We can’t help it: Despite having almost no factual information to go on, we are really angry at Thomas Eric Duncan, the first Ebola patient to infiltrate the United States. And we are really angry at the Texas Health Dallas Presbyterian Hospital nurse who screened him on the night of September 25, and somehow didn’t get it across to the treating doctor that Duncan had just come from Liberia, the hottest of the Ebola hot zones in West Africa. The doctors sent him home, and people were unnecessarily exposed to Ebola as a result of this mistake, perhaps tragically.
But in thinking about how the mistake might have happened, we have tried to put ourselves into the shoes of a man from Liberia who was about to find out for certain that he had what he must have feared most – Ebola.
This is going to be an exercise in empathy. There is much empathy needed, and much lacking, in almost every aspect of the unimaginably horrible Ebola epidemic. Empathy is needed especially because one of the most dangerous hallmarks of Ebola is denial. As we have written many times over the years, other people’s empathic understanding – or lacking that, their empathic effort to understand – can help people let go of their denial and start to bear their fears.
With regard to this infuriating and frightening missed opportunity to quickly protect many people from a sick Ebola patient, we are going to hypothesize – imagine – try to understand – what might have gone wrong. It will be pure speculation.
We realize that the truth about what happened that night may come out at any time – even before we get this column posted – and that truth may be totally inconsistent with the speculation that follows.
Not much has been revealed yet about what happened when Thomas Eric Duncan went to Texas Health Dallas late on September 25, feverish and complaining of abdominal pain.
Hospital officials admit that he was asked whether he had recently been in Africa, or West Africa, or countries where Ebola is epidemic, or something along those lines. Officials admit that his answer was yes. And they admit that somehow, “regretfully, that information was not fully communicated throughout the full team,” and so the team decided to send him home, apparently with some meds, where he continued to endanger others (including five children) for another two days. By September 28 his condition had worsened, and he went back to Texas Health Dallas by ambulance, where this time Ebola was suspected and he was finally, very belatedly, isolated.
We don’t know exactly what he was asked, or exactly what he answered, or exactly what the screening nurse wrote down on his record. There may be debate forever over the first two questions. The last one is presumably documented, though the document hasn’t been released.
In a normal course of events, Texas Health Dallas will eventually conduct a morbidity and mortality conference to review what went wrong (as well as what went right) in its handling of the Duncan case. Its results, too, may never be made public. But if hospital officials are wise, they will openly share their findings (with the patient’s permission, if he lives), perhaps after redacting some of the names. If there are Congressional hearings, some of this information will be revealed. If there are lawsuits, all the results may become public.
In shared semi-ignorance, many commentators are understandably criticizing Texas Health Dallas, and to a lesser extent Duncan himself, for what was obviously an extremely serious communication error.
Dr. Anthony Fauci, one of the U.S.’s most senior health officials, told CNN:
A travel history was taken, but it wasn’t communicated to the people who were making the decision…. It was a mistake. They dropped the ball…. You don’t want to pile on them, but hopefully this will never happen again…. The CDC has been vigorously emphasizing the need for a travel history.
We had the same reaction – especially after we read the important New York Times scoop that a few days before flying to Dallas, Duncan had very close physical contact with at least one late-stage Ebola patient shortly before she died in Monrovia, Liberia. Thus he had every reason to suspect that his own symptoms were probably signs of Ebola.
“How could he go to the emergency room on September 25 and not make sure the doctors and nurses treating him knew what he probably had?” we asked each other. “How could anyone in that emergency room hear he had just come from Ebola Land and fail to isolate him instantly? How could the medical team possibly send him home?”
The lost travel history also revived our anger about two cases last spring. Two doctors from Saudi Arabia came to the U.S. infected with Middle East Respiratory Syndrome (MERS) virus, a hard-to-catch disease with a horrifying 42 percent fatality rate if you do catch it. (Ebola’s fatality rate is even worse, around 71 percent so far, according to a World Health Organization analysis.) One ended up in a hospital in Indiana, the other in Florida. In both cases, either the hospitals did not ask for travel histories at the time of admission, or the patients did not answer accurately, or the hospital personnel did not understand the significance of the answers.
