Since the US media has apparently lost interest in Ebola, it is not too early to consider why we have learned so little about the country's first experience with the virus.
The first three Ebola cases diagnosed in the US were initially managed at Texas Health Presbyterian hospital, the flagship hospital for Texas Health Resources (THR). On October 15, 2014, I noted that statements by the generic managers in charge of the hospital and the system left confusion on many points:
- How was the decision to send the index patient, Mr Eric Duncan, home after his first emergency department presentation made (given he apparently had a fever in the ED, and an ED nurse knew he came from Africa)?
- Why did THR leaders insist they were prepared for Ebola when later evidence suggested they had not set up organized processes and lacked proper equipment?
- Did hospital managers try to prevent health care professionals from talking about what really went on?
Furthermore, as I noted on October 9, 2014 and InformaticsMD had discussed in depth, e.g., here, whether the the electronic health record (EHR) used by THR enabled Mr Duncan to go home undiagnosed remained unclear.
However, as stated in a Dallas Morning News editorial of October 14, 2014, taking better care of future patients requires better understanding of what went wrong when Texas Health Presbyterian first had to grapple with this disease previously unknown in the US:
now the hospital can do a world of good by helping the medical community learn from its experiences. This requires complete transparency and truth-telling
Yet the response of managers at Texas Health Resources since then seemed to be more about buffing their own image and protecting their own status than transparency and truth-telling.
A Week of Obfuscation after Public Relations Takes Over
As the NY Times reported on October 15, 2014, one of the first responses by THR to all these unanswered questions was to hire "Burson-Marsteller, the global public relations firm, to help tell its side [of the story]." Through the next week, hospital managers' provided a lot of verbiage, some warm, some heated, but little useful information to inform the medical and public health response to the Ebola threat.
October 15 - Vague Apologies
A top THR leader, Dr Daniel Varga, the chief clinical officer, testified to congress (per the (UK) Guardian),
'Unfortunately, in our initial treatment of Mr Duncan, despite our best intentions and highly skilled medical team, we made mistakes,' Varga wrote in testimony to the US Congress. 'We did not correctly diagnose his symptoms as those of Ebola. We are deeply sorry.'
However, he failed to provide much detail about these mistakes and why they were made.
October 16 - Nonspecific Refutations
The next day, Ms Brianna Aguirre, a nurse at Texas Health Presbyterian, went public about her concerns about the hospital handled Ebola. Per the NY Times, she described a "confused and chaotic scene" when Mr Duncan returned to the hospital, leading to inadequate isolation of Mr Duncan for three hours. She also claimed that staff caring for Ms Nina Pham, the first nurse to acquire Ebola while caring for Mr Duncan, it turn received inadequate protective gear, and had little training in its use.
That led to an indignant but nonspecific response from hospital management, per a Dallas Morning News article,
[To] claims that Duncan remained in an area with other patients for several hours before he was placed in isolation. Hospital officials said he was isolated immediately.
[To] complaints that personal protective equipment was inadequate and left them exposed, particularly at the neck. Nurses said they had to use penetrable medical tape to try to protect themselves. The hospital defended the equipment, saying it met the CDC’s guidelines at the time. Hospital officials said that it was the CDC that recommended using tape to pinch together the necks of the protective gowns and that hoods were ordered for the staff after concerns about the tape were raised.
October 16 - Shifting Blame, to the Government, "Outsiders," and the Media
At the same time, as reported by the Los Angeles Times, hospital managers were pointing fingers elsewhere,
The hospital's response -- its second in two days -- in part shifted responsibility to the federal Centers for Disease Control and Prevention and to the protocols the agency issued this summer to guide the handling of a patient infected by the virus, which is thought to have killed more than 4,400 people in West Africa. The hospital said the protocols changed frequently, frustrating caregivers and management.
They also implicated outside troublemakers,
The hospital also blasted 'third parties who ... are seeking to exploit a national crisis.' That was a dig at the National Nurses United union, which does not represent the Dallas hospital's nurses, but which made their complaints available to the media.
Then they blamed the media,
'Many of the comments we have seen or heard in the media are only loosely based on fact, but are often out of context and sensationalized,' the hospital statement said. 'Others are completely inaccurate.'
Finally, hospital managers resorted to indirection,
In televised interviews Thursday, Aguirre said she feared retaliation for speaking out about worker protection. An attorney accompanied her during the interviews.
“Texas Health Dallas has a strict non-retaliation policy,” the hospital statement said. “Employees are encouraged to raise issues and concerns via the chain of command.”
Left unsaid was whether the policy was enforced, and whether despite the policy there was any reason to fear retaliation.
