- Dr. Atul Gawande
a surgeon at the Brigham and Women’s Hospital in Boston, a staff writer at The New Yorker and professor at Harvard Medical School. He is the author of several books, including The Checklist Manifesto: How to Get Things Right. His most recent book is Being Mortal: Medicine and What Matters in the End.
Sierra Leone is pleading for more international help to fight the Ebola outbreak in West Africa. On Saturday, the country recorded 121 deaths in one of the single deadliest days since the disease appeared there more than four months ago. At least 678 people have now died in Sierra Leone, with the official toll for West Africa topping 3,400. On Monday, President Obama said his administration is working on additional protocols for screening airplane passengers to identify people who might have Ebola, but ruled out a travel ban on West Africa. Meanwhile, the first patient diagnosed with the disease on U.S. soil, Thomas Eric Duncan, remains in critical condition at a Dallas hospital. The handling of Duncan’s case has raised questions about the how U.S. hospitals are prepared to handle a domestic Ebola outbreak. We are joined by Dr. Atul Gawande, a surgeon and best-selling author, regarded as one of the most influential healthcare policy writers in the country. “Our response was pathetic,” Gawande says. “We simply mounted no substantial response. It might have been the best thing that has happened that the first case to leave the African continent came to America, because it brought our mobilization to realize that what happens there matters to us here. This is a disease that is eminently stoppable with basic public health measures.”
AARON MATÉ: Sierra Leone is pleading for more international help to fight the Ebola outbreak in West Africa. On Saturday, the country recorded 121 deaths in one of the single deadliest days since the disease appeared more than four months ago. Sierra Leone President Ernest Bai Koroma spoke on Monday.
PRESIDENT ERNEST BAI KOROMA: [translated] In all of this, we should be mindful that Ebola is still around. We need more treatment centers. We need at least 1,000 treatment centers in the whole country. And what we are doing is our responsibility. And as a government and Sierra Leoneans, it is our responsibility to do it. But we need the partners who want to help us to come as fast as possible. We need them yesterday. But if until today they are not here, they should not wait for another day. They should come tomorrow.
AMY GOODMAN: At least 678 people have now died in Sierra Leone. Overall, the World Health Organization says at least 3,439 people have died of Ebola in West Africa, but the actual toll is believed to be higher. In Washington, President Obama said his administration is working on additional protocols for screening airplane passengers to identify people who might have Ebola, but he ruled out a travel ban on West Africa.
PRESIDENT BARACK OBAMA: We’re also going to be working on protocols to do additional passenger screening both at the source and here in the United States. All of these things make me confident that here in the United States, at least, the chances of an outbreak of an epidemic here are extraordinarily low.
AARON MATÉ: The first patient diagnosed with Ebola on U.S. soil, Thomas Eric Duncan, remains in critical condition at a Dallas hospital. He was diagnosed after flying in from Liberia, the country worst hit by the epidemic. Duncan, who is a Liberian citizen, is now receiving an experimental therapy initially intended for other viral diseases.
The handling of Duncan’s case has raised questions about how U.S. hospitals are prepared to handle an Ebola outbreak. On September 25th, Duncan sought treatment at Texas Health Presbyterian Hospital after he began feeling ill. Despite telling a nurse he had just returned from Liberia, he was initially discharged with antibiotics. On September 28th, he returned to the same hospital by ambulance after vomiting outside the apartment complex where he was staying. He was then diagnosed with Ebola.
Meanwhile in Spain, a nurse in Madrid has become the first person to contract the disease outside of West Africa. She had treated an Ebola-stricken priest who died after returning to Spain from Sierra Leone.
AMY GOODMAN: To talk more about Ebola and other health issues, we have our own doctor in the house, Dr. Atul Gawande, one of the most influential health policy writers in the country. Dr. Gawande is a surgeon at the Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School. He’s also a staff writer at The New Yorker. He’s the author of several books, including The Checklist Manifesto: How to Get Things Right. His most recent book has just been published; it’s called Being Mortal: Medicine and What Matters in the End. We’ll talk about the new book in the coming segments, but we’re going to start off with Ebola.
