BU Experts: U.S. Response to Ebola Raises Ethical, Legal Questions.

It was the bike ride seen ‘round the world.

When Maine nurse Kaci Hickox hopped on a bike last Thursday, openly defying a quarantine order to stay home after she had treated Ebola patients in West Africa, she intensified a legal and ethical debate likely to have far-reaching consequences in the U.S., according to a panel of BU and Massachusetts health experts convened last week on the BU Medical Campus to discuss the Ebola outbreak.

“There are actually two epidemics going on,” said panel member George Annas, professor of health law, bioethics and human rights at the BU School of Public Health. “There’s an Ebola epidemic in West Africa. And there’s an epidemic of ignorance in the United States.”

Annas was referring to both overblown alarm about Ebola in the U.S. and resulting government actions, including the forced quarantine of Hickox, who was isolated in a tent at a New Jersey hospital for four days after she landed at Newark airport. She tested negative for Ebola, but was ordered to self-quarantine at home in Maine. On Friday, a Maine judge rejected state efforts to confine her in her home, but required her to submit to daily monitoring for the virus.

Annas and four other medical and legal experts – two from the state Department of Public Health and two from BU – said the handling of Ebola, both in Africa and in the U.S., has raised a host of ethical questions. The way the U.S. treats health workers returning from the three countries hardest hit by Ebola – Liberia, Sierra Leone and Guinea – could have a profound effect on the willingness of others to help, and on the course of the disease, they said.

“The entire health care system is decimated” in these countries, said Dr. Nahid Bhadelia, assistant professor of medicine at the BU School of Medicine and director of infection control at National Emerging Infectious Diseases Laboratories (NEIDL) at BU. She said a lack of resources has contributed to the “exponential growth” of Ebola cases, and she stressed the need for more physicians and health care workers to assist.

“We just don’t have enough hands to help out,” she said. “It’s the amount of work to be done and how few people there are” that’s fueling the death rate. There have been close to 14,000 reported Ebola cases and 4,922 deaths to date.

Bhadelia, an infectious disease specialist at Boston Medical Center who treated patients in Sierra Leone and is now heading to Liberia, noted that the survival rate from Ebola is over 50 percent if it is caught in time.

“This is a call to action for us,” she said. “Imagine what we can do with enough hands . . . which is why the discussion of health care workers here” is so important.

Annas and colleague Wendy Mariner, a BU professor of law and public health, said a lack of clarity over which agency is in charge of Ebola has contributed to conflicting messages. The World Health Organization has come under fire for not sounding the alarm about Ebola early enough and for not coordinating a response.

The Centers for Disease Control (CDC) recently issued guidelines that call for restrictions and monitoring of health workers who are at elevated risk of infection, but stop short of the strict quarantines that some states have imposed. Meanwhile, the Department of Defense announced last week that troops who return to the U.S. after deployment to West Africa will be isolated for 21 days — the incubation period for Ebola — even if they are symptom-free.

“I don’t know who’s in charge,” Annas said with a shrug. “There’s a vacuum of leadership.”

At the state level, New Jersey, Connecticut, Florida, Illinois and three other states are imposing quarantines on health workers who’ve had contact with Ebola patients. Mariner said that while states have broad powers, there are Constitutional limits on when citizens can be confined: Namely, they must have a serious contagious disease, and there should be a probability that they will transmit the infection to others.

“That second point is being lost,” she said.

Of New Jersey and the other states that are imposing strict quarantines, Mariner said, “When you hear somebody say it’s out of ‘an abundance of caution,’ you know they have no facts behind them.”

She said Massachusetts, which is not imposing mandatory quarantines, is “doing a good job — but they’re a rare bird.” The state has had no reported Ebola cases.

“We need courageous public health and legal officials . . . who won’t be bullied” or swayed by fear, Mariner said.

Two officials from the state Department of Public Health (DPH) addressed criticism that the agency had not done enough to help to prepare for Ebola, saying the DPH is working closely with hospitals and emergency responders, while also trying to allay fears of contagion. The agency is in discussions with hospitals about whether to create regional Ebola-specialty facilities.

Dr. Alfred DeMaria, state epidemiologist and medical director of the Bureau of Infectious Disease for the DPH, said that even if some hospitals are deemed regional centers, the entire health care system needs to be prepared to deal with cases.

“Patients aren’t going to go to an ‘Ebola hospital’” when they have symptoms, said DeMaria, noting that people likely will go to the nearest hospital or health-care provider. “We still need to build a system” of community providers trained and equipped to treat Ebola.

All state hospitals have invested in training and equipment to prepare for the possibility of an Ebola patient, state officials said. Boston Medical Center is building a three-bed bio-containment unit that is expected to be ready in mid-2015.

DeMaria said that the DPH is following CDC recommendations that any identified, higher-risk individuals restrict their interactions and undergo active monitoring for symptoms and fever at least once daily.

“We’re going to be very diligent in applying the least restrictive measures . . . while ensuring the public’s health,” he said. Of returning health care workers, he said, “We should be embracing them with gratitude, not shutting them (in) and locking them up.”

DeMaria said the department has been trying to allay fears that the virus, transmitted through bodily fluids, is airborne or easily spread. He noted that the one person who has died of Ebola in the U.S., in Texas, had possible contacts with more than 100 people, but that only two nurses who treated him at the end stage of his illness had contracted the virus.

“Distance is your best protection,” he said.

Mary Clark, director of the Office of Preparedness and Emergency Management at the DPH, said the agency began working with health care and emergency providers in August to prepare for Ebola cases. The DPH has set up a special email account for residents who have questions about Ebola: AskEbola@state.ma.us.

At the forum, an audience member asked panelists why Ebola had attracted so much more public attention than illnesses such as malaria and pneumonia, which claim many more lives in Africa.

Initially, Mariner answered that those other illnesses have been around so long, people have grown tired of hearing about them. Then she added: Because Ebola has “jumped here.”

Annas agreed, adding that he hoped the Ebola outbreak ultimately might lead to better health care for West Africans with other diseases, if health systems in those countries are strengthened.

Contributed by Lisa Chedekel