Ebola and Politics Don't Mix

Don't let politics get in the way of doing the right thing on Ebola.
Park your hobbyhorses outside, please.

To summarize Twitter and my Facebook feed this morning: "The Ebola virus proves everything I already believed about politics."

You might find this surprising. The Ebola virus is not running for office. It does not have a policy platform, or any campaign white papers on burning issues. It doesn't even vote. So how could it neatly validate all our preconceived positions on government spending, immigration policy, and the proper role of the state in our health care system? Stranger still: How could it validate them so beautifully on both left and right?

Here are some of the most prominent memes I saw, here is why I think they're, um, misplaced.

Ebola demonstrates why we need to restrict immigration. Ebola is a hideous disease. But so far exactly one person in the U.S. has died of it: a Liberian citizen visiting family in the U.S. One of his nurses is sick, though for all I know, she may be an immigrant. But even if the nurse dies, that will be exactly one non-immigrant fatality caused by immigration. As a reason to close our borders, this ranks below, well, pretty much anything else you could muster. I support high immigration levels. But even if I didn't, this is not the argument against them that I'd choose to make. It's like deciding that everyone needs to give up driving because one person crashed their car.

Ebola demonstrates why it's impossible to close the borders. In response to calls for flight bans from the affected areas of Africa, experts have been asserting that this is inhumane, and also, impossible. That assertion is bleeding over into broader arguments about whether we could close our borders. As I say, I'm pretty supportive of immigration, but I can't figure out why experts are making this argument about Ebola, much less what it has to do with our immigration policy. Ivory Coast cut off all travel from the affected areas in August, and if you look at maps of the outbreak, this actually seems to be controlling it pretty well within their borders. Even if all it did was buy the government time to prepare, that might help them lower their fatality rate. You can still argue, of course, that such bans are inhumane and costly. But at least from the evidence we have, closing the borders does seem possible, so we should probably stop insisting that it isn't. And we should stop acting as if this has any relevance to U.S. immigration policy, which takes place in a much different context, and over a different timeframe, from African travel in the time of an epidemic.

Ebola demonstrates the folly of cutting research budgets. Thank Francis Collins, the head of the National Institutes of Health, for this one. If his budget hadn't been cut so much, he says, we'd probably already have an Ebola vaccine. It's not exactly the first time that an organization has claimed that some crisis could have been averted by giving them boatloads of money ... and sadly, not the first time that such pronouncements have been treated, not as a self-interested party schnorring for a bigger budget, but as the modern equivalent of tablets handed down from Mt. Sinai. I generally support higher government spending on basic scientific research, but I'm narrowly skeptical of the claim that a doubled research budget would almost certainly have delivered a vaccine for a rare virus that had, until now, never infected a patient on U.S. soil. Medical research is not a vending machine that spits out a candy bar when you put in a quarter; it's a slot machine where a lot of the time, you pour in a bunch of money, and walk away with nothing.

What happened in Dallas demonstrates why we need single payer/we need more government control over the health care system/the U.S. is accepting a third world healthcare system because we don't care what happens to poor people. Let's recap what happened in Dallas, and examine which bits might have been prevented by a single payer system.

  • September 15: Neighbors report seeing Thomas Eric Duncan carry an infected neighbor while transporting her to and from the hospital, where she was turned away due to overcrowding. The neighbor, a young pregnant woman, died that night. Several days later, he flew to the U.S., writing on his exit documents that he had not had contact with anyone who was sick.
  • September 25: Duncan shows up at the Texas Presbyterian emergency room, complaining of abdominal pain and a headache. The intake worker, working off a Centers for Disease Control Ebola checklist, asked him if he had been to Africa, and whether he had had contact with sick people while he was there. He replied yes to the former, but no to the latter. He had a fever that ran as high as 103 degrees, but after running tests, doctors decided it must be sinusitis and sent him home with antibiotics and Tylenol for fever control. His time in Africa does not seem to have registered with the other staff after the intake person wrote it down.
  • September 28: Duncan shows up back at the ER, this time in an ambulance, with extreme vomiting and diarrhea. This time, doctors realize he has been in Africa, and perform the exam wearing a full gown, mask, and gloves.
  • September 30: Doctors confirm Ebola. They move to even stricter protocols involving hazmat suits.
  • October 6: Duncan dies.
  • October 12: A nurse at Texas Presbyterian tests positive for Ebola. The CDC says it believes she breached the protective treatment protocol.

I'm at a loss as to how anyone thinks single payer, a more centralized national health system, or some general "government program" would have prevented this. The CDC issued guidance on dealing with Ebola 2.5 months ago, and the hospital seems to have received it, because its staff were asking about African travel; Duncan appears to have lied about his contact with an infected woman. Perhaps the hospital should have assumed that anyone who had been to West Africa had Ebola, but first, I'd like to know whether that is a feasible use of hospital resources; and second, I have no evidence that this is what hospitals in other countries were doing in late September.

