The CDC’s overseas epidemic prevention activities, a veritable gift from America to the world, were effectively eviscerated in early 2018 by Trump and the then Republican-controlled Congress in alignment with the White House’s “America First” ideology. This wholesale slaughter on global public health preparedness later left China unable to take advantage of the CDC’s expertise once the novel coronavirus had been detected, thereby propagating the crisis around the world. What we have left from the CDC are recommendations of tiered prioritization of COVID-19 testing and the use of pieces of cloth in lieu of face masks – leaving many to compare the America of today to Liberia, Guinea, and Sierra Leone at the start of the Ebola epidemic in 2014.
While we are drawing parallels between the Ebola epidemic 5 to 6 years ago and the COVID-19 crisis today, the major difference is that in 2014 and 2015, we knew the monster we were dealing with. This is not the case with COVID-19, where we are learning as we go along. With so much unknown, it is eminently appropriate for healthcare workers to err on the side of caution, especially given asymptomatic transmission of COVID-19. (This differs quite substantially from Ebola where only those symptomatic could transmit the virus.) For this reason, in order to protect healthcare workers and their patients, first, the Defense Production Act should be instituted immediately for the production of PPE as it was for ventilators. Secondly, OSHA should endorse the BSL-3 PPE we used in West Africa for all patient care activities related to COVID-19. Finally, similar to West Africa in 2014-2015, the performance of healthcare activities will have to undergo profound transformations until this pandemic is vanquished.
During the Ebola crisis, we had strict rules in how we approached patients and had structures as to when and how rounds were performed. Only patients who screened negative for Ebola were allowed inside of the Government Hospital for accessing non-Ebola care. All persons under investigation for Ebola were sent to the Ebola Treatment Unit (ETU) nearby. At the ETU, there were three shifts in 24 hours. In each shift, rounds were performed twice only. Rounds were limited to 90 minutes, no matter the extent of the workload. No one ever went in alone, and no one went in without the appropriate PPE: full stop. If there was an acute incident in the hot zone that occurred between rounds, we did not rush to reenter. We donned our PPE in the same careful fashion and went with a buddy. As responders, we were repeatedly told that our safety was paramount. Management made it known to clinicians that should any of us fall sick, we would convert not just serologically but from a response amplifier to a consumer of precious healthcare resources and precarious labor supply. Government officials and healthcare administrators Stateside in 2020 should have instituted similar rules and structure in response to the pandemic we currently have on our hands. After all, if or when they and their relatives fall ill, who will be left to take care of them?
To my fellow health care workers: yes, we swore an oath. We have a duty to our patients. We also have a duty to ourselves and our families. Our third duty is balancing the two. In the words of Aaron Mishler, an Army medic and fellow Ebola veteran: “There is no emergency in a pandemic.” These seven simple words together have a very powerful meaning. Our collective mindset regarding patient care must change. Our ways of concretizing our altruism must be modified. Now our altruism is evident simply by showing up to work. The extent to which we provide care is now delineated by our own right to safety and will run counter to our collective psyche fixated on quick response, dedication, and sacrifice. Understandably this will distress many devoted clinicians, but the alternative is ending up on a ventilator and being cared for by your colleagues who are now at even greater risk. Early on in the Ebola epidemic, West African clinicians without appropriate PPE nonetheless rushed to the aid of their patients in extremis, most of whom died anyway. Their reward for these actions was a slow, painful, and permanent fate. Today the resource-poor countries affected are still feeling the effects of these tragic losses in that there now exist even fewer health care professionals to meet today’s profound needs.
This gearshift in mindset and performance is one that is undoubtedly psychologically taxing once its results are made apparent. Me personally: there were many instances in the ETU where I most definitely acted in accordance with ETU rules, but anathema to the ideals imbued in all of us in our training. In fact, the worst fifteen minutes of my life occurred in the confirmed section of our ETU, and they haunt me to this day. While my heart still punishes me for the choices I had to make for my own safety, my brain tells me I did everything I could with the tools, resources, and time I had at my disposal. As a result, in the days and weeks afterward, I was able to continue providing care to other patients. Today I am a haunted man, but I am nonetheless alive and able to carry on with my life, career, and service to others.
A mentor of mine from residency once told me, “Never do anything in this line of work that makes you feel uncomfortable. You will only come to regret it.” That being said, do not perform patient care duties if you do not feel you have the appropriate equipment to do so safely. Again: “There is no emergency in a pandemic.” If facility-supplied PPE is inadequate, use your own NIOSH-grade equipment if you have it. The American Academy of Emergency Medicine supports you on this. Could it concern or scare patients? Yes. But our objective is to save as many lives as possible while still preserving ours, not to project a false sense of security.
Michael F. Drusano is a family physician.
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