HeaderTriumphofDeathBreughel1562

Uncharted territory for a system in overshoot

By Mary Odum

http-:www.flu.gov:planning-preparedness:community:community_mitigation.pdf-fig3a
http-:www.flu.gov:planning-preparedness:community:community_mitigation.pdf 1918 pandemic CFR = <3%. Where would Ebola’s CFR line be on this graph?

We are in uncharted territory with the Ebola virus disease (EVD). The last time we had a plague that was this deadly was the Black Death in the 14th century, when there were only 450 million people in the world. That pandemic killed 30% to 70% of the population. There is no benchmark for EVD, which kills 3 out of 4 people it touches, and is emerging into a global population of 7 billion.

Ulgiati et al., 2011, Emergy-based complexity measures in natural and social systems - Emergy flows plateau in modern Rome as an example of a high-transformity system
(Ulgiati, Ascione, Zucaro & Campanella, 2011, Fig. 1) Emergy-based complexity measures in natural and social systems – Emergy flows plateau in modern Rome as an example of a high-transformity system

This pandemic signifies a turning point for society in response to peak oil, highlighting the problem of globalization for a planet of 7 billion people. We have lost control of a deadly outbreak, and our responses to its exponential growth are linear at best, ensuring that this plague will most likely spread further. Many in first world countries think we are immune to plagues. How might transmission of EVD change as it moves from a low-resource or low-transformity setting in West Africa to resource-rich (high-transformity) countries?  How might the battle against this epidemic change as it breaks out into different environments?

World views in transition

Media pundits have labeled recent world events with the words “perfect storm.” The use of this term suggests a rare and unusual event that comes once in a lifetime. But the term also suggests that our world view is incomplete. First world views of society are dependent on the preservation of infinite growth.  When we lack the world view to explain a new phenomenon, especially when denial is a reason, our brains may assemble responses that displace our fears, or blame the situation on powerful control from the top, and not a global system in transition during descent. We lack the systems view to explain predicted outcomes of descent. But crises not only sharpen one’s focus; crises also restructure dysfunctional paradigms.

Margaret Bourke-White, Louisville, KY, USA, 1937
Margaret Bourke-White, Louisville, KY, USA, 1937

Public health has gotten a free ride in the fossil fuel era, as everyone’s socioeconomic status, including sanitation, clean water, and healthy, safe food improved. That process of rising socioeconomic status during the last 200 years occurred because of fossil fuels, but because fossil fuels have been ubiquitous, we did not see it. Rosling’s video from Gapminder on 200 Years That Changed the World identifies the trend, but misses the cause. His plots could be better expressed by plotting life expectancy against global per capita fossil fuel use. Our first world exceptionalism is a function of fossil fuels and the hierarchy of complexity and not some special character trait.

In energy descent, the energy basis for our public health basis will decline. Maintaining public health in local communities will need more effort and resources, especially in response to disasters from the larger scale. But Americans in particular will no longer have the resources to act as the world’s healthcare provider or police officer. The world’s population growth has created a situation where top-down control during a crisis is not possible.

High resource versus low resource systems

The epidemiological triangle consists of host, agent, and environment. The future of this epidemic will be dependent on the different environments that it travels to, as well as host factors in different countries, and agent factors as the virus mutates. EVD has only affected low resource healthcare systems historically. What might be different in a high-resource (high-transformity) system which might make combatting this disease easier or harder?

epitriangle
The epidemiological triangle

Pandemic factors related to the agent, the virus, include the relative infectivity, in terms of the R0 (R-zero or R-nought) and Case Fatality Rate (CFR). The R0 of this disease is relatively high for a disease that is not considered very contagious, estimated at between 1.4 and 2.0, which is higher than seasonal flu, for which there is some population immunity. The CFR is somewhere between 70 to 80%, which is twenty-fold greater than the death rate of flu. Though epidemiologists claim that this disease is not very infectious, we have my heroes and heroines, Médecins Sans Frontières (MSF) walking around in cobbled-together moonsuits with no exposed skin, but who are still getting infected, either in hospital settings directly, or indirectly through the community.  One apparent gap is treating unsuspected Ebola patients with universal precautions, when heightened droplet precautions with visors and N-95 or N-100 masks are really what is required, especially during procedures where aerosols occur.

