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Ebola and nursing in the news media

Smiling eyesDecember 2014 -- The Ebola crisis has drawn nurses into the public eye like few recent world events. And in 2014 it sparked a surprising amount of attention from the global news media for nurses as health experts and central players in Ebola care, as well as an upsurge in nurses themselves speaking out in the media. Examples range from a Washington Post op-ed by Emory University Hospital chief nurse Susan Mitchell Grant explaining why her hospital accepted the first U.S. Ebola patients, to first-person accounts in the Guardian by nurses discussing the challenges of caring for Ebola patients in West Africa, to the work of Kaci Hickox, the Maine nurse who has advocated strongly against stigmatizing health workers following her own unnecessary quarantine. On the other hand, many press items have followed the familiar media model, suggesting that physicians are the ones who really matter in Ebola care, consulting only physicians for expert comment, and using "doctors" to encompass the whole health care team. Notable examples include extensive reports about the crisis in West Africa in the New York Times. Many of those pieces do not completely ignore nurses, but do suggest that it is the work and insights of physicians that are really worth hearing about. Some of the most striking physician-centric Ebola images were the photos of Texas nurse Nina Pham's joyful release from a National Institutes of Health hospital in Maryland after she had become infected caring for Ebola patient Thomas Eric Duncan. Pham seemed to be surrounded by a large group of physicians, with no nurses in sight. At the end of the year, Time chose "the Ebola fighter" as its "Person of the Year." Although the magazine's long feature focused to a predictably great extent on physicians, it also credited nurses and others, including Liberian school nurse Iris Martor, who spearheaded an effort to identify and contain the disease in her community. Fatu Kekela And CNN reported on the work of 22-year-old Liberian nursing student Fatu Kekula (right), who single-handedly saved most of her family from Ebola, in part through her own "trash bag method" of infection control. On the whole, while the major media has a long way to go, many 2014 reports did highlight the critical role nurses play in Ebola care. We encourage nurses to make that happen more!

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Head nurses and top doctors 

The Washington Post runs strong op-ed on treating Ebola patients by Emory chief nurse Susan Mitchell Grant

The field marshal and the burial boys

The New York Times on deputy nurse matron Josephine Finda Sellu, defying the odds in Sierra Leone

Life and death on the frontline

The Guardian (UK) publishes harrowing accounts of three international nurses treating Ebola in West Africa

Nurses want to know

NPR consults nursing leader Diana Mason on Ebola

A litany of damning assertions

The Los Angeles Times on Ebola treatment problems at Texas Health Presbyterian Dallas

On the road

Karin Huster's New York Times op-ed on the role of transportation problems in Ebola

Turning the policymaking tables

Theresa Brown's CNN piece on Ebola and increasing awareness of the importance of nursing

Science and compassion will overcome fear

Kaci Hickox on stigmatizing health workers in the Dallas Morning News and the Guardian

Agonizing and abandonment

In this long New York Times report, Ebola care in Liberia seems to be mostly about the expatriate physicians

Welcome to afternoon

In another long New York Times report, Ebola care in Liberia seems to be mostly about the expatriate physicians

Nurse staffing is critical, say esteemed physicians

New York Times highlights "supportive care" for Ebola, but sees no need to consult those who provide it

White coat syndrome

Media messages big and small about which Ebola care givers really matter

The Ebola fighters

Time's "Person of the Year" feature is mostly about physicians, but it does make a point of crediting nurses, including Liberia's Iris Martor

She'll be a great giant of Liberia

CNN on Fatu Kekula and the trash bag method

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Head nurses and top doctors

The Washington Post runs strong op-ed on treating Ebola patients by Emory chief nurse Susan Mitchell Grant

On August 6, 2014, the Washington Post published an op-ed by Emory University Hospital chief nurse Susan Mitchell Grant with this title and sub-title:

I'm the head nurse at Emory. This is why we wanted to bring the Ebola patients to the U.S.: These patients will benefit -- not threaten -- the country

Susan Mitchell GrantSetting a nurse up as that kind of leader is very helpful. And the op-ed itself is courageous and generally good for nursing. Although Grant does not discuss what Emory nurses do for Ebola patients in very specific terms, she does speak with real authority about why caring for the first two patients was an example of good health policy and why fears of health risks to the wider population were misplaced. In particular, she argues that Emory had trained for years to provide care for just these kinds of patients; that doing so would increase knowledge of Ebola and how to fight it; and that treating such patients was simply the right thing to do, particularly for stricken health workers who had themselves dedicated their lives to caring for others in times of greatest need.

There was one damaging statement in the piece. Early on, Grant referred to the "team of highly trained physicians and nurses" who were caring for the Ebola patients, and she also noted pointedly that "at least two nurses canceled vacations to be a part of this team." But inexplicably, in the piece's final paragraph, Grant stated that "we all hope that if we were in need of superior health care, our country and its top doctors would help us get better." Really? Just "top doctors"? Of course, as some of the later pieces make clear, nurses play a central role in providing skilled care to patients with diseases like Ebola. But evidently, even nursing leaders are not immune to the common assumption that physicians are the only health care stars.
 

The field marshal and the burial boys

The New York Times on deputy nurse matron Josephine Finda Sellu, defying the odds in Sierra Leone

On August 23, 2014, the New York Times ran a long report about the nurses and "burial boys" of Sierra Leone who have continued to care for Ebola patients even as many colleagues have died or fled. "Those Who Serve Ebola Victims Soldier On," by Adam Nossiter and Ben C. Solomon, is mainly about the effects of the crisis on these caregivers, who face difficult working conditions and terrible stigmatization. There is very little about the nurses' skills or what they do for patients specifically. But the piece does give a good sense of the nurses' strength, as well as the key role they play in Ebola care.

Josephine Finda SelluThe main figure profiled in the piece is Josephine Finda Sellu, the deputy nurse matron at a government hospital in Kenema, Sierra Leone. The piece notes that 15 of Sellu's nurses had died of Ebola, but she kept coming, part of "a select club, consisting of perhaps three women on the original Ebola nursing staff who did not become infected, who watched their colleagues die, and who are still carrying on." The piece emphasizes her authority over the other nurses and how much they rely on her, observing that "she resembles a field marshal in light brown medical scrubs, charging forward, exhorting nurses to return to duty, inspecting food for patients, doing a dance for once-infected co-workers who live -- 'nurse survivors,' she called them enthusiastically -- and barking orders from the head-to-toe suit that protects her from her patients."

The piece does not focus only on nurses, but tries to give a fuller picture of those coping with the crisis than most reports do. Thus, the piece describes not only the work of "doctors and nurses who give their lives to treat patients who will probably die," but also "janitors who clean up lethal pools of vomit and waste so that beleaguered health centers can stay open; drivers who venture into villages overcome by illness to retrieve patients; body handlers charged with the dangerous task of keeping highly infectious corpses from sickening others"--young men the piece says are known as "burial boys." These workers face not only the deadly disease, little or no pay, and difficult working conditions, including all the protective gear they must wear, but also terrible ostracization in their communities, where they have become "pariahs."

The report spends a lot of time on the effects the deaths have had on the hospital staff, and Sellu in particular. The piece notes that the nurses and physicians had initially relied on their experience treating Lassa fever, another deadly disease, but those precautions proved inadequate. Here the piece includes its few notes of physician glorification:

The inadequate initial precautions had fatal consequences, even for the revered young doctor who headed the Lassa unit, Dr. Sheik Umar Khan. "Such a careful man, always saying, 'Don't do this, don't do that,'" Ms. Sellu said. "That is the mystery." Dr. Khan died on July 29, a huge blow to the nation.

The piece does not make clear why the loss of one young physician was a "huge blow to the nation" when the deaths of 15 nurses are not described in such terms. Was it just remarkable that a physician would risk and lose his life because it had so much relative value? The piece does describe the effects of all the deaths on Sellu, and that is the one thing that causes her projection of strength to crack a bit. But mostly we see that strength:

At the height of the deaths last month, her two teenage children and her family in the capital, Freetown, urged her to stop. The remaining nurses at the hospital staged a revolt. One morning, 40 of them appeared outside the door of her home in Kenema, yelling, "If one of us dies again, prepare yourself to die!" Frightened, her children warned her. "'They have come for you! Mummy, don't go there again!'" she recalled. "And my relations in Freetown were saying, 'Don't go there again!'" Ms. Sellu disobeyed all of them.

The piece concludes by noting that infection control at the hospital has greatly improved, with international help, although the nurses "continue to face stigma" and "shunning" outside the hospital.

Although this report has little about the nurses' skills or what they do for patients specifically, it certainly makes their central role in Ebola care very clear. It also has a genuine hero in Sellu, someone who has faced the abyss and carried on, leading her staff through an extraordinarily difficult time. And although the piece passes on the reverence apparently accorded the physician Khan without explaining it, we note that Sellu's words about him are measured. She seems to be praising his carefulness and wondering at his infection, but it's hard to miss the edge in the "don't do this, don't do that" comment. In the end, the piece presents Sellu as a formidable and complex professional.
 

