We crowded into a small room at my internal medicine clinic and looked at each other. Some decisions had to be made. Soon. We were charged to answer one fundamental question: What would we do if a patient suspected of having Ebola were to walk in our clinic door? As simple as it may seem, this is an incredibly complex question. It requires considering the well-being of the patient, the risk to other patients exposed to him (or her, but I will use him for simplification) in our waiting room, and the risks to medical and ancillary staff who are attending to him. We must concern ourselves with the risk of over-reaction as well as that of under-reaction. We need to consider the imperfect state of our understanding of the mode and ease of transmission. And we must recognize that risk and response changes daily with an ever-evolving national and international epidemic. Confronted with this question in that small room, to a person, there was sincere concern about the patient, earnest concern about personal safety and a clear sense that there is a lot of uncertainty about this virus and the epidemic that is unfolding day by day. And yet, that has not been the message from the government leaders or the Centers for Disease Control. If anything, there has been an abundance of assurance. For example,
“I have no doubt that we’ll stop this in its tracks in the U.S…The bottom line here is that I have no doubt that we will control this importation, or this case, of Ebola so that it does not spread widely in this country.”
“Essentially any hospital in the country can safely take care of Ebola. You don’t need a special hospital to do it.”
– Thomas Frieden, Director of the Centers for Disease Control (CDC)
“The Ebola virus is not easily transmitted from person to person, and we have an outstanding infrastructure in place both to contain the virus and trace contacts. There will not be an Ebola epidemic in the United States.”
– Peter Hotez, Dean of the National School of Tropical Medicine & Baylor Professor of Medicine
“Ebola is a very hard disease to contract.”
– New York City Mayor Bill de Blasio
“We feel confident that there won’t be an outbreak,”
– Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases
“We know how to fight this disease…We know the protocols. And we know that when they’re followed, they work.”
“Trying to seal off an entire region of the world—if that were even possible—could actually make the situation worse.”
– President Barack Obama
Now here’s the thing. I don’t want to give the impression that the existence, transmission and wicked deadliness of the Ebola virus is the fault of the President or his appointees. That would simply be unfair and ridiculous. Throughout history we have seen the ravaging effects of infections such as swine flu, polio, measles, rubella, small pox, HIV and syphilis irrespective of the governing leadership. Yet with stumbling feet we have found our way to vaccinations, HAART therapy and antibiotics that can prevent or manage these illnesses.
And while there are innumerable better decisions that could have been made in reaction to this crisis, it is what has been forgotten that is most damning. Sir William Osler, pioneering American physician and thinker, once claimed,
Or in my words, medicine, like all endeavors touched by human hands, is rife with uncertainty and imperfection. Knowing this and admitting this is okay. The longer I have practiced medicine, the more I have come to appreciate why Hippocrates said what he said.
“Medicine is a science of uncertainty and an art of probability.”
“First, do no harm.”
Because one of our greatest risks is to downplay uncertainty and believe in our own (or our system’s) perfection. Once we are overconfident in our understanding and our abilities – once we are not tempered by our inherent fallibility in practice and understanding – that is when we do the most damage. We become mindlessly dogmatic. That is when we become “frequently wrong, never in doubt.”
“Medicine is a science of uncertainty and an art of probability.” Which means we cannot be exact. We play odds. We hope, but aren’t completely sure. A friend passed on to me a speech given at Johns Hopkins University by Michael Osterholm, the former Minnesota State Epidemiologist and current Director for the Center for Infectious Disease Research and Policy of the University of Minnesota. If you have thirty-five minutes to watch the speech, it is here (at the bottom of the site) and it is excellent.
In it, Osterholm admits that after researching over 900 articles and studies on Ebola (and related viral hemorrhagic fevers), he feels he know even less about this Ebola outbreak than before. Why is this particular outbreak so deadly and persistent? Are we confident that it has no associated airborne transmission? Why do some people have fevers and others don’t? Why do some with high degrees of exposure remain healthy while some with personal protective equipment or minimal exposure get sick? Is it wise to presume all health care facilities can manage this illness?
If a bright epidemiologist who has engaged in a respectable amount of research on Ebola finds himself grappling with uncertainty regarding these fundamental questions, how much more does it generate further questions? For example, why, though imperfect, would a temporary travel ban from festering hot zones not be helpful? How do we know our criteria for illness is accurate (or even adequate) when it relies on fevers which numerous infected individuals simply do not have? Are we certain there is no respiratory (droplet or airborne) element to Ebola’s transmission? How much more draconian should we be regarding enforcement of quarantine when even physicians flagrantly disregard it?
By asking these questions, we are attempting to better understand this illness and improve our response to it. I mean, honestly, we know there are things we simply don’t know (known unknowns) and things we can’t even anticipate (unknown unknowns or catastrophic “black swan events”). Essentially, there is uncertainty. We also know that we can be flawed in our practice. There is imperfection. And while we seek to minimize uncertainty and imperfection, it will always be with us. To deny this is to fool no one. And to admit this is not to create willy-nilly, chicken little pandemonium. Perhaps, by treating people like adults, leveling with them, and openly seeking a constructive solution, confidence will be engendered and a certain (albeit nervous) peace will be maintained. It is arrogant, officious and disrespectful to do otherwise.
In that small room at my clinic, brainstorming and collaborating, we established a plan. We honestly discussed our objectives. People laid out their concerns. We talked openly about the controllables and the uncontrollables. And when we walked away, it seemed we could move forward with a vision and strategy that was deemed effective while fully, yet humbly embracing our uncertainty and imperfection.
Perhaps our government could do the same.