Host and environmental  factors that might speed transmission in first world countries are related to a high-transformity system that loses control. High mobility is one of the biggest cultural factors of a high-transformity system. A high-transformity system could potentially create a larger R0, since there is a larger ecological footprint, with highly mobile imports and exports, reliance on services, and a 3-day shelf-life for goods. Americans have to shop to survive, and economic growth is our main imperative.  We must work to keep our economy and wall street humming–shutting down the economy is unthinkable to most.

Host and environmental factors in first world countries that might slow transmission include less density in housing such as nuclear families, better public health, sanitation, water, and nutrition, more healthcare providers, and better handwashing. The case for handwashing as protection in first world countries is arguable—we have the means, but do we do it?

http://instructor.mstc.edu/instructor/csebasti/images/ChainOfInfection.jpg
http://instructor.mstc.edu/instructor/csebasti/images/ChainOfInfection.jpg

Our high-transformity healthcare system is probably the biggest problem with community/hospital preparedness. The two imported EVD patients at Emory Hospital reportedly created 40 bags of medical waste per day. Logistics of caring for patients with a deadly illness would snarl routine care in unimaginable ways–probably one reason sick healthcare providers are returning to different flagship hospitals experienced in infection control, for trial runs with the process. The chain of infection involves six different steps which all need to be attended to, and in a high transformity environment, those issues expand. Perencevich illustrates this problem when he discusses PPE, saying “over-protection does not equal protection,” which also applies overall, to the relative protection of high resource availability. In an era of a shrinking emergy basis, especially in complex hierarchies such as hospitals or cities, a sudden pulse of disorder from the larger scale such as a pandemic may create just as much chaos, if not more, as it does in a low-resource system. Over-protection in one corner of the system does not make us safe from gaps in the chain of infection in other segments of the situation where less control exists. Even if we are assiduous in hospital settings, once EVD lands by air and gains a foothold, transmission might occur in other concentrated community settings where infections spread, such as cities, schools, prisons, and military operations. We are in uncharted territory here, and how this plague unfolds in other countries remains to be seen.

(Ulgiati, Ascione, Zucaro & Campanella, 2011, Fig. 2) Emergy-based complexity measures in natural and social systems
(Ulgiati, Ascione, Zucaro & Campanella, 2011, Fig. 2) Emergy-based complexity measures in natural and social systems – a heavy reliance on developed and technological sources of Emergy . . . “a high source diversity ratio in technological systems, although providing a comparative advantage, cannot last forever, and is therefore only a warranty of temporary higher resilience thanks to the higher complexity achieved. This is why societies should plan ahead in order to be ready to replace the sources that become no longer available or to quickly shift to a different internal organization that better fits the new source options that become available.”

In a low-resource system, waste is minimal, with infectious mattresses as one of the most complicated waste disposal problems. Contrast the 40 bags of waste per patient day in a hospital in Atlanta with the low-resource system for personal protection devised by Fatu Kekula, a nursing student of Liberia who made her own PPE with trash bags and kept her family alive. Kenyan and Malian hospital workers have made their own local alcohol handrubs from sugar cane. In a low-resource system, adaptation to a disordering pulse may be easier as people are more likely to be inventive, independent generalists, not as psychologically or physically reliant on a highly specialized hierarchy of goods and services. Frieden illustrates the problem of waste, suggesting that even in a low-resource setting,

“to pick up one body you might need nine full changes of PPE [personal protective equipment]. Four for the people to put the corpse onto the truck. One for the person to spray them down so they don’t get infected. And then again four to take them off the truck” (Frieden, Sept. 29, 2014).

In a high resource setting, how many more changes of disposable PPE would be required in order to comply with standards and maintain safety for this one task alone, for the multiple specialties involved? And many high-transformity systems are automated. What additional disinfection requirements would be needed with those, and how much equipment would simply have to be discarded (and where)? EVD in a high-transformity setting quickly slides down a rabbit hole of receding compliance and expanding demands on resources. High-transformity healthcare systems will need to adopt lower-transformity methods such as reusable or resterilizable equipment fairly quickly in order to keep up with this epidemic over the longer term.