Life and death on the frontline

The Guardian (UK) publishes harrowing accounts of three international nurses treating Ebola in West Africa

Despite a few articles like the Times one discussed above, though, the major media did not include much commentary from nurses about Ebola until the first infections appeared in the U.S. and other developed nations. One excellent early piece appeared in the Guardian (U.K.) on October 13, 2014. That one consists of three lengthy first-person accounts by nurses from different nations caring for Ebola patients in West Africa. The piece is "'A teenage girl bled to death over two days': Ebola nurses describe life and death on the frontline." The introduction explains that "three nurses who volunteered to help fight the virus in Liberia and Sierra Leone, the worst-affected countries, describe the daily horror." The piece includes photos of two of the nurses, as well as a number of other photos showing health and burial workers doing their work in protective gear. Taken together, the pieces place nurses at the forefront of Ebola care, present nurses as skilled in that care, and give readers a sense of the hardships nurses endure to provide it.  

Bridget MulrooneyThe first nurse is Bridget Mulrooney, a U.S. nurse working for the International Medical Corps in Liberia. She explains that she is an experienced international volunteer who has been at an Ebola treatment unit for about two weeks, and she provides some detail about what that is like. Much of her focus is on getting patients to eat and drink, to replace what they are losing because of the disease symptoms. She also notes that the protective gear workers wear ("personal protective equipment" or a "PPE" suit) is so hot that they can only spend up to two hours in it without a break. It is clear that the health workers confront death regularly, and she notes simply that "Ebola is mean . . . it can tear families apart one by one, or take them all out together." Here's an example:

We recently had a teenage girl bleed to death over two days of IV-site oozing. Sounds easy to fix, right? Pressure dressing, elevation, blah blah. Sorry, that's not how things work in an Ebola unit. You do all the normal interventions but a 20-gauge needle hole in a hand can slowly and fully drain the life source out of someone. Walking into a room that is covered in blood, finding a semi-conscious girl face down on a bed pooling with barely congealed blood is hard. It's harder the second day when you know all your efforts couldn't slow that life destruction. I cleaned her up, and put her in a pair of still-tagged jeans. She half smiled and took some medicines. I won't forget her smile. Nor her soft moans as her body was fading away.

Mulrooney also explains that although her own family is very supportive of her work, she worries about the "backlash against healthcare workers who are responding to the crisis in West Africa"--an early expression of concern about the issues that would soon become prominent in the controversy about Kaci Hickox. Mulrooney notes that calls for lengthy quarantines for people like her "are not based on the medical facts," since "people only need to be quarantined if they are showing symptoms and if you do not have a fever, there is no risk of you transmitting Ebola to someone." She notes that Ebola care givers like her work hard and endure a lot, and when she gets time off, she would like to think she would be free to travel anywhere, but she fears that will not be the case. This brief and plain statement is advocacy not only for Mulrooney, but also for her patients, because that kind of stigma will discourage volunteers.

Sue Ellen KovackSue Ellen Kovack, an Australian Red Cross working in Sierra Leone, provides a more detailed account of what the nurses do in an Ebola treatment setting, including the daunting infection control procedures:

We need to synchronise putting the PPE on with other team members, because if one is slower than the rest we end up waiting and baking in the sun. We have a dresser to make sure we are completely covered, or we work in pairs and check each other. First on are gloves and a jumpsuit. Then a second pair of gloves, a thick duckbill mask, a hood, and an apron that is tied by the dresser so we can untie it with one pull. Then on go the goggles with a generous drizzle of antifogging spray, a final check in the mirror and a final check with each other. The checking does not stop there, as we must ensure during our time in the high-risk area that we are still covered, that a mask has not slipped, or that a piece of skin has not been exposed. If that happens, we leave the area immediately. We check the time -- 45 minutes to one hour is the maximum allowed in the PPE. . . . Patients who are too weak to move away from their own vomit, faeces and urine need the most help. We clean and care for as many as we can, but if we need to leave the area because of heat exhaustion or feeling unwell, the priority is to get out. You are a danger to your colleagues if you go down in your PPE.

Kovack also explains the procedures for undressing, which seem at least as onerous, with laborious removal of equipment in a specific sequence and frequent chlorine spraying. When inside the treatment unit, Kovack says, nurses "might offer some pain relief, or a smile from beneath our PPE (yes, you can smile with your eyes)." She stresses that local nurses "have amazing courage to work" in the unit, in part because their own families ostracize them, "but they still come, to try to bring an end to this brutal, invisible 'war.'" Kovack concludes her piece by describing a female patient who arrives by ambulance. She looks terrified and is "flailing wildly, a dangerous situation in itself." It turns out "she is just trying to cover her exposed area below her waist," a modest impulse "in her last moments." The team manages to get her into the tent and asks her name, her marital status. "She responds, 'I am married,' looks away and dies. . . . That was a tough moment."

Anine KongelfThe third nurse is the Norwegian Red Cross's Anine Kongelf, who is working in Sierra Leone. Her piece does not focus on the technical aspects of care or infection control, but on the highs and lows of the work, emphasizing the joy when there are survivors. Kongelf describes the death and burial of a young boy, followed by the nurses' breaking of the sad news to family members who had just arrived from far away. But most of the piece is about an 11-year-old girl, Kadiatu, who is finally being discharged, Ebola-free.

As we wait for her transport home to Freetown, we can finally sit together. Kadiatu is brought breakfast and vitamins, but the nurses no longer need to wear the personal protective equipment, and the psychosocial counsellor can talk to her in private and uninterrupted. Kadiatu makes us dance for her as she sings, and we can take photos together without being worried about coming too close. Magically, our first survivor is this beautiful, strong 11-year-old with the widest, whitest smile I have ever seen, and as the car drives off I know she will be fine. Her mother and siblings are waiting for her at home, and for us, the staff at the treatment centre, we know that people can survive Ebola and that there will be many more happy days like this one in the midst of all the fear and despair.
 

Nurses want to know

NPR consults nursing leader Diana Mason on Ebola

Diana MasonNurses have also been consulted as Ebola experts, although less often and mainly in the context of the controversies related to the first U.S. infections in Texas. One fairly good, if short, item appeared on the National Public Radio website on October 14, 2014. Nancy Shute's piece was a short Q&A with nursing leader Diana Mason, the former editor of the American Journal of Nursing and currently president of the American Academy of Nursing. Despite the helpful central fact of the piece--it consults a nursing leader as an expert--the headline is not so helpful: "Nurses Want To Know How Safe Is Safe Enough With Ebola." We know what the headline means, but the way it's phrased suggests that nurses are just empty vessels waiting for someone to dump health information into their heads. Of course, to the extent nurses understandably don't know everything about Ebola because it is not their specialty, the same would be true of physicians who are not Ebola specialists. But as health professionals, nurses can and should take a more active role in become more educated about Ebola. And in fact, plenty of nurses--like the three in the Guardian piece, not to mention those who have devoted their careers to infection control--already know what is and is not safe when it comes to Ebola. We are not aware of many infections among those nurses. The item's first paragraph also says that nurses, in the wake of Nina Pham's infection, are "mad" and have "lots of questions about how to care for future patients safely." Sure, of course many do--but would a journalist have written that physicians are "mad" and "have lots of questions," as if they were somewhat unstable, unskilled workers waiting for instruction?

Diana Mason quoteIn any case, the piece says that in light of concerns that Nina Pham became infected even though she was following her hospital's infection control procedures, NPR called Diana Mason. The piece helpfully notes that Mason is "a professor of nursing at Hunter College and president of the American Academy of Nursing."

First, Shute asks about remarks by Centers for Disease Control director Thomas Frieden suggesting that a "breach in protocol" led to Pham's infection. Mason correctly notes that there is "outrage" in nursing about those comments, and says that "it's blame the nurse again." It's certainly true that some find it convenient to blame nurses for care problems, although it's also important that nurses take responsibility as health professionals. Nurses can't expect credit for good things they achieve as educated, autonomous health professionals without accepting responsibility for problems, and in particular, they do have an independent responsibility to seek the information they need to practice safely. Shute asks for details about the Ebola care systems, and Mason gives some sensible general information about the importance of gowning and degowning properly. Shute asks about staffing, and Mason makes the great point that the 12-hour-shifts many nurses work are a concern, because of the high potential for a lapse; "you won't want an exhausted worker caring for Ebola." Finally, Shute asks about whether Pham "knew what she was getting in for." Mason responds:

Someone asked a nurse, what do you make? I make sure your seriously ill father is cared for. I make sure that when you're incontinent you're cared for. It's this everyday, profound yet intimate work that people do. People don't understand it. It requires incredible cognitive and emotional intellect to do it. You are with someone at the most difficult and challenging and joyous moments of their lives. If your hospital's not prepared for Ebola, the nurses will know it. You want to pay attention to what they're saying. But I'll tell you that many nurses who speak up end up being given a really hard time in some institutions.

