Ebola: An Enemy of The People

Sure, it’s a little affected to title an article referencing an Ibsen play; but the similarities are too great. In that play, a doctor was darling of a community until he did not do what the community wanted. This is similar to what is happening to healthcare workers who treat Ebola patients.

The facts here are changing by the minute. The more I write, the more the news changes. The quarantining in New Jersey of the nurse who returned from western Africa has raised many issues. She is currently threatening to sue the State of New Jersey because she feels her civil rights have been violated. As of now three states, New York, New Jersey and Illinois have executive orders stating that they will quarantine anyone who has had direct contact with an Ebola patient, including American healthcare workers returning from Africa. (What about someone sitting next to them on a subway? Is that direct contact? )

What bothers me is how she was apparently being treated. According to her she is being kept in an unheated tent outside of Newark Airport and being given nothing to wear but hospital scrubs. Where are we, in Liberia? Obviously the fear and “cootie syndrome” created by one doctor who tested positive for Ebola and roamed the streets of New York while possibly contagious, has caused politicians to act rashly if not illegally. Without knowledge of Ebola and the science that surrounds it, they have caved in to public frenzy and have jumped the shark. They had no plan of action as how to quarantine anyone exposed to Ebola, except to isolate them. They have no definition of what “exposure” is. Does someone sitting next to someone on the subway who turns out to have Ebola count as an exposed person? Will they then be quarantined? Where does it end? They don’t know. They are playing it by ear. That is a scariest thing.

I do know one thing, in the long run this type of quarantining may be increasing EVERYONE’s chances of getting Ebola. Soon few doctors and nurses will go to western Africa to treat patient’s with Ebola if this is what awaits them upon their return. You cannot expect good Samaritans to risk their lives to save us all and then accept being treated like lepers upon their arrival home.

But don’t we quarantine people with dangerous communicable diseases all the time? The answer is yes. The HUGE difference is that we do that once we KNOW they have a communicable disease, not when we just suspect they do. You may think that the stakes are higher here because Ebola is so dangerous. But as of now no one has died from contracting Ebola in the US. Which causes me to have a huge moral dilemma. I believe in quarantining health care workers on the honor principle as a way of stopping spread… but I do not agree with the way it is being done now. However, there may be a solution. The solution once again is science.

There is a test that is used both to detect and follow the progression of HIV. It is called the PCR (polymerase chain reaction) test. It is also used to test for progression of the Ebola virus in someone’s body. If you do not have Ebola in your blood this test will be negative. It is not like the antibody test that can take days or weeks or months to be positive. If you do not have the Ebola genetic material in your blood this test will be negative. What I have not been found in the medical literature is how soon after you are infected with Ebola will this test be positive. If this test is positive within a day or two after infection then problem solved.

When a health care worker returns to America from an endemic area he or she should be given an Ebola PCR blood test and then be placed under home observation, in his or her own home. They must report to health authorities twice a day after that. They must have a PCR test every two to three days. If they have successively negative PCR and do not develop symptoms after a set period of time that “science” has determined to be safe, they can then be released from observation. That is of course if we know that my theory is correct.

Regardless, I hope that the government is taking Ebola PCRs form all health care works returning from western Africa so that we can learn more about the natural progression of this disease. If not, they should create a voluntary research protocol that does this.

If it looks like I have reversed my position on mandatory quarantine, I have! After seeing the reaction of the public and the government, I am now much more concerned about the frightened town’s people storming Frankenstein’s castle, than I am of the virus.

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EBOLA: Quarantine or Internment?

Last Friday night I was asked again by CNN to be a medical expert regarding the Ebola epidemic. Unbeknownst to me, in the interim between CNN’s ask and my actual on air segment, the governor’s of New York and New Jersey had decided to imposed mandatory quarantine on anyone, including healthcare workers, who landed in their state from the most Ebola ridden countries of western Africa. I heard a little bit about this on my earphone before my segment. While one air was then asked what I thought about mandatory quarantine.

