Ebola: Triumph of fear echoes early days of AIDS
A toxic mix of scientific ignorance and paranoia’
After the index case of Ebola in the U.S. died and two nurses who treated him in a Dallas hospital became infected, there was an outbreak of irrationality that spread as rapidly as any epidemic.
People that had merely visited Dallas, miles from the hospital involved, were told not to return to work. Incinerated waste, burned beyond viral recognition, was not allowed to cross state lines to a landfill. People wore hazmat suits at airports and every passenger on a plane with even a symptomless Ebola patient was perceived to be in grave danger. Yet no person on any plane acquired Ebola from a fellow passenger.
Some of the same themes seen with Ebola characterized the early days of AIDS — stigmatization of certain groups, mistrust of public health officials, rumors of airborne spread and a litany of other falsehoods and fears that undermined the response to the epidemic.
Two AIDS activists recently wrote that the reaction to Ebola — a "toxic mix of scientific ignorance and paranoia" — was very much reminiscent of AIDS in the 1980s.1 They reminded where such fears can lead, as at one point the New York Times actually published an op-ed piece wherein the late William F. Buckley Jr. proposed in apparent seriousness that Everyone detected with AIDS should be tattooed in the upper forearm."2
In terms of the threat to health care workers, there were occupational HIV infections due to needlesticks and blood exposures that were tantamount to a death sentence before the first treatments and post exposure prophylaxis regimens were available.
"Those of us who are HIV-positive and have survived all these years owe a deep debt of gratitude to health care workers," the AIDS activists wrote. "None of us would be alive today if it were not for their generosity and passion for their work and their willingness and even eagerness at the start of this plague to treat some of our country’s most marginalized populations, including gay men, drug users, and sex workers."
Yet these providers — some of whom acquired HIV trying to treat the first AIDS patients were subjected to threats and witch hunts that could mean a loss of livelihood if their infection was discovered.
This era reached a fever pitch in 1990 when the Centers for Disease Control and Prevention reported provider transmission of HIV to six patients in a Florida dental practice.3 At one point during the heated debate, Sen. Jesse Helms (R-NC) introduced an amendment — which the Senate approved by a vote of 81-18 — calling for a minimum 10-year prison term for HIV-infected health care workers who perform invasive procedures without informing patients. A compromise was eventually reached involving expert review panels for infected providers, but fear triumphed over reason for much of this unfortunate chapter in American medicine.
An infection preventionist for decades before he transitioned into public health, Eddie Hedrick, MT(ASCP), CIC, has seen these recurrent themes emerge in outbreaks and pandemics.
"Every outbreak that I’ve been involved in — going back to 1976 with Legionnaires, swine flu, all these major epidemics — we do three predictable things," says Hedrick, project coordinator in the state Bureau of Communicable Disease Control & Prevention in Columbia, MO. "First, we want to quarantine people because we always feel [safer] if they are over there and we are over here. Most of the time that is a false sense of security because the majority of diseases are contagious before you show signs and symptoms. With Ebola, that doesn’t appear to be the case, however people continue to believe that."
The second common response is a tendency toward overkill in donning personal protective equipment (PPE), which paradoxically may increase risk because it increases the likelihood of contamination when the equipment is removed. This is particularly true if there has been only a cursory review of donning and doffing the PPE, which was no doubt the case in many hospitals before the first case of Ebola was admitted for treatment.
"Training is everything," Hedrick says "I worked with some emergency response people recently who I thought were highly skilled. They put on hazard suits and much to my dismay they really weren’t [prepared]. All of them contaminated themselves taking the PPE off. If people don’t do this a lot they don’t get very comfortable with it."
And the third recurrent response to a pandemic or an outbreak in Hedrick’s trifecta? The assignation of blame.
"That depends on the scenario, but if you go back to plague the rich blamed the poor. Go back to HIV we blamed the gay community and the drug abuse community," he says. "With H1N1 we blamed Mexico. It even happens in hospitals — the hospital blames the nursing home for MRSA [infections] and the nursing home blames the hospital."
The CDC has certainly been blamed during the Ebola outbreak, particularly over the decision to screen and actively monitor travelers to the epidemic area rather than stopping all flights from the three main countries at the epicenter — Guinea, Liberia, and Sierra Leone. The CDC wants to keep travel open to keep aid and workers moving in and out of the area, which could be subject to economic collapse and chaos if the rest of the world shuts it off.
"Ebola has captured our headlines but in Liberia, Sierra Leone and Guinea, it has shut down their countries since March," says Walter Tsou, MD, MPH, a professor of health policy at the Center for Public Health Initiatives at the University of Pennsylvania in Philadelphia. "Nothing can reverse an economy with the speed of an infectious disease out of control. We are widely ignorant that we live in a global economy and what is happening in other countries matters here."
- Gonsalves G, Staley P. Panic, Paranoia, and Public Health — The AIDS Epidemic’s Lessons for Ebola. New Engl Jrl Med Nov. 5, 2014: http://bit.ly/1u22nCm
- Buckley WF. Crucial Steps in Combating the Aids Epidemic; Identify All the Carriers. New York Times March 18, 1986: http://nyti.ms/1otnhoy
- Centers for Disease Control and Prevention. Possible transmission of human virus to a patient during an invasive dental procedure. MMWR 1990;39:489-493.