TravelDelayModel
http://www.mobs-lab.org/ebola.html In a model run by the Mobs lab, the US had similar risk of introduction as Nigeria, based on the assumption of flights creating relatively virtual neighbors, depending on your connections.

EVD introduction to the US is probably more likely by plane than by boat, as a boat allows time for the disease to emerge. A recent model suggested that an 80% reduction in air travel would slow the introduction of EVD to the US, but not stop it. We won’t reduce air travel by 80%

overall_country_invasion_prob_by_2014-09-01_and_2014-09-22_based_on_2014-08-21-seats_and_orig-dest-vert-NEW_v2-600x509
http://www.mobs-lab.org/ebola.html Because it’s bad for business, and we can’t reduce air travel by 100%, because we live in a society with a 3-day shelf life—shutting down any sort of commerce is inconceivable.

because it’s bad for business, and we can’t reduce air travel by 100%, because we live in a society with a 3-day shelf life—shutting down any sort of commerce is inconceivable to most, and is also political suicide. In another run of the same model, the US had similar risk of introduction as Nigeria, most likely based on the assumption of direct flights creating virtual neighbors. The volume of infection in other countries eventually makes its way everywhere, through the wonders of modern air travel. The Black Death took 8 years to spread to Europe through eastern trade routes–camels are slower than airplanes. I am getting a good geography lesson as I watch the news and see suspected EVD patients popping up in obscure parts of the world.

Host and environmental factors that impact fitness include genetic, cultural, systemic, and behavioral factors. Genetic fitness of the population is enhanced when there is less medical rescue, and less high-tech medicine resulting in patient sub-populations with immunosuppression or other genetic vulnerabilities. There is also the issue of increased background radiation as the result of various nuclear accidents. The radiation background in many countries has increased in the last 65 years, especially post-Fukushima.

Think globally, act locally?

afludiary.blogspot.caCrises delineate the problems, focus the issues, and crystallize intent. What is the solution to deadly, global pandemics either now or in the future? Is the answer global health teams to rescue impoverished societies, more high-tech healthcare for everyone, or high-tech vaccines for every mutating strain of virus and new antibiotics for bacterial infections? No—we cannot continue with more growth and high-transformity globalization of society in the face of waning oil production, not in a world of 7 billion, especially when a deadly plague is spread globally for lack of vinyl gloves. A call for high-tech PPE to cool or monitor healthcare providers illustrates this conundrum. When privileged westerners have air-conditioned PPEs and computerized heart rate monitors, or are evacuated to safety when they fall ill, but the community cares for victims without gloves, the inequities continue to accumulate in the war against a plague. We must act locally to strengthen basic systems of public health as the world contracts.

PieterBruegeltheElder1563TheTowerof_Babel
Pieter Bruegel the Elder, 1563, The Tower of Babel. In this painting, Bruegel depicted the transformation of nature into an urban hierarchy through the hubris of man, which was then destroyed by God. Breugel modeled the tower in the painting on the Rome Coliseum.

A thermodynamic principle explains the quandary—a proposed 5th thermodynamic law of Transformity states that “You shorten the cumulative length of the game the more you steal.” We  build hierarchies of complexity if there is surplus energy available. Those hierarchies of complexity include high-transformity items like computerized heart rate monitors for Americans’ PPE. By doing so, however, and contributing to increasing inequities, we shorten the length of the game by exposing the hierarchy to instabilities such as plagues. Are urban centers, which were created by surplus fossil fuels, more dangerous in plagues, especially in descent?

TR Frieden April 2010, 100 (4) AJPH Genetics is at the top of the pyramid, while environmental medicine is at the bottom.
TR Frieden April 2010, 100 (4) AJPH Genetics is at the top of the pyramid, while environmental medicine is at the bottom.

Political leaders are already talking about global health teams, more funding for vaccine research, and what we will do when the next pandemic hits. Or people worry about eating imported bushmeat, when they only have to look as far as the next Delta flight for the source of contagion. This rush to speak about Ebola in the past tense is a leap in thinking past the crisis at hand, which seems to be a form of denial and displacement anxiety. Americans similarly protect their psyches when they focus farsightedly on climate change as our biggest threat. We deny and displace our broader worries about society today with competing narratives of safe threat that could occur in the relatively distant future.  Prevention in the form of contact tracing, surveillance, and local quarantine appears to be the way to combat this disease, but surveillance only works if we can move past denial and irrational or panicky behavior. If an outbreak isn’t prevented locally, it could get out of hand quickly. Where is the United States’ awareness campaign, for example? Our media and leadership actions so far don’t suggest that a candid, direct public health perspective is in the forefront. Our actions instead are focused on stirring up war.

