It’s a question that’s left people scratching their heads: How does a fully equipped hospital send an Ebola-infected man home—right after he arrived from West Africa and complained about being sick?
Some observers and public health experts are beginning to wonder if there’s an elephant in the room that no one wants to talk about: race and the politics of health insurance. Texas Health Presbyterian Hospital Dallas, the private medical campus where Thomas Eric Duncan is currently under care and isolation, still can’t explain exactly how medical staff let the 42-year-old Liberian national go home with useless antibiotics. Hospital officials have only said that Duncan’s travel history wasn’t “communicated,” and now mainstream media reports are stuck on everything from malfunctions in Presbyterian Hospital’s electronic record system to Duncan being dishonest about the level of his Ebola exposure when he left Liberia.
But few want to touch the pointy eggshells of race and class in the frantic discussion over Ebola as it enters the United States. Did Duncan get initially turned away because he is black and, possibly, uninsured?
Would it have been different if Duncan had been white and insured?
We may never know for sure, and it’s unclear if Duncan had insurance (it’s unlikely, considering that he’s a Liberian national on a U.S. visa).
What we do know is that Ebola response in the U.S. is under enormous scrutiny as experts wonder if an already challenged health system—currently undergoing an Affordable Care Act renovation—is really all that prepared for something that is scaring us like a Contagion script. And the specter of race is lurking not too far behind: When white American aid doctors in West Africa showed signs of the virus, they were rushed back to the U.S. … stat. The same happened when a white freelance cameraman for NBC News in Liberia was immediately flagged for treatment.
But it’s been rough going for black Ebola sufferers—even when one manages to sneak into the U.S. and access one of the most advanced health care systems in the world.
Former District of Columbia Chief Medical Officer Dr. Ivan Walks, who led the response against Washington, D.C.’s first bioterrorism attack, believes it’s a question we need to start asking. “I was stunned,” Walks tells The Root. “You could put [Duncan’s] picture in the dictionary under what you look for when responding to Ebola. How do you miss that guy?”
That’s where factors such as Duncan’s race and level of insurance could have influenced the hospital’s first decision in either subtle or not-so-subtle ways. “There is a lot of research showing that different people get turned away in different places,” argues Walks. “So if they turned him away at first because he’s an African with no insurance, that would not be inconsistent with what we’ve seen over the years.”
Walks draws on lessons from a similar event in October 2001 when the D.C. area was struck by multiple anthrax attacks that hit postal facilities particularly hard. When two black Brentwood-facility postal workers—Thomas Morris Jr. and Joseph Curseen—dropped by Maryland hospitals complaining of anthrax-triggered symptoms, at the same time that news of the attack and Brentwood as a focus of investigation was plastered on every cable channel, they were sent home and died soon after.
But when white Brentwood postal worker Leroy Richmond arrived at a Northern Virginia hospital with the same symptoms, doctors immediately treated him and saved his life.
“What’s unique about populations in West Africa is that we’ve been seeing Ebola unfold among the have-nots,” Dr. Kavita Patel, a Brookings Institution fellow and managing director of clinical transformation at the Engelberg Center for Health Care Reform, explains in a conversation with The Root. “Here in the U.S., we’re now watching it unfold among both the haves and have-nots.”
Patel cites studies like a 2011 Health Affairs brief examining how people of color continue “receiv[ing] a lesser standard of care” and a 2008 Academic Emergency Medicine Journal study (pdf) delving into “persistent [health care] disparities based on race.”
“That gets into a subtle, yet documented phenomenon,” observes Patel. “We know that African Americans get different care—but no one wants to admit that. We know that gaps and disparities do exist.”
Duncan—who flew in from Liberia on Sept. 19 and didn’t go to Presbyterian Hospital until Sept. 25—was initially sent home when hospital doctors misdiagnosed him. It wasn’t until Sept. 28—nearly a full four days later—that Duncan was placed in isolation at that same hospital.
“I don’t think any of us can say what happens when an uninsured person actually shows up at an ER. However, hospitals must stabilize anyone who shows up with life-threatening symptoms under the EMTALA law,” Urban Institute Health Policy Center Director Steven Zuckerman tells The Root.
