00:00There is concern that the facts that we have, the data that we have, aren't painting a complete holistic picture
00:04of how wide this outbreak is.
00:06Your sense, from your experience, of how accurate that count seems to be?
00:10Well, it's certainly an undercount.
00:13The case numbers when they announced the outbreak just over a week ago were just under 250.
00:19Now that's pushing 800 in the official count.
00:24But for cases to go up that quickly, that's not new transmission.
00:28That's just beginning to get a sense of how much is already out there.
00:32And I don't think we fully have that sense yet.
00:34There's not a full contact tracing and case finding operation underway yet.
00:38And so there is still a lot out there that we're not seeing.
00:41I'm sure it's over 1,000 cases by now.
00:43It could be multiples of that.
00:45This is already on paper the third largest outbreak in history.
00:51It's well on its way probably to becoming the second largest given the trajectory that it's on.
00:56And I think it's going to be exceptionally difficult to contain.
01:00I know when you're trying to fight an outbreak, you're fighting not just a disease, but you're also fighting misinformation
01:06and disinformation.
01:07And talk to us a little bit about how hard that battle is as well.
01:11Because I was reading about this crowd that set fire to one of the few functioning hospitals that treats Ebola
01:17specifically in the eastern DRC.
01:19And partially that was because there was mishandling.
01:21They didn't understand why they couldn't have the body back.
01:23There's an issue with burial customs where they're washing the bodies.
01:26And then that water is being passed around.
01:28And it's easy transmission.
01:29How do you fight this on two fronts, especially when you're short-staffed?
01:33It's such an important point.
01:35And it's easy to get caught in this idea that we just need a health response.
01:40We just need clinics.
01:41Secretary Rubio has talked about setting up 50 health clinics.
01:45And the health clinic piece of this is important.
01:49It's also really difficult to scale.
01:51And, of course, you need for those clinics to mean anything.
01:55People need to have confidence that they can use them.
01:57They have to have confidence and trust that they will get the treatment that they need and that they understand
02:05that that's what they need to do.
02:07And that all really comes down to trust.
02:09And so an outbreak response, the foundation of an effective outbreak response is trust between the communities who are at
02:17risk and the health responses or the operational and health response itself.
02:22And we saw this the last time there was a major outbreak of Ebola in eastern Congo.
02:26That was in 2018-19.
02:29That was the second largest in history after the West Africa one that I worked on in 2014.
02:34And we saw these kinds of patterns.
02:36It's not surprising to me that people are – our community members are behaving this way because they haven't –
02:44they don't understand the disease.
02:46They're not necessarily familiar with it.
02:47They don't necessarily believe everything they're being told.
02:50There's a lot of skepticism.
02:51This is a part of the country that has been affected by war for decades, that is quite – often
02:56quite hostile towards the central government.
02:59And so when they have the Ministry of Health from the central government telling them something, they won't necessarily take
03:03that at face value.
03:04So that's going to be a huge hill to climb.
03:06Jeremy, I want to ask you about the role that the U.S. is playing or isn't playing at this
03:10point in time.
03:11So we've seen the U.S., as Christina mentioned, withdraw from the WHO, not playing an active role in that
03:16organization any longer.
03:18I mentioned in the last hour we were talking to our colleague, Jason Gale, who covers public health, that we've
03:24both been kind of inundated with emails from the State Department over the course of this last week detailing what
03:28the U.S. has done here, noting that the CDC is running point here, and saying that the overarching objective
03:33here is to keep Ebola from coming into the United States.
03:37How different is the response posture from the U.S. this time around than what you lived through in 2014?
03:43Jason Gale mentioning to us that Tom Frieden, who ran the CDC, said that the Ebola outbreak was a full
03:48-time job back when he was in that position.
03:51And here we're in a position where a lot of these key marquee positions in the public health apparatus in
03:56the U.S. are unfilled or filled by interim appointments.
04:00Yeah, and Dr. Frieden and I worked very closely together on that response.
04:04We actually, early in the U.S. response, traveled out there together to Liberia to assess firsthand and to meet
04:12with the president of the country.
04:14There is just dramatically less capacity in the U.S. government to tackle a challenge like this than there was
04:22even two years ago.
04:23You know, we had learned a lot of lessons from that 2014 Ebola outbreak.
04:27At that time, of course, USAID existed.
04:29There was a very robust CDC.
04:31We were a member of the World Health Organization.
04:34And all of those things were really important.
