COMMENTARY

What Ebola Has Taught Us About Managing COVID

Robert D. Glatter, MD; Syra Madad, DHSc, MSc, MCP; Craig A. Spencer, MD, MPH

Disclosures

April 08, 2021

This transcript has been edited for clarity.

Robert D. Glatter, MD: Hi. I'm Dr Robert Glatter, medical adviser for Medscape Emergency Medicine. I want to welcome two public health experts based in New York City who recently authored an article in The Lancet arguing how the United States response to Ebola in 2014 could have better shaped and informed our response to COVID-19.

Dr Syra Madad is senior director of the Special Pathogens Program at NYC Health and Hospitals, where she is also part of the executive leadership team which oversees New York City's response to COVID-19 in the city's 11 public hospitals. She also played a key role in the response to Ebola in Texas in 2014-15. Dr Craig Spencer is director of global health and emergency medicine at NewYork-Presbyterian Columbia University Medical Center, where he is also associate professor of emergency medicine. He coordinated the Doctors Without Borders national response in Guinea during the Ebola outbreak and also became an Ebola survivor himself. Welcome.

Craig A. Spencer, MD, MPH: Thanks for having us.

Syra Madad, DHSc, MSc, MCP: Yes, thank you.

Glatter: I want to first congratulate you both on putting together this insightful article highlighting the lessons learned in responding to and managing the Ebola outbreak in 2014. In light of the poorly managed US response to COVID, I really wanted to stress the key takeaways you describe in your article for managing Ebola and how this could have changed our trajectory. I want to start with one of the key points of the article, that outbreaks always expose the shortcomings in healthcare systems.

https://twitter.com/craig_a_spencer/status/1368059352368771072?s=21

Syra, I'll let you begin.

Madad: That's exactly correct; this is not our first rodeo. We've dealt with many different epidemics and pandemics before in history, and it has always shed light on our various gaps and challenges. Unfortunately, much of the approach that we've had has been the bubble gum and Band-Aid type of approach, where we have short-term solutions and we don't look at it from a long-term standpoint. We're always shortsighted in the ways that we respond to epidemics and pandemics. I do hope that with the particular situation that we're in, in this COVID-19 pandemic, we take the lessons learned and really make sure that we have long-term solutions moving forward.

Glatter: Craig, your thoughts?

Spencer: Dr Madad and I had met a few months prior to COVID-19 at an Ebola conference that she had helped put together, and basically arguing this, that we know that this is going to come. It was when some funding was running out. There was an argument that was being made. Ronald A. Klain, who is now Biden's White House chief of staff and was the Ebola czar in 2014-2015, was there. There was this big argument that we need the funding and preparedness, because the next pandemic is around the corner. Both Dr Madad and I knew that, as did everyone else in attendance. I don't think any of us necessarily expected that it would just be a few months from that time. But I think it highlights how important, acute, and critical these investments are. Not just financial, but in building up the health systems here and abroad to make sure that we're able to respond to them.

Glatter: And it's our standing in the world. As the United States, we should be the leaders promoting public health and really garnering support in the world. Obviously with Ebola and what we went through, the lessons learned, where were we approaching this pandemic? That's really what bothers me — and I think so many other healthcare professionals in the world at large.

Madad: I will add (because what you just mentioned is such an important point) that the United States should have been a model and a leader. When we look at what's happening in this current pandemic, and we all know the pillars of outbreak response, these are things that we've done over and over again.

The one thing that obviously has made a huge difference is leadership. That can definitely make or break any type of response. You may have the best contact-tracing workforce, the best case-management approach, the best healthcare system; and if you rate yourself an 80% or 90% before a pandemic hit but you don't know who your leadership is, that's what's really going to drive a successful outcome.

Glatter: Right. I think what you're saying is that preparedness — and this is how you lead the article off, and I'll quote: "undervalued, underfunded, and largely treated as optional" here in the United States. Whether that's the world view, I'd like to approach that with both of you. I'm not sure how you feel about that. Craig, what would you say to that?

Spencer: I do want to say that when it comes to preparedness, if you look at the Global Health Security Index (GHSI) before the pandemic hit, the US was ranked number one in nearly every category. We were expected to be the most prepared. Now look at what's happened a year later with the pandemic. We have the highest number of deaths of anywhere in the world, and the highest number of cases. We've been hit disproportionately hard, and it's disproportionately hit certain populations in our communities that have been marginalized and made vulnerable by a healthcare system that underinvests in those same critical elements that are necessary to respond to a pandemic: primary care, having trust in your local family physician or pediatrician, whomever it may be.

