Softer Care for Harder Cases, of Ebola and Everything Else

The evolving Ebola outbreak is very disconcerting, to say the least. The situation in West Africa is, obviously, truly dire- with projections of the toll escalating from terrible to calamitous day by day. A dreadful, transmissible disease in a part of the world where access to clean water can be elusive is a very bad and volatile mix.

But the situation in countries putatively far more capable of confronting this kind of problem effectively has provided little comfort to date. Transmission in Spain apparently owed something to the ravaging of public health resources in an austerity economy. Here in the U.S., we are navigating through an embarrassing sequence of public health blunders. We, too, have routinely raided the never copious public health coffers whenever economic challenge came calling. Even so, we should certainly be able to do better than this.

So, yes, even as someone formally trained in epidemiology, I find the situation- not just in Africa, but right here at home- disconcerting. I rather wish I hadn’t recently watched Dawn of the Planet of the Apes, much as I enjoyed the movie- because a virus catching a plane and going global has life imitating art a bit too closely for comfort.

That said, I hasten to note that there are still some important differences in perspective attached to formal training in public health.

First, Ebola is bad enough as a quasi-natural occurrence, compounded by a series of unfortunate events (or actions). There is no basis for the conspiracy theory nonsense all such crises propagate.

Second, the risk of Ebola transmission to any one of us in the U.S. or Europe is- until or unless truly dramatic and very unlikely changes occur- vanishingly small. Thus far, there have been one death and two infections in the U.S. There have been 24 deaths in the U.S. from lightning strikes so far this year. National Geographic tells us that five people die from shark attacks every year.

OK, you are not worried about lightning hitting the shark that’s eating you. Let’s move on.

Third, while new, exotic, and seemingly scandalous threats for which we can hold someone else accountable fascinate us, we routinely dismiss, disparage, and neglect the vastly greater risks we have the means to manage. I have lamented this many times myself, but now have the excellent company of Frank Bruni, who did so masterfully in this week’s New York Times. Globally, measles kills over 100,000 people annually. Even as we eagerly await news of effective Ebola vaccines, we forgo use of those we have- invoking a toxic blend of paranoia and complacency. So measles is back.

These points have all been made before. There is, however, another consideration in all of this, a connection I have not yet seen others make. We need all of our care- clinical and public health alike- to be more holistic.

Holism may evoke butterflies and wildflowers, as the term has taken on a New-Age, touchy-feely kind of glow. Holism suggests not so much the rigorous analytics of applied epidemiology, as the soft touch of doting humanism. My argument here is that if holism is indeed “soft,” then the softest of care may best suit the hardest of cases.

Consider that the origins of the Ebola crisis relate not directly to public health, but to ecosystems, native diets, and biodiversity. We have known for a long time that bats and primates were prone to harbor viruses that could infect humans, Ebola included. A failure to think holistically, however, precluded culturally tailored approaches to modifying traditional diets, providing for ample alternatives, and sparing the world its current catastrophe. It’s not too late, however, to prevent the next one.

As for Ebola containment, holistic thinking is clearly essential. Control of an outbreak is not limited to treating the sick, but managing the social network of every index case. Hospital care becomes the workings of a village, with the comings, goings, tasks, and interactions of providers inextricably tangled up with the patient’s requirements, and the vulnerabilities of us all. The social contacts of a hands-on caregiver, both in the hospital and beyond, suddenly have clinical relevance.

The lesson here is that they always do. The nature of care and social interactions influence the propagation of heart disease, too. That some populations are so much more prone to diabetes than others isn’t about biological distinctions, but social ones. Type 2 diabetes is, fundamentally, a social disease.

We will spend a fortune on a global Ebola response. We might have spent much less, proactively, on the source of the problem, and saved both lives and money. There is nothing unique to Ebola in that. We spend billions on after-the-fact treatment of chronic disease and obesity every year, and pitifully less to address them at their origins, use what we know- and add a bounty of both years to life, and life to years as a result.

Imagine for a moment if we thought heart disease were “infectious.” In a sense it is, since families tend to share vulnerability- and it runs in social networks. But we take this to be due to behaviors and exposures we can ostensibly control, not some virus we cannot. So we are complacent about it. The result is that millions are diagnosed with heart disease every year in the U.S., and it kills some 600,000 of us prematurely. Ebola, of course, terrible as it is, is a very long way from any such toll.

We know heart disease to be preventable 80% of the time, if not more. But we just keep treating cases as if each man and woman to succumb were an island- and the carnage goes on.

The ramifications of more holistic thinking extend to medical enigmas. Patients suffering from what they are apt to call “chronic Lyme,” for instance, have a choice between clinicians who endorse the condition and treat with antibiotics often long after the last spirochete is dispatched, or those who renounce the condition altogether. What about a likely truth in the middle? Bodies exposed to a serious infection and then antibiotics may suffer long-term symptoms as a result of either or both, whether or not active infection is “chronic.” More holistic thinking about such cases expands treatment options, and obviates the need to tie symptoms warranting attention to a specific, controversial diagnosis. There is more to the patient than the name of their pathology.

Effectively addressing the Ebola crisis, now and in the future, can’t just be about infectious disease. It also needs to be about hunger and diet, poverty and culture, ecosystem management and biodiversity. Different, but related ripples spread out from every case of diabetes, and heart disease; depression and chronic fatigue.

Holism tends to bespeak the touchy-feely end of the medical spectrum. And indeed, thinking and treating holistically does tend to result in softer, gentler, more caring care. But there are ways to operationalize holistic care that involve rigorous thinking, and invoke systematic methods. That would serve us well now, as ever. For it may be that in the hardest of all medical situations confronting individual patients and populations alike, the seemingly softer aspects of care are just what the doctor ordered.

-fin

David L. Katz, MD, MPH, FACPM, FACP
Author, Disease Proof
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