every sense of the word.

When I Googled “Dallas Ebola and quarantine” just now, however, I discovered that the EMT crew members who transported the Dallas patient have been quarantined and the ambulance pulled from service, according to the headline. That would make sense (and answer one of Wolla’s questions), because they would have been exposed to the patient’s bodily secretions without hazmat suits. But reading the article itself, I find that the crew has merely been “restricted to their homes,” which is not the same as quarantine. Their conditions are being “observed” and I would assume as soon as they show symptoms they would be raced to the hospital.

But that seems a foolish way to handle the situation. Not only can we not be 100% certain that people are not contagious until they show symptoms, but if they are only removed from contact with others when they show symptoms, wouldn’t it already be too late to stop the disease’s spread?

Also, as Wolla asked, what about others—including staff—in the emergency room and the hospital in general? The article about quarantine says that 12 to 18 people are being “monitored” (not quarantined) in this manner. Some are members of his family, some are not, and my guess is that others are people such as the staff in the emergency room he visited the second time. What about the first time? And what about all the days he was symptomatic in-between? Was he only in his home?

I’ve also seen no serious talk by officials yet of barring flights and/or passengers (especially non-citizens) from West Africa to this country. Why not? Some airlines have done it voluntarily, even before the Dallas patient arrived, but they seem to mostly be European-based. How did he get here? Are there direct flights to the US from the West African countries involved? Or is it all done through Europe, and therefore harder to control?

I wish there was a sense that smart and competent people are in charge here. Sadly, that sense is lacking.

[ADDENDUM: The Ebola patient in Dallas seems to have had more common sense, and been more on the ball, than the health workers he encountered in the Dallas hospital:

The first Ebola patient diagnosed in the United States told relatives that he notified health care workers the first time he went to the hospital that he was visiting the U.S. from Liberia, the man’s sister said Wednesday…

Dr. Mark Lester confirmed Wednesday that a nurse asked Duncan on his first visit whether he had been in an area affected by the Ebola outbreak that has killed thousands in West Africa, but that “information was not fully communicated throughout the whole team.”

All the protocols in the world cannot stop human error, if people don’t follow them. This was handled so badly that one would think the Secret Service was in charge.]