In the early 1980s it was apparent that all San Francisco hospitals had a medical crisis happening and, something had to be done. There were many patients coming into the emergency rooms that would be admitted and never leave. The health of these patients had not yet been identified; with a disease that would ultimately reach epidemic proportions. All hospitals in the San Francisco Bay area were feeling the crowded conditions.

 

Each hospital administrator, from every hospital, met to discuss how the hospitals were going to handle this population of people dying from an unknown disease. The heads of each department within those hospitals met to discuss their needs and issues. Every hospital already had nurses who did not want to administer to the people in the wards with the patients that had wounds that would not heal. Safety precautions were felt not sufficient enough.

 

The medical staffs had to contact the Center for Contagious Diseases to find out what they were up against and what level of containment standards needed to be implemented or, at the very least, met. Some health care professionals had already caught the disease and were dying. More data had to come in as to how to not only treat these people, but which hospital was going to be responsible for hosting the terminally ill patients.

 

San Francisco General Hospital was, chosen, to have a ward dedicated to these patients with specially trained and volunteer health professionals for this ward. This helped the other hospitals staffing problems. The CDC was sending trained staff to help assist the medical crews’ already in place and to hold seminars to teach all hospital staffs what the disease was and how to try and contain the spread. People in dire need were transferred to SFGH. Costs were mounting and then the news came in that the disease had a name and, there was no cure. The fact there was no cure made staffing a major issue and sources of revenue for these people, a difficult problem.

 

A secret command center was established at the Presidio. The Presidio still looked like a military base from old glory days and was easily readied for the military staffs from around the country and the CDC doctors to house themselves at and, all units made necessary plans to help the medical community with the ever increasing spread of the disease. Initially, only a few medical personnel knew about the command center but after three years the whole community knew and the people wanted more answers and more help. Pamphlets were produced at the Presidio and distributed. The pamphlets were continually being updated and it was difficult to have enough on hand. Other states were asking for information and then the whole world was looking to San Francisco for answers. The word “epidemic” was used freely on newscasts and in newspapers.

 

San Francisco General Hospital is a large sprawling hospital that has seen better days. The emergency rooms are usually crowded with people who use the services because they cannot afford to make an appointment with a family doctor. The floors set aside for the terminally ill HIV patients were starkly decorated in those days and everyone working on those, ever-increasing, floors had masks on and gloves on at all times. In the beginning, before the secret command post, there were no masks.

 

The look on the faces of the “ill” on those floors is and was a vacant stare, which uncannily was mimicked by the medical staff. The faces of people who know there is no hope, no hope at all left---is beyond words.

 

There are numerous safety measures now for the safe disposal of the syringes and all utensils used and, it is safe to say, no one even thinks about how many people were infected before those measures were put in place.

 

An open system of management was initiated, because flexibility and adaptability came first. In the beginning, a functional design was used, but that gave way to a divisional design, which was incorporated within the hospital and a few floors to support the needs of the patients and staff and the institution. That took care of structuring the care, but the costs were insurmountable. Government sources of revenue began to come in, after the military people silently took over.

 

For the hospitals the issue of the insurance companies canceling policies of people with Acquired Immune Insufficiency Disease or Syndrome, (AIDS) became a paperwork nightmare. The hospital was faced with rising costs and no funds coming in for these people.

The need to consider the workers and their future psychological conditions was not approached. In fact, none of the workers and staff in any of the Bay Area hospitals were thought to need or should have counseling, either short-term or long-term. These medical workers would be handling patients with a disease that was not only horrible to look at in the terminal state, and no matter how excellent the medical care, the people were still going to dies, and some of those people would be the medical staff.

 

Alliances other than the military had to be made and the hospitals turned to the private sector. AIDS awareness groups sprung up all over San Francisco and the surrounding areas. There were concerts given and private money was solicited, and it did come. As more became known about the disease, people in the health care system who had caught the disease volunteered their services to the hospital ward with the terminal patients. People who had lost love ones volunteered their services and hospices were becoming more prevalent in the community and the terminally ill would go to the hospices and the Presidio to die and this relieved the hospitals of some care and they returned to diagnosing and initial treatment. They (the other hospitals in the Bay Area) still continued to send patients to San Francisco General Hospital.

 

The enormity of the crisis was not revealed to the world because San Francisco is and was a town that consumed a large revenue base from tourism. But word was leaking out and tourism began to have a downward turn. So many health professionals were ill with the disease that areas of some of their work were affected and it was common knowledge that the blood supply was not carefully inspected. As the writer of these events; I speak with certainty that a crisis existed for the entire community for many years.

 

During a surgery procedure at Stanford Medical Center in the Palo Alto area, this writer received tainted blood from a transfusion during surgery and now has Hepatitis C, because the blood bank had only tainted blood to give. They were not testing for Hepatitis C in 1988. But they did begin testing for C in 1989. That is difficult to understand but it is a truthful statement. This writer, as well as many patients from the Bay Area, lives in fear the blood received through transfusion, the fear that the HIV infection is lying dormant and will someday reveal itself. This writer’s doctor apologized for the need to give the tainted blood, but many other doctors did not even tell their patients and, a black secrecy approach was prominent around medical circles. A, “I did not know”, or an “I did not see” mentality prevailed in the health community circles.

 

The secret military doctors encouraged this thought process.

One sad outcome was the allowing of newborns to die if their mother was found to be HIV positive. This was not a well-known matter, but it was happening. Every now and then a story would reach the papers but it was not front-page news. The stage in San Francisco had been set and the city was having third-world issues.