The Indiana patient’s travel history – and thus the suspicion of MERS – surfaced the day after his admission. The CDC’s Morbidity and Mortality Weekly Report (MMWR) reported:
Before implementation of contact and airborne infection control precautions at the hospital in Indiana, 53 health-care personnel (HCP) had contact with the patient.
The 53 staffers were furloughed on 14-day “voluntary home quarantine.”
Shortly after the Indiana MERS case was in the news, a second doctor from Saudi Arabia came to the U.S. with MERS, landing at an Orlando hospital. His travel history was obtained the morning after his admission, at which time full isolation was instituted. Sixteen hospital staff members were quarantined because of possible exposure prior to appropriate isolation of the patient.
Nobody at either hospital came down with MERS, thank goodness. But we were infuriated by the two hospitals’ triumphal celebrations of how well they had handled the first MERS cases in the U.S. There was almost no criticism of their delayed discovery that the patients had come from Saudi Arabia, where they had been working in Saudi hospitals.
Thus in the spring of 2014, a very dramatic teachable moment about taking travel histories was completely lost, six months before the western hemisphere’s first unannounced Ebola patient turned up in Dallas.
Texas Health Dallas’s defense has been partly that the first time Duncan came to the hospital, he “presented with low-grade fever and abdominal pain. His condition did not warrant admission. He also was not exhibiting symptoms specific to Ebola,” such as diarrhea and vomiting.
However, according to the CDC’s Ebola case definitions page for healthcare workers, Duncan might have been considered a “Person Under Investigation” for Ebola based on fever, abdominal pain, and travel history alone. If his fever was less than 101.5°F, he wouldn’t have fully matched at least one version of the CDC criteria, although he would have matched a different version. So maybe the hospital has a legal path out of this mess if the patient’s “low-grade fever” was less than 101.5.
But we doubt that will help the hospital avoid criticism. Nor will it help much that Duncan apparently didn’t tell anybody in the emergency room that he had recently helped transport a convulsing, bleeding pregnant teenager who was dying of Ebola back in Monrovia.
With that early and shifting information in mind, we tried to empathize our way into what might have gone understandably wrong, instead of culpably wrong.
1. The language barrier?
We started by wondering about possible language barriers between Duncan and the screening nurse. Liberian English is very different from American English. We blundered into this important fact when we started to wonder whether the Liberian word for Liberia might be something other than “Liberia.” In search of the answer (it’s “Liberia”), we ended up listening to several Liberian English videos on YouTube, and discovered to our shock that we had trouble catching more than an occasional word.
Try this one , for example, made under optimal conditions: relaxed, comfortable Liberian women recording a video message for their friends in the U.S. After several hearings we could make out some of it. But at first we weren’t certain it was even in English.
We don’t know how good Duncan’s English is. For all we know, maybe he’s entirely understandable to an American listener. But we doubt it. Why would he be? He has never lived here or gone to school here, as far as we know.
And what about the screening nurse who ran through a list of questions with him – including the all-important travel history question? Was English that nurse’s mother tongue? Or was it his/her second (or third or fourth) language?
2. The culture barrier?
Accounts differ about whether this was Duncan’s first visit to the United States or his third visit to the United States. We don’t know what other travels he may have had to Western countries. But he sounds like a working class Liberian, employed in Monrovia as a driver until he recently quit without warning. His now-removed Facebook page lists no education beyond his 1989 high school graduation.
This was almost certainly his first time in a U.S. hospital, probably his first time in a big metropolitan Western hospital, quite conceivably his first time in any hospital.
Hospital cultures are weird, even in your own country. We get nervous in hospitals, though one of us (Jody) is an M.D. After walking down long, poorly signed, labyrinthine corridors connecting multiple buildings, we register with rushed, sometimes brusque receptionists. We clutch our written lists of symptoms experienced, medications taken, and questions we want to remember to ask the doctor.
Thinking about Duncan, scared and feverish, trying to do this in a hospital in a culture vastly different from his own, we can easily imagine communication gaps, even if he was accompanied by his partner.
