By LOUIS FLORES
In New York City, hospitals have yet to treat their first patient with Ebola, but the fear of an outbreak of the virus has certainly unsettled the public and healthcare workers, but city and state officials not so much.
Last Tuesday, when city health officials first announced that Bellevue Hospital would treat Ebola patients in New York City, the announcement was cheered by health officials of other city hospitals, who had feared that they would have to treat Ebola patients. However, the relaxed mood didn't last long, before Gov. Andrew Cuomo (D-NY) expanded the list of hospitals, which had been designated to receive and treat Ebola patients. Of eight hospitals statewide designated by Gov. Cuomo, four are located in New York City : Mount Sinai Medical Center, Bellevue, New York-Presbyterian Hospital, and Montefiore Medical Center. Besides designating the eight hospitals, the state announcement last week also required that all hospitals follow “protocols for identification, isolation and medical evaluation of patients requiring care.”
To isolate and treat people with Ebola at Bellevue, the city’s flagship public hospital, health officials announced that Bellevue has four single-bed rooms in its infectious disease ward and nine isolation units in its emergency department. Isolating people with Ebola is key to containing the spread of the virus. The number of rooms in its infectious disease ward could be expanded, health officials said, but by what extent is not known. A question about the size of the possible expansion in the number of beds in the infections disease ward of Bellevue was sent to each of the city’s Department of Health and Mental Hygiene and the city’s Health and Hospitals Corporation, the latter which oversees Bellevue, but that question was referred to the state’s Department of Health. A request for an interview with the Public Affairs office at the state’s Department of Health was not answered.
An official with the press office of the city’s Department of Health and Mental Hygiene did issue the following statement by e-mail : “NYC has been planning since July for early identification and isolation of anyone suspected to have Ebola. If a case is introduced into the NYC, we are confident that we will be able to contain it. We also have extensive plans for how to safely monitor the health of people exposed to Ebola, which, in some situations, may involve quarantine. It is extremely unlikely that a massive outbreak of Ebola would occur in NYC.”
For it’s part, the city’s Health and Hospitals Corporation referred to statements issued last week by city and state officials, which do not speak to the scalable size of the capacity to handle more patients with Ebola at Bellevue beyond the capacity initially announced last week. Health officials are hoping that an outbreak, if any, of Ebola in New York City will be small and manageable.
So that medical information could be shared with the public, Progress Queens spoke with a physician, who has a medical affiliation with one of the hospitals in New York City that has been designated by the state’s Department of Health to treat patients with Ebola, on the condition of maintaining the physician’s identity anonymous. The physician has experience in emergency medicine. The physician agreed that the best way to treat a person with an infections virus like Ebola is through designated medical centers. The physician agreed with the two main goals expressed by health officials : to keep the outbreak contained and to allow the best-trained medical staff to treat people with Ebola. Treating people at designated hospitals would accomplish these two goals, the physician said.
The designated hospitals have more experience with treating rare diseases and viral outbreaks, the physician noted. Speaking from knowledge and experience, the physician said that at two major Manhattan hospitals, the staff have experience screening patients for infectious diseases, such as Middle East Respiratory Syndrome, or MERS, a viral respiratory illness ; malaria, a disease spread by mosquito bites ; and chikungunya, a virus common to the Caribbean that is also spread by mosquito bites. “We have doctors in Infections Diseases, who tell us what we need to know,” the physician said, adding that the ability exists to test patients and receive test results back within the day. Until such time as test results are returned, the patient would have to be quarantined, the physician said.
To keep transmission rates low, health officials are counting on the fact that Ebola is not airborne, that doctors know the symptoms for which to look, and hospital screeners have been told to have a sensitivity to patients’ travels to known countries, where Ebola is currently concentrated. If a person is showing early signs of possible exposure to Ebola, a patient is questioned to determine if the patient has had possible contact with another person or persons with a known Ebola infection. The current outbreak of Ebola is primarily centered in the African nations of Liberia, Guinea, and Sierra Leone.
Notwithstanding the hopes of health officials, who wish that New York can escape unscathed from the Ebola outgreak in Africa, New York has been identified by the Centers for Disease Control and Prevention as a facing some risk. “New York City (NYC) is a frequent port of entry for travelers from West Africa, a home to communities of West African immigrants who travel back to their home countries, and a home to health care workers who travel to West Africa to treat Ebola patients,” according to an article published in Morbidity and Mortality Weekly Report.
While only eight people have been treated for Ebola in the United States, the local medical outlook is guarded. “If we have 15 to 20 patients, we should still have the resources and knowledge to contain it,” the emergency medicine physician told Progress Queens, adding that, “If we had 200 to 300 patients, it would be scary.”