 

Social conditions changed not only in the medical community but also outside this inner circle because of the HIV concern. Promiscuity did not prevail, anymore. The casual dating experience took on a whole new meaning and seriousness. On Market Street in San Francisco, cards were being issued with proper laboratory papers that indicated on them, the bearer was HIV free, and these cards could be updated every three months. People began showing their card to future companions and some joked about the cards and others just wanted to see them and make sure that the person they were dating was HIV free.

 

Some upper-crust medical offices made sure their staffs were HIV checked regularly, as a condition of employment. Laws were being broken every single day to ensure that those who were not infected stayed infection free. There were AIDS awareness days that were initiated, not just to raise money for the cause, but also to inform everyone about the crisis. Condoms were given away free at high schools and few parents complained. Some tried to stop the practice of giving free condoms and needles to those that needed them, but soon those voices stopped complaining due to public pressure.

 

The entire Bay Area medical community was pulling together to stop the spread of the disease and to find a cure. That was over twenty-years ago and today those silent heroes are forgotten. The Bay Area still has the highest rate of AIDS cases in the world except for Africa. There are now many health centers that help AIDS patients, but the main hospital for the terminally ill is still San Francisco General Hospital with a scattering of hospices around Northern California.

The questions for this case study are:

 

1.      When an epidemic hits a community and the health providers in that community are over-whelmed, what steps should be taken from the beginning to the conclusion and beyond for the care of the terminally ill?

2.      Should all financial burdens fall on just one hospital?

3.      Can care be shared?

4.      Who should be in charge of the decisions?

5.      Did the San Francisco Bay Area serve its citizens well by bringing in the military and CDC?  

 

1)     When a true crisis has hit a community there is a change in turf battles. Alliances are made quickly and almost as if the physicians are in an emergency critical care area. Politics enter into the situation for structure and guidance. Competition goes to the sidelines.

 

            In this case study it was necessary to bring in the military and the CDC due to the enormity of the situation. The fact that the same hospital is still being used for the terminally ill after all this time speaks volumes as to the way these strategic alliances handled the stress and were able to make correct decisions under public pressure. The stages of the life cycle model of organizational alliances in health care goes from emergence and the uncertainty about valued resources with different ideologies, to a transition which is motivated by a need for the alliances. This need emerges into a willingness to put the alliance and its’ interests first and the stated objectives are achieved through a maturing of the alliances as trust is formed in knowing what they, the alliance, did was correct. The need in this case for a centralized area, as in the Presidio, and then the use of one hospital for test procedures was managing well the alliances.

 

The realization that the military and the CDC was more capable than the physicians for the organizational design of the containment issues, spoke well for the medical staffs and their capable way to put individual egos aside for the betterment of the project at hand. The head medical supervisors of the various hospitals worked as one mind and capable wise decisions. The steps taken by this community of hospitals was correct. First they met and agreed to have one hospital handle the patients, so the other hospitals would not be overwhelmed and they were able to centralize the research and staffs that became knowledgeable on how to handle these patients.

 

Secondly they were able to say they needed help and ask for it as soon as they knew the disease was getting away from them. (Meaning they were losing control.) They called the CDC and the military to strictly enforce what they had agreed upon in their discussions. They did not let this issue sit for years or months. They acted upon it right away.

 

2)     No, all financial burdens should not fall on just one hospital. In the future for epidemic situations the medical staffs need to have, in place, an emergency plan and be able to implement it when needed.  

 

            This plan should be in every city in the United States and towns where an epidemic could and would affect the lives of many people. Insurance plans need to be in place for hospitals so they are not just handling the entire financial burden. The other hospitals and clinics should know of a plan to send patients, who would normally be theirs, with a link to payment from one institution to the other. This could be initiated by computer and payment received by one hospital and forwarded to the receiving hospital and if the patient recovers, then they could be transferred back to the original hospital because the insurance carrier is paying the original hospital. An action plan such as this could be devised and implemented without a great deal of work, so long as each hospital has their computer system programmed for such an occurrence.

 

3)     As stated in the answer to question two---care costs would be shared through insurance. The primary care hospital would receive payments and transfer such to the secondary hospital and then when the patient is healing, the primary care hospital can handle the patient’s rehabilitation needs, etc.

 

4)     In an epidemic situation the CDC, the Center for Contagious Disease should be in charge. This gives a centralized operating unit to plan the situation from the beginning and continue focusing on possible outcomes.

 

            The military is a formal and structured unit and is capable of keeping order in case of panic. The heads of all the hospitals and clinic would need to be kept informed at all times in case the situation got out of hand. In the even the situation did become unmanageable by the various medical staffs, then the military could take over in a more visible role.

 

            Maslow’s hierarchy of needs is met and establishes order through meeting the physiological needs, security needs; belongingness needs, esteem needs, and the self-actualization needs.

 

            As Herzberg found---when hygiene factors are negative or absent then dissatisfaction results, and in a CDC approach and a military staff overseeing this intense project Maslow’s hierarchy could and would prevail and satisfaction should be found because the hygiene factor is being met.

 

5)     Yes, the San Francisco Bay Area served their citizens well by bringing in the CDC and the military. There were no other options. 

 

Today, if another epidemic were to mobilize units within a community, it would be wise for the community to bring in executives from the major insurance companies in order to form alliances with the hospitals, so the people would be helped and the medical centers could be paid in an efficient manner. This is not far-reaching---it is a logical alternative for a crisis. Not having the insurance companies on-board from the beginning caused undue stress to the patients and the medical centers and staff.