3. Post-traumatic stress?
Duncan had been through a horrific several months in Monrovia, watching as his city crumbled around him. When a young pregnant member of his landlord’s family became deathly ill with what looked like Ebola, her relatives called an ambulance. But no ambulance came. So Duncan helped them carry her to a taxi – and then, when no hospital would accept her, helped bring her home again, where she soon died. At least one other person in that taxi with Duncan and the dying girl came down with Ebola before Duncan did.
A few days later, still symptom-free, Duncan flew from Monrovia to Brussels to Washington to Dallas, where his sister, his partner, possibly his son, and other friends and relatives lived.
Like much of the information here, “still symptom-free” on the plane is tentative and may turn out false. Duncan passed whatever temperature exit screening was in use at Monrovia’s airport. Nobody has come forward to say he looked ill on any plane or in any airport (unlike the way the late Liberian-American Patrick Sawyer looked in July, after his sister died of Ebola and he flew while sick from Monrovia to Lome to Accra to Lagos, Nigeria – where he started a chain of Ebola that infected about 20 Nigerians). If Duncan had symptoms while flying, they escaped notice, perhaps even his own. Or perhaps they were mild enough that he got away with hiding them, just as he got away with lying on his Liberian exit paperwork about having had no contact with any Ebola sufferers. It’s not hard to guess why a Monrovia resident who thought he probably had Ebola might want to escape to the United States, especially if he already had a ticket and friends and family waiting at the other end.
On September 30, CDC Director Tom Frieden said Duncan posed “zero risk” to his airplane seatmates. That is almost certainly true if he was asymptomatic on his flights. For sure he posed a lot less risk to his fellow passengers than he did five days later to his housemates, EMTs, nurses, and doctors.
According to one small study of symptom duration in a different Ebola epidemic, “Patients presented to an Ebola ward after a mean self-reported delay of 3.5 days (range 0 to 8) following symptom onset.” Duncan sought medical care late September 25; he flew September 19–20, five to six days earlier – well within the study’s range. So although Duncan has said his symptoms started about September 24, it isn’t beyond the realm of possibility that he might have begun feeling sick on one of his flights, five to six days before he made his futile and potentially tragic first trip to Texas Health Dallas Presbyterian Hospital.
After all he had just been through – his recent nightmarish experiences in Monrovia, his emerging illness, his culture shock – Duncan might not have been thinking very clearly when he got to the hospital late on September 25.
4. Terror, panic, or denial?
We can only try to imagine Duncan’s state of mind that night in the Texas Health Dallas emergency room. He knew that he had been exposed to Ebola, big time. He knew firsthand that Ebola was highly lethal. And he knew that he was sick, and getting sicker.
- He might have been terrified.
Terror is a level of emotional arousal that’s too high – high enough to interfere with clear thinking and wise precaution-taking. We define “fear” as the level of emotional arousal that’s conducive to the wisest precaution-taking in an urgent crisis situation. “Concern” is too low. “Terror” is too high.
- He might have been panicking.
Panic is the highest level of emotional arousal, beyond terror. Panicking people don’t just act sub-optimally. They act in ways that endanger themselves or others; they do things that they would know not to do if they were thinking straight.
- He might have been in denial.
Although panicky feelings are common enough, true panic – panicky behavior – is rare, largely because people who are about to panic tend to trip an emotional circuit-breaker and go into denial instead. In denial, we fail to take precautions we should take. Denial occurs frequently in people threatened with deadly diseases, from breast cancer to melanoma to heart disease.
We have an ever-larger collection of Ebola denial examples. Here are two: an infected, symptomatic Ebola hospital doctor who went to work (and even socialized) in Sierra Leone; and an infected, symptomatic doctor in Nigeria (infected when he treated an Ebola patient who had fled quarantine in Lagos) who operated on patients and invited friends home to meet his newborn baby.
Whatever Duncan’s state of mind on his first visit to the Texas Health Dallas emergency room – we hypothesize terror, panic, or denial – there is reason to think he might well have had difficulty articulating the dreaded, mortal risk he faced.
