Preparing our national Ebola response

Ebola is an extremely vicious health and social threat. It has the definite potential to incapacitate or kill its victims, as documented through the large number of fatal Ebola cases in Liberia. As of today, the virus is considered to spread from person to person only through direct contact with the body fluids of a person with an active Ebola infection. The World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) are monitoring the advance of this virus every day on a worldwide basis.

At least two efforts to develop a human vaccine against Ebola currently are underway. Similarly, control procedures, such as quarantine, can be implemented when active cases are suspected or discovered. However, it is imperative that effective response planning occur now. Mental health and substance use services are essential components of that response planning.

A Potential Scenario

The following scenario is entirely hypothetical and is intended to motivate action, not to frighten anyone.

Today, one or more air travelers bring Ebola to New York City from West Africa. The CDC employs screening and quarantine procedures for these air travelers, but these procedures are not fully effective, and the virus escapes into the population of New York City through one or more people with an Ebola infection, but who were not actively ill at the time of arrival.

Within three weeks, New York City hospitals are confronted with active Ebola cases. CDC traces other people who have been in contact with these persons with active cases, and identifies several hundred people who potentially have been exposed, including some children. Shortly thereafter, New York City schools consider closing to prevent the spread of the virus, and many workers want to stop going to work to avoid potential exposure on the subway system, in their offices, and in restaurants. Essential police, fire, and infrastructure services, such as electric power and telephone, are very difficult to maintain because personnel are frightened of being exposed to Ebola in the course of their work. Help from other cities and states also is very difficult to mobilize because they too are fearful. Society, as we know it, quickly begins to become disorganized because of fear.

So how do we prevent this scenario from ever occurring? Immediate planning is necessary. A complete description of all the components that will be required for this planning is far beyond the scope of this short commentary. However, some essential steps can be outlined for mental health and substance use services.

The Field's Role

Both mental health and substance use services will be essential components of the response to any Ebola outbreak. First, ongoing services for current clients must be maintained, particularly for those who have case managers and who are prescribed psychotropic medications. Second, many new cases of bereavement, depression, post-traumatic stress disorder, and substance use are very likely when family members, neighbors, and friends become seriously ill or die, or when people are unable to cope with the effects of panic and social chaos. Third, professionals from these fields will be asked to play important roles in mitigating panic. For example, they will be asked to work with the broadcast, print, and social media to craft effective messages and to gauge responses.

Mental health and substance use services, however, are likely to suffer with the same types of infrastructure problems as other essential services. Workers likely will be less willing to come to their clinics, and help will not be available from elsewhere because of fear.

Plan Now

Planning must begin immediately if we are to mitigate the consequences outlined above. Thankfully, some of this planning already has begun, but planning should remain continuous to take into account changing situations. Key features of this planning include the following:

• The federal government will need to plan for financial resource reallocation for emergency mental health and substance use services, mobilization of human resources to work in urban areas that are hardest hit, and appropriate technical assistance to states, counties, and cities. Legal and regulatory reform may be required now so that these essential tasks can be accomplished when needed.
• State, county, and city governments will need their own response plans. The federal government should help develop these plans. An essential feature of these plans will be to assure continuity of operations and to designate backup personnel for those who occupy essential mental health and substance use service delivery positions.
• States, counties, and cities also will need to work with employers so that each business has its own response plan. Designation of backup personnel for critical infrastructure roles is a high priority.
• At all levels, work with the broadcast, print, and social media should be undertaken now. Messages need to be crafted and tested for different audience segments, including different demographic groups, those receiving mental health and substance use services, and others. The goal of this work will be to communicate effectively while mitigating panic reactions in the population.
• Behavioral health agencies should be preparing plans to cope with Ebola and should discuss their plans regularly with staff, payers, regulatory organizations, and clients.

Looking to the Future

Hopefully, we never will never be required to implement these plans on a broad scale. The virus may not spread broadly into the population. Also, the longer the interval we have to prepare, the more direct prevention and treatment strategies are likely to improve.

(Author’s Note: I am very grateful to President Obama for naming Ronald Klain as National Ebola Czar over this past weekend, and I am also very grateful to the CDC and its Administrator, Dr. Thomas Frieden, for the very careful work being done to control the spread of Ebola. This article is a minor reworking of one that I prepared on June 30, 2006, “Preparing for a Bird Flu Pandemic.”)