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Supporting Those Who Go to Fight Ebola

Michelle Mello, Maria Merritt, and Scott Halpern discuss healthcare institutions’ responsibilities to support their employees’ volunteer efforts in Ebola-affected regions. This is a pre-publication version of a manuscript that has been accepted by PLOS Medicine as a Guest Editorial.

Image credit: DFID, Flickr
Image credit: DFID, Flickr

The Ebola epidemic is testing virtually every aspect of the public health and healthcare systems in the U.S., including healthcare institutions’ public service commitments. Although the number of cases in the U.S. remains very small, an extraordinary amount of public and hospital resources have been devoted to preparing for new cases domestically [1, 2, 3, 4] In contrast, although US hospital and medical professional organizations have called for an “enhanced focus” on containing Ebola in West Africa [5], there is a striking absence of public commitments on the part of US healthcare institutions to contribute to the containment effort.

By quickly mobilizing qualified health care professionals (HCPs) to work in Guinea, Liberia, and Sierra Leone, U.S. hospitals could not only meet the needs of desperate patients, but could contain Ebola at its source, averting global risk [6]. Yet, US institutions’ response to the West African epidemic has been muted thus far. Reports indicate that many institutions—even those with a tradition of sending personnel to respond to other humanitarian crises—have asked their HCPs to stay home this time [7, 8, 9].

Although some academic medical centers (AMCs) in the U.S. have invoked their usual policy that the university will support overseas work with services such as emergency travel assistance, others have specified that staff who serve in Ebola-affected regions do so in their personal capacity, not as employees. Still others have strongly cautioned against serving, prohibited official travel to affected regions, required staff to take vacation time or unpaid leave for 21 days following repatriation before returning to work, and made clear that the university will not assist if the HCP falls ill.

The concerns that may motivate hospitals to discourage volunteers do not outweigh the countervailing considerations. At a minimum, institutions ought not to impede service; ideally, they would promote it.

Arguments for Facilitating Service

There are several reasons why institutions should facilitate HCPs’ service in Ebola-affected regions. First and most obviously, facilitating the deployment of medical personnel to affected regions in the near future could make the difference between turning the tide of the epidemic and forfeiting the opportunity to avert regional and even global catastrophe [10]. Many have argued persuasively that higher-income countries have a moral obligation to render humanitarian assistance to affected African nations because it can be done at relatively modest cost and because of basic considerations of global justice [11]. But intervening to stop the spread of Ebola is also a vital way to protect the rest of the world. Hospitals ought to consider the role of HCPs’ service in the future protection of their own patients, workers, and communities [6].

Another reason to support service in Africa stems from professional duties to treat. HCPs may be motivated to serve in Ebola-affected regions for different kinds of reasons. They may consider such service an outgrowth of their professional duty to care for the sick, a perception supported by professional ethical guidelines [12, 13]. Some may be called to this crisis by its extraordinary scope and urgency. These motivations are not merely matters of personal conscience; they exemplify core values of the healthcare and public health professions that institutions and society should encourage.

Without institutional support, it is hard if not impossible for HCPs to answer the call for service overseas. Furthermore, HCPs should not have to shoulder avoidable risk. The value of reciprocity counsels that those who step forward must be assured of the best medical treatment and maximal respect for their rights [14, 15], including the right to return to work in the U.S. with the least possible infringement on their liberty commensurate with ensuring public safety. Providing pay, psychological support, assistance accessing care in the U.S., and other services all minimize the burden [16].

A final set of considerations applies primarily to AMCs. As institutions of higher learning that receive public and private funds to generate publicly actionable knowledge and to train domestic and global health providers of tomorrow, AMCs are engaged in explicitly outward-facing endeavors. US AMCs not only receive tax exemptions for such public-service, but also receive endowments and other forms of private support thanks to their branding themselves as institutions with external missions. Such benefits are typically well deserved and serve vital purposes here and abroad, but also carry responsibilities to live up to the advertised goals. Supporting HCPs in serving in Africa is also a way of modeling our ideal behavior to professional trainees.