We're a little uneasy with the less-than-specific "caring" and "everyday" themes because people are pretty well aware that nurses play those roles, and that awareness has not been enough to get nurses the real respect and resources they need. But Mason makes excellent points, including her comments about nurses knowing when a hospital is not prepared, nurses being the ones to listen to, and nurses tending to get a hard time when they speak up. That was very much the story of Ebola in Texas, as would become clear soon after this interview.
 

A litany of damning assertions

The Los Angeles Times on Ebola treatment problems at Texas Health Presbyterian Dallas

Many major news outlets reported on the concerns of nurses about the infection control procedures at Texas Health Presbyterian Dallas, the hospital where Thomas Eric Duncan was treated and where Nina Pham and Amber Joy Vinson later became infected.Deborah Burger NNU On October 15, 2014, the Los Angeles Times ran "Nurses at Dallas hospital describe poor safety measures with Ebola victim," a piece that was credited mainly to Geoffrey Mohan and Tina Susman. Like many other reports, this one described a conference call with reporters in which Deborah Burger (right), co-president of the union National Nurses United, read a "statement outlining a litany of damning assertions" that were apparently based on statements by nurses at the hospital who did not want to be identified for fear of retribution. Although the union does not represent the nurses, its executive director RoseAnn DeMoro reportedly said that the nurses all worked at the hospital and had knowledge of Duncan's care. She said that the nurses were angered by suggestions by health officials that Pham's then-recent infection was the result of a mistake she had made. The fact that the nurses felt compelled to go through a union that does not even represent them, of course, says a lot about nursing disempowerment.

The statement from the Dallas nurses described "a confused and chaotic" response after Duncan's return to the hospital from which he had been sent home two days earlier, despite months of alerts from the Centers for Disease Control about the potential threat from Ebola. The nurses reportedly said that Duncan had spent hours in a room with other patients, that (in the piece's words) "the nurses tending him had flimsy protective gear and no proper training from hospital administrators in handling such a patient," and that "a nurse supervisor arrived and demanded that he be moved to an isolation unit, yet faced stiff resistance from other hospital authorities." The nurses said that although they encountered a lot of contagious body fluids in caring for Duncan, "they wore gloves with no wrist tape, flimsy gowns that did not cover their necks, and no surgical booties," and nurses who cared for him also performed "normal patient-care duties," putting others at risk. The hospital released a generic statement assuring that it was committed to safe care.

Jennifer JosephThe piece provides a fair amount of additional context. Jennifer Joseph (right), a friend of Pham's, said Pham had confidence in the hospital's infection control protocols and "described Pham as a 'brilliant' and caring nurse who was drafted to tend to Duncan because of her calm demeanor and experience." Pham herself released a statement saying she was "blessed to be cared for by the best team of doctors and nurses in the world." The piece also reviewed the CDC's role in the case. These ranged from director Thomas Frieden's arguably inconsistent statements, alternately praising and faulting the hospital, to the agency's plans to launch a more robust "Ebola response team" to help hospitals with Ebola patients in the future.

This report is generally helpful, highlighting some powerful advocacy by the Texas nurses and National Nurses United. Pouring knowledgeIt certainly sounds like the nurses who provided most of the skilled care to Duncan did not have the equipment or information they needed to do so safely. Speaking up in this way, even if anonymously, helped to alert the nation to critical problems in Ebola preparedness as well as the key roles nurses play in Ebola care. And the description of the nurse supervisor who pushed for Duncan to be isolated is an example of strong patient advocacy. We do have to note, as we have in looking at other press pieces, that it's important that nurses not be presented as passive order-takers waiting for someone to pour knowledge into them. These are autonomous health professionals with college science degrees, and they do have a responsibility to take an active role in preparing for their own health care roles, from managers to direct care nurses. We doubt a piece about physicians would place all responsibility for Ebola preparation on some "hospital administrators" whose job it is to tell physicians what to do with patients. Some subtler elements of the piece also underline the sense that direct care nurses are not active or skilled; note the repeated references to nurses "tending" patients. The reference to Pham as "brilliant" doesn't mean a lot in isolation and without any specifics. Still, the report's overall presentation of nurses speaking truth to power is a good one.
 

On the road

Karin Huster's New York Times op-ed on the role of transportation problems in Ebola

Karin HusterIn the wake of the infections of the Texas nurses, U.S. nurses began placing a number of strong opinion pieces about nursing and Ebola in the mainstream media. One was an op-ed by Karin Huster (right, in pink), entitled "Fighting Ebola, and the Mud," which appeared on October 20, 2014 in the New York Times.

The main aim of Huster's op-ed is to highlight the role that poor roads have played in the crisis in Liberia where, the piece notes, she works for the NGO Last Mile Health. Huster describes a tortuous recent trip with an Ebola patient from the hospital where he had just been diagnosed to the nearest Ebola treatment center. The nurses accompanying the patient had to remain in their sweltering "full Ebola combat gear" for a 16-hour journey over 200 miles of muddy, cratered roads in the rainy season, occasionally stopping to help the patient out to urinate--"carefully spraying with chlorine everywhere he had stepped." After two more hours of negotiating to persuade the patient to enter the unit, the nurses disinfected the ambulance and could at last shed their suits.

Huster argues that in treating Liberia's thousands of Ebola patients, the nation's

dysfunctional transportation system is standing in the way. Patients have died on grueling journeys to treatment units. Blood samples have sat waiting for days, eventually becoming invalid.

Ebola, Mud, Karin HusterHuster offers several potential solutions. The best, she says, is building more accessible treatment centers so that less travel is needed. She notes that the U.S. military is doing this, but it is taking time; Save the Children has already done it to some extent. Huster also recommends decentralizing lab testing of blood samples, making more portable labs available, so that samples no longer need to go all the way to Monrovia, the Liberian capital. Summing up, she notes that Liberian "transportation issues only exacerbate the enormous difficulties of combating this disease," but that "health care workers and ambulance drivers put their fears aside and work nonstop to ensure that, no matter the cost, blood samples can be analyzed, and patients can reach a place where better treatment options await."

Huster's op-ed has a little about what nurses do for patients, although it is mainly a sense of just how difficult their job can be, sweltering in hazmat suits for hours and negotiating with understandably frightened patients. However, she does not really highlight nursing skills directly. The real value of her piece for nursing is the underlying fact that she, a nurse, has written this powerful piece of public health advocacy. The op-ed, appearing in one of the most prominent newspapers in the world, shows that nurses are articulate health professionals with a well-supported vision for improving care for Ebola patients.
 

Turning the policymaking tables

Theresa Brown's CNN piece on Ebola and increasing awareness of the importance of nursing

Theresa BrownTheresa Brown, who has written about nursing for the New York Times and other newspapers, published a piece on the CNN site on October 23, 2014, entitled "Ebola will elevate respect for nurses." The piece argues with some force that the outbreak will compel society to recognize the contributions of nurses. Along the way, Brown makes some very good points about the distance between what society thinks about nursing and what nurses really do, although her apparent view that the outbreak is certain to have a big long-term impact on nursing empowerment seems a little premature.

Brown starts by noting that at one time nurses had to give up their seats for physicians, observing that while those days are gone, "nurses didn't have a guaranteed seat at the health care policy table--until now." Brown observes that (as the items above show) the epidemic has brought nurses "fully into the national conversation about how to handle this potential public health threat," and she correctly argues that "for the overall good of our health care system, we need to stay there."

Brown points out that nurses have always worked on the front line in caring for patients with infectious diseases, but Ebola forced the public to recognize that. At first, she says, there was some "scapegoating" of nurses at the Texas hospital where the first U.S. infections appeared, from the initial failure to admit Thomas Duncan through Amber Vinson's travel after her infection. This time, Brown says, "the profession pushed back," citing the work of the American Nurses Association, National Nurses United, and others in pointing out that the CDC's infection control guidelines were "oddly lax." Brown seems to credit ANA more for the issuance of stricter CDC guidelines, but it seems clear that NNU's actions in publicizing the problems in Dallas were a critical factor.