EMTALA—or what Walks jokes is called the “wallet biopsy”—is the 1986 federal law that requires doctors, in any location, to provide immediate care regardless of insurance status for an “emergency medical condition.”
Still, as Patel notes, the burden of proof is on the hospital. If the patient, like Duncan, isn’t exhibiting any severe, life-threatening signs, then doctors can simply circumvent EMTALA and discharge the patient.
Presbyterian Hospital counters that Duncan didn’t exhibit any symptoms during his first visit—but there’s that 21-day incubation period. Plus, words like “Liberia” and “Ebola” have now reached such prominence that common sense should have instantly raised red flags. The Centers for Disease Control and Prevention, expecting that at some point the dangerous viral infection would reach the United States, even issued detailed “infection prevention and control recommendations” for hospitals back in August.
Now experts wonder if Duncan was turned away like many uninsured people of color who are routinely dismissed by hospitals because of lack of coverage—and lack of cultural sensitivity. It’s in stark contrast with the action of a hospital in the Washington, D.C., area, such as Howard University, which immediately placed an ill patient traveling from West Africa in isolation. The difference may be that certain medical campuses, like Howard, are used to treating low-income, uninsured and foreign populations of color.
In Dallas County, low-income and uninsured residents can typically turn to the publicly funded safety-net hospital known as Parkland. But, aware that an overwhelmed Parkland is suffering from budget cuts and staffing layoffs, many will opt for other locations such as Texas Health Presbyterian.
Interestingly enough, in contrast with Presbyterian, the budget-burdened Parkland has screened more than 30,000 patients since the CDC protocols were issued, identifying 16 as having traveled to Ebola-impacted countries. One reason Parkland is prepared: It serves immigrant populations like the large West African community, including 10,000 Liberians, who reside in the Dallas area.
Lack of health insurance is a real problem in Dallas, and it could create challenges for certain underserved populations in the event of an outbreak. Some wonder if the local health care system can adequately respond to viruses like the mysterious enterovirus-68 that’s struck 40 states, including in Texas’ northern region, where there are now 10 confirmed cases in Dallas County.
Dallas County is more than 23 percent African American, and its core city, Dallas, is more than a quarter black, too. But it also ranks ninth in the nation in uninsured residents, with nearly 27 percent of county citizens lacking any type of health insurance, according to the U.S. Census Bureau.
The black uninsured rate in Texas is in critical condition. Even though the state’s population is 12 percent black, the rate of nonelderly uninsured African Americans is 23 percent, according to a Kaiser Family Foundation disparities study.
Texas overall has the nation’s highest uninsured rate. Critics charge that’s mostly because of former 2012 GOP presidential candidate and current Gov. Rick Perry’s refusal, along with the Republican-dominated state Legislature, to expand Medicaid coverage in the state out of political resistance to the Affordable Care Act.
That’s beginning to evolve into a talking point of interest for Democrats who want to hit Republicans hard on cuts in federal health-prevention budgets. A stinging $1.55 billion cut in the National Institutes of Health budget during the infamous 2013 sequestration, as well as a $13 million cut to the CDC’s Emerging Infectious Disease Center, could make a small Ebola outbreak worse.
But what black health activist Dr. Misee Harris ultimately fears is that an event of that magnitude will also reveal a system in which “you may not get proper health care because of the color of your skin or the size of your income.”
“It is a trend,” Harris tells The Root, describing situations where she’s seen it firsthand as a pediatric dentist. “Racial profiling sets in and doctors don’t want to deal with it. That would’ve never happened to a white family.”
Charles D. Ellison is a veteran political strategist and a contributing editor at The Root. He is also Washington correspondent for the Philadelphia Tribune, a frequent contributor to The Hill, the weekly Washington insider for WDAS-FM in Philadelphia and host of The Ellison Report, a weekly public-affairs magazine broadcast and podcast on WEAA 88.9 FM Baltimore. Follow him on Twitter.