04:36USAID, CDC, and WHO worked together hand in glove to lead the international response to that outbreak and then reprise
04:46that again in the large outbreak in the same area of eastern Congo in 2018-19.
04:55And that's mostly gone now, that partnership.
04:59CDC is a shell of what it was, particularly their global capabilities, have really been degraded.
05:05They're still there.
05:06I mean, look, the people are excellent.
05:07The people have tremendous knowledge.
05:09But will they be listened to by the people running U.S. health institutions right now?
05:16That's a big question.
05:18USAID, of course, is completely gone, and the U.S. is no longer a member of WHO, and often CDC
05:24staff are barred from even speaking to WHO.
05:27So that partnership has been just demolished.
05:30I want to read some statements, as David mentioned, we've been getting from the State Department, saying,
05:34it's false to claim that USAID reform has negatively impacted our ability to respond to Ebola.
05:39In fact, by bringing USAID global health functions under a new bureau at the State Department, our efforts are more
05:44aligned and effective.
05:46You also mentioned on Tuesday the State Department announced they'd be funding these 50 clinics to aid in the DRC.
05:52But the top civil servant in Uganda's Ministry of Health said in an interview that the government was not aware
05:58of the pledge,
05:59and it wasn't immediately clear where those $13 million were part of, where that pledge was going, or where those
06:04clinics were being set up.
06:06Where is the breakdown there?
06:07Is this something that would usually happen through WHO, these organizations?
06:11What is the line of communication, and is this something you can just stand up,
06:15or does this need logistics and things on the ground that, as we've talked about, don't really exist?
06:19Yeah, I really am disheartened by that whole exchange, because you see a few things there.
06:27First, so it was my job in 2014 to oversee the planning and development and funding of about 30 Ebola
06:34treatment units
06:35that we stood up across West Africa in that outbreak.
06:40Those things were wildly expensive.
06:43It cost us hundreds of millions of dollars to stand up and operate those things.
06:46So $13 million is barely a start to what it's going to cost to get this under control.
06:53But I think, and they're hugely complex.
06:56It took us months to stand those up, because Ebola clinics are highly specialized facilities,
07:02because they are built around very high-end infection prevention and control,
07:08because you don't want to enable more transmission.
07:10It's the whole point of those facilities.
07:12They're very different from a normal health clinic and very difficult to set up.
07:15But really importantly, we did all that in close, close partnership with the ministries of health
07:21in the countries we were working with.
07:23And the last thing we would have ever wanted to do is catch them off guard with an announcement
07:27we hadn't discussed with them first and didn't have their buy-in on.
07:30So to see that sort of an exchange between the U.S. Secretary of State and one of the affected
07:36governments
07:36just, I think, speaks to the lack of coordination, the lack of engagement between the U.S. and those governments.
07:43And again, that's the sort of function that USAID would have facilitated,
07:47because there were deep, deep webs of relationships between the USAID health personnel in those countries
07:53and their counterparts in ministries of health.
07:55And of course, that's all gone now.
07:57Jeremy, let me ask you, as we wrap up here, how worried you are just about the circumstances
08:01that we're seeing in Africa right now.
08:05This is a different strain than we've seen before.
08:07There isn't a treatment for it.
08:09As you said, the numbers seem to be undercounts of what's likely the case there in the DRC.
08:16How concerned are you about the state of things now and where they're likely to go?
08:19And can you say, unequivocally, that without having USAID, without having the public health apparatus in place
08:24that we've had in the past, that's likely to make this outbreak much, much worse?
08:29It's going to make the response much harder.
08:31And when you have a slower and less effective response, of course, the outbreak lasts for longer
08:36and it spreads further.
08:37And ultimately, a delayed or underpowered response just makes the ultimate job of containment harder,
08:46more expensive, more difficult.
08:47It will take longer.
08:48I fear that's what we're going to see.
08:50We're going into this with four strikes against us.
08:54This outbreak has the most momentum upon discovery of any Ebola outbreak in history.
08:59It's in eastern Congo, which is a conflict zone with three and a half million displaced people.
09:03And we know from the 2018-19 outbreak, it's very, very hard to fight Ebola under those conditions.
09:09That one took two years to get under control.
09:11There are no countermeasures and no vaccine for this, unlike the normal Ebola, not normal,
09:17but the other kind of main Ebola strain that we've seen, which is the Zaire version.
09:22And, of course, we're doing this without USAID, without the U.S. being part of WHO and with a weakened
09:27CDC.
09:28So all of those things are going to make this job much harder.
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