Monday, November 9, 2015

Ebola one year later: an open letter to Robert J. Vickers

Dear Mr. Vickers,

One year ago today I arrived in Sierra Leone where I worked in the Maforki Ebola Treatment Centre in Port Loko. Saturday, November 7, 2015, Sierra Leone was declared Ebola-free. Two incubation periods have passed since the last case of Ebola virus disease (EVD) was diagnosed in that country.

Since returning to the U.S., I have given several presentations on EVD including a presentation to an ethics class at Pacific Lutheran University, a global health class at University of Washington, Tacoma, and, most recently, a presentation at the Washington State Public Health Association annual conference on the experiences of health workers returning to the U.S. after working in Ebola treatment facilities in West Africa. This is an image that I have included in some of those presentations:

 
On October 31, 2014, the Seattle Times published an opinion piece you wrote titled, Ebola aid workers can't be trusted. In it, you criticized Kaci Hickox and Craig Spencer, two health care providers who had worked in Ebola treatment facilities in West Africa. Craig Spencer is the only person to have developed EVD while being monitored for symptoms of the disease since the Centers for Disease Control and Prevention (CDC) published its guidelines for monitoring people with potential Ebola virus exposure. Dr. Spencer is also the only health worker to have developed EVD after returning to the U.S.


Kaci Hickox
Time Person of the Year 2014

Mr. Vickers, it had been established long before you wrote your article that ebolaviruses are not transmitted by asymptomatic people. It had also been established that at the onset of the "dry" stage of the disease, the stage at which Dr. Spencer presented himself for isolation and treatment, the amount of virus in the blood is usually too low to be detected by polymerase chain reaction (PCR). That is why EVD cannot be ruled out until 72 hours after the onset of symptoms. It is not until the "wet" stage of the disease, characterized by diarrhea and vomiting, that a person with EVD person becomes infectious. This is the reason the CDC has never recommended quarantining asymptomatic health workers who wore appropriate personal protective equipment (PPE) while caring for people with EVD.

Those of us who have worked in Ebola treatment facilities have watched people die from the disease. It is an ugly, painful death. We have also watched people recover from EVD and know that survival is dependent upon aggressive fluid and electrolyte replacement. It seems absurd to me that someone could think that those of us who have seen this disease would jeopardize our own probability of survival or the safety of those around us by ignoring or failing to disclose symptoms of the disease.

I find it ironic that you suggested a comparison between health workers, like me, and Ga√ętan Dugas, who was erroneously identified as "patient zero" in the AIDS epidemic. Ironic, because a number of authors have compared the hysteria around Ebola and stigmatization of health workers to the hysteria around AIDS and stigmatization of people believed to be infected with HIV in the 1980s (See Davtyan et al., 2014 and Gonsalves & Staley, 2014). As the authors of Ethics and Ebola: public health planning and response wrote, “Similar to epidemics that have come before, the current Ebola epidemic reveals how social perceptions of infectious diseases can lead to unethical infringement of civil liberties and stigmatization of the ill, those who treat them, and those who otherwise come to be associated with them.”

I am fortunate that I returned to Washington State after working at Maforki. The Washington State Department of Health Guidance for local health jurisdictions regarding follow-up of asymptomatic persons with potential exposure to the Ebola virus is essentially the same as the CDC guidelines. By and large, there were no restrictions placed on my movements. I came home to my wife and son, I went to church where I was warmly received by the congregation that had prayed over me before I left, I went out to dinner with my family, and I spent a week playing with my little boy before I returned to work. If the weather had been warmer, I would have gone for a bike ride. If I had wanted to, I could have gone bowling.

Andrew, Halloween 2015
Many of my colleagues were not as fortunate. One of my colleagues in New York State wrote, “I was escorted out the main doors of the airport by two EMS, two National Guard, two Department of Health workers and two security guards. I felt like a criminal. I was then taken home in an ambulance with a National Guard escort." This was in full view of that person's neighbors. Several of my friends chose to spend three weeks in Europe rather than return to their home states to be unnecessarily quarantined. I have a friend who was harassed by her coworkers when she returned from Sierra Leone, another who was asked not to return to her apartment, and others who were told not to come to their families' holiday celebrations.

Kaci Hickox received a Diploma in Tropical Nursing from the London School of Tropical Medicine and Hygiene. I received a Master of Public Health and Tropical Medicine (MPH&TM) from the Tulane University School of Public Health and Tropical Medicine. Both schools are home to respected virologists who have studied ebolaviruses for decades. I also attended the CDC Safety Training Course for Healthcare Workers Going to West Africa in Response to the 2014 Ebola Outbreak before going to Sierra Leone. Those of us who donned PPE and worked with patients with EVD understand the risks and modes of transmission of ebolaviruses. Only a handful of U.S. health care personnel were infected and none of them transmitted the disease to anyone else.