There seem to have been clear errors here: The initial intake worker failed to make clear to the team that the patient had been in Africa, and the nurse who caught Ebola likely failed to follow the protective gear protocol. But why assume this wouldn't happen in a more centralized health care system? "A critical piece of information failed to be communicated effectively" is probably the single most common organizational failure, and no organization, no matter how dedicated or well organized, can say they never experience this problem. (Well, they can say it. But it will be a lie.)

I'm not saying that Texas Presbyterian didn't make a mistake. In hindsight, the hospital probably should have immediately isolated a patient with a high fever who had just come from Africa, and it, and other hospitals, should learn from that. (In fact, I'd argue that they have). But this is not a problem that a more centralized system would have fixed, because the CDC guidelines do not call for it; they emphasize the danger of contact with the bodily fluids of an Ebola patient, which Duncan denied ever having.

There also appears to have been a failure with the protective gear, though I'm a little less sure of this; CDC seems to be inferring this from the fact that the nurse caught Ebola. But assuming that this is the case, how does a more centralized, egalitarian, government-financed health-care system prevent this?

Everywhere in the developed world, single payer or no, you have your top research hospitals with a crack team of infectious disease specialists, and local and regional hospitals that rarely see a "unique" disease such as Ebola. My understanding is that those hospitals used to be top-notch at hewing to draconian infectious-disease protocols ... 60 years ago, before we had antibiotics and vaccines. But as deadly infectious diseases waned, so did the number of workers who were used to dealing with them on a regular basis. Nowadays, outside of top infectious disease facilities, your inexperienced health-care workers may well be trying to learn how to protect against Ebola from a checklist and some brief training.

Reading the description of what the top facilities are doing, you see well-trained people going above and beyond protocols -- hand-washing at every step, wearing extra gear, having teams who help people dress and undress, maybe with a person whose sole job it is to watch for breaches. Keeping to that sort of ceaseless vigilance 100 percent of the time is a marvelous organizational feat, most likely to be achieved by facilities well-staffed by people who have regular experience with very dangerous infectious diseases. Those people are in short supply, here or anywhere else, because to repeat, we do not have many of those cases any more.

Again, this is not to say that these mistakes are okay. But it's important to understand their source, which is not the absence of an all-powerful CDC giving more forceful orders. It's maybe that the CDC guidance isn't strong enough, and definitely that doing this stuff is really hard, especially if you're not used to it. Getting a health-care system for a country as big as the U.S. to execute flawlessly in the face of a new disease would be a Herculean task even if we had the Canadian single-payer system, the Dutch public health minister, and the U.S. Marine corps all dedicated to the task.

There is no perfect system that would have kept a couple of individuals in a Texas hospital from making mistakes. If they had more experience fighting infection -- say if they'd all been part of the Dutch war on MRSA -- then the mistakes would have been less likely. Yet no one is complaining that this shows we all need to move to the Netherlands, even though this actually makes more sense than linking these Ebola failures to the U.S. health insurance system.

Both liberals and conservatives commit a fallacy when criticizing the system: They point out actual failures, and compare them with an idealized government or private sector that never makes important mistakes. As someone who has spent a fair amount of time studying both businesses and government programs, I feel confident in saying that this is, always and everywhere, triple-distilled balderdash. Organizations of all types and sizes make terrible mistakes, because getting a group of people to coordinate on some complicated and exacting task is one of the most difficult feats that human beings try to pull off. And fighting infection is one of the most complicated and exacting tasks we know. Bacteria and viruses are formidable foes, even if we may have forgotten this in the magic era of antibiotics and widespread vaccination.

Ebola shows that Barack Obama is a bad president. I'm surprised to hear this from conservatives, because they're not usually fans of the Jed Bartlet "West Wing" model of the presidency, where our nation's Genius-in-Chief uses his Nobel Prize and a few sly asides to fix every problem the nation ever faced. Where has Obama failed us? Should he have issued more forceful orders to the health-care bureaucracy to do a good job? (Please see above). Closed all the borders to everyone and everything? Interrogated Duncan personally to expose the lie? Used his magic healing powers against the virus?

To sum up: The Ebola virus is a terrible, deadly disease that we should fight assiduously. Our health-care system dropped the ball in Dallas, with potentially tragic results for that nurse. We should absolutely be talking about what our government, and our hospitals, might need to do differently. And all of this really has nothing to do with your prior positions on everything from health-care finance to immigration. Dragging out your political hobbyhorses is not helping; rather, it is a most unwelcome distraction from the conversations we do need to have.

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