I Was Wrong

by abclarke

Whoops

Last week, in a post about the most important thing a manager does, I made a silly comment in a foot note about managing a potential SARS outbreak:

“My guess was quarantine the hospital. Wrong. If you want to know why, e-mail me and I’ll tell you because I’m too lazy to write it in a footnote that no one reads.”

Many e-mails later, I see now that I was wrong, and I apologize. It appears people do sometimes read the footnotes(1). I’m sure the apology is more important than the actual explanation, so I’ll end it at that(2).

– Art

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(1) I had thought no one read the footnotes because I was not reprimanded by the Pope or the Anti-Defamation-League for my footnotes in this article. Is it possible the Pope doesn’t read my blog?

(2) OK just kidding. Here goes:

To refresh your memory, the scenario was as follows:

You are a local government mayor in Indonesia. You have read about SARS in the local paper but there are no cases in Indonesia. Suddenly you get a phone call from a local hospital where the head of the hospital informs you they have a patient who seems to have SARS-like symptoms. What’s the first thing you do?

So, why should the mayor not quarantine the hospital?

Technicalities

First the lame (but correct) answer: He shouldn’t quarantine the hospital because he is not an epidemiological expert, and therefore doesn’t know if this is the best first step to take in fighting an epidemic. The best first thing the mayor should do is (a) ask the head of the hospital how he can best help and (b) ask to be kept in the loop.

But that’s lame, as it allows me to sidestep the question (not that the Supreme Court is against that form of argument to sidestep an argument).

To make it more interesting, suppose you are the local chief of the WHO, you are in fact an epidemiological expert, and you’ve been given the authority by local governments to take whatever actions you want to protect the population (highly unlikely, but go with me here…). In that case, why wouldn’t you immediately quarantine the hospital?

Generalities

First the general answer. When faced with a crisis we often think action is most valued, but more often than not action without thinking results in making the situation worse. Crisis managers are taught, when first dropped into a situation, to take as much time to think through the problem and listen to those around them as prudent before taking a step.

This is why first-aid classes teach you to first look around a collapsed body and think about why he or she collapsed before approaching them; what if they tripped on a live wire and you get fried while trying to save them? (Note: don’t spend minutes doing this, but do spend at least 5 seconds.)

This is why firefighters will first assess a burning building for likely causes of a fire before commencing fighting it; what if they just poured water onto an oil fire? (Note: they don’t spend days doing this, but they do spend a minute or two).

So, if you’re our WHO expert the first words out of your mouth should never be, “quarantine the hospital”. A better answer is, “tell me what’s going on here, and how can I help?”

Specifics

Ok, even that answer is lame because it gives general (but good) reasons. Now, here’s the specific reason why you probably don’t want to quarantine the hospital.

In this specific case where an entire nation (Indonesia) has not had a case yet, quarantining the hospital is unlikely to make the situation better, and may make the situation worse.

Why Quarantining Probably Won’t Make Things Better

Well, given that the local head of the hospital called you with the diagnoses, you could assume (but should check) that the patient (let’s call him Patient Zero) is already in isolation. Most medium sized and large hospitals worldwide have good procedures for handling contagious diseases, and therefore your chances of the hospital being a major site of future contagious infections is very low. And to be brutally frank, you should care a lot more about future infections than about current infections!

What if the patient is not in isolation? While rare, in this case it may be prudent to ask the doctors to put him in isolation and/or quarantine the hospital, but you’ve got to weigh the benefits of doing this against the costs of doing it — And the big cost is it distracts you from the most important job at hand when you only have one case: find out as much about Patient Zero as you can.

Did he just land on an airplane? If so that’s bad (because he was on a small metal tube with lots of other people) but also good (because those people are trackable). If so, start tracking down the people on the plane. They are likely to cause future infections!

Is he a farmer who normally only interacts with his animals? If so that’s good (it means he most likely has contracted something SARS-like but not SARS) but also bad (it could still be SARS in which case how the hell did he get it, or it could be something worse). Make sure you’ve got a team headed out to his farm to quarantine it (not the hospital!) and that you’re working up Patient Zero as efficiently as possible. This will help you determine if and where future infections come from.

Why Quarantining May Make Things Worse

Well, quarantining a hospital is both an epidemiological move and a political move. In the context of SARS, where people are scared about the unknown, and a fast move like that could either reassure people that authorities are on top of things, or scare them unnecessarily resulting in (at the very least) economic damage or (worse case) massive panic. If you’re dealing with a medium sized hospital with isolation procedures for a disease that you know how it transmits (in this case water vapor), your chances of SARS spreading are highest amongst people not already in the hospital.

Therefore you should not quarantine the hospital, but you should find all people who’ve been in contact with Patient Zero and bring them to the hospital.

What’s The Right Thing To Do?

So the right thing to do in this situation is (a) stop and think, (b) ask questions and listen, (c) think again and then (d) act. More specifically, if the team is not doing everything they can to track down the path of infection and path of interaction of Patient Zero, you should concentrate on that before you quarantine the hospital.