Neither Kaci Hickox nor Craig Spencer placed the public at risk. The public's trust was betrayed by certain politicians and the media. I have singled you out, Mr. Vickers, not simply because my wife subscribes to the Seattle Times, but because I feel that your comments are representative of the most inflammatory and irresponsible statements I have heard from or read in the media regarding Ebola and the health workers who cared for people with the disease. There are, of course, others who bear greater responsibility for the shameful treatment that many of my colleagues received after sacrificing their time working to bring West African Ebola epidemic to a close. Perhaps worse than the abusive treatment of my colleagues, the stigmatization of health workers and threat of unnecessary quarantine may have dissuaded others from working in the Ebola response.

Sincerely,

Matthew Rollosson, RN, MPH&TM

P.S. Couldn't you come up with a more contemporary clich√© than Nurse Ratched? Kaci Hickox hadn't been born when the movie One Flew Over the Cuckoo's Nest was released.


Afterword

I highly recommend reading Dr. Spencer's article in the New England Journal of Medicine (cited below). The following quote, taken from that article, eloquently describes what, I believe, many of us felt while caring for people with EVD:

"Every day, I looked forward to putting on the personal protective equipment and entering the treatment center. No matter how exhausted I felt when I woke up, an hour of profuse sweating in the suit and the satisfaction I got from treating ill patients washed away my fear and made me feel new again."

Update

"Travelers from Sierra Leone entering the United States will continue to be funneled through one of five U.S. airports conducting enhanced entry screening (New York JFK, Washington-Dulles, Newark International, Chicago O’Hare, and Atlanta Hartsfield-Jackson). Travelers from Sierra Leone will continue to have their temperatures taken and answer questions about travel history and possible exposures to Ebola. Travelers will also provide their contact information so that the health department at their destination can connect with them, if needed. Under the modified entry screening, travelers from Sierra Leone with no enhanced risk factors will receive a version of the CARE kit that includes information about Ebola, a thermometer, and contact information for state and local health departments. Travelers will be encouraged to watch their health for 21 days after leaving Sierra Leone and to contact their local health departments if they develop symptoms consistent with Ebola.  Travelers from Sierra Leone will no longer need to be actively monitored by or be in daily contact with their health departments."
 http://www.cdc.gov/media/releases/2015/s1109-airport-screening.html

Two down, one to go!

References

Centers for Disease Control and Prevention. (2015). State and territorial Ebola screening, monitoring, and movement policy statements – United States, August 31, 2015. Morbidity and Mortality Weekly Report, 64(40), 1145-1146. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6440a4.htm.

Davtyan, M., Brown, B., & Folayan, M. O. (2014). Addressing Ebola-related stigma: lessons learned from HIV/AIDS. Global Health Action, 7. http://www.globalhealthaction.net/index.php/gha/article/view/26058.

Gonsalves, G. & Staley, P. (2014). Panic, paranoia, and public health – the AIDS epidemic's lessons for Ebola. New England Journal of Medicine, 371(25), 2348-2349. http://www.nejm.org/doi/full/10.1056/NEJMp1413425.

Infectious Diseases Society of America. (2014). IDSA statement on involuntary quarantine of healthcare workers returning from Ebola-affected countries. http://www.idsociety.org/2014_ebola_quarantine.

Presidential Commission for the Study of Bioethical Issues. (2015). Ethics and Ebola: public health planning and response. http://bioethics.gov/node/4637.

Spencer, C. (2015). Having and fighting Ebola – public health lessons from a clinician turned patient. New England Journal of Medicine, 372(12), 1089-1091. http://www.nejm.org/doi/full/10.1056/NEJMp1501355.

Vickers, R. J. (October 31, 2014). Ebola aid workers can't be trusted. Seattle Times. http://blogs.seattletimes.com/opinionnw/2014/10/31/ebola-aid-workers-cant-be-trusted.

2 comments:

  1. Media hype causes so much destruction. I am so sorry for what your coworkers experienced. And we were all so glad you came home safe. Excellent read.

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  2. Hi Matthew Rollosson,

    I greatly admire the work you did in Sierra Leone and your writings on the experience. I'm a graduate PA student at UW working on a capstone project on Ebola in Sierra Leone and would love to interview you for my (not for publication) project, if you would be willing. If it is something you would consider, please send me an e-mail at mccons@uw.edu.

    Many thanks!
    Sarah

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