With waning fossil fuels, the answers to resilience in general lie in relocalization and simplification. We need to ask ourselves, “Does my action further new relocalized society or does it further the old growth regime? Does my action work to improve socioeconomic status at the bottom of the pyramid, or serve to make inequities worse through a taller pyramid?” Actions now during a time of social destabilization could be particularly effective.

In addition to basic personal preps, including gloves, masks, and bleach, my global action is to give to MSF, as I cannot bear to see caregivers without gloves. But mostly my actions will go towards volunteering at the local community level to strengthen local community preparedness, since I believe in relocalization. I signed up for the American Red Cross this week, in response to a comment by Sally Sellers, RN, in an earlier post.

“I’m currently working on my MSN and conducted a field community preparedness project this past summer in response to climate change threats. What an eye opener! I became a Red Cross volunteer to get a first hand look at Orlando’s preparedness . . . it is a total illusion. A wing and prayer is what we’ve got. Here we are a metro-city of more than a million strong and 4 . . . count them four…nurse volunteers for the health services for central Florida. Since my project the Red Cross has actually cut back and reduced paid staff state wide due to lack of funding. This might not be so bad but the surrounding counties have cut their employees who would serve as shelter operators and have instituted plans to rely on the Red Cross volunteers! One county even cut its #311 county wide emergency call system for lack of funds.”

The answer lies in a smaller society, with simpler, basic healthcare for everyone—less healthcare, but we can hope that everybody gets some, resulting in healthier communities and society. Nature will take care of the smaller society, as wars beget famine and pestilence which beget wars.

All recent posts on Ebola can be found using the category pull-down menu at upper left, or at this link
Didier Pittet, an expert on handwashing, at TedX, on the multi-cultural complexity of changing handwashing behaviors, which requires a “multimodal behavior change strategy. . . . One must dare to disagree. . . Clean hands save lives.”

Header Art: Triumph of Death, Peter Breugel the Elder, 1562. Interestingly, Breugel painted the Tower of Babel a year before he painted Triumph of Death.

  • Holger Hieronimi

    Thank you very much for this interesting (& a bit scaring) series of posts on the Ebola outbreak – interesting the little media atention this crucial topic gets – saludos nuevamente desde México

    • ¡what an interesting time to be alive! I agree, Holger, as long as it doesn’t kill you first. Thus the series. Plus, a crisis reveals the big holes in the system and illustrates the principles. You’re welcome to translate anything you want and pass it on.

      Yes, Mr. Fox–there’s a lot to do.

  • cognizantfox

    I feel vulnerable in Fairbanks though most folks couldn’t imagine why. I have much to do.

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  • Sally Sellers RN

    Its here folks! First Dx case in USA…..Dallas…….all the way from West Africa.
    God help us!
    Sally RN

    • Yes, and apparently the patient shopped EDs in Dallas, too, getting turned away from one, then going home for a couple of days and resurfacing later at another. Not good. No insurance, I imagine. We should’ve bought that universal healthcare plan.

  • Asimov and the “Freedom of the bathroom” metaphor, from a 1988 Bill Moyers interview (2 minutes). The issues of democracy and free movement tangle with quarantine and medical martial law somewhere in our near future, more uncharted territory, with no way out.

    http://afludiary.blogspot.com/2014/10/why-airport-screening-cant-stop-mers.html

  • Sally Sellers RN

    My toes curled when I saw an airport official in Liberia taking temps of folks in cars approaching the airport…..one after another with no barrier or cleansing in between people……..OMG! fomites anyone! Surfaces anyone? Germ theory has been around for many many many years yet we haven’t thought one about using the same unprotected thermometer on multiple people? We haven’t the basics down! And like this is the first person who has or will get off a plane out of West Africa. The CDC granted doesn’t want panic and fear….but the facts need to be put out on how to mitigate infection and soon. Wash your hands! Sally RN

  • Back to the basics, Sally. Here’s a TedMed video on how Cuba trains physicians for a sustainable system. We no longer can afford cadillac healthcare for some, with no healthcare for others. It’s past time for us to change the system–crisis brings opportunity and opens a dialogue.

    http://www.ted.com/talks/gail_reed_where_to_train_the_world_s_doctors_cuba

    • Sally Sellers RN

      Great TedMEd talk! Sounds like they are training Nurses!! not USA docs!