Brown argues that these guidelines gave nurses and physicians "an unusual level of parity" in that they applied equally to both groups and that "registered nurses arguably outstrip medical doctors in importance because they face greater risk from Ebola than physicians." This is a good point, although Brown might have made clearer that to the extent parity between the professions is "unusual," it is because of sadly unequal levels of power, not any formal subordinate relationship, since nursing and medicine are distinct, autonomous professions. She does observe that nurses are "partners in care with physicians," and that nurses' input must count, because nurses are critical to why people are admitted to hospitals, not just workers who administer drugs and talk to families: 

Being a front line care provider means that nurses must be constantly alert to worrisome changes in patient condition: sudden shortness of breath, crushing chest pain or the inability to respond. Nurses are also the "final check" on all doctors' orders, meaning that before we implement the orders we need to verify for ourselves that they are correct. And it's the nurses' job to assess and report on what the patient needs, whether an increase in pain medicine, a change in diet or an emergency response team.

This is a generally good statement about what hospital nurses do, despite the unfortunate use of the term "orders" to refer to what advanced practitioners prescribe, a term that suggests nurses are subordinates who must comply with anything physicians want. We're also not sure why "final check" is in quotes, as if nurses were doing something other than, and perhaps less than, simply providing a vital check on physician practice.

Brown closes with a plug for the "National Nurse Act of 2013," proposed legislation which at that time would have established a "National Nurse" to "work with and complement the surgeon general in public health campaigns, including Ebola transmission, the need for flu shots, or worries about enterovirus." We're unsure why the name of the proposed law and the National Nurse position are in quotes, as if they were part of some odd nursey thing--we don't see "Surgeon General" in quotes, nor is it common to refer to the "Affordable Care Act." We assume these are not scare quotes.

Wrapping up, Brown notes that to ensure the best health care, "nurses need to take that chair we're now allowed to always sit in, and be welcomed with everyone else at the health care table." This is a good thought, but as with the comment at the start of the piece about a "guaranteed" place at the policymaking table, it seems very optimistic--"allowed to always sit in"? Have all hospital boards in the nation suddenly become composed mainly of nurses? Does the media now consult and report on nurses as much as physicians? Does the ANA have as much power as the American Medical Association? Perhaps these suggestions that nurses are now permanently guaranteed parity are conscious efforts to mold readers' behavior:  Angela NanniniThat is what Brown wants to happen, so she is going to help make it happen by saying it's already true. If so, we applaud the effort--which is guaranteed to succeed!

As you might imagine, though, not every nurse commenting in the media shares the view that nurses are assured of equal treatment, now or in the future, because of the recent media pieces about their role in Ebola care. For example, on October 30, 2014, the Boston NPR affiliate WBUR posted a strong piece by University of Massachusetts nursing professor Angela Nannini (right). She made a number of great points about nurses' traditional absence from health care policymaking, despite the key part they play in care for diseases like Ebola. And Nannini noted that so far, she had seen little evidence that nurses had actually been included at any Ebola policy-making table.
 

Science and compassion will overcome fear

Kaci Hickox on stigmatizing health workers in the Dallas Morning News and the Guardian

Kaci HickoxAnd that brings us to Kaci Hickox, who cannot be accused of having too rosy a view of how decision-makers and the public have reacted to the Ebola outbreak. Many people know Hickox as the Maine nurse who was not exactly welcomed back after her return from caring for Ebola patients in Sierra Leone and who then resisted the quarantines that the states of New Jersey and Maine tried to impose on her. People may not know that Hickox is a veteran public health nurse with experience in many developing nations as well as masters degrees in nursing and public health from Johns Hopkins.

One of the first things Hickox did that attracted public attention was to publish an account of her initial treatment upon arrival in the U.S. On October 25, 2014, the Dallas Morning News published "Her story: UTA grad isolated at New Jersey hospital in Ebola quarantine." In a long editor's note, the Morning News explained that Hickox, at the time still in quarantine in New Jersey, had written the piece with the help of Dr. Seema Yasmin, a Morning News staff writer who had "worked with Hickox as a disease detective with the Centers for Disease Control and Prevention."

In that first piece, Hickox explains that after her return from working with Doctors Without Borders in Sierra Leone, she was quarantined. Now she is "scared about how health care workers will be treated at airports when they declare that they have been fighting Ebola in West Africa." She describes her time at Newark Liberty International Airport, which included being kept in an isolated office for many hours while a succession of people in protective gear asked her questions, including at least one from the CDC. Meanwhile, she was "tired, hungry and confused." She reported that her temperature was taken with a forehead scanner at 98. Three hours passed with no information. She asked for food and drink and was given a granola bar and water.  Some time later, an official using a forehead scanner recorded her temperature as 101: "The female officer looked smug. 'You have a fever now,' she said." Hickox explained to the official that the reading was likely inaccurate, elevated because she was "flushed and upset."

Kaci HickoxAfter another three hours alone in the room at the airport, Hickox writes, she was driven to Newark's University Hospital with an escort of eight police cars: "Sirens blared, lights flashed. Again, I wondered what I had done wrong." She was escorted to a tent outside the hospital, where "infectious disease and emergency department doctors took my temperature and other vitals and looked puzzled"--her temperature was normal based on an oral thermometer, although a forehead scanner read 101 because, as a physician confirmed, she was flushed. Her blood was tested and came back negative for Ebola.

Kaci HickoxHickox says that, as she sat in the tent, she worried about health colleagues who would return home from treating Ebola patients, only to face potentially being made to feel like criminals. She describes her last night at an "Ebola management center" in Sierra Leone. There, she tried to help an afflicted 10-year-old girl having seizures--"I coaxed crushed tablets of Tylenol and an anti-seizure medicine into her mouth as her body jolted in the bed"--but ultimately the girl died. Hickox notes that the epidemic continues to ravage West Africa, so "we need more health care workers to help fight the epidemic in West Africa. The U.S. must treat returning health care workers with dignity and humanity."

This is strong, articulate advocacy for health workers who treat Ebola patients, and by extension for the patients themselves, since deterring professionals from providing Ebola care by confining and ostracizing them on their return ultimately hurts the patients. Hickox is understandably baffled at her treatment, since she knows that she would not be contagious without symptoms--a fact the piece might ideally have included.

Of course, it's not clear if stressing that fact or any other would have reduced the nation's strong negative response to Hickox's advocacy. This piece alone generated more than 5,300 comments on the Morning News site as of October 29, just four days after it was posted. Many comments opposed Hickox in harsh personal terms, revealing the commenters' fear and ignorance about the true nature of Ebola risks, as well as, in many cases, partisan political hatred. A common theme was that Hickox was a selfish person who was willing to endanger others and/or just looking for fame and attention, as if she had sought the treatment described in the piece so she could become a famous troublemaker. Kaci Hickox Saturday Night Live A few comments also seemed to reflect indignation that some uppity nurse would be pushing back--in other words, not acting like a handmaiden or an angel, two key nursing stereotypes. A related media narrative was that Hickox was aggressive and reckless to the point of being unhinged, as a November 1, 2014 Saturday Night Live parody suggested, an image that seemed to draw on the battle-axe stereotype. We doubt she would have generated such powerful reactions had she been a physician. She did have a few strong defenders. In any case, Hickox did much to engage the nation in a worthwhile debate about how health workers who care for Ebola patients should be treated and she deserves a lot of credit.

On November 17, more than 21 days after Hickox's last day of caring for Ebola patients, she published another piece, this time in the Guardian. The piece, to which her lawyers "contributed," commendably includes her basic educational background and international experience. "Stop calling me 'The Ebola nurse'" essentially picks up where Hickox's prior advocacy left off. She begins by stressing that she never had Ebola and has now passed the incubation period, "so please stop calling me 'the Ebola Nurse' -- now!" Hickox proceeds to go after the "overzealous politicians" who quarantined her:

My liberty, my interests and consequently my civil rights were ignored because some ambitious governors saw an opportunity to use an age-old political tactic: fear. [New Jersey Governor Chris] Christie and my governor in Maine, Paul LePage, decided to disregard medical science and the constitution in hopes of advancing their careers. They bet that, by multiplying the existing fear and misinformation about Ebola -- a disease most Americans know little about -- they could ultimately manipulate everyone and proclaim themselves the protectors of the people by "protecting" the public from a disease that hasn't killed a single American. Politicians who tell lies such as "she is obviously ill" and mistreat citizens by telling them to "sit down and shut up" will hopefully never make it to the White House. Here's my good news: the unconstitutionality of forcing asymptomatic healthcare workers into in-home quarantine was determined by due process of law, and a courageous and insightful judge agreed with science and public health law.

Kaci Hickox and Ted WilburHickox goes on to note that the "disregard for reason" extended to her partner, Ted Wilbur (right), who was banned from his Maine nursing school after she returned from Africa. It even affected the health workers who had to cancel their attendance at the American Society of Tropical Medicine and Hygiene's annual conference because of Louisiana's misguided quarantine policy for those coming from West Africa--"interfering with the legitimate expansion of knowledge to help combat the disease, thanks only to illegitimate fear." Hickox finds it disheartening that politicians are "still escalating anxieties and giving the public permission to discriminate, stigmatize and even hate aid workers like me." She notes that she went to Africa to help but, despite her efforts, watched people quickly deteriorate and die. She emphasizes the need for U.S. policies that encourage health workers to help:

Workers returning from West Africa must be supported -- and the first step of that support process is to make sure that evidence-based policies are developed and implemented by public health officials so that aid workers get the monitoring and care they need and the public are simultaneously protected. No one should be victimized by being placed in a quarantine if they do not have any symptoms of Ebola, because asymptomatic people are not a health risk.