We have prioritized specialists, specialty preparedness, and all these other wonderful things that got us through Ebola. We spent tens of millions of dollars on Ebola treatment centers and places to contain it in the United States. But we didn't do anything in the aftermath to actually address the issues that were most critical — the reasons that people are hesitant to go to providers (eg, they may be less willing to reveal and expose their travel history). Those are the things that we need to more indelibly and permanently invest in, as opposed to assuming that we can just put a bunch of money on top of stuff, meet all the requirements to be number one in the GHSI rankings, and assume that we're going to be better prepared next time, because clearly that is not the case.

Glatter: Syra, what would you say to that?

Madad: Everything that Dr Spencer mentioned, and I'd add that preparing for pandemics and epidemics is an active process. You can't just say, "I'm pandemic ready" or "I'm in a state of readiness and we're good to go." That's a false assumption. These are active processes that we need to continue to work toward.

One thing that I'll mention, just to show the glaring gaps that we have, is when we talk about hospitals. Hospitals unfortunately have always been an afterthought when it comes to preparedness and response, even though they're on the front lines of responding to any type of situation that we're in, whether infectious disease or an all-hazards approach. When we look at investing in funding specifically for hospitals — we have a hospital preparedness program, and we had an all-time high of over $500 million that was invested in it. Over the years, it has taken a substantial number of cuts, and now we're at a little over $200 million. That goes to show you that our problem that we have here in the United States has always been the panic-and-neglect cycles. So, when we have a problem, we throw in so much money for it and try to squander the issue. But then when that problem is gone, all the funding goes away and all that expertise and the resources that we've built over time also begins to dissolve.

A great example is the Regional Ebola and Special Pathogen Treatment Network that we have here in the United States. In 2014, we had millions of dollars that was put into developing this network. Now that we're in the middle of a pandemic, just this past year, that entire infrastructure dissolved. The only things that remain are 10 Centers for Excellence and NETEC (National Emerging Special Pathogens Training and Education Center). We have over 6000 hospitals in the United States, so we need to make sure that we're funding preparedness in a way that is sustainable and is ongoing. That way, we can maintain the state of readiness on an ongoing basis.

Glatter: Right. One of the last points you made in your article is that training and hands-on real-life experience are critical. If you have people that participate in exercises in actual real-life training in situations, then they're better prepared to come back to our country and be the educators and thought leaders, the ones to push the agenda. That's something to me that stood out.

Spencer: Yeah, this is something that I'm incredibly passionate about. I was upset in 2014 and 2015 because in the US we sent very few of our providers, despite having some of the best public health and medical institutions in the world, to respond in West Africa. Compare that to a place like the London School of Hygiene & Tropical Medicine, which sent a big percentage of their faculty to actually do boots-on-the-ground research, get that real-life experience. That was critical in helping them understand what is needed to respond to and prepare for pandemics.

Here in the US, we didn't really have that. Our best institutions made it nearly impossible to send our best providers. And the result was that when COVID came, we had very few people who were capable of understanding what a unit directional flow model would be, for example, or how to actually use personal protective equipment (PPE), why a PPE buddy is so critical — very basic things that you learn on day one in West Africa. We didn't do that, and it wasn't as straightforward here because we didn't have that experience.

When I first went to West Africa and I was trying to put in IV lines on patients... I'm pretty darn good. I work in an emergency room. It's one of my goals to put in a line every shift to make my nurses happy and to keep my own skills up. It took me days in West Africa to do it because I was afraid every single time that I tried. If I missed, if I poked myself, it was 100% fatality. A needle stick with an Ebola patient really gets in your head.

When I went to Bellevue and was being treated for Ebola before I was diagnosed, an ICU nurse who had 22 years of experience tried putting an IV in me. I am very easy to get access in, and she missed twice and the third time hit a nerve. It's not because she wasn't good at it; she could find a line in an orange. It was because she was so afraid and worried.

Without having had that experience — we don't need to mandate it, but I think we need to, in our institutions, make it optional, make it something that we support like many other countries do, and make it so that we can support our providers to respond to outbreaks in other places. Not only does it help end them there, but it also gives providers the experience necessary to help us respond to and prepare for a pandemic at home. That's something that was shortsighted in our response to Ebola in 2014 that we should have done better and really caught flat-footed here.

Glatter: Syra, would you tend to agree?

