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154919_600Me, interviewing applicant for medical school: So, have you been following the Ebola outbreak? What do you think?

Student, very sincerely: I have been and I guess I would go. Isn’t taking care of the sick what we sign up for when we get into medical school? I do spend a lot of my time trying to talk sense into my friends who are caught up in the hysteria so maybe that should count for something.

Fear has often been used by people in power to exert control. Fear of disease is powerful, especially when that disease has elements of the unknown. The latest Ebola hysteria seems by many to be whipped up, in part, to “demonstrate” the powerlessness of people, the monolithic failure of government, and the need for us all to purchase guns, vote for individual responsibility (mostly Republican, it seems), and build individual border fences around our homes to keep out the eye bleeding zombies.

The counter-argument is not being made very well. Partly is is because we have “A PERSON WITH EBOLA” in this country and everyone is yelling about it, drowning out civil discourse. Partly it is because America seems to go on despite the presence of Ebola, much to the chagrin of the yelling class. Why is that?

1) The food supply in this country is safe – Much has been written and said about the number and amount of calories available and the subsidization (through what used to be called food stamps before that term was demonized). Many west Africans live on a subsistence diet. This diet relies on “bush meat” as a protein source. Bats, monkeys and other primates, pangolins, and other assorted animals found in the wild constitute bush meat. How does this spread Ebola? These animals are a natural reservoir. They bite, kick, and scratch while being captured and killed. Unscrupulous hunters are likely to bring in an animal found dead to market (less biting) and the consumer is none the wiser. So, every day you wake up without Ebola (or dysentery,  ptomaine, botulism, etc) thank the feds.

2) We have safe water and sanitary sewers – although the direct link is difficult to prove, it is very likely that poor sanitation has contributed to the spread of the disease. Though many people think of Ebola as the “bloody eyed ISIS monsters coming from Mexico” disease, it is actually more akin to cholera. The death is not caused by zombification but actually by profound diarrhea (as much as 5 and 1/2 liters per day). It is spread through contact with body fluids and if there is that much vomiting and diarrhea, chances of exposure are high. Most west Africans in villages have no sanitary water. In Liberia, only 17% of the population has access to toilets. If there is NO TOILET and 5 and 1/2 liters of diarrhea, the chances of exposure are very high. The Environmental Protection Agency plays a large role in making communities comply with laws regarding clean drinking water and those  requiring sewage treatment prior to emptying the raw sewage into the nearest body of water. Next time you don’t wake up with cholera, typhoid, polio, or Ebola, thank the feds.

3) We have access to medical care – Although not perfect, the experience with Ebola in this country shows that western medicine does help. With cholera, there is not much vomiting so oral rehydration is sufficient. With Ebola, the patient vomits it back up so early and massive amounts of IV fluids are proving essential. If Thomas Eric Duncan had been admitted at the earliest sign of the disease, we now think he would be alive. IV fluids are not available in many areas of western Africa. Early access to care is now guaranteed to most Americans through the Affordable Care Act. Next time you have a fever, vomiting, and contact with a friend with Ebola and want to seek care, thank the feds.

A lot of work is left. This disease has been around a while. If this were a disease of the west, it is likely there would already be a vaccine developed. Let us hope that happens next. If it does, the development likely will be funded through the National Institutes of Health. And if it is, you can thank the feds…

63514_cartoon_mainNews item: An airplane in Birmingham is detained because a passenger threw up (into a vomit bag, I hope) and, not being clearly Caucasian, concern was raised among the crew about EEEEE BBBBB OOOO LLLL AAAA. Two hours later, the fellow passengers were allowed to deplane and the poor, sick Jordanian (home to no Ebola) who had a layover in Turkey (also straddling two continents without Ebola) was allowed to go to his destination. I hope to take his Zofran and suffer in peace.

News item: A woman in Mobile, Alabama who has lived in this country for seven years BUT who had visitors from the Congo ( in east Africa, where no Ebola is but sure sounds like Ebola should be there) was transported via ambulance (with roads blocked off in case the Ebola jumped out, I suppose) to a local hospital where, upon taking an effective history, the patient’s lack of Ebola was confirmed. Who paid for the ambulance ride was not discussed.