5. Beliefs about Western selfishness or malevolence?
Finally, there are the beliefs and rumors in West Africa’s Ebola hot zones that Westerners already have medications to cure Ebola but are withholding them from Africans. Given some aspects of African colonial history, you can see why this might seem credible. And there are some Ebola facts that provide a kernel of truth. For example, ZMapp and other experimental treatments have indeed been reserved almost entirely for Westerners; and it is Westerners who get evacuated to Western hospitals.
The West has no magic bullet for Ebola. What use would the West make of our magic bullet if we had one? We’ll have to wait and see whether an Ebola vaccine is developed, and if so where the first doses are deployed.
So here’s a different take on the known facts. On September 25, Thomas Eric Duncan went to a Dallas hospital emergency room, sick with what he had reason to think was probably Ebola. Maybe he tried to tell the foreigners in the hospital as much as he could. Maybe he thought they had understood more than they did. And then they gave him some medicine. Maybe he went home that night greatly relieved: “It’s true, they do have a pill for Ebola! Thank God I got here in time!”
This is all hypothetical, obviously.
No one knows how communication actually failed between Duncan and the nurse late on September 25. Or between the nurse and the treatment staff. Or even between Duncan and his partner: Did she know he had been exposed to Ebola in Liberia the week before?
The most tempting explanations place furious blame – on the patient, on the nurse, on the medical staff. Certainly on the public officials who kept this part of the story secret on September 30, when they announced America’s first un-moon-suited Ebola patient. Some of that blame will probably turn out justified.
This is just an Ebola empathy exercise, an effort to look at this ghastly mistake from a viewpoint that doesn’t simply assume reckless irresponsibility on either side.
A Different Empathic Scenario
On October 15, nearly two weeks after we posted this Ebola empathy exercise, we received an anonymous email suggesting a different scenario:
I liked your empathy exercise. Here’s another possibility.
Duncan interpreted “Ebola is spread by bodily fluids” the way, as you say, most people do. Perhaps he didn’t think he had been exposed to her fluids when driving his landlord’s daughter to and from the hospital, so he said he hadn’t been exposed. Or if the question was, “Have you cared for someone with Ebola?” the answer could equally be “no,” since “cared for” could easily be taken to mean “nursed at home.” I’ve seen those questions and answers reported differently….
So (stringing together different “facts” I’ve read, plus filling some in) a different narrative could be:
Duncan and his fiancée fall in love 20 years ago in a camp for refugees from the violent civil war. She is given the opportunity to move to the U.S. and he is not. He says, “Don’t stay here with me – go, it will be a better life for you and our child.” (Or he could have stayed in Liberia in order not to abandon a parent, sibling, etc.) She goes, marries, divorces. Unable to forget Duncan, she works to save money to bring him over. At last they are able to make a plan for him to come – tragically, coinciding with the epidemic. Duncan, knowing he is to leave soon, is extra careful. But being a kind person, he cannot bring himself to refuse to help a dying pregnant woman.
He observes the bodily fluids precaution, as he understands it, and thinks he is safe. Grief-stricken and traumatized by his country’s plight, he gets on the plane, grateful that he has survived to reunite at last with his love and his child, thanking God for allowing him to live till this long-awaited day.
An empathic afterthought of our own: Perhaps Duncan wasn’t clear about his prior exposure to an Ebola sufferer because he did not think he needed to be. Many people assume that their doctors “can just tell” what’s wrong with them, so they often neglect to give a good history, especially if it’s embarrassing. That kind of magical thinking isn’t some West African cultural characteristic. It is widespread in the U.S. and the rest of the developed world as well.
Remember: The purpose of this exercise isn’t to figure out what actually happened in the Presby emergency department on September 25–26. Maybe the lawyers and judges will eventually get to the bottom of that quagmire. And we don’t mean to dehumanize or objectify Eric Duncan by imagining fictional scenarios about him.
Our purpose is simply to practice telling ourselves empathic stories about people we are too easily inclined to hate and scapegoat.
List of Ebola Risk Communication articles.
Copyright © 2014 by Peter M. Sandman and Jody Lanard