What the Administration’s Defense of the Ebola Response Misses

Last week I spent an hour on NPR’s On Point discussing the ongoing Ebolavirus outbreak in the Democratic Republic of the Congo and what the American response to it reveals about the current state of the Centers for Disease Control and Prevention. The conversation aired the day after the acting director of CDC published an essay in the Wall Street Journal defending the administration’s handling of the outbreak. The contrast between those two accounts is worth examining carefully, because it captures something important about how an institution can be described as functioning while the operational reality on the ground tells a different story.

The episode opened with the experience of Laura Kelly, a foreign policy reporter for The Hill, who flew home from Uganda to Dulles International Airport on the same day the United States announced enhanced screening at that airport for travelers returning from Ebola-affected countries. Kelly passed through Customs and Border Protection, exchanged a few words with the officer, and walked out. There was no secondary screening. There were no questions about her travel history beyond a generic prompt about whether she had anything to declare. The system that had been announced from podiums in Washington was not yet operational on the ground.

This is the gap that I want to take seriously, because it is the gap that every meaningful failure of outbreak preparedness in the modern era has lived inside. The capacity to respond to an outbreak is not the same thing as the announcement of a response. The difference between them is the difference between a press release and an operational system, and operational systems require people, training, coordination, and institutional memory that cannot be conjured on the timeline of a news cycle.

What an Operational Outbreak Response Actually Requires

When I led New York City’s response to the West Africa Ebola outbreak in 2014, the screening system that eventually worked depended on capacities that no announcement could substitute for. Customs and Border Protection officers at five designated United States airports were trained to interview returning travelers in detail about where they had been and what they had done. Travelers identified as having any potential exposure were routed to CDC personnel who had been mobilized to those airports from across the agency. Those CDC officers conducted a second interview, collected detailed contact and itinerary information, and handed each 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.

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 would be staying. Our team at the New York City Department of Health downloaded the information into a call center. We hired and trained hundreds of staff. We seated them 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 to find them in person, and we built a working relationship with the New York Police Department’s Missing Persons Unit to locate the small number of people who had moved, changed numbers, or otherwise become difficult to reach.

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. The Biden administration created an Office of Pandemic Preparedness in the White House to ensure that this kind of coordination would not have to be reinvented from scratch the next time. That office was eliminated by the current administration.

The Defense of the Current Response

The essay in the Wall Street Journal defends the current response by describing a whole-of-government effort involving the State Department, Defense, Homeland Security, HHS, and the White House. It notes that the administration has secured agreements with Germany and the Czech Republic to provide treatment for exposed Americans, has sent United States Public Health Service officers to a new facility in Kenya to quarantine exposed Americans, and has implemented targeted border screening. It concludes that the United States is again demonstrating its leadership role in global health security.

I am not going to dispute that these announcements have been made. The question, as I said on the air, is whether these are aspirational or actually going to happen The story of the reporter walking through Dulles unscreened suggests that at least one element of the announced response was not yet functioning on the day it was supposed to function. CDC officials have publicly acknowledged that the agency learned of the World Health Organization’s declaration of a public health event of international concern only a day before it became public, which is a departure from decades of practice in which CDC was treated as a peer in such determinations. My colleagues who remain at CDC, and with whom I am in regular contact, still cannot get clear answers about what the facility in Kenya is actually for and what happens to an American who becomes severely ill while quarantined there. Public health systems should not have ambiguities of this kind when they are functioning.

The Specific Problem with the Kenya Plan

The decision to quarantine exposed Americans in Kenya rather than evacuate them to the United States deserves particular attention, because it gets at a deeper truth about how outbreak responses actually work. I spent nearly six weeks in Sierra Leone during the height of the West Africa outbreak. If the deal at the time had been that an American who became infected would be transferred not to a high-resource hospital in the United States but to a facility in a neighboring country, I might not have deployed, and many of my colleagues might not have deployed either. The mortality rate of Ebola is close to zero when treated with the resources of a modern American hospital. It is dramatically higher when treated elsewhere.

The bargain we make with people we send into outbreak zones is the same bargain we make with the military personnel we send into combat zones. If you are injured in the line of duty, you receive the best care your country can provide. That bargain is what enables the recruitment of the highly skilled responders that outbreak response actually requires. Eroding it makes it harder, perhaps impossible, to staff future responses with the people who know how to do the work.

The Diagnostic Question

The essay also explains the delayed detection of the current outbreak by reference to a technical issue with diagnostic tests. The Bundibugyo strain of Ebola, which is causing the current outbreak, is rare and is not detected by the standard tests designed for the more common Zaire and Sudan strains. This is technically correct. It is not, however, a complete explanation of why detection was delayed.

Detection of an emerging outbreak depends on more than diagnostic tests. It depends on local health workers who recognize something unusual and report it, on ambulance services that bring patients to facilities where they can be characterized, on laboratory networks that can run specialized tests when standard ones fail, and on international coordination that ensures unusual findings reach the people who can act on them. The dismantling of the United States Agency for International Development has removed a substantial portion of the international workforce that performed precisely these functions. The cuts to CDC’s Global Health Center have removed a substantial portion of the American personnel who supported them. A diagnostic test that does not work in isolation is one problem. A diagnostic test that does not work in a system that no longer has the people to investigate why it does not work is a different and larger problem.

What Walks Out the Door of CDC When Cuts Are Made

Pierre Rollin, who spent twenty-five years at CDC in the Special Pathogens Branch and who helped train the medical staff in Dallas during the 2014 Texas Ebola case, offered the most striking moment of the On Point episode. He described the current outbreak in the Congo as looking identical to the 1995 Kikwit outbreak he worked on thirty years ago. The protective equipment is the same. The pattern of transmission is the same. The dynamic between health workers and grieving families is the same. What has changed, in his account, is that the United States is no longer present in the way it once was. He suggested that perhaps the answer is to create another agency and call it what was formerly known as CDC.

I have spent considerable time thinking about Rollin’s framing since the show aired. His point is not that the current CDC is incapable of doing this work. His point is that the people who carried the institutional knowledge of how to do this work have left, and that the agency in its current state lacks the capacity to train the next generation of people who would otherwise inherit it. Every outbreak is slightly different from the last one. The value of an experienced epidemiologist or laboratory specialist lies in the ability to recognize what is familiar and what is not, to apply the lessons of the last response, and to know which corners cannot be safely cut. That kind of expertise does not return on the timeline of a single political cycle.

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 networks that pick up novel infections, the hospitals that can care for patients safely, the international coordination that detects threats early, and the workforce that carries the institutional knowledge of how to do this work. Those are choices, and the consequences of those choices are measured in detection delays, in transmission chains, and ultimately in human lives.

The current administration is making different choices than the one that defined the 2014 response. The National Institute of Allergy and Infectious Diseases has been gutted. The Department of Defense research unit that worked on Ebola and related diseases has been closed. CDC personnel have been restricted from routine communication with the World Health Organization. The Office of Pandemic Preparedness has been eliminated. The agency itself has lost as much as a third of its staff and has gone for extended periods without a confirmed director. These are not the conditions under which an operational response to an outbreak is mounted. They are the conditions under which an announced response is described while the operational reality remains substantially out of reach.

The full On Point segment is available through WBUR, and I am grateful to Meghna Chakrabarti and her team for the chance to develop these arguments at length. The Ebola outbreak in the Congo will eventually be contained, with the help of the international workforce that remains and despite the diminished capacity of the institutions that should be leading the response. The harder question is what we do before the next one.