Fear, Ebola, and the plague doctor's outfit

An earlier post mused that, in some ways, modern healthcare workers in contact precautions might appear as the plague doctors did in the Middle Ages to their febrile, terrified patients. The imagery of the plague doctor's outfit has survived centuries in association with a horrific event responsible for significant death and social disruption. Today, the doctor's outfit remains a powerful symbol of desperate times.

While the current epidemic of Ebola virus disease is unlikely to have the depopulating effect that plague did in the 1300s -- the Black Death is estimated to have killed up to 60% of the European population at the time -- the deadliness of this virus as it circulates in Western Africa must produce a fear similar to that of the Black Death in the Middle Ages. It makes me wonder if, years from now, pictures of doctors and nurses in Ebola personal protective equipment (PPE) -- the garb healthcare workers must wear to care for patients -- will conjure up similar reactions to those of the plague doctor's outfit.

Think of the similarities. If the case fatality rate (CFR) of plague in the 14th Century was similar to that of plague in the US between 1900 and 1941 (i.e., in the pre-antibiotic era), the CFR of the Black Death could have been over 60%. The CFR of Ebola in West Africa is currently estimated to be near 70%. Probably due to this high CFR during the Black Death, people were often deeply skeptical of doctors, as as Giovanni Boccaccio  describes in The Decameron:

Which maladies seemed set entirely at naught both the art of the physician and the virtue of physic; indeed, whether it was that the disorder was of a nature to defy such treatment, or that the physicians were at fault - besides the qualified there was now a multitude both of men and of women who practiced without having received the slightest tincture of medical science - and, being in ignorance of its source, failed to apply the proper remedies; in either case, not merely were those that covered few, but almost all within three days from the appearance of the said symptoms, sooner or later, died, and in most cases without any fever or other attendant malady . . . 

As we have read in this event, distrust of healthcare workers in Western Africa has led to attacks on doctors, though this sentiment may partially stem from historical events. Indeed, serious issues with healthcare in this region are nothing new.

Of course, there are important differences between bubonic plague in the Middle Ages and Ebola in Africa today as well. Plague is caused by a bacterium whereas Ebola virus disease has a viral etiology; Yersinia pestis is carried by domestic rodents and vectored to humans by fleas whereas Ebola virus is directly transmitted between humans; et cetera. Perception is reality, however, and one overarching public perception is proving a difficult to alter: Ebola is terrifying. Ebola PPE is a modern plague doctor's suit, a tangible symbol of fear, a fear that we have but to turn on any newscast to see spread.

I feel strongly that we must never forget the human dimensions of disease. Physiologically speaking, Ebola virus disease in Homo sapiens is increasingly well understood, but the impact of the disease on the human condition is perhaps less so. If we are to control the spread of Ebola virus, we must understand this better; it seems clear that we don't. Fear and panic only make the situation worse. We must control the fear.

(image source: Wikipedia and WHO)

The baggage of contact precautions

Contact precautions (CPs) have long been employed for breaking the chain of infection in hospitals. The basic idea is that by removing surfaces (e.g., gloves and gowns) contaminated in the course of patient-HCW interactions, mechanical transfer of infection between patients via care providers can be prevented. The theory makes sense, though a study by Morgan and Kirkland on how some physicians view the efficacy and impact of the approach is illuminating.

In fact, the recent literature has several studies illustrating issues surrounding contact precautions. Zahar et al suggest that, under certain circumstances, contact isolation of ICU patients is associated with increased rates of medical errors and adverse events and Karki et al show that patients under CPs have an increased risk of injuries and medication errors. Mehrotra et al demonstrate that patients under CPs are more likely to perceive problems with their care than those not under precautions.

Regardless of what you think about CPs, it's clear that they carry some baggage. One of my favorite blogs, Controversies in Hospital Infection Prevention, discussed the Morgan and Kirkland paper a year or so ago within the context of the plague doctor's outfit: the bizarre hats, waxed cloaks, and bird-beak masks stuffed with herbs and flowers worn by medieval doctors caring for plague victims. I've often thought about how terrifying the doctor's garb must have been to patients in the delirium of plague in the middle ages.

But has that changed for modern patients? Though familiar to HCWs, contact precautions surely can be terrifying to patients who are already upset from their condition. Consider the febrile patient in the fragile months following bone marrow transplantation. The incidence of infection in this patient population is often high, and these infections can be fatal. Having been rushed to the hospital late at night, say, such a patient -- a person, after all -- is typically surrounded by unrecognizable people in masks, gloves, and yellow gowns (hopefully properly worn and tied!) while being poked with needles for blood draws. Our clinical and research degrees aside, maybe the patient experience hasn't changed as much as we might have hoped from the days of plague masks and leeches. Food for thought.

(image source: Wikipedia)