Have our best hospitals and universities learned their lesson? | by Craig Spencer MD MPH | June 2021

Academic medical centers in the United States haven’t done enough to tackle Ebola in West Africa – it cost us when Covid hit.

photo by Andrei Metelev at Unsplash

I only vaguely remember the frantic activity as they rushed me from the ambulance to the isolation room. But I vividly remember the nurse trying to start an IV line in my left arm. I watched as she missed three times, hitting a chord on her last attempt.

I later learned that the nurse had worked in the intensivee care unit for over 20 years. And she was part of the team that, a few hours before I arrived, organized an exercise simulating the care of a mock Ebola patient. In all respects she was the most qualified person to start my IV. Yet she failed several times.

She learned – just as I had done a few weeks earlier – that exercise and practice only gets you up to a point in the face of a fatal infectious disease in real life.

During the Covid-19 pandemic, academic medical centers (hospitals affiliated with schools of medicine and public health) played a vital role in the United States, but they were also woefully ill-prepared for it.

Some of the reasons were obvious: a shortage of protective equipment, chronic underfunding of public health, and the “corporatization” of medicine. But as I noted recently in the Lancet, the failure to implement lessons learned from previous epidemics, in particular the Ebola outbreak in West Africa from 2014 to 2016, also contributed to our imperfect response to the pandemic.

In 2014, when Ebola hit West Africa, many international organizations joined in the fight to end the epidemic. They provided expertise from previous outbreaks, medical supplies and financial assistance. But one of the lingering shortages was in health care providers to manage Ebola patients in the newly built treatment centers.

This is in part because in the places hardest hit by Ebola – Guinea, Liberia and Sierra Leone – there were fewer doctors in those three countries combined than in the one hospital where I was treated for. Ebola in New York.

Despite being keenly aware of the need for more healthcare providers, America’s academic medical centers – including some of the world’s best hospitals and medical schools – were reluctant to allow their faculty and staff to work first. line against Ebola. A lot not allowed completely.

Others created a Byzantine approval process – getting approval from department heads, requesting an exemption from the dean’s or chancellor’s office, and providing an evacuation plan separate from the university’s evacuation provider. Completion of this process was not a guarantee of approval. AT Harvard, an exemption was only considered “in exceptional circumstances” and only when it was deemed “absolutely necessary”. In Columbia (where I work), the university forced a colleague to temporarily resign before starting a managerial position in West Africa. Another quit her hospital job after failing to get formal approval.

The reasons for the bans were numerous: first and foremost, legal considerations. What would a university do if one of its providers were infected during an intervention abroad (an unlikely scenario, but as my personal experience shows, not impossible)? Could they somehow be held accountable?

Hospitals were also concerned that patients would stay away if their providers were recently in West Africa, fearing potential exposure. One hospital reported that patients had canceled heart catheterizations when it was revealed that a hospital staff member had recently traveled to Africa, albeit thousands of miles from the outbreak.

All of this is not to say that academic medical centers were completely absent from the Ebola response. Many offered advice on how to contain the outbreak, helped design research studies, and pointed out how the global community was not doing enough to end the outbreak.

And some have deployed frontline providers. But most did not. And the number sent by US academic medical centers across the board to bolster the response in West Africa was extremely small.

One could argue that it is not the role of academic medical centers to contribute to this response on the ground, especially since government agencies like the CDC are almost always deployed. That’s right: CDC’s disease detectives help countries prepare for and respond to infectious diseases. But throughout the pandemic, we’ve seen how funding shortages and political trends can limit the reach of these organizations when they are needed most. And CDC staff rarely provide direct patient care.

During the Ebola outbreak, academic medical centers had obvious financial and legal reasons for preventing their staff from intervening in West Africa. This is exactly why the “who’s who” of our major medical institutions had relatively few faculty members contributing to patient care in West Africa. On its surface, the calculation was obvious.

That is, until Covid hits.

When patients with difficult breathing flooded into our emergency rooms, we had relatively few providers who had ever served on the front lines of a frightening epidemic. Few have really had to depend on PPE for their lives; few people knew the importance of having a PPE partner to ensure that their mask was put on correctly and that there were no holes in their glasses; few who have experienced firsthand how physical exhaustion on the front lines slowly turns into mental trauma, which many of our medical providers have experienced during the Covid pandemic.

By preventing our providers from responding in West Africa, hospitals in the United States have confronted Covid with relatively few combat-experienced doctors or nurses. Of course, we see and do difficult things every day, including managing other infectious diseases. But drilling and preparation can only get you so far – it’s on the ground that you really learn. The nurse who tried to start my IV could definitely attest to that. And she’s not alone – I’ve been through the same thing myself.

I worked in the emergency room for over 13 years and put an IV line on every shift. I’ve done this a thousand times and almost always got it right the first time. But in my early days of treating Ebola patients in Guinea, I failed every time I tried to put on an infusion. I blamed the double gloves, the intense heat and the hazy goggles we wore to protect ourselves.

But, in fact, a frightening fear was actually to blame. I knew that if I accidentally pricked myself with a needle used to start an IV on an Ebola patient, I would almost certainly die. It took a dozen attempts to do something that I had considered to be part of my expertise.

When Covid hit, I was much better prepared than most of my healthcare colleagues because of the experience. I was the only one in my department to have treated patients in West Africa. In fact, I’m one of the only (maybe, the only) in my hospital that did.

Of course, not everyone wants to react to frightening epidemics – my own story of Ebola infection is reason enough for anyone to refuse. But there are many who do, and our academic medical institutions have historically made it too difficult.

If we are to be better prepared for future pandemics, our academic medical centers must act in accordance with their mission statements, many of which express the importance of world service. We need to make volunteer service an expectation, not an exception, especially in epidemics where we can provide a much needed helping hand. Not doing this is not only selfish, it is also self-destructive.

There are a lot of lessons we will learn from Covid. But there were many lessons from previous outbreaks that we should have implemented before the pandemic struck. Failure to do so was immediately obvious to anyone who saw Covid walk through our doors.

As Covid draws to a close in the United States, a flurry of white papers, journal articles and upcoming conferences will outline how we are better preparing for the next pandemic. I hope that university medical centers do not neglect the essential role they must play. They have done it once before, and it has cost us dearly.

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