Ebola Update

Monday, November 10, 2014
Stephen Morse

Professor of Epidemiology, Columbia University Mailman School of Public Health

Helene D. Gayle

President and Chief Executive Officer, CARE USA

Jordan S. Kassalow

Chairman, VisionSpring

Experts discuss international efforts to combat the Ebola outbreak in West Africa.

KASSALOW: With us today, we have Drs. Helen Gayle and Stephen Morse, both renowned experts on international health and infectious diseases. Dr. Helen Gayle, as you know, is the president and CEO of CARE USA and has been in that role since 2006. Prior to her role at CARE, she was the director of the HIV, Tuberculosis and Reproductive Health Program at the Bill and Melinda Gates Foundation. And she's also had leadership roles at USAID and the Centers For Disease Control.

Professor Morse is the professor of epidemiology at Columbia University's Mailman School of Public Health. He was a global director—co-director of PREDICT, a USAID project to strengthen global capacity for surveillance and detection of new infectious disease threats, and is also the founding chair of ProMED, the program to monitor emerging diseases.

His book Emerging Viruses was selected by American scientists as one of the top 100 science books of the 20th century.

So we're very pleased to join—have us join with Drs. Gayle and Morse, and we're going to start with Dr. Morse, or Professor Morse, to ask you, Steve, if you could just give the audience a little bit of a history of the Ebola virus—what the patho-physiology of the disease is, and what are some of the realities of how this disease is transmitted. I know there's a lot of misunderstanding in the world. And giving people just an Ebola 101 before we start to get into some of the more substantive aspects of the conversations would be really helpful to our members.

So over to you, Professor Morse.

MORSE: Thank you very much. And it's a pleasure to join you. And thank you all for dialing in.

Ebola is a virus that probably has a storied reputation and of course a tremendous fear factor thanks, in part, to Hollywood and to all the various books such as "The Hot Zone" and other classics that have focused on Ebola. It's not a new virus. Actually, it first became known to Western medicine in two almost simultaneous outbreaks in 1976, one in Zaire, now the Democratic Republic of the Congo, and the other in Sudan—now actually in South Sudan, giving rise to the names for the two major and most frequent species of Ebola viruses, we used to call them strains: Zaire and Sudan.

Zaire is the one that people most generally think of when they think of Ebola, and classically it's had a very high case fatality rate, usually in the neighborhood of 80 percent to 90 percent, although here in West Africa in this last outbreak, it's been much less for a variety of reasons, not all of which are known.

Ebola causes what we call a viral hemorrhagic fever, now officially called Ebola virus disease or Ebola viral disease. And basically, this is a fever with shock, abnormalities of blood clotting and leakage of blood vessels. So that in the end, unfortunately, the end result is very much like any other shock situation, if you're familiar with septic shock after severe bacterial infections in children, for example.

One thing that was not appreciated early on, and has become more appreciated recently is the degree of dehydration that occurs as a result of both considerable diarrhea which is profuse and often bloody, and that it's essential to replace those fluids. Many operations like Medicins Sans Frontieres, Doctors Without Borders, in the field will now do this with oral rehydration. This is very much like what is done with cholera. And they feel it's made a very big difference. And those who have treated it here in Atlanta, for example, also feel that it's made a very big difference in survival rates.

Ebola starts out, although it ends up, obviously, as a very severe disease, it starts out very simply, like everything else, a flu-like illness, but very often also with abdominal pain, diarrhea, vomiting sometimes, and often the vomiting will become much more pronounced later, and sometimes, strangely enough, hiccups, which are not actually a rare accompaniment of Ebola.

It's been known in Central Africa in a number of outbreaks and beginning a few years ago, some additional outbreaks were found with giving rise to some other Ebola viruses that are very similar. There was an outbreak in Northern Uganda in a place called Bundibugyo, which gave obviously the name to another Ebola virus. And there have been several since mostly in Democratic Republic of the Congo and Gabon, but also a small outbreak in Cote d'Ivoire, which was a different Ebola virus, and Sudan, of course, and more recently several in Uganda.

In West Africa in the three countries now where we've seen it, it probably started, as all Ebola outbreaks do, by someone going into the forest and coming in contact with the natural animal host of this virus, the reservoir.

We think, although we don't know, and it's been a mystery for sometime, the current preferred hypothesis is that it's probably a fruit bat that actually naturally carries this virus as an infection that probably causes very little damage to the animal, but obviously can be very severe if we happen to come in contact with infected material left behind by the fruit bat or by some other animals—gorillas, chimpanzees, and certain types of antelopes can also become infected. And of course, people can become infected when they take the carcasses home for food.

Despite Evola's fearsome reputation, it actually does not spread very well at all. This sounds like a very strange thing when you think about all the cases that are now occurring in these parts of West Africa, and that includes of course right now we're up to about a little over 13,000 cases with just under 5,000 deaths.

However, having started in what is probably a rural area in southeastern Guinea, with someone going into the forest and probably becoming infected there, it then spread from person to person within family, usually beginning with families, or then at funerals. And because this also bordered those two other countries—Liberia and Sierra Leone—and because there is easy access to the capital cities from those areas, those border areas, it rapidly came into the capital cities and became the largest Ebola outbreak in fact that we know of in all the history of Ebola. It's larger than all of the past numbers combined for number of cases.

The virus is transmitted by direct contact with infected secretions. It does not spread by the aerosol route or by any respiratory route unless you happen to be unlucky enough to be very near someone who might spit up some infected material. Blood, however, bloody diarrhea, vomit and other infected secretions are the usual means of transmission through either mucous membranes or broken skin, which is why we use very careful protective precautions.

