The First Horseman of the “Four Horsemen of the Apocalypse” is usually pictured riding a white horse and is believed to represent “Pestilence” in some interpretations (Revelation 6:1-2). Five years ago, in my June 2009 Editorial1, I wrote about the preparations for, and response to, the H1N1 (Human Swine Influenza) outbreak ('Swine Flu'). At the time, the disease was spreading fast and we were all unsure what the final outcome would be. While ultimately the pandemic was to prove less severe that feared, the planning, monitoring, preparations and responses to a pandemic were put to the test.
Five years on, we are contemplating another pandemic, this time Ebolavirus Disease (EVD) in West Africa, which has already seen over 10,000 infections and 5,000 deaths in an epidemic that is not abating, While there are many similarities with the 2009 pandemic, particularly around the need for good preparations, leadership and decision-making, and good media management, there are some differences in approach, which, as medical administrators, we need to address.
The need to be prepared continues. While this is a disease that is yet to reach our shores, its lethality, lack of specific therapy beyond good general support and proclivity for infecting under-protected health staff, has added a whole new emphasis on how we manage highly dangerous infectious disease. Even if we are fortunate enough not to get an EVD case, the preparations occurring around the country will better prepare us for whatever comes along in the future.
The requirement for effective leadership and decision-making remains important. The willingness of senior health personnel to take hard decisions, despite media and public criticism, has yet to be tested, but is anticipated to be a key factor in the containment of the disease should it arrive. This will be achieved through a great deal of national consultation, cooperation and a general desire to achieve the best outcome for both individual jurisdictions and the nation overall.
As always, handling the media is a key consideration. Communication remains a critical aspect of the response and must be effective in ensuring that the population is informed in a measured way that neither overplays the risk nor underplays the disease. The opening reference to “Pestilence” was not meant to be an idle allusion – Ebolavirus Disease conjures up more public fear, with its close to 50% mortality rate, than Influenza or most other infectious diseases ever could. Working with the media and other key government agencies to communicate the real risk, particularly if a confirmed case is identified in Australia, will be crucial. Done well, the public can be reassured and act appropriately; done badly, the fear will flow into responses that will impact on both individuals and the community, including within a healthcare setting. Medical administrators have a key role to ensure that the communication is rational, evidence-based and effective.
Staff management is also essential. The impact of cases in Australia on staff will be complex and we need to be preparing for a range of responses. Any treatment of these EVD cases by staff will be voluntary. As such, some staff may elect to refuse to treat such patients, while others, who are happy to treat patients, may request accommodation from the hospital in the 3 weeks post treatment, as they do not desire to take a possible infection home. These staff responses will need to be managed compassionately, while maintaining treatment to the patient. Good training, access to appropriate personal protective equipment and well documented processes will assist to increase staff confidence in their ability to manage these patients.
Finally, health services will need to address how they will handle health care workers who elect to assist in stemming the epidemic at it source in West Africa, either through work with a non-government organisation or possibly as part of a government-sponsored team. A sensitive and science-based approach to dealing with these workers is paramount, particularly given the hurdles that have had to be overcome to provide this care and the not inconsiderable risks that they may have faced.
As always I would be very keen to have your feedback on how we need to continue to develop The Quarterly over the coming years.
Dr Andrew Robertson
The Royal Australasian College of Medical Administrators
Dr Andrew Robertson, , p720