Diseases know no borders.
With ebola in Texas, the return of whooping cough, and some new paralyzing virus making the rounds of children’s hospitals, public health is back on the agenda in a major way. The questions are how do we deal with contagious diseases when they brew in less developed nations and how do we deal with contagious diseases when a group of people refuse to comply with public health guidelines.
The United States has an adequate way of dealing with contagious diseases that don’t have the complications of a resistant minority and international issues. When Ian was diagnosed with whooping cough a few years ago, I was flabbergasted at the speedy response by officials. After the seven minute drive home from the doctor’s office, I walked into the house with my sick, flushed kid. My phone was ringing. The local public health nurse was on the phone.
For 30 minutes, she had me trace back everybody that we had been in contact with over the past two weeks, and where they were. Whooping cough is tough, because you are contagious before you come down with symptoms. This was incredibly complicated, because we had just finished with the Christmas holidays and we had been to a ton of parties. My in-laws stayed with us and then travelled to Cleveland, where they saw a ton of people, including an aunt who was on dialysis.
The entire family was immediately put on antibiotics. Ian missed a couple weeks of school. I think I had to keep Jonah home from school, too. The nurse alerted our guests’ and friends’ the public health officials. She alerted the school districts. Ian’s school sent home a notice to every child in his school. (Luckily, Steve and Ian didn’t get anybody else sick.)
The public health machine worked well. The disease ended on our doorstep. Sure, there were some errors. Steve was misdiagnosed by the family doctor. Steve must have gotten the disease from work, where there were a large number of workers who travelled internationally or who had lived in countries without our vaccination requirements. Still, the local response to our ill kid was impressive.
But these tried and true methods of dealing with infectious diseases can’t handle the two new challenges of a resistant minority (those who refuse to vaccinate their children) and the poor public health systems in developing nations. Public health policy needs some new ideas.
UPDATE: Uh, I guess I wrote a blog post about this right after it happened. The public health officials responded a day later, as soon as the doctor got the results.
Apt. 11d 
I want to know the real story of how a guy from Liberia who comes to the EC with a fever, vomiting, and diarrhea gets sent home with some antibiotics and a note to rest. My guess is insurance (or lack thereof) has something to do with it. If that turns out to be the case, maybe this can be the impetus for real healthcare reform in the US.
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I also think that we need to see more investigation about what happened in that emergency room. The key seems to be that they lost the information that he had travelled from Liberia. It *could* have been insurance related, but, I also think that if the information was available there were lots of other incentives to correctly check for ebola. We check for ebola for everyone else (including the health care workers), not just the patient. Ebola diagnosis is not the case of many other diagnoses, where our health care system might benefit financially from letting the patient go home to die or suffer. Was language an issue? Was general knowledge? Was general overwork and underpaid support staff an issue? The information seems to have been lost in the chain starting with an intake nurse. Was the miss a result of complicated team care that is now the health care idea of the day? Can we speed up the testing process to absolutely identify ebola? Test for it more quickly? That might be a technological solution, though it would require means of testing that didn’t increase the probability of spreading disease.
Ebola is hard to diagnose, because lots and lots of people present with the early symptoms, and infinitesimally few of them, in the US, have ebola.
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Also, we need to have broader discussions about civil rights and their interaction with infectious diseases. I don’t know enough of about the different diseases to posit the correct balance by myself, but I do worry that some of our civil rights concerns are having us balance too far in the direction of voluntary compliance. For example, Laura says that she might have had to keep Jonah home from school. But, in the case of the potential ebola exposures in Dallas, the newspapers report that compliance is voluntary. Whooping cough is different from ebola (spread by airborne contagion rather than body fluids, which makes a huge difference in exposure risk), so its possible that the compliance requirements are different.
But, I do wonder, if voluntary compliance is the standard, and that one problem faced in controlling disease is the differing liklihood of voluntary compliance. Laura stayed home, and thus, could voluntarily keep everyone home; educated, insured people were willing to be tested, because they would be treated and helped. In marginal populations, none of those expectations are compatible with voluntary compliance. How do we handle the differences?
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“Our expectation is that people who are sick or people who are exposed should be getting the message they shouldn’t be traveling.”
The costs of admitting illness are way to high to expect voluntary compliance to catch those who are infected. The traveler in the Dallas outbreak (can you have an outbreak of one?) is now being treated in a hospital in the US. At least two of the Liberians he had contact with are all dead. Who in their right mind would voluntarily chose death in Liberia over traveling, surreptitiously if necessary?
(from the NYT article: http://www.nytimes.com/2014/10/02/us/man-in-us-with-ebola-had-been-screened-to-fly-but-system-is-spotty.html?hp&action=click&pgtype=Homepage&version=HpHeadline&module=a-lede-package-region®ion=top-news&WT.nav=top-news)
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Plus the very probable and human reaction of complete denial. Ebola symptoms are vague and mimic lots of other far more common diseases. If the stakes are high of admitting to yourself and others that you are ill (e.g. getting stuck in Liberia), it doesn’t even have to be outright lying for someone to not own up to expecting they have ebola. Until you’re actual extremely ill (which I understand isn’t that long once the symptoms set in), I would expect a non negligible number of people to rationalize away the very early symptoms like crazy.
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This NYT story about ebola in Africa is chilling. http://www.nytimes.com/2014/10/02/world/africa/ebola-spreading-in-west-africa.html?smid=tw-share
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I am in Dallas (Northern suburb) and local papers and media are reporting that the patient lied about having been in contact with Ebola patients in Liberia. And bj’s point about voluntary compliance is very true – today, one of the 5 children who had been in contact with the patient has gone to school, citing attendance concerns – which blows my mind, but I don’t know their circumstances.
All of which is making me, for one, very nervous about the health-care system as a whole. And the hysterical “All is well” editorials and articles in various papers is having the converse effect, I now suspect that things are a lot worse than originally stated!
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Given a choice between “stay here and die” and “lie and live,” many, many people will choose to live. Does no one in charge or talking to the press have any knowledge of human nature or history? Desperate people do desperate things. Always have. Always will.
The only way to stop this would be to implement a real quarantine. Cut off travel to and from the affected countries. If travelers do emerge from those countries, they must abide by 3 weeks of quarantine, during which time they are observed for any sign of the disease.
I don’t get why everyone is insisting that we shouldn’t worry, because it isn’t airborne. It seems to be pretty darn infectious as it is. If people are catching it from hospital furniture or normal hospital care, that’s reason to take action. If it’s hard to find anyone to clean up after the first American Ebola victim, how’s that going to scale?
I’m sure Mr. Duncan isn’t the only person traveling with Ebola. I’ll believe our authorities are serious people when they start behaving like serious people.
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