Hickox says that she wants "to live in a country that understands Ebola," one that reaches out to returning aid workers with love and support: "We can define compassion, instead of being ruled by fear and fear-mongers." She urges readers not to let politicians divide them or "make public health policy without the input of the scientific community." She concludes: "I, for one very healthy example, hope that humanity, science and compassion will overcome fear so that we can conquer Ebola. It can be done. It must be done."

Kaci Hickox and Ted WilburThis is another strong, persuasive piece of advocacy. Hickox argues forcefully that stoking fear and stigmatizing health workers will only undermine efforts to fight Ebola, as well as, needless to say, harming health workers and those close to them. In particular, Hickox chooses powerful examples to support her rhetoric, such as the supremely ironic application of Louisiana's scientifically baseless quarantine rule to effectively bar participation at a conference aimed at increasing understanding of diseases like Ebola. On the whole, this is another compelling and valuable subversion of the stereotypes that nurses are low-skilled handmaidens and smiley angels. We thank Kaci Hickox for her courage and skill in advocating in the media for decent treatment of nurses and all health care workers.
 

Agonizing and abandonment

In this long New York Times report, Ebola care in Liberia seems to be mostly about the expatriate physicians

Despite all of the generally helpful pieces like those discussed above, much of the coverage of the 2014 Ebola outbreak by the elite news media has followed traditional patterns, sending the message that physicians are the ones who really matter in Ebola care. Granted, such items were somewhat more likely to appear before Kaci Hickox, Nina Pham, and Amber Vinson became household names.

Sheri FinkThe New York Times has run notable examples of unduly physician-centric coverage, some written by its prominent physician reporter Sheri Fink (right). One particularly striking problem at the Times is that the persons responsible for the paper's Ebola headlines and photo captions regularly use the term "doctors" even when the piece or photo is not entirely about physicians, or even about them at all. That may occur because of an assumption that any media item about health care must be mainly about physicians, or simply a view that "doctors" serves as an adequate shorthand for all health workers, perhaps because of the damaging misconception that physicians manage all health care.

On August 16, 2014, the Times published a report by Fink headlined: "With Aid Doctors Gone, Ebola Fight Grows Harder." For this piece, the headline was probably fair, because the long, comprehensive piece was to a large extent about physicians, and it did wrongly suggest that expatriate physicians were the ones who really mattered in Ebola care in Liberia--a striking distortion of the reality that Ebola care is mainly a nursing endeavor.

Fink sets the stage immediately, emphasizing the "wrenching choice" facing Clarine Vaughn in Liberia: "Should she send home, for their own health and safety, four American doctors working for Heartt, the aid group she led there?" After "much agonizing," Vaughn "pulled the doctors out and canceled plans to bring in more." African physicians and nurses who were left behind reportedly "felt abandoned." Questions Sheri Fink might have askedFink briefly broadens the discussion to include the "departure of many Western development workers from Guinea, Liberia and Sierra Leone, the West African countries hit hardest by Ebola," which has "further weakened the region's understaffed health systems," only to return immediately to the physicians-are-everything theme: 

Liberia, population four million, has fewer than 250 doctors left in the entire country, according to the Liberia Medical and Dental Council. Seven doctors there have contracted Ebola, and two of them have died.

How many local nurses have died? How many were there before, and how many now? And what about expatriate nurses--have they been pulled out? What was the effect--were there feelings of agonizing and abandonment?

The piece does then give a more general update on the status of Ebola care in West Africa. The report speaks more broadly of "volunteers" and even quotes one local nurse (!) along with five identified physicians (all in leadership positions in health or international aid organizations) and other aid workers. Fink describes the local sense that something very bad is happening and that the locals are on their own, noting that "at least 170 workers have gotten the disease, according to the World Health Organization, and more than 80 have died." She does not break that total down, but she does name one patient:  Dr. Kent Brantly, the American treated at Emory who eventually recovered.

Questions Sheri Fink might have askedThe report notes that the situation has been "volatile," and this is where the nurse comes in. The piece explains that recently several hundred protestors had gathered in Monrovia's "West Point slum" and broken into "a former school that had been converted days earlier into a holding center for people with suspected Ebola."

Samuel Tarplah, 48, a nurse running the center, said Saturday evening that the protesters wanted to shut it down. "They told us that we don't want an Ebola holding center in our community." He said the intruders stole mattresses, personal protective equipment, even buckets of chlorine that had just been delivered. "They took everything."

So the local nurse is worth consulting about the basics of criminal activity, but not specific aspects of Ebola care. Later, the piece returns for more local color from Tarplah. The nurse, who served in the military during Liberia's civil war, says:  "The enemy you're fighting you don't know. This one is worse than the war . . . . In a war, the bullet only strikes one person." Those are powerful quotes, but again, nothing revealing nursing expertise.

Among the physician experts the piece quotes is Doctors Without Borders president Joanne Liu, who emphasizes the severity of the epidemic and reports "an acute need for materials as well as for more human resources -- and not just experts and bureaucrats, but also the kind of person who is ready to 'roll up his sleeves.'" Hmm--we wonder who that might be. World Bank president Jim Yong Kim, who is also a physician, notes that "skilled health care workers with the right equipment can snuff [Ebola] out"--another statement that at least does not put things mainly in terms of physicians.

But the piece's final paragraph does. There, Fink emphasizes that the Heartt program's director Vaughn

said she hoped that trained infectious-diseases doctors and C.D.C. experts would help bring the outbreak under control and create mechanisms to protect health workers. That would allow her organization to convince American universities that their medical residents can safely return to Liberia.

Thus, the piece concludes with another strong suggestion that physicians are the keys to Ebola care.
 

Welcome to afternoon

In another long New York Times report, Ebola care in Liberia seems to be mostly about the expatriate physicians

Exactly two months later, on October 16, 2014, the Times ran another long Sheri Fink report from West Africa, this one focused on the experience of volunteer U.S. physician Steven Hatch (below) in treating Ebola patients in Liberia. A number of elements in the article, especially the photos and videos, suggest that only Hatch and the other physicians really matter, although the piece does include some text about U.S. nurse Bridget Mulrooney--the same nurse whose Guardian account, discussed above, appeared a few days earlier.  

Steven Hatch Ebola physicianLet's start with those photos and videos. The piece's headline sounds pretty general: "In Layers of Gear, Offering Healing Hand to Ebola Patients in Liberia." But the images are a different story. All four photos are of physician Hatch, mostly by himself, but even when he is with others, he is the only health worker identified. One video features a physician showing how to don Ebola protection gear, assisted by an unnamed "helper." The caption: "To enter the Ebola ward in Suakoko, doctors must dress in a sealed protection suit resistant to splashes and punctures. No skin can be left exposed. Dr. Colin Banks demonstrates the process." The last video shows a health worker, identified as an "assistant," decontaminate another health worker, identified as a "doctor"--it seems to be Banks. The caption: "After leaving the Ebola ward, doctors must get properly sanitized so they do not spread any of the Ebola virus." So the important thing is examining what physicians undergo to work with Ebola. Never mind all the other health workers--many of whom actually spend more time confronting the hazards and discomfort involved.

Most of the text traces Hatch's journey from his work as a disease specialist in Massachusetts to his current stint at a Liberian clinic run by the International Medical Corps. Hatch's efforts to cope with the dangers, the protocols, and the heat drive the piece. We also hear about his interactions with other physicians, including Banks, who is a Stanford emergency physician, and Abraham Borbor, one of Liberia's "top physicians" until his death from Ebola in August. It was Borbor's death that motivated Hatch to volunteer for his current four-week stay, since Hatch had taught medical residents with Borbor the previous year in Monrovia, apparently for two weeks. The piece explains that Hatch first took a CDC training course in Alabama that nurse Bridget Mulrooney also attended. The report includes a little about their efforts to learn Ebola infection control in a simulated treatment unit.

The text does devote some attention to Mulrooney--which makes sense since, as the report notes, she "had volunteered in other crises and had worked four years in Haiti." It includes some quotes from her about her difficult first days at the Liberian treatment center, when she saw children die. Hatch, arriving a week later, noted that she had lost weight. Yet we also hear that Mulrooney "serves as a motivator. 'Welcome to afternoon!' she said one day, doing a little dance for a nurse who had come in on her day off." Bridget MulrooneyAnd while the report notes that Hatch "carried a malnourished 9-year-old girl, Blessing Gea, into the unit for those confirmed to have the disease," the piece then focuses on Mulrooney's care for her:

The next night, Ms. Mulrooney, clad in full protective gear, tended to the lonely little girl. She let her lean against her as she squeezed a packet of peanut butter-based supplement into the child's mouth. She changed her clothing, put new sheets on her bed and wrapped her in a fuzzy blanket for the chilly night, stroking her head. Three days later, a blood test showed the girl had recovered from Ebola.

