O, Safety, quo vadis?   

By Jack Aslanian

It is unlikely that any of us, members of EMWA, readers of Medical Writing, and participants in our various ways in the health care enterprise, would disagree that ritual played prominently during the shamanistic-religious era of medicine. Perhaps less obvious is that even in the context of contemporary scientific, evidence-based medical care ritualistic behaviors can and do insinuate themselves – for lack of more sustainable alternatives, by way of appeasing the compulsion to appear to be doing something in the face of peril, or for the sake of PC (procedural and political correctness) — and, with dismaying regularity, mindlessly.

I had observed our surgery clinic nurses disinfecting a procedure room after a patient’s treatment. One day, however, I saw the process again, as usual, but reflected on it, for the first time. And I reached a rather dispiriting conclusion: the specter of futility cannot ever totally be banished from our doings; we will never have absolute safety. Hands gloved, the nurses would spray disinfectants and wipe surfaces clean and relatively bacteriologically safe (one hoped) — performing more or less as they had been trained to. But then, hands still gloved, they would gather soiled linen and instruments, exit the room, and pull the door shut. In final analysis, the greatest protection they had provided was for themselves; yet even at that not thoroughly, because they inevitably would be returning to open the same door, turning the same invisibly contaminated handle, but this time without gloves on. Another example: a dentist whose patient I no longer am is in ritualistic compliance with safety dicta. Only half-clear on the concept, he has plastic film on the handles of his procedure light, wears gloves, seems (only seems) to set out a fresh and presumably clean instrument tray … But when the phone rings, he takes the receiver with hands gloved (he is in a thoroughly solo practice), and then resumes his treatment without changing gloves. How many phone calls has he answered similarly mindlessly? I do not know; but I am fairly certain that he does not wipe clean the handset of the phone between patients.

That the solution of a problem often delivers other problems is well recognized. As our ideas of allopathy (other-caused illness) have evolved so have our efforts to prevent contagion: public and personal hygiene, quarantine, isolation, sterile technique, antisepsis, inoculation, etc. But it was the emergence of HIV and AIDS, infamous and fear inspiring scourges, that underlies the mannerisms and rituals to which we resort these days to protect ourselves from others’ pathogens and, one hopes, prevent transmission to others. The result is costly, both economically and environmentally.

For a moment let us sidestep the ideologically and politically loaded contention that our fears and needs have been opportunities for industries to emerge and thrive in previously unpredictable arenas, and to make contributions to GDP. Let us briefly (and informally, non-exhaustively) list the burdens of our not unfounded, but perhaps inflated, fear of contagion.[i] These can be broken down into the economic costs, both individual and public, and environmental costs (think green) of the various defensive measures to which we have resorted, expecting them to in turn provide individual protection or universal protection[ii] — sometimes both equally, sometimes more of one than the other, and certainly not thoroughly all of the time.

Our contemporary and, let’s say, Western approach to the potential of infection is associated with increased costs (materials and labor) that are passed down to us in the overall cost of healthcare and increased environmental effluent.

• So many individuals, in any sort of function that entails frequent contact with the public, have taken to using disposable gloves and change them frequently (and in my opinion in certain instances unnecessarily and in a copycat manner — grocery store clerks are one example) even when not required in their jobs to do so.
• The increased use of gloves has increased the frequency of latex allergies and given rise to a new industry to produce and market latex-free gloves.
  • Disposable gloves then require disposal as waste.
• Sightings of the use of facemasks by the public are increasing. Often this is unnecessary and reflects extremist reactions to theoretic hazard, and more often than not it is an affectation.
  • Facemasks eventually require disposal.
• The use of an extra sheet of paper towel to grab handles of WC doors from inside before exiting is possible because trees are cut to produce the paper towels, which then become trash.
• The disinfectants and hand cleansers used institutionally, and now increasingly by individuals, contain chemicals, which cannot but enter the environment with as-yet-unknown effects.
  • Not unrelated to such practices is the potential of the emergence of pathogens resistant to the compounds or of individuals allergic to the chemicals.
• There are, also, the costs of (a) determining the magnitude of a particular infective threat, (b) drawing up policy to deal with it and (c) implementing preventive measures — not the least through educational programs.

The list could go on, and the collateral burdens of others of our evolving safety-seeking habits could be treated similarly.

George Monbiot[iii] often writes on population growth, environment, the environmental consequences of our increasingly materialist and consumerist habits, and related topics, and he concludes that to help save the environment [and ourselves] we must change our habits and expectations. But he is realistic enough to allude to (though he does not outright admit) the futility of such well-intentioned and hopeful prescriptions.

Despite time spent in training, our nurses were (they likely still are) unaware that had turned scientifically reasonable prescription into mindless ritual. With contagion in mind, a similar judgment could be made about airport security procedures: (a) Take off your shoes! And never mind that in passing you'll pick up some germs off the floors of airports. (b) Have the contents of your carryon luggage hand examined by an inspector who does not change gloves between penetrating inside one valise and the next one (not voluntarily, at least).

Given the human element lurking inexorably in the background, that the incidence of infections is not higher does not speak for the efficiency and efficacy of safety procedures. It more reassuringly indicates the resilience of the human body and its inherent, though not inexhaustible or infrangible, capacity to fight off pathogens. Yet ironically, it is the human element that prevents a definitive dismissal of the notion that prescribed, but often ritualized, safety measures may at the end be futile … Because our professional and personal lives have become increasingly complex and demanding. We are increasingly overloaded with information that stoke fears and dreads. We are overloaded by regulations. We are overloaded by prescribed formal procedures. We are burdened by time limits and expectations of optimal productivity.

It used to be that people worked to live. Then, in certain Western societies, people started to see their duty to live to work — work became and end in itself. Now work is rapidly turning into something necessary to support our pursuit of increasingly enticed self-indulgencies — the new ends in themselves. We are distracted, because tantalizing parties wait for us to appear at to drink and dance, or because we have heard of an incredibly enriching, greatly discounted “sale” we must not miss. Ever changing electronic gadgets and opportunities increasingly spellbind us and turn us into play-seeking infants. Our minds tend to be elsewhere[iv].  Excellence is turning into either a fast receding ideal or an intrusive one. We do our best, and the best just no longer seems either good enough or deserving our sacrifices. And if it is close to being good enough, it is costly. Education is costly; implementation is even more enormously costly.

Perhaps without safety policies and procedures we would be worse off. But we should not be deluded into believing that safety procedures can or will ever fully allay our fears. At the end, when we consider safety, we must ask not only what safety is and how to achieve it, but also the following questions: Ah, Safety, wither doest thou go? How safe is your safety net? At what cost?

Jack Aslanian, MD, ELS

Freelance medical editing. jaclanian@earthlink.net

(Please note that a version of this article was originally published in Medical Writing, Volume 21, Issue 2 - Medical Writing in Paediatrics but has been edited and reworked as a web editorial for these times of the COVID-19 pandemic).

References:

[i] For brevity, I confine the argument to the hazard of infection.

[ii] The purists would be correct to point out that when individual protection becomes widespread it ushers in universal protection.

[iii] His essays have appeared in The Guardian Weekly, among other venues.

[iv] The assessments can more confidently be applied to US society.