It has been a long time since we have had a good pandemic scare in this country. A pandemic, typically caused by an infectious agent, is notable for  its ability to cross over country boundaries and in general wreak havoc.America tends to be protected because of our size, limited number of international boundaries, and  public health infrastructure. The last really good pandemic we had was the “Spanish” flu which was blamed for almost 700,000 deaths in the US. The stories from that era consistently identify the randomness of being stricken as a dominant feature (person gets on the streetcar healthy and at the end of the line is found dead). It is the randomness of being afflicted that seems to create havoc as much as anything else. When a pandemic comes, there are often voices prematurely calling for closing the borders and the schools. Way back in 2009-2010, the public health officials were able to resist such calls when swine flu came. They were able to vaccinate the population and keep public concern to a minimum through creative use of media. They were also fortunate in that the case mortality rate was 1:2000 (as compared to 1:40 for the Spanish Flu and an apparent 1:2 for Ebola).

American reaction to pandemic risk can be constructive. For example, it was a measles epidemic in 1989 to 1991 that led Congress to change the way vaccines were distributed, creating the Vaccines for Children program. Maybe some day we’ll look back and see improved infection control in our hospitals in response. For now, my current hope is that the media, medical establishment, and all branches of government will act responsibly.

Some facts about Ebola:

  • As of today, there are 0 deaths of American citizens from this virus.
  • It is only transmitted through blood and body fluids of a person with a significant infection. People who are contagious are REALLY SICK. Don’t be afraid of the not so sick ones. Casual contact with a person will not infect you if there is no blood or body fluid transmission. If someone looks sick and you happen to touch their skin, hand sanitizer is likely sufficient protection
  • It is found in the semen of people who have recovered for 3 months. It is wise to avoid sexual contact with men who have a questionable illness history (likely always wise).
  • Avoid eating bats and monkeys (especially ones found already dead)
  • Avoid hospitals in West Africa. They don’t have enough gloves. In fact, get a flu shot so you can potentially avoid health care workers completely

Interestingly, Shep Smith on Fox News makes the same points…go figure.

'When did you first notice your timbers were shivering?'I get the New England Journal of Medicine (NEJM) delivered to my home. I know, I know, it is so 1980s to read a journal in paper form (ok, even to read a journal) but I enjoy browsing the most current science and sometimes retain a factoid that later might be useful. I still remember the time I read the Clinical Pathological Conference about a person with confusion and thrombocytopenia (low platelets) where the diagnosis turned out to be thrombotic thrombocytopenic purpura (very rare) and darn if a person with that exact same presentation didn’t call me about a month later. I, the junior resident,  called the hematologist who was at a party and he said something to the effect of “Yeah, right, what do you know…” I elected not to say “I read the New England Journal of Medicine, sir.” Instead I cited all the evidence without mentioning the NEJM article and he agreed with my diagnosis and came in. The patient survived without knowing that her life was saved (or at least the diagnosis was made in a timely fashion) because I got a journal and actually read it.

Many of the diagnoses for those complex cases in the NEJM hinge on an unusual piece of history. Typically, that history is not in the story of the illness (in doctor lingo, the HPI). A fever that starts a week ago is pretty much the same whether it is the flu or malaria. Instead, the clue is in the family or social history. “The patient reports swimming in a waterfall pool in Hawaii” would make me think “leptospirosis” (an infection carried by rats and spread through their urine, typically in large concentrations in the stream above the waterfall…kind of makes you think twice about those movie love scenes, doesn’t it). Part of the job of the health care team is to gather the correct information and synthesize it, keeping the valuable information (swimming in a waterfall pool) and discarding the red herrings (wearing a blue bathing suit). Part of the fun of medicine is to put things together and make a diagnosis so as not to miss a NEJM moment.

Although the details are sketchy, apparently someone in Dallas missed their NEJM moment and is blaming the computer. If you have not heard, Thomas Eric Duncan, a Liberian national, got on an airplane feeling well in Monrovia. He then flew to Brussels, Washington DC, and ended up with family in Dallas. When he started to feel ill, he want to the Emergency Room. At the time (5 days before he got really sick) he had some fever, body aches, and in general wasn’t feeling well. This is where the facts become murky but clearly the moment was missed. Even a doctor, half paying attention (“Ok, so any travel? New pets?”) should raised an eyebrow when a person with an accent says “Well, I did just get in from Liberia.” Reading between the lines of the Slate article, the hospital apparently assigned someone to take a history and enter it into the electronic medical record (perhaps to save the clinician time). Thus, “travel to Liberia” was buried in the record.

Doctoring is very expensive and interpreting symptoms is often unrewarding. Of 1000 people with fever, 999 will have something self-limited. This is especially true in America, where many infectious diseases have been eliminated. There is something, however, to be said for inefficiency. Every now and again, what one person thinks is a red herring (just where is Liberia, anyway) another puts into a pattern and prevents an epidemic. Doctors have got to want a NEJM moment enough, though, to pay attention.

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