  • Sally Sellers RN

    just listened to the Texas brigade … I don’t know what was more reassuring, Gov Perry’s smart glasses or the hospital VP trembling like a school girl going to cry after pigtails dipped in ink! This only outdone by the “Doing a hellava job Brownie” frat boy who heads up the Texas Dept of Health….ooops….yes the nurse did ask and the pt did tell….but that info was not shared with DX team. I guess all that stimulus $ given to the hospital and docs to adopt meaningful use EHR (electronic health records) hasn’t paid off just yet….allowing a seriously ill Ebola pt to re-enter a US metropolitan city. My mind is doing the math….the patient in family car….the kids in family car….the patient on the couch….the family on the couch….pt in ER …..patients and healthcare in ER….the ambulance parked 2 days after contamination. I once heard a doc tell an infected patient complaining “Why me?” answer bluntly, “Bugs want to live too.” And that’s what we’ve got…..bugs or in this case viruses want to live too. Along with the virus attacking the neurological system of pt in Boston and elsewhere. We can only hand over our power and currency for so long until our defenses are low enough to be knocked out ….. I guess the party line is we have to work smarter?

    • LOL. The triage nurse was probably too busy trying to fill in the blanks on the EHR, and there was no check box yet for “recent travel to Africa.” Don’t get me started on the EHR and how that complicates matters.

      And the school kids, who an ER doc friend once said, are the “germiest things on the planet.” How many contacts would have to be traced (and to where!) if the patient had been symptomatic and infectious on his [three?] flights?! You do the math.

    • Do NOT get me started, Sally. From tonight’s twitter feed @WTKR.com:

      “(CNN) — The Texas hospital treating the first person diagnosed with Ebola on American soil says a “flaw” in its electronic health records prevented doctors from seeing the patient’s travel history. Patient Thomas Eric Duncan told the nurse he’d been in Africa, but that information was entered into a document that isn’t automatically visible to physicians, Texas Health Presbyterian Hospital Dallas said in a statement Thursday. After discovering this, the hospital says it has changed the system so doctors and nurses will see travel history documentation. “We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola,” the hospital said.”

      • Sally Sellers RN

        Its like watching a train wreck in slow motion! The inhumanity of locking up exposure victims with infectious materials and not even knowing it until Anderson Cooper from CNN talks to the partner under Marshall law?! WTH! People with no food/supplies/bedding/toilet paper! I mean really…..First World Fears on display here. We are watching the play book being written in real time…..the law enforcement going into the apt now under paid leave from the force for monitoring. The kids showing up in school as late as Thursday….and watching the school “disinfection” team dressed in white jump suits with the sleeves pulled up to elbows singing a dirty rag around as they dance down the hall for the TV crew…..oh Jesus! How many ways has infection control been broken? Truth is we can not rely on anyone but ourselves to prevent infection…..this is the new normal. Just hear a case of questionable Ebola admitted into DC area hospital.
        As long as I’m ranting…..what the hell are “their” plans to dispose of the corpse? Can’t figure out how to dispose of the sheets…..they need to wake up to today….what’s the plan for the dead?
        Yes….agree with your EHR assessment……I did a project to assess/recommend/deploy EHR into a fiction community hospital …..omg! The reports out there in the literature about how patients’ lives/professionals/millions of $ are flushed bc EHRs are so full of bugs/flaws. Take about building a plane while we fly it! Hospitals have actually go bust bc of the $ lost and inability to bill (again thank God we have a healthcare system for profit!!!) bc the EHR system doesn’t link to acct’ing. Its a mess.
        We are watching the sky fall! Wish I could say differently….but this first “test” case through the hatch has proven just where our values have been……..certainly not on preparedness/public health/safety/poverty/racism/….just name it. Our values have been on moving $ to the 1%. We will soon learning of the next case in this outbreak…..just about time for the virus to show itself. My spouse says we need to tell it like it is….Ebola turns people into virus spreading machines. But talking heads just keep talking in confusing circles….understandable no sense in spreading panic….or god forbid education to help folks protect themselves! Breathing…Sally RN

        • Yep high transformity healthcare–specialization, automation, extra layers of bureaucracy and doing extra things that don’t really need to be done, high mobility, inequity that makes people flee to somewhere safer or better economically–all will contribute to spread. Rumor has it some dudes in street clothes were power-washing the vomit off the street in Dallas! This is just not going to work.