Health officials are hoping no New Yorker will need to be treated for Ebola, and for good reason. Based on information received by Progress Queens, the city’s Ebola plan should be able to safely handle a threshold of cases that is not publicly quantifiable by health officials, perhaps in the range between 25-40 cases, hypothetically speaking, without either taxing the city's designated hospitals and testing facilities or exhausting the required safety supplies of hazmat suits, trained medical staff, and other resources. But at some point, a population of cases in that kind of range can be troubling, because an identified population of cases in that range may mask unidentified cases, given the exponential way that viruses like Ebola spread. If a person waits until he or she is very ill from Ebola, then the patient will be seeking medical help when he or she may be most contagious, when the patient may be suffering from diarrhea and nausea, increasing the chances that other people may have come into contact with their bodily fluids that may be carrying the virus or with objects, such as clothing or bed sheets, that may have, in turn, come into contact with the patient’s bodily fluids, raising fears of possible transmission to others before the patient can be safely isolated in a controlled hospital setting.
In a situation where city and state officials may need to increase the number of single-bed rooms or isolation units dedicated to people with Ebola, officials would have to plan to accommodate a secondary threshold of patients possibly in the low hundreds. City health officials did not want to comment on that possibility, and state health officials did not answer a request for an interview.
If the best-case scenario is that the city’s designated hospitals do not touch the ceiling of that first hypothetical threshold of 25-40 cases, then what can be done to prevent Ebola from even reaching New York City, as city health officials hope ? Thomas Farley, the former Commissioner of the New York City Department of Health and Mental Hygiene, is now a member of the advisory committee to the director of the Centers for Disease Control and Prevention. Dr. Farley advises against a travel ban with the three African nations, where Ebola infection is most concentrated. A travel ban is opposed on the grounds that it would compromise efforts to fight the disease in the African region, and such a ban might force people to flee by other means to neighboring countries, creating new travel routes that may potentially spread Ebola. Further, it is not practical to expect to be able to seal national boarders of impacted nations that include forests. How do poor nations that cannot afford to adequately fund public health turn around and afford new security checkpoints in impossible areas, such as forest ?
With so much attention being paid to travelers from Africa entering the United States through airports, city and state health officials chose not to designate a Queens hospital to receive passengers arriving or passing through La Guardia and JFK airports. Physicians reason that a person suspected of having Ebola can be safely transported by ambulance to one of the designated hospitals, regardless if the trip takes a little bit longer.
With a travel ban seemingly impossible to impose, as well as opposed by President Barack Obama, there appears to be little that health officials can do here to guarantee that the city’s designated hospitals will not have to treat the first person with Ebola. For the current New York plan to work, the world would have to instead marshal resources to Liberia, Guinea, and Sierra Leone, to place people with Ebola in medical quarantine, treating patients there according to a protocol that would stop the spread infection. Although, the global effort will have to play catch-up. As Dr. Farley has pointed out in an editorial published by The New York Daily News, “At every step, the world’s response to this crisis has been shamefully feeble.” The world has to get its act together and fully provide Liberia, Guinea, and Sierra Leone with the resources they need to contain and treat people with Ebola in those nations at the same time that forecasts show that the number of people expected to contract Ebola is going to grow. By the beginning of December, the World Health Organization predicts that it is a possibility that 10,000 news infections could be reported each week, according to a report in The Economist. According to other estimates published by The Economist, it would cost between $1 and $2 billion a month to run a 100,000-bed project in Africa, not including construction costs. These facilities wouldn’t be expected to be full-fledged hospitals, but, rather, care centers, or “halfway houses,” as one Harvard doctor described. The global response would have to scale up from feeble to swift to fully-funded in the matter of weeks to contain and treat the Ebola outbreak in Africa.
Efforts to combat Ebola in Liberia, Guinea, and Sierra Leone are also hampered by the death of many of the region’s few healthcare workers as a result of exposure to Ebola mostly due to a lack of necessary medical supplies, such as hospital gowns, latex gloves, medical masks, and face shields, to ensure a rigorous adherence to a healthy hygiene protocol. Under stifling conditions, it’s not recommended that healthcare workers wear their full protective gear due to the heat for more than 2 or 3 hours when attending to people with Ebola. Therefore, to properly address the needs in Africa, the world would also need to fly in medical staff to work or train others to work at existing and new treatment centers in Africa. Handling the dead for burial also has the possibility of spreading Ebola in Africa if bodily fluids still carrying the virus make contact with other people. The scale of the needed global response to successfully contain the Ebola outbreak in Africa is massive.
In New York City, the main way Ebola would be transmitted would be from human to human, which, according to the World Health Organization, could happen through “direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.” People with Ebola tend to be most infections when they are made most ill by the virus, when they are afflicted with diarrhea and nausea, making adherence to a careful hygiene protocol extremely important. The World Health Organization reports that healthcare workers are most at risk of contracting Ebola, because of their close physical contact when treating people with Ebola, forcing healthcare workers to deal with possible contact with a patient’s blood, loose stools, or vomit, making following hygiene protocols imperative. Other bodily fluids also pose a risk to transmit the Ebola virus.