This is a pretty good passage because it does give some specifics of what the nurse does for patients, with apparent good results, although of course the tasks described do not highlight technical skill. In any case, on the whole the piece is a vehicle to experience Ebola treatment in West Africa through the eyes of a U.S. physician.
 

Nurse staffing is critical, say esteemed physicians

New York Times highlights "supportive care" for Ebola, but sees no need to consult those who provide it

Denise GradyOn October 31, 2014, the New York Times ran a long article by Denise Grady (right) that focused on the urgent need for more staff to provide intensive "supportive care" to treat Ebola symptoms in Africa. The report pointed out that the availability of this care in the United States has been critical to the far lower mortality rate. Although most of the care discussed in the piece would be nursing, the piece did not quote a single nurse, relying instead on a half dozen physicians and carefully explaining the special expertise of each one. Despite all the information in the piece about how important nursing is in treating Ebola, the piece's approach suggested that physicians are more expert than nurses even about nursing, that nurses are not in charge of their own profession--perhaps they are like medical equipment, just something else physicians deploy--and, to some extent, that nursing is not very difficult intellectually, with one physician noting that the fluid replacement needed is "not rocket science."

"Better Staffing Seen as Crucial to Ebola Treatment in Africa" is mainly a series of quotes by these six experts. Physician Rick Sacra contracted Ebola in Liberia and recovered at Nebraska Medical Center. Nurse delivering intensive IV therapyHe contrasts the woefully poor staffing in Liberia, where each nurse cares for 15 or 20 patients and cannot work long because of the heat, with what the piece describes as the "meticulous intensive care that saved" him in the U.S., where a nurse never left his room and "dozens of people were involved in his care." The well-known physician Paul Farmer, a Harvard professor and co-founder of aid group Partners in Health, urges a "medical moon shot" to improve African health systems and says that we can get Ebola under control with "the four S's . . . Staff, stuff, space, systems." Physician Daniel Bausch, a Tulane infectious disease specialist who has treated Ebola patients, makes the not-so-helpful observation that fluid replacement requires good staffing but is "not rocket science" since it is routinely done in the U.S. However, those who actually do the work know that monitoring and replacing the fluids and electrolytes of critical patients such as those with Ebola, cholera, or burns can be complicated and challenging, and should be done by skilled, well-educated nurses.

Physician Bruce S. Ribner, who reportedly "directed the care of patients evacuated" to Emory, says that "his medical team" was surprised by the amount of fluid and potassium lost and "alerted doctors at treatment centers in Africa that patients there might need more replenishment than expected." ToolsSo evidently Ribner was in charge of all the care given at Emory, "his medical team" was surprised about the losses, and they "alerted doctors" in Africa about it--all of which suggests that physicians direct rehydration and the rest of nursing care, while nurses are just physician tools.

Some of the language in the piece also reinforces the sense of physician dominance. One paragraph begins by explaining that "doctors say" that the key to surviving Ebola has been "a higher level of 'supportive care' to treat deadly symptoms like severe fluid loss and organ failure." The article explains that this means giving IV fluids and salts--guess who does that? The report notes that U.S. patients also got experimental drugs or plasma, but "doctors say rehydration played a major role in saving them."

There are a few helpful quotes from physician Armand Sprecher, "a public health specialist for Doctors Without Borders." Sprecher says that Ebola wards need high levels of staffing, particularly with the heat and infection control challenges, and that rather than more ventilators or infusion pumps, he would most want "more person-hours of skilled nursing for patients." Of course, the report undermines this somewhat be describing it as a "need for more pairs of hands." At another point Sprecher is explaining the need to develop better options to deliver food to stricken patients: "Intravenous nutrient solutions may be needed, he said, but they are not simple to administer, and the obstacle once again is staffing." Ah--not simple to administer? This again suggests that there is a need for skilled nursing, whether it's "rocket science" or not. Sprecher also discusses the importance of finding some way to routinely monitor electrolytes so as to "fine-tune" treatment for severe fluid loss, and although nursing is not mentioned directly, it again sounds like that calls for some health care skill.

But overall, the piece presents information about the importance of nursing in a way that still suggests nurses are marginal physician subordinates.
 

White coat syndrome

Media messages big and small about which Ebola care givers really matter

Many shorter media items about the Ebola outbreak have undervalued nursing while overstating the role of physicians. Several trends are worth noting.

Some pieces simply report on the role and status of physicians as if that was all that mattered. It is common to hear the status of affected nations described in terms of very low physician-to-population ratios, but far less likely that a major media report would even mention how few nurses such nations may have. In addition to the August 16 piece in the New York Times, discussed above, a September 25, 2014 CNN report by senior medical correspondent Elizabeth Cohen was headlined "Battling Ebola: Two Doctors for a County of 85,000 People." Gorbee LoganAs you might expect, one of these two physicians that Cohen profiled, Gorbee Logan (right), is portrayed as the most precious resource known to humanity. The piece explains that Logan has been "working around the clock" to treat Ebola patients even though he has not been given the real Ebola treatment unit he desperately needs. The piece does say at one point that "Logan and his staff are doing a heroic job" treating Ebola under the circumstances--note the suggestion of his supervision of all staff there--but that's about as close as we got to any mention of the critical nursing role explained in the October 31 New York Times piece just above. Readers could be forgiven for thinking that all that matters in Ebola care is how many physicians there are.

Another variation is the coverage when a physician dies of Ebola. Any such event is tragic and worth attention, of course, but an extraordinary disparity in media treatment shows the undervaluation of health workers who are not physicians. Godfrey GeorgeOne such piece was the November 3, 2014 Associated Press report by Clarence Roy-Macaulay, "Sierra Leone says another doctor dies of Ebola." The 236-word item was mainly about the death of Godfrey George, the medical superintendent of Kambia Government Hospital and the "fifth local doctor" in the nation to die of the disease. That was "a blow to efforts to keep desperately needed health care workers safe in a country ravaged by the deadly virus." The piece notes that the nation's health system was already fragile:  "The country had two doctors for every 100,000 people in 2010, compared to about 240 doctors for the same number of people in the United States, according to the World Health Organization." The piece does say that "doctors and nurses have been particularly vulnerable to contracting Ebola." But we don't hear about any nursing deaths--even though they have almost certainly been far more numerous, based on other reports, such as the August 23 New York Times piece noting that 15 nurses had died at one hospital alone. Nor do we get any data about the critical shortage of nurses in such nations, which is, of course, especially devastating now because of the importance of nursing in Ebola care. We have never seen a stand-alone piece like this one about the death of an African nurse from Ebola.

Joanne LiuIn other media items, the undervaluation of nurses and other health workers is more subtle. For example, on August 19, 2014, the New York Times posted a short video in which Doctors Without Borders president Joanne Liu spoke of her group's

need for people with hands-on, in the field, who are willing to roll up their sleeves and do the work, not being behind computer, we need operational people, they're gonna go from house to house to explain what is Ebola, they're gonna go from house to house to go and find where are the contact tracing, that's what we need.

How did the Times summarize Liu's plea? Let's check the headline:

"Ebola Aid Official on Need for Doctors"

And the video caption:

Dr. Joanne Liu, president of Doctors Without Borders, describes the lack of doctors in the field to help Ebola patients.

So even though Liu was very clear that she needed health workers who would go into the field and canvass neighborhoods, and perhaps provide hands-on care, whoever created the Times identifiers translated that into a request for physicians. Perhaps the Times assumed that whatever specific words Liu may have used, she must surely have wanted physicians, or that physicians are, again, an adequate shorthand for all health workers, since they presumably direct them all and physician knowledge encompasses all health knowledge. Whatever the reason, the result is a damaging distortion of Liu's request and, incidentally, a damaging message about who is vital in addressing the Ebola crisis.

Of course, it must be said that the name of Liu's organization--Doctors Without Borders--itself suggests that only physicians work for the group, so perhaps the Times should be forgiven. Indeed, one of the Truth's leaders spent years in Cambodia, where MSF had a substantial presence, yet she did not even consider seeking to work for the group because she assumed, based on its name, that it would not employ nurses. As it turns out, however, nurses outnumber physicians within MSF. We have been asking MSF for almost a decade to change its name to one that does not suggest it is all about physicians, in part because that can easily lead to damaging assumptions like the Times made in this case.

