Ebola Outbreak and CDC: The Difference Between Announcing a Response and Mounting One

The opening of my recent conversation on NPR’s On Point turned on a small anecdote that captured a much larger problem. A reporter returning from Uganda, where Ebola virus has been circulating, passed through a United States airport without being asked a single question about his travel history. The Centers for Disease Control and Prevention had announced enhanced screening at airports several weeks earlier. The reporter’s experience suggested that whatever was being announced from podiums in Washington was not yet translating into the kind of operational reality that actually stops a virus at the border.

This gap between announcement and operation is the issue I want to focus on, because it relates to every failure of outbreak preparedness in the modern era, and the current moment is exposing it with unusual clarity.

The Operational Reality of the 2014 Ebola Response

When I led New York City’s response to the West Africa Ebola outbreak in 2014, the system that worked depended on capacities that were anything but glamorous and that no press release ever fully captured. Customs and Border Protection officers at five designated United States airports were trained to interview returning travelers in detail about where they had been, what they had done, whether they had attended a funeral or visited a hospital or cared for someone who was sick. Travelers identified as having any potential exposure were routed to CDC personnel who had been mobilized to those airports from across the agency, often pulled away from their regular work to fill the gap.

Those CDC officers conducted a second, more detailed interview, and they collected something more important than information; they handed the traveler a thermometer, a logbook, and in many cases a mobile phone, because we knew that monitoring a person for twenty one days required a reliable way to reach them, and we knew that not everyone arriving in the United States had a working device of their own. The CDC officers then used a secure electronic system called Epi-X to transmit each traveler’s information to the state and local health department where that person was actually going to be staying.

Our team at the New York City Department of Health downloaded that information and staffed a brand new call center. We hired and trained hundreds of staff. We seated them on a floor of the health department with headsets and screens, and twice a day for twenty one days they dialed the phones we had distributed at the airport and asked the same set of questions. When someone failed to answer after several attempts, we sent teams out to find them in person, and we built a working relationship with the New York Police Department’s Missing Persons Unit to help us locate the small number of people who had moved, changed numbers, or otherwise become difficult to reach. You can read all of the details about this massive response here.

None of that operation existed by accident, and none of it could have been stood up in days. It took weeks to build even with the full backing of the White House, which in 2014 appointed Ron Klain as a dedicated Ebola coordinator with authority to compel cooperation across the Department of Homeland Security, the airline industry, state and local health departments, and the CDC itself. That kind of cross-agency coordination is what turns an announcement of enhanced screening into a screening operation that actually catches the next case, and it is also what was learned painfully during the weeks before the system was fully in place, when the Liberian patient in Dallas became ill and the country watched the gaps in real time.

What Walks Out the Door with Experienced People

The operational details I have just described eventually led to detailes playbooks developed by CDC in collaboration with other US government agencies. They exist on paper in documents developed during the past few administrations. They exist in practice, having been built, tested, refined, and documented during the 2014 and 2015 response. And they live in the institutional memory of people who did the work. The question that should concern anyone paying attention to the current Ebola outbreak is whether that playbook is being used, and the evidence of a reporter walking through an American airport unscreened suggests that it is not.

The reason it is not being used has less to do as much with budget cuts as it does with people. The agency has lost an enormous share of its experienced workforce over the past eighteen months. Some were forced out through reorganizations and reductions in force. Others left because they were being asked to do work that violated their scientific judgment. The remaining staff at CDC are, in my experience and in the experience of every former colleague I have spoken with, deeply dedicated and highly skilled, and nothing I say here should be taken as a criticism of the people still doing the work.

The problem is that the work itself requires more people than currently remain, and it requires people whose decades of accumulated experience cannot be quickly replaced. Every outbreak is slightly different from the last one, and the value of an experienced epidemiologist or quarantine officer lies in their ability to recognize what is familiar and what is not, to apply what they learned from the last response, and to know which corners cannot be safely cut. The playbook for screening travelers from an Ebola outbreak needs to be refined each time, and the judgment to know what to keep and what to adapt is the kind of expertise that walks out the door with the person who held it.

The Global Network That Keeps Americans Safe

The same dynamic is playing out internationally, with consequences that flow back to American shores. During my years at CDC, I worked in Southeast Asia, in China, and in Africa, and the value of that work was almost never about being the visible Americans coming to save anyone. We sat at desks inside our partner countries’ public health agencies and we helped them build laboratory capacity, surveillance networks, and the technical skills to detect emerging pathogens. The capacity we helped build in China is part of what eventually allowed the world to detect novel coronaviruses, including the one that caused the pandemic that reshaped this decade. The lab systems we strengthened across Africa are part of what makes the current detection of Ebola possible at all.

When the United States dismantles its Agency for International Development, when it instructs CDC personnel to stop routine communication with the World Health Organization, when it cuts the global health workforce that served as our eyes and ears on the ground, the country undermines its own early warning system. CDC officials have publicly acknowledged that they learned of the WHO declaration of a public health event of international concern only a day before it became public, which represents a departure from decades of practice in which CDC was treated as an equal partner in global outbreak assessment. That kind of exclusion is the consequence of policy choices, and the cost is paid in detection delays that translate directly into more cases and more transmission.

The capacity to detect an Ebola outbreak in Congo, to recognize it as something unusual, to investigate it, to characterize the genome, to share the information with the World Health Organization and through WHO with the rest of the world, depends on a global public health network that the United States has spent decades building. Spillovers from animal reservoirs to human populations will continue to occur, and we cannot prevent them completely; what we can control is what happens after the first case, and what happens after the first case is determined by the systems we have chosen to build or to neglect.

A Choice We Are Currently Making

Infections are inevitable. Outbreaks like this one are a choice. We cannot prevent a virus from spilling over from an animal reservoir into a human population, because those interactions will continue to occur wherever people and animals live in proximity. What we have the capacity to choose is whether we invest in the diagnostic tests that pick up a novel infection, the hospitals that can care for patients safely so that the disease does not spread, the laboratory networks that characterize what they are dealing with, and the community partnerships that make safe and dignified burial practices possible. Those are choices, and the consequences of those choices are measured in human lives.

The current administration appears to be making a different choice than the one that defined the 2014 response. The choice is reflected in the gutted National Institute of Allergy and Infectious Diseases, in the closure of the Department of Defense research unit that worked on Ebola and related diseases, in the silencing of CDC’s routine communications with WHO, and in the elimination of the White House office of pandemic preparedness that the Biden administration created precisely to ensure that the lessons of Ebola and of COVID would not be forgotten. The choice is broader than money, although money matters; it concerns whether the country believes that infectious diseases are a serious enough threat to justify the standing infrastructure that detects, contains, and prevents them.

What gives me hope, and what I closed the On Point conversation with, is that public health infrastructure can be rebuilt, and that the people who built it the first time are still alive, still in the field, and still willing to teach what they know. The work of restoration will take longer than the work of dismantlement did, because that is the asymmetry that defines every kind of institution worth having. It can be done, and doing it requires the kind of political and community commitment to public health that ordinary citizens express through voting, through community organizing, and through demanding that elected officials at every level treat public health with the same seriousness they treat public safety. The fire department does not wait until the building is burning to be funded, and the police department does not get dismantled because crime rates fell last year. Public health deserves to be understood the same way.

The full On Point segment is available at the WBUR site, and I am grateful to Meghna Chakrabarti and Willis Ryder Arnold for the chance to develop these arguments at length.