        • will, mdjd

          Yes, what about the transport and disposal of hazardous bodies?

          • All kinds of people are professing on the MSM about what is safe and what isn’t, with very inaccurate ideas about transmission, and nothing but hope that this won’t spread. EHR won’t last, Sally. This is a gamechanger for that too, perhaps, as the crisis forces big changes that EHR can’t keep up with.

            The MSF had to bring in a livestock incinerator from Europe. We will have to incinerate massive quantities of hazardous waste, too.

            What happens, Will, to ED care with the massive influx of people, many without insurance? Even without Ebola, the worried well who have the flu will overload the system fairly quickly? We just can’t handle it.

            http://www.sott.net/article/286289-Livestock-incinerator-imported-from-Europe-to-cremate-corpses-from-Ebola-plague-I-ve-never-seen-this-amount-of-bodies-before

          • will, mdjd

            Yes, it’ll be almost like a Hajj, but a pilgrimage to the lower class medical care Mecca, the ER, where the price of admission is symptomaticity and the wages of the pilgrimage may be catching something or losing your job. Who will go? And for how long? Where will they sit? What will they touch? How will they decontaminate after the visit?

            And yes, the quarantine. Who will be quarantined? Who will avoid it? Many will hide their symptoms, thinking that they can’t afford not to work, that they could be fired if they’re quarantined, that they could catch it in the ER, that they hate the way they’re treated there, that if it’s Ebola they’re dead anyway. Tell them that’s all not so, and they’ll believe you?

      • will, mdjd

        Most have ignored this, but you rightly point out, Mary, that the treatment was inappropriate even for the condition that was (actually, but incorrectly) diagnosed. I suspect this is an indicator of how bad routine ER care may be. If you have to go to the ER and your primary care doc doesn’t pave the way for you, might the ER presume you’re one of the underclass and give you underclass-appropriate care?

  • Here is the whole series on Ebola from this blog–also found from the pull-down menu of categories at upper left.

    http://prosperouswaydown.com/category/subtopics/healthcare-subsystems/ebola-healthcare-subsystems/

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  • TH53
    • A long history of research abuses with indigenous peoples and impoverished in other countries makes WHO jumpy, and there is no solid evidence for colloidal silver as an antibacterial, much less as an antiviral. And nano anything could be dangerous.

  • will, mdjd

    Great post, Mary! I’d thought the public health system was better than this, but I’m probably thinking of what it was like before all those austerity (for the 99%, that is) cutbacks and the progressive chasm between two tiers of medical care. Add to that the doctors’ arrogance (see, e.g., a Lennox Hill (NY) ER physician, as reported by Bloomberg, spouted off about Ebola risks he clearly didn’t understand): “The virus is only spread by direct contact with bodily secretions, which requires prolonged and close contact,” Robert Glatter, an emergency physician at Lenox Hill Hospital in New York, said in a telephone interview. “Unless there is a break in the skin or some open cut it’s very unlikely to transmit. The virus doesn’t live for long periods on a plain surface, such as a bathroom or counter top.” http://www.bloomberg.com/news/2014-10-02/dallas-parents-worried-over-ebola-exposure-at-schools.html.

    It’d be a comedy of errors if it weren’t a tragedy: “Dallas Hospital Alters Account, Raising Questions on Ebola Case”: http://www.nytimes.com/2014/10/04/us/containing-ebola-cdc-troops-west-africa.html.

    But the real problem is that even those of us who think we understand much more than appears anywhere in the mainstream media don’t know how to make a meaningful difference. I’m very grateful to Mary for her prescient writings, but I worry that in the end what we write isn’t preaching to a crowd of five or six people. Can we make it any different than that? Sure, we can volunteer and do our little bit, but, since almost no one is listening to what we know or say, isn’t it like, to use Bolivar’s metaphor, like plowing the seas?