I said, that I believed in quarantine. I had thought long and hard about this in the prior days; but obviously not long and hard enough. I gave what I thought was a thoughtful and educated answer. My friend, who was waiting in the greenroom, was uncharacteristically silent when I returned. When he finally gave me his opinion about my segment, all hell broke lose. I feel our discussion was representative of many discussions occurring throughout the U.S. Science vs. Fear. Practicality vs. Rights.

My friend was a bit in shock about my on air response. He felt that my opinion was more in step with the very conservative FOX network than with CNN. (By the way the good people of CNN and FOX have both used my services) He wondered how I could be in agreement with mandatory quarantine, in a hospital or hotel, of ANYONE returning from western Africa; whether they were symptomatic or not. Apparently, the woman who was quarantined at Newark International had a horrible experience; almost to the point of being treated like a prisoner. Much like Japanese-Americans were treated during World War II. The more I read about the episode the more I understood my friend’s anger toward me. The more I read about the incident, the more it became evident that I had to clarify my stance, because we, and I mean America, were at the intersection where fear, science and action meet. We need to be clearheaded here, because it can get ugly quickly if we don’t.

Firstly, let me make my opinion very clear. I believe that anyone who comes from an area where Ebola is endemic must go through a 21-day quarantine period before they can resume their normal day-to-day activity. I also do not believe that this should be at a hospital or make shift quarantine facility being managed by people who are poorly educated on medical facts and techniques. Did we not learn anything from Dallas? People who come from these unfortunate areas, should be sent to their homes for 21 days. They need to report to local or national health authorities twice a day. If they elicit any symptoms they must then report to a designated “Ebola-knowledgeable” hospital to be evaluated.

From what I understand, Doctor’s Without Borders, makes their health care workers follow rules similar to this once they return home. However, find their recommendations not stringent enough. The New York case tends to prove this. The physician in New York City who recently tested positive for Ebola, upon his return from Africa was advised not to go to work and to check in twice a day with his temperature reading. However, he was not prohibited from going out to public places. This walking among the masses when one is possibly infectious is what is fueling the fear that is making many people, including politicians, have knee jerk reactions.

I know that Ebola is not transmissible until someone has symptoms. But what I don’t know is what those symptoms really are. The physician in New York said he felt sluggish two days before he spiked a fever. Is that when he was contagious? Should he have reported it then? Should he have gone to a hospital at that time? I say yes.

The danger that we are facing, which is as menacing as, if not more than, Ebola is that fear may lead to behavior that strips good law abiding American citizens of their rights. We are risking that doctors and nurses not go to western Africa to help contain this epidemic because of what they may face upon their return. This cannot happen. EVERY expert will tell you that the best way of keeping Ebola from coming here is by stopping it there.

I am supporting a middle ground. I am suggesting that anyone coming from an area where Ebola is endemic, who has had direct contact with someone infected with Ebola, be placed under house quarantine under his or her own supervision. They must not go out in public and must report to the appropriate HEALTH authorities under penalty of law. Hopefully this will not deter the good people going to Africa to fight OUR fight from doing so.

We are all a bit scared; but fear cannot prevail. I saw inhumanity win too many times during the beginning of the AIDS epidemic. Let us not repeat those mistakes. We must walk a fine line between humanity and civil responsibility. There is no other choice. We must walk carefully; if not we run the risk of becoming more horrific than Ebola.

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Ebola Spreads to Other Countries

As I sit in an airplane heading toward New York City, a man in front of me coughs. Coincidentally, I am reading an article on CNN stating that there are now five documented cases of Ebola in Nigeria; one of them being a nurse who took care of that American citizen that died there of Ebola after taking care of his ill sister. They also report that a businessman died of a hemorrhagic fever that is very likely Ebola in Saudi Arabia after being in West Africa. There is no doubt in my mind now. Ebola has gone global. The man in front of me continues to cough.

I try not to be an alarmist; but I have a foreboding sense of immediacy. I completely believe in the ability of science to soon discover a vaccine to prevent the spread of Ebola and medication to treat it. But “soon” may be a year. In the meantime transcontinental transportation and mass transit may spread this virus like no one has ever witnessed before. The approximately 30 million people worldwide who have died of HIV may pale compared to the number that may die of Ebola.

