Tuesday, October 28, 2014

A Crisis of Conscience: Healthcare Workers, Ebola, and You

Staff Writer, R. Patrick Chapman and DL Mullan
Medicine / Ebola

Today in the sea of bacteria and viruses, in the United States we have the best medical system in the world, including consummate professional healthcare workers.

Waa-What? We don't? 

Let's start from the beginning, shall we? 
Hickox, a nurse who had been treating Ebola victims in Sierra Leone, landed at Newark Liberty Airport Friday night just hours after Christie's abrupt announcement about the mandatory quarantine, made in conjunction with New York Gov. Andrew Cuomo (D). In an op-ed published in the Dallas Morning News Saturday, Hickox described the "emotionally exhausting" ordeal she endured following her arrival, during which she was held in a quarantine office for six hours and only given a granola bar and water while officials refused to answer her questions.
She complained she had a portable toilet, no television, no shower, and sparse cellular reception. Oh, boo hoo. Instead of thinking like a healthcare worker who has been attending to patients with a lethal virus such as Ebola and that she might need to be quarantined for the 42-day gestation period like any normal, sane professional would extrapolate, Ms. Hickox called for a lawyer instead.

Because that in no way sounds morally or ethically corrupt.
Kaci Hickox, the nurse currently being held in quarantine at Newark University Hospital despite testing negative for Ebola, has hired a prominent civil rights attorney to help get her out of isolation.

The lawyer, Norman Siegel, told the New York Times on Sunday that Hickox's quarantine order has "raised substantial civil liberties issues."

Siegel told Reuters that Hickox will file a federal lawsuit over her quarantine.
How about the civil rights of rest of us? Don't we have the right not to be infected by Ebola or similar contagion by people who travel in areas known for a deadly epidemic? Especially those individuals who volunteer to assist the medical needs of infected patients and know the risks, know the quarantine perimeters, and know they can at any time be isolated by any government or agency? 

If you cannot handle the rules of the situation, why did you go knowing that you could be put in quarantined isolation? 

Healthcare workers who have in practice given up their civil rights to be placed in a quarantine status at any time as part of their social contract to the rest of the world are now complaining about it?

Doctors Without Borders states that:
Click to Enlarge
Every district in Sierra Leone is now affected by the epidemic. Current hotspots for the disease include the capital, Freetown, and the areas of Port Loko, Bombali, and Moyamba. There are continued issues with poor surveillance systems, full transit centers, delays with lab testing, and too few ambulances, which all increase risks of cross-contamination. The government has now moved the national Emergency Response Committee from the jurisdiction of the Ministry of Health to the Ministry of Defense.

With so many deaths from Ebola, MSF is still seeing an increasing number of orphaned children in our centers, and a lack of caregivers.

As the health system has collapsed due to the Ebola crisis, MSF is planning an intervention to reduce mortality. This includes a distribution of 250,000 protective and disinfection kits and 500,000 anti-malarial kits, mosquito nets, oral rehydration salts, and medications for respiratory tract infections.

The international response is beginning to get underway, but it is slow and uncoordinated. Governments and various NGOs have sent teams to construct new centers at different locations around the country, including Jiu, Port Loko, and Freetown. Getting these new centers up and running is a matter of urgency.
So Sierra Leone is an active Ebola virus area but the response of a supposed seasoned nurse created an even bigger situation. 
"I was tired, hungry and confused, but I tried to remain calm," she wrote. "My temperature was taken using a forehead scanner and it read a temperature of 98. 
"Hickox later registered a temperature of 101 (which she said was a result of being flushed and upset), and she was subsequently put into quarantine at Newark University Hospital, where she tested negative for Ebola but is still being held.
Instead of being professional and waiting out the quarantine, Ms. Hickox gave authorities a reason to hold her longer. Just because a medical test comes out negative or positive does not mean that test is correct. The display of a fever was enough evidence that the test may be wrong and the authorities held Ms. Hickox for observation. 

In the article, Medical False Positives and False Negatives (Conditional Probability), we learn how medical tests are not absolute. In probability, a negative result is usually correct, nearly 100% of the time, unless you use numbers in accordance with a known disease and its statistics. Take breast cancer for instance: 
Now you can compute probabilities. First, the false-positive rate, the likelihood of a positive result where there’s actually no cancer, was given as

P(positive | no cancer) = 1% to 3% (I used 2%) 
Click to Enlarge

But you’re interested in the probability that a positive result has actually detected cancer, and this is not 100% minus 2%.

P(cancer | positive) = 25,800/27,200 = 95%

The given false-negative rate, the probability that a woman who has breast cancer gets a negative biopsy result, was given as

P(negative | cancer) = 10% to 18% (I used 14%)

But what’s the probability that a woman with a negative result actually has breast cancer?

P(cancer | negative) = 4,200/72,800 = 6%

These discrepancies come from the difference between P(A|B) and P(B|A), such as the difference between “getting a positive result if cancer is present” and “having cancer if the test result was positive”. The differences are less than they were in the original example, because the incidence is greater (30% versus 0.1%).
So when Ms. Hickox showed signs of a fever, she could be one of the few whose test did not match the possibility of not having the viral contagion. As a healthcare worker, shouldn't she also know this fact? 

A lot of facts do not add up here. You either are a professional or you are not when dealing with deadly illnesses. If you cannot be professional and hold up your social contract to be quarantined by officials at any given moment, then why are you in that profession?  

The CDC and the State of New Jersey should have been more forthcoming in their approach and information to Ms. Hickox, but given the outbreak and her volunteerism, the quarantine should have not been broken.  

Being a whiny brat should not preclude anyone from their duties to be contagion free when they are a volunteer healthcare worker in virus infested countries. 

The only crisis here is the crisis of conscience. 

What would you do? Go out in public with a fever? Or stay in quarantine until you were given the all clear? 

In a terrible situation like this one where Ebola is rampant and killing, we need professionals. We need people to act like adults.

But until then, we should have the rules set: you volunteered; you get quarantined. It is not about your civil rights being violated (you already acquiesced to that). It is about having a conscience that the rest of us matter too. 

10/29/14 Updated Information: Some May Carry Ebola Virus Without Having the Symptoms, Human asymptomatic Ebola infection and strong inflammatory response, as well as, Symptomless infection with Ebola virus, which tries to calm any fears of the former studied results, but cannot make a full explanation as to how individuals were exposed to Ebola in contact only with asymptomatic persons.

So the determination again is of your conscience.

In addition, read the VDP Gazette's article: Legal Authorities for Isolation and Quarantine

Source: Tompkins Cortland Community College, Huffington Post, Doctors Without Borders