The politicization of U.S. handling Ebola may carry over to Zika

Greer said politicizing some health issues is “not all bad,” pointing to what is occurring a bit closer to U-M’s home with the Flint water crisis. Michigan Democrats have been critical of the Republican administration and largely have driven the campaign to make political leaders accountable for decisions that resulted in lead contamination of the city’s drinking water, and to keep them moving forward to find solutions.

In an article in the current Health Economics, Policy and Law, the researchers lay out what they call a case study in the politics of public health in the United States.

Public health leaders, including many experts at U-M, correctly predicted that the United States would be well equipped to handle Ebola if it reached the country, and could keep the disease from being the threat it was in Africa and other nations that have less sophisticated health care systems. There were eleven cases of Ebola in the United States, four diagnosed here and seven transferred from African countries.

Two nurses were contaminated and required treatment because of the lack of coordination and clear protocol for handling the very first victim identified in the United States, Thomas Duncan, the researchers said. Duncan arrived at the Texas Health Presbyterian Hospital in September 2014, was stabilized and sent home without an Ebola diagnosis, and returned in two days. He died less than two weeks later.

The authors said despite the success overall, their case study shows overconfidence in the health care system’s ability to handle Ebola.

“The way that the U.S. political and health systems are set up lends itself to mismanagement, confusion and uncoordinated responses,” said co-author Phillip Singer, doctoral student in the School of Public Health. “Management of public health crises within the U.S. political system is marked by fragmentation and overlapping responsibilities. There is very little formal or hierarchical governance within the United States.”

In any major public health situation, there are local, regional and state health departments with their own rules and practices, state offices including the governor, and federal organizations including the Department of Homeland Security, the Department of Health and Human Services (which includes the Centers for Disease Control and Prevention) and the White House.

In such a fragmented system, the authors said, the responses “tend to be driven by suasion — persuasive expertise — and executive action by presidents and governors, rather than a coherent bureaucratic response.”

Until an Ebola czar was appointed later in the outbreak, there was no effective central coordination.

“We need to create some permanent coordinator. We shouldn’t have a czar per disease,” Greer said, predicting that a Zika czar might be the next appointment.

Singer said that Ebola czar Ron Klain has the right idea for fixing the system by creating a public health emergency management agency, which “would have the funding and expertise to respond to the increasing number of infectious disease crises.”

Singer also noted the benefits of more organization around infectious disease.

“Not every hospital has the clinical expertise and the physical space to handle patients presenting with infectious disease symptoms for the long term,” he said. “What is needed is a system where individual hospitals are able to triage a patient with symptoms and then transfer patients to a more appropriate level of care.”

This ultimately is what happened with Ebola — a few health care systems capable of handling the disease were sent the later patients.

Singer also said the executive branch needs to streamline and coordinate among its agencies, and give the appropriate organization the larger leadership role.

“Homeland Security has very little practical public health experience, whereas the CDC has the expertise and very clearly delineated connections to similar state agencies across the country,” he said.

Greer offered what he calls a pie-in-the-sky remedy: “Can we please not make a political football out of this?”

— Read more in Scott L. Greer and Phillip M. Singer, “The United States confronts Ebola: suasion, executive action and fragmentation,” Health Economics, Policy and Law (2016) (doi:10.1017/S1744133116000244)