Madad: Oh, absolutely. Here in the United States, a lot of our providers and frontline clinicians had a very difficult time with extended use and reuse of PPE. In our basic infection-control training, we always talk about one-time use: You wear an N95 mask and after that one time, you go ahead and discard it. When COVID hit and we had significant supply chain issues, everything that we were doing was extended use and reuse because of crisis and contingency capacity, and they were not used to that at all. You saw a lot of cross-contamination. You saw a lot of healthcare workers very uncomfortable trying to figure out when to use this N95 — not just the entire shift, but up to five times. How am I going to store it? How am I going to put it back on? When should I swap it out? What if it becomes wet or contaminated?

So, there was a huge learning curve when it just came to basic infection control. And, as Dr Spencer mentioned, these are things that you learn overseas when you're in these types of environments, and everyone had to learn it from scratch here. That took a lot of time and effort in the beginning, as we were trying to get providers and clinicians and nurses and everybody that was on the front line responding on how to pivot from those infection-control strategies to what we were dealing with, and then to ensure that we were keeping up with the competencies. And it's still a struggle today. I would go as far as to say that it probably resulted in many different infections of healthcare workers because of that cross-contamination. They were not used to wearing that level of PPE for an ongoing basis and then having to do the extended use and reuse. That was a huge disadvantage.

Glatter: That was the stress that I underwent, certainly in the emergency department. That brings us to one of the additional points in your article, that protecting the healthcare workforce should always be a top priority. It's not just the physical safety, as you talked about in your article, but it's psychological and tied to mental health issues. I think all of us experienced some form of this in the past year. Craig, your thoughts?

Spencer: It's almost exactly a year ago that I wrote in The Washington Post an opinion piece that was titled "How Long Will We Doctors Last?" because I was not worried just about the physical impact — obviously, not having enough PPE, which was the case for many providers in many institutions throughout the country, especially early on. That was particularly concerning because we knew that we were having iatrogenic nosocomial infection. We knew that our providers were at risk. But also it was just physically demanding and difficult. I knew that my colleagues would be able to hold up for that. But I knew after having worked in West Africa that it was only a few weeks before the mental anguish really kicked in.

Seeing so many of your patients die while feeling helpless, like there's nothing that you could do — turn them over, try a different medicine. We didn't know what worked early on, and we saw so many people die. I saw more people die in one of my shifts here in New York City than on almost any day that I was working in West Africa from Ebola. So that had a profound mental health impact on our providers.

I'd be remiss if I didn't mention my friend and colleague, Dr Lorna Breen, who nearly a year ago died by suicide after having worked in the emergency department here with us at Columbia. And now, her family and other providers are doing everything they can to highlight the mental health stigma and the burden that we as medical professionals face and really don't have the ability, access, and space to share those issues without fear of retribution and fear of losing our license. On top of this, we had a pandemic thrown in, for which many of us physically responded to, but in terms of mental health impact, weren't necessarily either prepared for or didn't have access to the right resources to help them better prepare.

Glatter: Moving on to the last point I want to discuss is that health experts must be placed at the forefront to educate the public. With misinformation going around and the lack of a unified voice that we certainly saw during this pandemic, this is something that has to change. Syra, how would you respond to that?

Madad: Making sure that we have experts at the forefront when we talk about responding to misinformation — this is not something new. And if you compare it to SARS, MERS, and Ebola in 2014, when you have these types of instances that occur, people want to seek information and they want information right away. We live in an age where you can go on Google and find anything that you're looking for, and if you can't find it from an expert, you'll find it somewhere else. When we look at outbreak response, crisis communication or risk communication is so important.

We did a terrible job in the beginning of this pandemic of giving individuals the right information based on science and public health. This is a cornerstone of outbreak response: making sure that you're providing information that is transparent and honest, giving people the information that you know and that they can tailor to themselves and make behavioral changes, if that's what the request is. We're seeing right now in this COVID-19 pandemic, for example, that countries that have had a more successful communication strategy have had generally a better outcome in terms of cases and mortality. We definitely want to speak to that one-voice approach.

One thing I'll quickly add to what Dr Spencer mentioned on the mental health aspect. In New York City (being the first epicenter), one of the things that has launched is the COVID-19 "battle buddy," seeing that healthcare providers were not only responding to the pandemic and the contagion but also looking at the mental health aspect and looking at it from a military standpoint. Because early on in this pandemic, there was a lot of military support that was provided to healthcare systems. So, taking down that mental model that they had and providing a COVID-19 battle buddy has been so important. I really hope that other healthcare systems can replicate something like that because it's really shedding light on this silent epidemic that we're seeing today.

Glatter: I want to thank you both. This has been quite informative, and your article really came at a time when we're looking back at the pandemic and trying to understand more, and it truly helps everyone. I want to thank you both again for a very insightful effort.

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