Arguments for Restricting Service

Image credit: CDC Global
Image credit: CDC Global, Flickr

Institutions in the U.S. that have backed away from supporting HCP service in West Africa may have three concerns. First, some AMCs may worry about whether they can adequately protect their employees overseas. Uncertainty surrounds the continued availability of medical evacuation, and there may also be concerns that violence and civil unrest may break out in Ebola-affected countries [7]. Such problems often motivate universities to issue travel advisories or prohibitions. What makes the current situation so challenging, by contrast with the typical scenario of elevated risk, is that both sides of the risk-benefit calculus are magnified. On the risk side, the potential harms to travelers and the surrounding uncertainties are unusually daunting, particularly because of shortcomings in the local infrastructure of affected regions. On the benefit side, whereas university travel is ordinarily conducted for scholarly and teaching purposes, the Ebola epidemic involves rendering an urgently needed public health service that HCPs are uniquely able to provide. These potential benefits are of exceptional magnitude and global in their reach. To minimize the risks and maximize the benefits of HCPs’ service, AMCs and other institutions should require that HCPs who volunteer to serve do so only through established and qualified organizations, and help HCPs to inform themselves fully of all residual risks and uncertainties.

Second, institutions are likely concerned about exposing local patients, staff, and community members to a risk of Ebola infection by returning clinicians. To be sure, healthcare institutions have ethical and legal obligations to protect these groups. Transmission risks can be minimized by requiring clinical staff to register their travel and prospectively commit to complying with CDC guidelines [17] on their return. Because risks to others are manageable, they should not dominate the discourse about supporting service.

A third concern may be that the protracted absence of key personnel could create operational challenges for hospitals, potentially jeopardizing their ability to serve their patients. Service in Ebola-affected regions may involve a longer deployment than typically occurs in humanitarian disasters, as well as several days of training and perhaps several weeks of remaining away from the workplace after returning. Arranging clinical coverage may be costly, and may not suffice in the short run to guarantee standard timeliness and staffing of care. Conceivably, nurses might need to care for more patients each than is normal, and continuity of physician care might temporarily worsen. Institutions may also incur costs arranging for the medical evacuation, care, and sick leave of HCPs who develop Ebola symptoms, and in screening returning HCPs to clear them to return to work.

There is a point at which such costs could become so burdensome that a department chair or other hospital leader might reasonably deem it appropriate to limit the number of HCPs who could be absent at once. Minor decrements in the quality of domestic care could be tolerated by healthcare institutions and patients given the circumstances, but substantial limitations may be more difficult to justify. However, presently, the number of HCPs willing, able, and qualified to go is small. Thus, for many if not most hospitals, the burdens encountered would be minor, comparable to those routinely assumed in providing HCPs with family and medical leave.

Conclusion

Given the opportunities for HCPs to care for patients in desperate need and help avert global harm, the consistency of such service with HCPs’ professional ethics and AMCs’ missions, and institutions’ ability to manage risks attributable to HCPs’ temporary absence and return to work, healthcare institutions should routinely support willing and qualified HCPs’ service in West Africa. At a minimum, institutions should not impede employees from fulfilling their perceived professional duties to help the sick and, thereby, to do their part in responding to a global public health emergency. This means refraining from adverse action against those who choose to travel, arranging for others to provide the services the travelers normally render, and not imposing restrictions that exceed CDC recommendations for returning travelers.

Ideally, institutions would go farther and actively promote HCPs’ service by enabling them to go as employees and preserving the full net of supports and protections this status confers in the U.S., including travel insurance, worker’s compensation coverage, and pay. Such institutions would also assume liability for harms to third parties, although these situations would likely be rare.

Finally, institutions could fulfill their ethical responsibilities to contribute to the fight against Ebola in different ways. Some hospitals might step forward as primary centers of care for Ebola patients domestically while others focus on facilitating HCPs services’ abroad. However institutions choose to address these responsibilities, it is heartening that there are HCPs who wish to provide care in West Africa. This heroism is remarkable and reflects a deep humanitarian instinct. It calls for validation, not discouragement, by healthcare institutions.

Acknowledgments

The authors thank Michele Barry, MD, Jonathan Links, PhD, and Nancy Kass, ScD, for useful comments on an earlier draft.

References

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[2] Hladky GB (2014). Hospitals Have Spent $5 Million to Prepare For Ebola. Harford Courant. December 1, 2014. Available: http://www.courant.com/health/hc-ct-ebola-costs-20141201-story.html Accessed 5 December 2014.