Welcome to Democracy Now! It’s great to have you back, Dr. Gawande. Let’s talk for a moment about the piece you just wrote on Mr. Duncan and what happened in this Texas hospital.
DR. ATUL GAWANDE: Well, it showed some of the gaps we’ve had, that I’ve been writing about for a long time. The Checklist Manifesto hit on the idea that, you know, we know the checklist for what needs to be done when people come in with potentially infectious disease. They actually deployed the checklist at this hospital about asking about somebody who has a fever and their travel history. The nurse captured that he had been to Africa. He actually didn’t tell them Liberia. It was a more vague—said, “Africa.” But she recognized that this might be an Ebola case, entered it into the records, and then the doctors—there was a communication breakdown. The doctors didn’t pick it up. This kind of breakdown, though, likely happens all over the country all the time. This was not a special event there. And I think it has forced our hospitals to realize they have to download the checklists and then learn how to use them. The big mistake, the most common failure, is a communication breakdown like this—the failure to pass information that’s critically important.
AMY GOODMAN: I wanted to go back for a moment to The Checklist Manifesto. It doesn’t directly relate to Ebola, but the point that you are making about, you know, a surgeon, as you are, being in surgery and what it means just to acknowledge the people, the nurses and the others, who are with him to assist him. Talk about that whole scenario.
DR. ATUL GAWANDE: Well, so, this is almost a philosophical issue in our profession, right? Do we follow the known procedures that exist, or do we just kind of go with our judgment every time? Well, in the operating room, the known ways to make it go more safely is there are a few things you do around infection practices, there are a few things you do in communication. You make sure that the nurses have a chance to speak up and name their concerns. You make sure that the anesthesiologist has reviewed the medical history and specific concerns of the patient. And then the surgeon reviews what the major concerns are and plans they have for the operation. You’d think we’d do this every time, right? You know, it’s like getting in an airplane: You run the before-takeoff checklist. We hadn’t. We found that making that go into place, we could lower the death rate 18 to 47 percent.
AMY GOODMAN: I mean, knowing the nurses’ names lowers the death rate?
DR. ATUL GAWANDE: Yeah, knowing who your team is, everybody introduced, everybody huddle. It’s like, you know, a football team having the huddle before they go to the line. If they didn’t have the huddle, people wouldn’t necessarily know—they’d just assume you know where the ball is going. Same thing happened on Ebola. So, in an operating room, we are seeing 18 to 47 percent reductions in death when people use these kinds of basic tools. The Netherlands implemented this across the country, and compared to their control group, they lowered the death rate 47 percent. We have a project in the entire state of South Carolina, making sure that this happens across the state. And it’s hard to pull off, because it’s a cultural barrier. That’s the barrier we saw in the Texas hospital, but it’s happening all over the country. Two million people come into hospitals, and they pick up infections in the hospital that they didn’t come in with, because people weren’t wearing the gowns properly, putting on the gloves properly, washing hands properly. We know how to do the right thing, but we don’t always systematically walk our way through it.
AARON MATÉ: You talk about the importance of simple verbal confirmation.
DR. ATUL GAWANDE: Yeah. So the breakdown here, the most common kind of breakdown in the safety of hospitals, is people don’t communicate the critical information. Just because you put it in the computer doesn’t mean anybody is going to know it and use it. And it’s called closed-loop communication. In high-risk other industries, you communicate verbally to somebody else the critical information and make sure they received it and understood it, either one way or another. It could be electronically confirming that they got the information or face to face. Well, if you’re concerned you’ve got someone with Ebola, you don’t put it in the computer. You tell them, and you hear that it’s been fed back. And that’s where it broke down.
AMY GOODMAN: I mean, this also goes to the whole issue of digital medical records—having spent time visiting people in hospitals, seeing the frustration of the nurses and doctors spending more time facing this computer screen, trying to figure out how to categorize particular things, when they want to just convey impressions that they have.