I have spoken on CNN a few times recently about this epidemic. Perhaps it is my 25 years as a researcher of HIV and Hepatitis C and a frontline clinician that gives me some credibility…and pause. As a researcher I know that an answer WILL be found. I also know that even under the best circumstances it will take months to years to get treatments approved by the FDA. As a clinician, I know that if we wait any longer to enact strict preventative guidelines the thousand people who have died of Ebola could quickly become the tens of thousands or God forbid, the millions.

Therefore the time to set guidelines to prevent the spread of Ebola is now. Here are a few of my recommendations:

  1. Create a mass producible assay that is both specific and sensitive to diagnose Ebola. The luxury of waiting days to receive a lab result while quarantining a patient will soon be unrealistic. Hospitals will run out of appropriate isolation areas. Plus, with the impending cold and flu season, worried symptomatic patients will undoubtedly be rushing to their health care providers for diagnosis and treatment. There needs to be a quick method to diagnose Ebola vs. has viral enteritis.
  2. Give definite guidelines to physicians and nurses on how to properly handle a person with Ebola. The rate at which healthcare workers are contracting Ebola is infinitely higher then medical personal contract HIV or Hepatitis C from their patients. We don’t want doctors being vectors of this disease.
  3. Institute strict travel guidelines. In my opinion anyone who has a fever should not be allowed to board an airplane and eventually other forms of mass transit. A questionnaire is valuable only if the person is honest. Travel personal must receive preventative education and perhaps even special equipment (gloves, etc.) to protect themselves and others.

Alarmist? Perhaps, but let’s start the dialogue anyway shall we? This is as good a launching point as any. Remember, an ounce of prevention is worth a pound of cure. By the way, he is still coughing.

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EBOLA. Not IF; but WHEN

I am a virophobe, someone who fears viruses. Having treated people with HIV and Hepatitis C for my entire medical career I know the danger of these submicroscopic entities. Not really animals because they don’t have more than a strand of DNA or RNA, they survive by infecting a host and using it’s genetics to replicate. Therefore, the virus survives and host dies. Nature could not have created a more efficient killer.

Of course not all of them are killers, some like the Influenza virus make you ill and most people survive. But even the flu virus kills tens of thousands of people a year in the USA alone. That is a tremendously high number. Science has found that viral illness can be cured, as the recent breakthrough in the treatment of Hepatitis C proves. But this is the rare exception.

I remember hearing about H1N1 in Mexico five years ago and thinking that if a vaccine was not found immediately deaths could be in the thousands. Luckily there was a vaccine discovered and mass immunizations were successful. (Don’t even get me started on the ignorance of people who fear vaccines.) Now there is a greater threat on the horizon, the Ebola virus. It is not a matter of if it gets here, it’s a matter of when.

Ebola is a quick acting virus that causes the body to be unable to clot and up to 90% of the people who contract it eventually bleed to death within a few weeks. Whereas Ebola used to be contained to small villages in Africa, where the treatment was to isolate the whole village and let everyone die so that the virus could not spread, it is now spreading through four countries in western Africa. This week, an American returning home to Minnesota, died in Nigeria on his way home. He could have easily landed in the US and the epidemic would be in our back yard; probably to spread like wild fire because the public has not been educated about how to curtail its spread.

Let’s learn from HIV and Hepatitis C. We are not alone in the world. This is not “their” disease. This is “our” problem. This is not just about Africans in a distant land, expiring of a rare disease. This is a wildfire that is potentially about to take off. The time for the CDC and WHO to take action is now. Worldwide deaths could easily be in the tens, if not hundreds of MILLIONS. It is my opinion that airlines should not allow ANYONE to travel who has a fever. It may be extreme but some countries have been doing this for years during the outbreak of other viral epidemics. Secondly, Ebola vaccination research needs to be stepped up immediately. Thirdly, and most importantly, since Ebola cannot spread through casual contact, there must be a concerted global education effort to teach people about proper hygiene that will help prevent the spread.

I am not trying to be an alarmist, just sending a wake up call. Ebola is here. But if being an alarmist will eventually save lives… then I’m sounding the alarm.

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