  • will, mdjd

    Another limitation in control: we’ve been told over and over that this disease won’t transmit until the person has symptoms. Nevertheless, the CDC website says that they can’t detect viral markers (by a RT-PCR (real-time polymerase chain reaction) test) until the person has been symptomatic for three days (the window is apparently 3-10 days, after which time immunity may have suppressed the virus enough to make it undetectable). If cases in the U.S. become other than rare, that means almost everyone with a non-respiratory fever may not be diagnosable but have Ebola and be contagious. Will we quarantine all of those?

    • Yep, exactly, Will. Down the rabbit hole we go, and at the start of flu season, too.

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  • Sally Sellers RN

    10.12.14 Very troubling that CDC officials and Vanderbilt epidemiologist are stating that there was a breach of protocol that resulted in the infection of a Texas nurse. Very troubling. All nurses know that on a unit we have a dirty and clean room…..dirty for contaminated/dirty equipment/trash/linens/etc…. clean for clean supplies/equip/etc. and that the 2 are not to meet directly. Patient’s rooms/bathrooms/nurse’s stations etc are assumed to be dirty. BUT when it comes to an isolation room, whether it has negative pressure or not, there is only one ante room where both the dawning of clean PPE and disrobing of contaminated PPE is performed….where there is a linen cart for dirty PPE, where there is a trash can for contaminated supplies/PPEs. What the heck are the chances that a nurse takes off her PPE correctly inside-out and disposes correctly…..but the ante room IS dirty as it is in contact with infectious material? Awaiting the well trained nurse to touch contaminated surfaces/etc in the ante room….awaiting the next healthcare worker who has yet to dawn PPE to touch contaminated surfaces/etc?
    There needs to be a system’s analysis done on everything before we start blaming the victim….ummmm “worker” as she was referred to by an official….thus devaluing her status and therefore devaluing the risk to us…right?!
    Ebola is taking out “healthcare workers” …..there is a reason why….and it won’t be discovered while busy CYA blaming the victim is tolerated.
    Sally RN

    • Exactly what I was thinking, Sally. Frieden has ticked me off–he should know better. He sounded panicky-he knows we’re not prepared in any way, shape or form for this. If the MSM takes this approach, the nurses are just going to say “I quit” like the nurses in Madrid. The optics on a bunch of wealthy white men who have never seen a disposable gown telling the nurses what to do and where they went wrong when their voices have been systematically muzzled is really, really bad. I’m inspired to write another post . . . .

      • Sally Sellers RN

        Great…..write that post! Address the fact that nurses are essentially all colonized with MRSA in our nares….that I brought home C-diff on my shoes and infected my dog repeatedly almost killing him….that I seroconverted from negative to positive for TB my very first year in nursing school….that a positive TB healthcare worker potentially contaminated hundreds of newborns in a Texas hospital just recently because we are only screened annually…..that the hospitals are where the bugs are. Willie Sutton, the famous bank robber, when asked why he robbed banks responded, “Because that’s where the money is!”. Well our hospitals are infectious agents because that’s where the money is! As you know, here in Florida our governor was CEO over Columbia Health….biggest Medicare fraud case to date. Give that thief a governorship over the state with the largest Medicare population.

        I’m watching the rich white guys parade TV camera crews through the hospitals passed everything from linen carts to nurse’s stations to the “isolation room” with paper posters hanging from the walls to ask patients are they pregnant! Not so long ago we had TB hospitals…sanitariums to care for infectious folks. I wouldn’t want to challenge the establishment, the healthcare stock market, the 1% or insurance industry…..but as a nurse I think we need to raise our collective voice loud and clear! Hospitals are notorious for nosocomial infections and “errors” caused by lumbering, poorly designed systems and spaces and filled with underpaid, overworked and understaffed staff. If the public only knew….I doubt seriously that they would be going in for elective surgery! Or taking that new designer “irritable bladder” or “erectile dysfunction” or “ADHD” or or or pill!
        I’m working on my MSN now….getting ready to teach nursing. And I’m wondering about the college/university liabilities with placing students in clinicals where they may be exposed to communicable disease. Never occurred to me back as a youngster in the 80’s when I was exposed to TB…..but on my more experienced/mature mind now! This is really going to cascade throughout our whole unsustainable system…..I believe its only a matter of time.
        Speaking of time…..very suspicious to me that other Duncan contacts haven’t displayed S/S yet? Yet….Frieden is able to state clearly that there was a breach in protocol…..ummmmm.
        Look forward to your post! And would love to collaborate with you on my nursing research project….the reasons for the nursing shortage and nurse faculty shortage. I start tackling it in earnest next spring.
        Sally RN

