Saturday, August 16, 2014

Managing Ebola Risk

The world these days is struggling with another infectious disease outbreak.  This time it is Ebola Fever.  As of today there are over 1000 victims to a terrible and miserable death, for which there appears to be little that can be done, at least in its current home of West Africa.  It is a major health problem, which cannot be diminished even when one takes into consideration the total population of west Africa being near 200 million.  (1000 cases represents 5 cases per million population).
The challenge to the more developed countries that the outbreak poses are many and varied, but the one that came to front of mind over the last few days in Canada, is how should Canadians health programs prepare for the possibility of a case arriving at a local hospital emergency department.  

This is a fair question to ask.  Canada is a country that sends diplomats and missionaries and aid workers around the world, some actively in West Africa.  And while there may not be a lot of tourists, there is a lot of business that goes on between the Canadian and Nigerian oil businesses.  It is not impossible that a Canadian worker could be exposed in their line of duty and then get on an airplane, and later manifest illness back in Toronto, or Montreal or Vancouver or Winnipeg. 
Regardless of how you look at the factors, the reality with respect to severity and occurrence is that the likelihood of occurrence is greater than one, and the severity of outcome would likely be considerable.  Regardless of how the S/O grid is plotted, the level of risk is going to be considered as High or Serious.  Some forward planning is clearly appropriate.

The challenge is what kind of risk strategy should be implemented; and that appears to not be a simple question.  It depends on your starting point.  If we start from the perspective of a business person who had recently visited Abuja on oil business who feels unwell, the probability of having a true case is not zero, but probably very very  low, but if we start from a doctor working with Doctors Without Borders (MSF) in the epidemic zone, the probability is higher.  

Further if one takes as the baseline the infection control and care delivery in a Canadian facility as opposed to West Africa, it would be fair to say that the risk of transmission in Canada is much much lower, but not zero.  (As an anecdote, we once had a case of human rabies in a Canadian hospital where one healthcare worker shot spinal fluid in his eye, and another cut her hand on a microscope glass slide, so incredible things can always happen!).

But does the level of risk in Canada require setting up bunker mentality barriers of hazmat suits and hypervigilance, or can one depend upon our same level of cautions as we would use for influenza or rabies suffice?  It is an interesting and important question.

The reality is that health care workers are humans and humans make mistakes.  Many struggle with even basic precautions, but putting in complex procedures are rarely sustainable.  The higher the degree of complexity, and the greater the level of stress, then the more likely errors is made.  Recent readings of Sydney Dekker make that pretty clear.  There are no perfect systems.  The other reality is that hyper isolation creates less than perfect care for some patients, especially the elderly.  Creating poor care for the “greater good” does not meet even the most basic oath of care: Primum non nocere” or "first, do no harm."

To my mind, the crafters of Risk Management standards and S/O grids have a solution.  High Risk or Serious Risk does not always necessitate extreme actions.  What it does require is engagement of the highest level of decision making.  In other words when the measures don’t contain the risk, the organization can say that the persons with the widest access to knowledge and information were engaged and the decisions had the highest degree of authority.  The buck stops at the top.

That puts a lot of pressure on the folks at the top, but that is why they are there.  In today’s world they have to take into consideration, not only the issues of risk and containment, they also need to consider the plague of 24 hour television news, public anxiety and hysteria, the politics of opposing voices, of workers refusing to work, and the general distrust of authority.  And who can forget the lawyers just waiting to pounce.   Sometimes, the loudest voice, not the best voice wins.

The reality is that this outbreak will come and go, just as did SARS, and Swine Flu.  But there will always be another.  And at some point we need to figure out how to implement risk management solutions that are truly fit for purpose.

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