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Ebola response shows flaws in US system

A worker sanitized the apartment where Ebola patient Thomas Duncan lived before being admitted to a Dallas hospital.joe raedle/getty images

The threat of Ebola over the last several months tested the nation’s ability to cope with an unfamiliar disease, raising troubling questions about what will happen when the next dangerous new germ arrives on US shores.

After Thomas Eric Duncan was misdiagnosed in a Dallas hospital and later infected two nurses with the deadly virus, government agencies and hospitals around the nation responded quickly to prevent another such incident. But it took that calamity in October to trigger measures that, critics say, a well-prepared system would have had in place.

“The approach has been shutter the firehouse until there’s a fire,” said Dr. Paul E. Jarris, executive director of the Association of State and Territorial Health Officials.


Federal money for public health and hospital readiness has been drastically cut since the now-forgotten fears of avian flu a decade ago, and an estimated 50,000 public health workers’ jobs have been eliminated amid state and federal cutbacks in recent years. And yet, public health officials say, the Ebola response demonstrated the importance of government’s role in communicating with health care institutions and the public.

The United States lacks a central authority and coordination among a constellation of federal, state, and local agencies, said Dr. Irwin Redlener, director of Columbia University’s National Center for Disaster Preparedness. In the United Kingdom and Canada, he said, national health systems permit the federal government to designate Ebola hospitals and to set clear, mandatory protocols.

“What we have here,” Redlener said, “are a collection of random acts of preparedness.”

The appointment of federal Ebola “czar” Ronald Klain has helped galvanize a response, Redlener said, and the nation is probably now, finally, ready to cope with the threat of Ebola.

“Again,” he said, “we’re laser-focused on what happened yesterday.”

But what will happen tomorrow?

It could be something much scarier than Ebola.


Within a well-prepared health care system, Ebola is easy to contain. The virus spreads through close contact with infected bodily fluids, so few are exposed, and even then it’s hard to get infected. Duncan’s fiancee and others who lived with him never caught it. People with Ebola are not infectious until they’re noticeably ill, and thus can be isolated to prevent transmission.

But if Duncan had carried a virulent new form of influenza, he would have left a trail of illness from the airplane to the streets of Dallas.

People can spread the flu for up to two days before they know they have it. The flu is easy to catch because it travels through the air. And the virus mutates constantly, meaning a deadly strain unfamiliar to the human immune system could arrive at any moment.

Such a scenario — a new type of flu, or a totally new bug — is considered more likely than ever, as the human population grows and encroaches on animal habitats, especially in places like Africa or Southeast Asia.

“Seventy-five percent of emerging pandemics in humans came from animals,” said Dr. Saul Tzipori, chairman of the Department of Infectious Disease and Global Health at Tufts University’s Cummings School of Veterinary Medicine. Ebola is thought to originate in fruit bats that bite primates.

“The Ebola outbreak shows how vulnerable the population is and why such diseases are much more likely to emerge more frequently,” Tzipori said.

To make matters worse, the ease and frequency of global travel ensures that no illness remains isolated for long.


When the Ebola outbreak began in West Africa, American hospitals knew that an Ebola case was an airplane trip away. But they expected that modern, routine infection-control procedures could contain it.

Asked about Ebola back in August, Boston’s major teaching hospitals expressed confidence in existing infection-control measures, with a couple saying they would reemphasize the importance of asking about travel history.

Thomas Duncan and the Dallas nurses he infected shattered that confidence. The hospital failed to diagnose his Ebola during his first visit.

“The idea that any community hospital can [treat Ebola patients] was not a good national strategy,” said Dr. David L. Lakey, the Texas health commissioner. “There’s going to be issues we never faced before, no matter how well you plan.”

As the Ebola response ramped up in Massachusetts, state public health officials did not have the authority to designate one hospital for all Ebola cases, and hospitals rebuffed the state’s suggestion that one of them step up.

In the end, eight hospitals agreed to share the burden in a process that Cheryl Bartlett, public health commissioner at the time, described as relatively painless.