"Because there is neither a drug to treat infected patients nor a vaccine to protect potential ones, the only option medical workers have right now to prevent the spread are efforts to quarantine people who are infected," CNN reported last week.
Having to place infectious people in quarantine reminds some New Yorkers of the initial healthcare response to the spread of HIV, a response which included a lot of misinformation, stigma, and discrimination. The state's response to HIV in New York in the 1980's was bungled by state efforts to decommission hospital beds at area hospitals, as a way to shrink the state's spending on healthcare and included the construction of a dedicated center in the Bronx to treat people with HIV financed by a group then headed by Andrew Cuomo. As concerns over an outbreak of the Ebola virus plays out in the minds of the public, health officials are again hamstrung by hospital closures first proposed by the Pataki administration's Berger Commission and recently continued by Gov. Cuomo's Medicaid Redesign Team. Since 2006, 13 full-service hospitals have closed in New York City alone, representing the loss of each of entire facilities, strategic community resources, and the capacity of thousands of hospital beds.
In the 1980's, when one New York City hospital was designated to provide hospice care to people with late-stage AIDS, the staff of the designated hospital erupted in turmoil, because there was so much stigma surrounding the treatment of people with HIV, at that time then. Will similar fears by designated Ebola hospitals or facilities undermine efforts to place or keep people with Ebola in quarantine today ? It’s too early to know how health officials confront the ethics of quarantine, or what health officials’ plans call for, if local hospitals cross that first threshold in the number of people, who needed to be treated for Ebola, such that health officials would be required to designate an entire facility to solely isolate and treat people with Ebola. However, any criticisms of the possible need to place people with Ebola in quarantine in New York don’t distinguish from the efforts to marshal resources to Liberia, Guinea, and Sierra Leone to isolate and quarantine people with Ebola in dedicated facilities over there.
Ever since the increasing number of Ebola cases in Africa has been on the news, public discourse has rightly increased, especially after a man died from Ebola in a Texas hospital, and 2 medical staff, who treated that patient contracted Ebola while caring for the man. Whilst some of the public discussion has been predictable, like how can American health officials be prepared for a possible domestic outbreak, some public discussions of Ebola have been called irresponsible. The experienced emergency medicine physician, who spoke anonymously with Progress Queens, said individuals, who have been recently claiming that Ebola could be spread by airborne means, like by a sneeze, were just trying to create hysteria. Although the source did not specifically cite any irresponsible statements as examples, the conservative political commentator George Will did raise concerns Sunday about possible airborne transmission of Ebola, even though claims of airborne transmission have been ruled out by the World Health Organization.
Even with the lack of specifics from city and state health officials, Paul Farmer, a doctor and professor of global health at Harvard, predicts that the United States will fare better in containing Ebola than African nations, where public health facilities, staff, and supplies are scarce. Dr. Farmer wrote about his experiences in Liberia, in an essay published in the London Review of Books, that “the Ebola crisis should serve as an object lesson and rebuke to those who tolerate anaemic state funding of, or even cutbacks in, public health and healthcare delivery.”
Notwithstanding the greater wealth and healthcare infrastructure in the United States, there will still remain some challenges. New York lacks a permanent commissioner of the state’s Department of Health. The state’s prior health commissioner, Dr. Nirav Shah, resigned last spring to accept an executive job in the private sector. Dr. Howard Zucker is the acting commissioner for the state’s Department of Health. When Dr. Zucker sat next to Gov. Cuomo during last week's announcement of the state’s plan to designate eight hospitals to receive and treat people with Ebola, emphasis was placed on the expectation that these hospitals would be able to contain infection, but this outlook ignores the possibility that people with Ebola might possibly infect others, such as friends or family who act as caregivers, or roommates, before people with Ebola are admitted into designated hospitals. In terms of local facilities, if New York hospitals cross that first threshold in the number of people, who needed to be treated for Ebola, the city would need to arrange for additional, dedicated rooms at existing hospitals to receive more patients, or the city could possibly seek to designate a dedicated facility to solely isolate and treat people with Ebola. If people make contact with a person with Ebola, those, who are exposed, are generally quarantined for 21 days to make sure transmission has not taken place. In the Texas case, those exposed were allowed to be quarantined at home. It’s unknown if New York city and state officials would require people needing 21 days of quarantine to be isolated at one of the eight designated hospitals or to be trusted to remain quarantined in their own apartments.
The city’s Department of Health and Mental Hygiene would not comment about the impact the closure of Long Island College Hospital, or LICH, or other recent hospital closings, would have on city plans to being able to effectively contain and treat an outbreak of Ebola in New York City. The closure of LICH earlier this year meant the loss of 506 hospital beds. Other important considerations raised in Dr. Farmer’s essay, like the failure of the market-driven pharmaceutical industry to develop treatments or vaccines for diseases that primarily strike people in poor countries, in low numbers at first, need to be addressed, as well.
This report was amended to add a reference to the number of full-service, New York City hospitals that have closed since 2006.