[3] Shabad R (2014). Ebola by the Numbers. The Hill. October 19, 2014. Available: http://thehill.com/policy/finance/221118-ebola-by-the-numbers Accessed 5 December 2014

[4] Lamantia J (2014). Hospitals Bleed Money As They Fight Ebola. Crain’s New York Business. November 10, 2014. Available: http://www.crainsnewyork.com/article/20141110/HEALTH_CARE/141119994/hospitals-bleed-money-as-they-fight-ebola Accessed 5 December 2014.

[5] American Hospital Association, American Medical Association, American Nurses Association (2014) Joint statement on Ebola from the AHA, AMA, and ANA. Available: http://www.aha.org/content/14/141017-specmessage-jointstatement.pdf Accessed 2 December 2014.

[6] Drazen JM, Kanapathipillai R, Campion EW, Rubin EJ, Hammer SM, et al. (2014) Ebola and quarantine. N Engl J Med 371(21): 2029-2030. doi:10.1056/NEJMe1413139

[7] Mangan K (2014) Universities Curtail Health Experts’ Efforts to Work on Ebola in West Africa. Chron High Educ 61(9): A12. Available: http://chronicle.com/article/Universities-Curtail-Health/149543/ Accessed 2 December 2014.

[8] Pérez-Peña R (2014). Ebola Prompts Universities to Tighten Travel Rules. New York Times. October 21, 2014. Available: http://www.nytimes.com/2014/10/22/us/ebolaprompts-universities-to-tighten-travel-rules.html?_r=0. Accessed 5 December 2014.

[9] Aizenman N (2014). Ebola Volunteers Are Needed—But Signing on Isn’t Easy. NPR.org. Available: http://www.npr.org/blogs/goatsandsoda/2014/10/14/356144079/ebola-volunteers-areneeded-but-signing-on-isnt-easy. Accessed December 5, 2014.

[10] Vogel L (2014). Call for Ebola Medics Falls on Deaf Ears: MSF. CMAJ. November 3, 2014 [Epub ahead of print]. doi:10.1503/cmaj.109-4934

[11] Rid A, Emanuel EJ (2014) Why should high-income countries help combat Ebola? JAMA 312(13): 1297-1298.

[12] American Medical Association (2004) Opinion 9.067: Physician obligation in disaster preparedness and response. Available: http://www.amaassn.org/ama/pub/physician-resources/medical-ethics/code-medicalethics/opinion9067.page. Accessed 2 December 2014.

[13] Huber SJ, Wynia MK (2004). When Pestilence Prevails: Physician Responsibilities in Epidemics. Am J Bioethics 4(1): 5-11.

[14] Bensimon CM, Tracy CS, Bernstein M, Shaul RZ, Upshur REG (2007). A Qualitative Study of the Duty to Care in Communicable Disease Outbreaks. Soc Sci Med 65(12): 2566-75.

[15] Thompson AK, Faith K, Gibson JL, Upshur REG (2006). Pandemic Influenza Preparedness: An Ethical Framework to Guide Decision-Making. BMC Med Ethics 7(12). doi:10.1186/1472-6939-7-12

[16] Wynia MK (2007) Ethics and public health emergencies: encouraging responsibility. J Bioeth 7(4): 1-4.

[17] Centers for Disease Control and Prevention (2014) Interim U.S. guidance for monitoring and movement of persons with potential Ebola virus exposure. November 28, 2014. Available: http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-ofpersons-with-exposure.html Accessed 2 December 2014.


Author List

Michelle M. Mello
Stanford Law School; Department of Health Research and Policy, Stanford University School of Medicine; mmello@law.stanford.edu

Maria W. Merritt
Johns Hopkins Berman Institute of Bioethics; Department of International Health, Johns Hopkins Bloomberg School of Public Health

Scott D. Halpern
Perelman School of Medicine, University of Pennsylvania

Discussion
  1. In Africa, especially Guinea, Liberia and Sierra Leone, thousands continue to suffer. More than 5,000 people have died from the virus since March, and the CDC estimates that by the end of January there could be 1.4 million Ebola cases………………….
    The main focus of Nothing But Nets is fighting Malaria, the leading cause of death among children in Africa. But since the Ebola outbreak, the threat of Malaria is on the rise. They are sending health workers to communities to provide critical malaria prevention, as well as diagnostic and treatment services……………….

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