“That took like one or two phone calls to design this system together,” she said.

But relying on the good will and untested competence of scattered, private hospitals allows for great variability in readiness from state to state.

When Duncan first arrived at Texas Health Presbyterian Hospital in September, he was sent home with antibiotics for his headache, abdominal pain, and fever, even though he had just arrived from Liberia.


According to the Dallas Morning News, the Dallas hospital had received a notice about Ebola from the US Centers for Disease Control and Prevention seven weeks before that visit. The hospital said it distributed subsequent alerts, but the doctor who misdiagnosed Duncan recalled only the original e-mail and did not know about any Ebola training.

In contrast, Rhode Island Hospital in Providence was already sending decoy patients to test a new system for detecting a possible Ebola case, and Massachusetts General Hospital’s emergency room displayed signs reminding nurses and patients to discuss travel history.

The inconsistency matters. “Illnesses know no boundaries,” said Richard Hamburg, deputy director of Trust for America’s Health, whose recent report on infectious diseases found wide differences state to state.

Dr. Daniel Sosin, deputy director of the CDC’s Office of Public Health Preparedness and Response, said the nation has made improvements in connecting public health with clinical medicine, but has more to do.

“More resources are needed to achieve those levels of consistency across all communities, so that when EMS gets a call, the paramedic takes [the patient] to the right place, and a forewarned facility takes appropriate cautions,” Sosin said.

The Dallas experience brought other lessons. It showed that the standard-issue protective garb nurses wore was inadequate. No one knows exactly how the two nurses, Nina Pham and Amber Joy Vinson, contracted Ebola after treating Duncan, but their gowns left skin exposed at the neck. They also might have encountered the virus when removing their outfits.


Dr. Paul Biddinger, Mass. General’s chief of emergency preparedness, said hospitals did not understand “how different this disease was,” producing liters upon liters of highly infectious fluid.

The Ebola response illustrated that hospitals require more than equipment, said Dr. Nicole Lurie, assistant secretary for preparedness and response at the US Department of Health and Human Services.

“We need to constantly be in a state of preparedness, which requires not only equipment and supplies, but planning and exercising,” Lurie wrote in an e-mail to the Globe.

Soon hospitals, including those in Massachusetts, were ordering full-body hazmat-type suits for staff and devoting hours to training workers in safely putting on and taking off personal protective equipment. Some made renovations to create isolation areas for staffers to don and remove their equipment.

Hospitals paid for this with no government help so far, although some may get reimbursed through the $5.4 billion emergency Ebola-funding package approved by Congress.

“These are difficult things for hospitals to bear when they come unpredictably and with relatively high intensity,” said Dr. Stanley Hochberg, senior vice president for quality, safety, and technology at Boston Medical Center.

The solution, said Mass. General’s Biddinger, is a system that provides federal money to a limited number of hospitals selected to handle new infections. “We spend an awful lot of money for the physical defense of this country,” Biddinger said. “I’d like for us to spend a fraction of that on biothreat defense spending.”

After the Texas nurses became ill, Ebola testing capacity was expanded to 42 laboratories in 36 states. The CDC produced guidelines for appropriate protective equipment, and worked with manufacturers to speed up production.

The CDC asked hospitals to volunteer to serve as Ebola centers, and 35 have met standards set by the agency. A screening system was established at 12 airports.

So far, the two Dallas nurses are the only people who have become infected with Ebola in the United States. Both survived, as did six of the eight people who were infected overseas and treated here.

Because of the new system, when a man traveled from Liberia to Boston in December, health authorities were notified and checked in with him regularly. When he developed a fever, an ambulance immediately took him to Mass. General.

The man turned out to have malaria. But the incident highlighted how much trouble might have been avoided if such measures had been in place when Thomas Eric Duncan flew over from Liberia, intending nothing more than a reunion with his girlfriend in Dallas.

Felice J. Freyer can be reached at felice.freyer@globe.com.