Nina Pham released from NIHConsider things as seemingly innocuous as the October 25, 2014 photographs published by the Associated Press and other news entities showing Nina Pham being released from a National Institutes of Health hospital in Bethesda upon her recovery from Ebola. Although nurses surely played critical roles in the recovery of Pham--herself a nurse who got Ebola while providing Ebola care--on her release she and her family appeared in a sea of white coats, presumably all or virtually all physicians. We realize many of these people were high-ranking NIH officials (who perhaps just happened to all be physicians). And we can't really fault the media for simply photographing the event as NIH set it up. But the message, again, was that physicians direct if not conduct all important Ebola care and they are the ones who deserve credit for Pham's recovery.
 

The Ebola fighters

Time's "Person of the Year" feature is mostly about physicians, but it does make a point of crediting nurses, including Liberia's Iris Martor

Toward the end of the year, some tried to step back and look at how the crisis had played out, with an eye to the future. This year Time magazine's "Person of the Year," described in a special double issue dated December 22 and 29, 2014, was "The Ebola Fighters." One goal of the massive feature story is to recognize a diverse group of courageous health workers who did their best to manage the outbreak despite bureaucratic fumbles and irrational fears. And as part of this, the piece does describe the nursing role in Ebola care to some extent, even including photos of and brief text by Liberian nurses Augustine Bindi and Princess Ideko, along with Kaci Hickox, Nina Pham, and Amber Vinson. There is a particularly good passage describing the efforts of Monrovia school nurse Iris Martor in organizing teams to canvass poor neighborhoods, searching for Ebola and addressing other health issues. Jerry Brown Ebola fighter TimeOn the whole, though, the magazine's year-end feature follows the familiar model, focusing to a disproportionate extent on the acts and thoughts of physicians.

The magazine actually ran five covers on each paper copy, in a row at the front of the issue. The first cover--the outside one that everyone would see--was of Jerry Brown (right), the "Liberian surgeon [who] turned his hospital's chapel into an Ebola treatment center." The four that followed were Liberian nursing assistant Salome Karwah--though unlike the others her job was not mentioned along with her cover photo--U.S. health educator Emma Watson-Stryker, Liberian ambulance supervisor Foday Gallah, and U.S. physician Kent Brantly. So, while 40% physicians and no nurses does not exactly give an accurate impression of who provides Ebola care, the covers do at least convey some of the diverse team that has been addressing the problem globally. And the first page of the issue past the covers shows four Liberian "nurse-hygienist trainees." This outward focus on those working in Liberia and the United States is reflected in the rest of story.

The "Person of the Year" feature, which spans 44 pages of text and ads, consists of a long narrative about the epidemic interspersed with photos of notable figures, along with some text by those in the photos. It seems likely that the eye-catching photos and accompanying text will get more attention than the long narrative that winds slowly through more than 30 pages of other material, so let's start with the photos. Of those whose subjects are identified by name (the vast majority), there are:

7 physicians (including Brown and Brantly),
5 nurses (Bindi, Ideko, Hickox, Pham, and Vinson (the last two share one photo)),
1 nurse's assistant (Karwah),
4 members of a "body-management team,"
1 ambulance supervisor (Gallah),
1 "health promoter" (Watson-Stryker),
1 geneticist,
1 virologist, and
1 other non-profit worker.

The comments of the Liberian nurses are short, general statements of purpose and resilience, although Bindi does make the revealing comment that they are fighting Ebola "through the grace of almighty God and the help of Dr. Brown." Vinson and Pham tell why they wanted to provide Ebola care despite the risks. To her credit, Vinson goes after the media as "disappointing in some ways, because it promotes fear"--a concern that was presumably influenced by widespread media criticism of her plane travel prior to developing significant symptoms. And speaking of fear, Hickox's text mainly summarizes her Newark adventure, closing with a note that she has seen both the devastation that Ebola itself causes and the "stigma that fear of this disease brings."

The text by the physicians, who are generally in leadership roles, tends to have more of a clinical focus and to be much longer than the nurses' statements (with the unsurprising exception of the text by Hickox). Besides Brown and Brantly, Joanne Liu describes some of the difficult aspects of directing MSF during the crisis, from persuading the WHO to take the outbreak more seriously to having to turn patients away because of lack of space. Bruce Ribner discusses the general infection control approach at Emory. Peter Piot describes discovering Ebola in a lab in the 1970s. Liberian Philip Ireland relates his own experience in recovering from Ebola. And Tom Frieden describes some notable aspects of the CDC's response to the crisis, including difficulties with the WHO.

The feature begins with a short essay by Nancy Gibbs explaining why Time chose the Ebola fighters as "Person of the Year" (rather than runners-up like the Ferguson protesters or Vladimir Putin). This essay offers an overview and some telling quotes from the players named above, including a good one from Hickox about the absurdity of spending so much time debating how to monitor health workers returning from "Ebola-endemic countries," when that time should be devoted to stopping the outbreak in West Africa.

David von DrehleThe main narrative, "The Ones Who Answered the Call," is mostly by David Von Drehle (right). It begins with a long description of the work of Liberian physician Jerry Brown and expatriate physicians working with him in preparing for Ebola with limited resources in Monrovia, including making the chapel a treatment center. After this long account ends with frustration at government and WHO inertia, the piece asks why the early efforts were left to volunteers--"doctors who wouldn't quit even as their colleagues fell ill and died; nurses comforting patients while standing in slurries of mud, vomit and feces; ambulance drivers facing down hostile crowds to transport passengers teeming with the virus; investigators tracing chains of infection through slums hot with disease; workers stoically zipping contagious corpses into body bags in the sun; patients meeting death in lonely isolation to protect others from infection?" That is a lot of dramatic activity--too bad the nurses are just "comforting" in the midst of filth, the kind of noble but not necessarily skilled work that has long reinforced the angel stereotype. We've just heard a lot about the physicians and others thinking, deciding, acting, and dying--did the nurses do any of that?

The physician experience continues to drive most of the narrative, as we learn about the chaos when Ebola overwhelmed Monrovia. One of Brown's colleagues was Kent Brantly, and the piece offers detail on his work and eventual infection. The feature also describes the efforts of Liu, Watson-Striker, and others at MSF, "arguably the most effective--and inarguably the cockiest--medical-relief organization in the world." And, we might add, the one whose name is inarguably the most damaging to nursing, suggesting as it does that the group is all about the work of physicians. The piece describes the skeptics and bureaucrats at WHO offices, one of which reportedly obstructed the efforts of the CDC to address the crisis early in Guinea. We learn about Liberian epidemiologist Mosoka Fallah, who did vital contact tracing to contain the spread of the disease in the Monrovia community. The piece also devotes some time to Bruce Ribner and his work in setting up the infectious disease treatment facility at Emory starting in 2001, a facility that apparently had virtually no patients until the 2014 Ebola outbreak. The heroic work of Monrovia ambulance driver Foday Gallah receives an appropriately long review. And the piece gives background on the original discovery and mechanics of Ebola itself.

What we do not hear as much of is nurses playing any kind of leadership role in managing Ebola, with two exceptions. Kaci Hickox and Ebola health teamA limited one relates to Hickox, not only for her strong advocacy against the needless quarantine and the stigmatizing of health workers, but also for a short passage in the main narrative about her work in Sierra Leone:

Deployed to Bo, Sierra Leone's second largest city, Hickox stepped into a grueling routine. "International staff typically works 12-to-14-hour shifts six days a week," she says. "It was in the high 90s when I was there and the suit is not breathable, because it's made to not be absorbent. You can only be in the suit for about an hour because of the heat--but on days when we had 35 patients in the unit and maybe nine health workers, you have a very limited time to meet the patients' needs." How can you properly comfort and encourage a patient who is moaning in agony when you're peering through fogged-up goggles and shouting through a double mask? Fighting Ebola, in other words, means living with "such a terrible feeling," Hickox says, a sinking, haunted sensation that no matter how much you've done, you could have done more.

What Hickox actually has to say shows knowledge, authority, and humanity--she is a serious health professional--but note how the text immediately undermines that impression by suggesting what she does is "comfort and encourage." Of course she does that, and it's very important, but everyone knows that about nurses (it's certainly consistent with the angel and handmaiden stereotypes) and without more, it will sound to most readers like she is not doing anything that requires much health education or skill.  

Iris MartorFortunately, one longer passage in the main narrative offers a clear example of nursing expertise and authority. That is an account of the work of Iris Martor (right), a nurse working at a school for vulnerable girls in Monrovia called the More Than Me Academy. Martor, along with US-born school founder Katie Meyler, reportedly "became Ebola fighters because there was no one else to turn to."