        • I seroconverted too, during a stretch of low vitamin D and too much work in Alaska. On that, we only had two negative pressure rooms in our CCU, so that could also have been an issue. Yes, it’s a rabbit hole. You look at the cleanup of that apartment in Dallas–dangerous because of inexperienced workers, and $100,000 bill. It took 15 people a weekend and 140 drums of waste were produced. They were cutting the mattresses up into pieces. That’s not sustainable–if this gets legs they’ll have to start just burning buildings.

          http://www.khou.com/story/news/health/2014/10/09/inside-the-dallas-ebola-cleanup-an-eerie-experience/16962277/

          When I first read the news this morning, my first guess was the nurses who were exposed in the first go round in the ED.

          You will be very valuable with your degree. My PhD was a systems model of the nursing workforce–or lack thereof. Email me at info at prosperouswaydown dot com

      • Sally Sellers RN

        Join the National RN Conference Call on Ebola Preparedness

        Wednesday October 15:
        12:00 Noon PST, 3 PM EST, 2 PM CST
        Register for the Webcast: https://www.webcaster4.com/Webcast/Page/731/6167

        For those that are unable to listen through their computer please dial in from your phone, then enter Participant Code 26306511#

        US and Canadian phone number: 1-877-384-4190

        International phone number: 1-857-244-7412

        Please RSVP Now for the Call and to Submit Your Questions: http://nationalnursesunited.org/page/s/nnu-ebola-conference-call-rsvp

        What is your hospital doing – or not doing – to prepare for Ebola?
        Do you believe patients, nurses, healthcare workers and communities are safe?

        “If there are protocols in place, the nurses are not hearing of them and the nurses are the first to be exposed”
        — RoseAnn DeMoro, executive director, National Nurses United

        “It is Ebola today, but other infectious diseases are not far away. All hospitals need to take steps now to protect patients, frontline caregivers, and public safety”
        — Bonnie Castillo, RN, director, NNU’s disaster relief program, Registered Nurse Response Network

        Add your Voice
        Wednesday October 15

        National RN Call-in Forum Discussion hosted by National Nurses United Noon

        Followed by your questions and answers

        This is an important opportunity for RNs across the nation to discuss their concerns, review what their hospitals are doing or not doing, and discuss ways to press for a comprehensive plan to protect front-line caregivers and the public.

        Click here to RSVP: http://nationalnursesunited.org/page/s/nnu-ebola-conference-call-rsvp

        In the tragic wake of the death of Thomas Eric Duncan in Dallas from the Ebola virus, registered nurses who would be among the first to respond and interact with other patients possibly infected still say their hospitals are lagging, according to survey responses from more than 1,800 registered nurses at more than 750 facilities in 46 states across the U.S. Click here for latest press release with current survey results.

        As a result of RNs speaking out, the voice and concerns of the direct-care RN is finally beginning to be heard on national and local media from coast to coast.

        CBS National News

        MSNBC – Ed Schultz show

        MSNBC – Joy Reid show

        Washington Post – Texas patient told hospital of travel from West Africa but was released

        New York Times – As Anxiety Increases, Agency Scrambles to Address Concerns of Health Workers

        Reuters – U.S. Nurses Say They Are Unprepared To Handle Ebola Patients

        Business Week — Workers Fearful of Ebola Want You to Know How Personal They Get With Body Fluids

        National Geographic – As Officials Track Texas Ebola Victim’s Contacts, Criticism and Questions Mount

        If you haven’t already please fill out the survey

        UNSUBSCRIBE | http://www.NationalNursesUnited.org | http://www.MainStreetContract.org
        National Nurses United | 8630 Fenton Street, Suite 1100 Silver Spring, MD 20910

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