DR. ATUL GAWANDE: Yeah, we’re in the—I would call it the DOS-Windows phase of American computerization. There’s no question that having the computers has made life incredibly safer for patients, that there’s information that you would otherwise not have, that prescriptions aren’t, you know, illegible and hard to read. But at the same time, we are now spending our lives facing the computer screen instead of the patients. Polls, surveys that have looked at demoralization among clinicians find that the computers are themselves causing tremendous demoralization. We’ve all become data entry workers, spending more and more time entering data and not doing what is really the work of taking good care of patients. The design of the systems is what has to change. We need that user-friendly—make it easier to be an expert taking care of folks along the way. And I don’t think that the computer industry is waking up to that yet.
AMY GOODMAN: Go larger than Mr. Duncan in this Texas hospital. Talk about the Ebola crisis. Thousands of people are now dead. You have the president of Sierra Leone desperately reaching out for help. What is going wrong here? Why isn’t this being contained? And what are the implications of this for public health?
DR. ATUL GAWANDE: Yeah, the epidemic in West Africa is severe, and it’s getting worse fast. And what people don’t understand is this outbreak started last December. Starting at March 31st, Doctors Without Borders said the hospitals in Guinea and in Liberia are overwhelmed, and they were crying for help. As late as September 2nd, they were telling the U.N. and others that the help being provided is a shambles, that this is a disease that is doubling in the number of cases every three weeks. And our response was pathetic. We simply mounted no substantial response. It might have been the best thing that has happened that the first case to leave the African continent came to America, because it brought our mobilization to realize what happens there matters to us here. And suddenly, we are now mobilizing thousands of people to go. The CDC has mounted the largest global operation for public health in U.S. government history. And it is going to be working district by district to create emergency treatment units and isolate the sources.
Now, what the second part of this is, this is a disease that’s eminently stoppable with basic public health measures, the most basic infection control measures that we generally follow, should be following, in our own hospitals. And so, it’s highlighting the fact that it’s in the places where the health systems are broken down. You have people being turned away from hospitals because the beds are overwhelmed.
AARON MATÉ: There are calls now for closing borders, even for a travel ban here in the U.S. from West Africa. What’s your take on that?
DR. ATUL GAWANDE: So, it’s a real danger to do that. In order to stem the tide, one of the things that the models show is that if you just try to shut this down with a travel ban, healthcare workers can’t get in. The disease just explodes within the confined area. It spreads even more widely. And you’ve only delayed it coming abroad by a few weeks.
The reality is that we will see a few cases over the next months that may come here. We know how to contain it. We know what the checklist is for taking care of it. And it will not become an epidemic here. The general public is not at risk. This is a hard virus to spread. It’s harder than the common cold. It does not spread in the air. It spreads because if you have contact with the vomit, the blood, the stool, the saliva of someone who is actively sick and infected, you are the only one at risk. And those are caregivers. That’s why the people getting this are healthcare workers and family members. And basic measures end up containing it and containing it very quickly.
AMY GOODMAN: Doesn’t this also go to the issue of public versus corporate health? I mean, with epidemics like these, it’s not in the interest of corporations to have developed cures for this. They don’t have a large profit margin. World Health Organization, World Health Assembly all had their budgets gutted at a time when it seems we need this more than ever.
DR. ATUL GAWANDE: Yeah, the vaccine for Ebola had been in development for more than a couple years in advance. And the interest in it was never going to come from a for-profit corporation, because, you know, you couldn’t bank on there being this kind of epidemic to drive it. And so, instead, the government—you know, you need public investment in public health and in this kind of research. It sat fallow. Now there’s tremendous interest, and now you have the NIH and a pharmaceutical company gearing back up this drug that was on the shelf for a couple years.
AMY GOODMAN: We’re talking with Dr. Atul Gawande. He is author of a number of books, The Checklist Manifesto. His most recent book, though, is Being Mortal: Medicine and What Matters in the End. And we’re going to talk about that in a minute.