Overnight, they converted the school into an ad hoc disaster-response center, holding meetings, organizing food distribution and even setting up an ambulance service for West Point with funds from a wealthy donor. . . . While [Meyler] established a temporary orphanage and quarantine program for children whose families were in treatment or wiped out, Martor organized a team from the More Than Me school to visit the homes of every student. "Praise be to God," she recalls, "none of them had gotten sick." But Martor realized their health was fleeting if the virus infected their neighbors. She went to Meyler with the suggestion that More Than Me sponsor teams of locals who could canvass as much of West Point as they could, house by house. Wearing boots and rain gear provided by the school, the "case finders" slogged through the muddy, viral streets. Martor's team followed Meyler's in their wake, keeping an eye out for developing Ebola cases but tending to other health issues in the community too. It was dangerous work because no one knew which houses were contaminated. Quote from Iris Martor"Don't touch," Martor instructed her nurses. "Don't sit." Late in August, Martor's infant daughter spiked a fever, followed by vomiting and diarrhea, and Martor was awash with fear that she had brought death into her own home. But it wasn't Ebola, and the child recovered, leaving Martor to reflect on the risks she was taking and why she would do such a thing. "Initially, I was afraid. I should admit that," she says. "But then thinking and looking at it critically--if I don't help, I will still not be free." Ebola would pose a danger until it is stamped out, and why shouldn't she be part of the effort? "If someone from America comes to help my people, and someone from Uganda, then why can't I? This is my country. I should take the first step."

Martor is presented here as a autonomous community health leader and innovator, organizing programs and instructing "her" nurses, being honest about the risks and her fears--not an angel--but persisting nonetheless.

On the whole, though, despite the fine work of all the nurses and other health workers identified, the Time piece is mostly an account of creative thinking and bold acting by physicians.
 

She'll be a great giant of Liberia

CNN on Fatu Kekula and the trash bag method

Fatu KekelaBut there is one, far shorter, year-end piece that is not physician-centric. That is a December 10 CNN report by Jen Christensen and Elizabeth Cohen headlined, "Woman who saved relatives from Ebola coming to U.S. for nursing school." It tells the remarkable story of 22-year-old Fatu Kekula (right), a Liberian in her last year of nursing school who saved the lives of three of four relatives who contracted Ebola by nursing them herself, using nothing beyond nursing knowledge, determination, and her own equipment, notably a "trash bag method" of infection control she developed. That appears to consist of wrapping her body parts in, yes, trash bags. The piece explains that after earlier CNN coverage, a nonprofit group started a campaign to help Kekula finish nursing school in the U.S. And the reporters take the liberty of noting that Kekula "definitely" holds a place among those being honored by Time's "Person of the Year" feature, even though she is not named there.

The report explains that when Kekula's parents, sister, and cousin got Ebola in July, she single-handedly took care of them. All but her cousin survived, which as the piece notes is a 25% mortality rate--much better than the overall estimated rate of 70%. And Kekula herself avoided the disease, even though "she didn't even have personal protection equipment -- those white space suits and goggles used in Ebola treatment units."

Fatu KekelaInstead, Kekula invented her own equipment. International aid workers heard about her "trash bag method" and taught it to other West Africans who can't get into hospitals and don't have protective gear of their own. Every day, several times a day for about two weeks, Kekula put trash bags over her socks and tied them in a knot over her calves. Then she put on a pair of rubber boots and then another set of trash bags over the boots. She wrapped her hair in a pair of stockings and over that a trash bag. Next she donned a raincoat and four pairs of gloves on each hand, followed by a mask. It was an arduous and time-consuming process, but she was religious about it, never cutting corners. UNICEF Spokeswoman Sarah Crowe said Kekula is amazing. "Essentially this is a tale of how communities are doing things for themselves," Crowe said.

Well, essentially this is a tale of how someone who had almost finished nursing school had done a thing for herself and her family. Fatu KekelaJust at this point, ironically, the online post includes a link to Cohen's earlier story about how the shortage of physicians is so devastating to Ebola care in Liberia ("Two doctors for 85,000 people").

Giving a little background, the piece says that Kekula's 52-year-old father got Ebola while at a hospital in Kakata for high blood pressure; then "the hospital closed down because nurses started dying of Ebola." Fatu took him to Monrovia, where three hospitals turned them away, then back to Kakata, where another hospital failed to do much, so she took him home. Unfortunately he then infected her 57-year-old mother, her 28-year-old sister, and their 14-year-old cousin. The piece notes that she "consulted with their family doctor, who would talk to her on the phone, but wouldn't come to the house." She got medicines from the local clinic and gave fluids "through intravenous lines that she started." It was stressful--at times their blood pressures dropped severely. But after two weeks, all but her cousin were recovering, and there was space for them at JKF Medical Center, one of the Monrovia hospitals discussed in the Time piece. Unfortunately, her cousin never recovered, and died at the hospital.

Looking to the future, her proud father started looking for funds to allow Kekula to finish nursing school. Because the epidemic had shut down many of Liberia's schools, including hers, she applied to Emory, which accepted her. The charity helping to raise the funds, iAMprojects, raised $40,000 for tuition, expenses, and travel. On its website, iAMprojects makes the point that one factor in Kekula's remarkable achievement was her three years of nursing education, an education that is well worth completing so she can help others. Indeed, the CNN piece closes by noting that her father has no doubt that his daughter will go on to save many more people: "I'm sure she'll be a great giant of Liberia."

Fatu KekelaThis report is generally great because it explains exactly what Kekula did to save her family, including a number of things that would call for nursing skill. Obviously, devising the "trash bag method" was critical, and the piece makes the valuable point that that method has been adopted elsewhere for situations in which other equipment is not available. In addition, starting and maintaining the IV lines is not something just anyone could do. And the piece repeatedly makes clear that Kekula saved her family's lives; no one tries to deflect the credit elsewhere.

We thank CNN and all the press entities that have managed to convey something of the importance of nursing in the global efforts to stop Ebola in 2014. That kind of reporting is not common enough, but like Kekula's work, it is worth encouraging.

 

See the articles:

"I'm the head nurse at Emory. This is why we wanted to bring the Ebola patients to the U.S. These patients will benefit -- not threaten -- the country," by Susan Mitchell Grant, posted on The Washington Post site on August 6, 2014. (pdf archive)

"Those Who Serve Ebola Victims Soldier On," by Adam Nossiter and Ben C. Solomon, published by The New York Times on August 23, 2014. (pdf archive)

"'A teenage girl bled to death over two days': Ebola nurses describe life and death on the frontline," The Guardian, by Bridget Mulrooney, Sue Ellen Kovack, and Anine Kongelf, posted on October 13, 2014. (pdf archive)

"Nurses Want To Know How Safe Is Safe Enough With Ebola," NPR, interview by Nancy Shute, October 14, 2014. (pdf archive)

"Nurses at Dallas hospital describe poor safety measures with Ebola victim," The Los Angeles Times, October 15, 2014, by Geoffrey Mohan and Tina Susma. (pdf archive)

"Fighting Ebola, and the Mud," by Karin Huster, published in The New York Times on October 20, 2014. (pdf archive)

"Ebola will elevate respect for nurses," by Theresa Brown, posted on the CNN site on October 23, 2014. (pdf archive)

"As U.S. Hospitals Prepare Ebola Response, Nurses Must Have A Seat At The Table," by Angela Nannini, posted on the WBUR site on October 30, 2014. (pdf archive)

"Her story: UTA grad isolated at New Jersey hospital in Ebola quarantine," by Kaci Hickox, published in the Dallas Morning News on October 25, 2014. (pdf archive)

"Stop calling me 'the Ebola nurse'," by Kaci Hickox, published on November 17, 2014, in The Guardian. (pdf archive)

"Been to an Ebola-affected country? Stay away from tropical medicine meeting, Louisiana says," by Martin Enserink, published on October 29, 2014, in Science magazine. (pdf archive)

"With Aid Doctors Gone, Ebola Fight Grows Harder," by Sheri Fink, published on August 16, 2014, in the New York Times. (pdf archive)

"In Layers of Gear, Offering Healing Hand to Ebola Patients in Liberia," by Sheri Fink, published on October 16, 2014, in the New York Times. (pdf archive)

"Better Staffing Seen as Crucial to Ebola Treatment in Africa," by Denise Grady, published on October 31, 2014, in The New York Times. (pdf archive)

"Battling Ebola: Two Doctors for a County of 85,000 People," by Elizabeth Cohen, posted on September 25, 2014, on the CNN site. (pdf archive)

"The Ebola Fighters: The ones who answered the call," Time magazine, December 22/29, 2014. See sub-pieces: "The Nurses"; "The Scientists"; "The Caregivers"; "The Doctors"; "The Directors."
(pdf archives -- main piece -- also see items written by nurses -- scientists -- caregivers -- physicians -- directors)

"Woman saves three relatives from Ebola," by Elizabeth Cohen, posted on the CNN site on December 10, 2014. (pdf archive)

 

 

 

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