October 18 - More Vague Apologies and Assurances
Then, per the Dallas Morning News, the THR bought a full-page advertisement featuring its CEO's vague apologies and assurances,
Presbyterian 'is a safe place for employees and patients,' Berdan said in a full-page ad Sunday in The News.
Pitched as a 'letter to our community,' Berdan again apologized for mistakes the hospital made in Duncan’s treatment and in failing to have deployed fully its training and education programs before the virus struck. He said the hospital hasn’t determined how the nurses became infected.
October 20 - A "Tight-Lipped" Pep Rally
Finally, an blog post in the Dallas Observer noted,
On Monday afternoon, dozens of nurses, doctors and other healthcare employees convened at the front entrance of Texas Health Presbyterian Hospital to discuss the recent controversy about how the hospital handled the Ebola outbreak. Despite definitive comments in support of the hospital, Presby's nurses remained tight-lipped on what actually happened during Thomas Eric Duncan's care.
During the rally a top hospital leader provided a fitting epilogue end to the week,
'Today we want our community and our country to know that the nurses at Texas Health Presbyterian are so proud of our hospital and proud of what we do,' said Dr. Cole Edmonson, chief nursing officer at the hospital. 'There are a lot of questions being asked about what happened. And I can't answer those today. A number of reviews are underway.
So what was the point, other than to provide further cover for his fellow managers?
In any case, it seemed to work. Since the week after THR hired Burson- Marsteller, coverage of Texas Health Resources and its role in the first US experience with domestic Ebola rapidly waned.
More Silence Purchased, and Managers Go Unchallenged as Memories Fade
Since October, no patients have been diagnosed with an Ebola infection in the US. The media have turned to other pursuits. Texas Health Resources has departed the headlines. Although at the end of October, CNN noted that "the hospital has made confusing and sometimes misleading statements" that remain unexplained, in November, explanations appeared even more remote.
During this quiet period, THR seemed to purchase some more silence. As reported by the Dallas Morning News, THR settled the lawsuit brought by the relatives of Mr Duncan, but the deal itself was "secret." As columnist Mike Drago noted, family spokesman Josephus Weeks had
vowed,'our family will fight for transparency, accountability and answers, for my uncle and for the safety of the country we love.'
We’ll never know whether the secret settlement announced Wednesday included any of the things Weeks indicated he was so determined to get.
What the public will probably never know, thanks to the secret settlement, are the details of who said — and did — what to whom when Thomas Eric Duncan went to Presbyterian on Sept. 25.
To recap, we still do not know why Mr Duncan was sent home from the hospital after his first emergency department visit, despite a fever manifesting during that visit, and a nurse's determination that he came from Africa. We still do not know whether problems with the design or implementation of the hospital EHR enabled Mr Duncan's discharge. We still do not know why hospital managers were so certain that they were prepared for Ebola, and whether two nurses contracted Ebola because of poor training, poor equipment, lapses in established protocols, or some other reason. We sill do not know whether hospital managers tried, and perhaps succeeded in silencing most hospital professionals' concerns about medical or management mistakes.
Finally, in an interview published by Modern Healthcare, THR CEO Barclay Berdan felt comfortable enough to say,
It was really important to make sure we had a really high level of communication and maintained the trust level inside the organization while we were in many cases being attacked from the outside, as the world moved really from science to political science to social science to superstition and fear
The reporter did not ask whether the appearance of "trust inside the organization" might have been driven by fears about job loss, or the outside attacks could have really been appropriate skepticism? He also did not challenge a "high level of communication" that seemed mainly devoted to obscuring specifics and preserving management's reputation. But perhaps Mr Berdan counted on how "Ebola memories fade" to deplete interest in such questions.
Public relations is an important tool used by generic managers to maintain control of their organizations, and hence their ability to continue living in the style to which they have become accustomed. Aggressive use of PR may be particularly helpful when events highlight the gap between a health organization's high minded mission and its actual performance. Perhaps Texas Health Resources' deployment of vague apologies and assurances, nonspecific but indignant refutations, and undocumented aspersions on the media and mysterious outsiders did let questions about management's handling of the first Ebola patients diagnosed on US soil fade.
However, better medical care and public health, and future successful management of Ebola or the next unexpected infectious threat requires answers to these questions. Health care and public health professionals, policy makers, and the public should not let health care managers put maintenance of their currently comfortable position ahead of patients' and the public's health.
The aftermath of our first US Ebola crisis makes it clear that we need true health care reform that focuses on the leadership of big health care organizations. In particular, we need leadership that is well-informed about health care and public health; that upholds the values of health care professionals, specifically by putting patients' and the public's health ahead of their own remuneration; is willing to be held accountable; and is honest and unconflicted.
Allowing the current dysfunction to continue, while it will be very profitable to the insiders who run the system, will continue to enable tragic outcomes for patients and the public.