Finally, many of the patients later on are health care workers, because they're the ones who are here, and family members, because they're the ones who are caring for the patients when they're the sickest and have the highest level of virus.

And with that, I'll turn over the floor to Dr. Gayle.

KASSALOW: Go ahead, Helen. I was just going to frame the question just to remind people that we've asked Dr. Gayle to bring us from the overview of Ebola right into the ground reality. We've all heard of an increase in responsive resources and the manpower being attributed to Ebola. Now, the question is has it made a difference? Do we see a waning? Is it just as raging as bad as it's always been?

So, if you can just help us understand what's the reality on the ground would be really great for our members.

GAYLE: Yes, thanks. And thanks to Steve for setting such a nice kind of foundation. And I think just picking up from where you left off, I think, you know one point that is important to mention—to kind of reiterate which I think oftentimes gets lost in what has become an incredible amount of focus on this in sometimes a somewhat fatalistic way is that this is a virus that we have a lot of knowledge about, and also evidence of what needs to be done in order to make a difference.

And if we mount that effort and are consistent in it, then in fact we can start to see real differences.

And so, you know, basically want to make a couple or so points, one, that, you know, on this side of this U.S. government, that the response is really, fairly robust and growing, hopefully, will continue to—you know, continued progress is going to be made by really putting in place the best public health response based on all that we know about the disease and—and fighting it at the source and that we also need to think about some of the longer-term impacts that are going to evolve as a result of what is already gone on.

And you know, I guess to your point—and let me focus first of all on, you know, what's going on on the ground.

You know, I think that there's a really great example that often gets forgotten or hasn't been talked a lot about, which is Nigeria, which was very able to successfully put in place core principles and practice around what it takes to control an outbreak and very quickly were able to, in fact, stop that.

And it was largely because—stop the further spread of Ebola, and it was largely because they had invested in public health infrastructure for polio eradication that they were able to quickly mobilize and make a huge difference in—in stopping the epidemic there in Nigeria.

I think if we look at some of the examples of countries in the neighboring West Africa where they have been able to mount a response, I think it does give the clear example that it is doable. So first and foremost, it is doable.

That said, you know, when I talk to my colleagues in organizations like the Centers for Disease and others who—Medecins Sans Frontieres, International Medical Corps, et cetera, people who've been in—fighting epidemics for a long time, they all say that what's going on now is really unprecedented and particularly in the very early days when we didn't get a jump on this to begin with.

And I think a real lesson is the ability to mobilize quickly is going to be more and more important, not only for Ebola today but for whatever next epidemic faces the world and particularly poor countries that already have weak infrastructures.

That said, I think there's a lot that is being—that is being done, and it's being done in—in several stages.

First and foremost, immediately getting to people and being able to provide treatment for people who are already sick.

And Steve mentioned that one of the biggest things is being able to provide fluid replacement for people who are losing huge amounts of body fluid as a result of—of this epidemic.

And so first and foremost, making sure that people who are already ill are getting the kind of supportive care that will allow them to then mount an immune response that allows them to—to recover from—from this infection.

Second is making sure that people who are isolated are actually—people who are isolated who had been exposed and beginning to show symptoms and then a big part of effort—it's a huge part of the effort that organizations like CARE, who have already been—who have been on the ground in countries like Sierra Leone for decades, are really working on community mobilization, because in many of these countries, people are very unaware of signs and symptoms of Ebola and making sure that we're getting out into communities, helping to provide health education and messages both around how people can prevent themselves from getting—from potentially being in contact with the infection and also making sure that people understand whether—what to do if they are sick.

And as—as was mentioned by the previous speaker, things that are normal, everyday behaviors in communities, like taking care of one's sick or washing the body of somebody who has died, are the kinds of things that are putting people at risk unknowingly for Ebola.

And so a lot of work is being put not only on the treatment but also looking at the preventive aspect, educating communities and making sure that people are aware of signs and symptoms and what to do if, in fact, somebody thinks that they may have been exposed to Ebola.

We're very involved in a range—ourselves, CARE and organizations like CARE are very involved with a range of things, including simple things like giving out hygiene kits that include buckets, chlorine, water, soap, gloves, making sure that people have protective garb, because there aren't enough hospitals or care facilities right now for people who, you know, in—in the environment and people who have potentially been exposed to Ebola.

So all of those efforts, I think, are being—are being mobilized, and we're starting to see, in countries like Liberia, for instances, where the government has been incredibly aggressive in—in—in mounting response, we're starting to see a slowing in the number of cases.

The question remains is this slowing because people have become aware and are concerned about being identified with Ebola, or is it because the cases are—are clearly—are starting to come down?

And it just—it points to the fact that stigma has been—has—is an increasingly huge part of this epidemic—stigma out of fear in the countries in which this is taking place as well as, we know, stigma here in our own country around people—people in countries where Ebola has been having its greatest impact.

The other corollary to the weakness of the health infrastructure and the fact that—that health systems are being flooded now in countries like in the three countries most affected—in Guinea, in Sierra Leone, in Liberia, where the health infrastructure was already weak, is that many people who—who would have sought care are staying away from or being turned away from health systems, staying away because of fear, of being in contact with someone from Ebola or being turned away because health facilities are preferentially treating people with Ebola as priorities, and so people with other treatable and preventable causes of death are being turned away—women dying in childbirth, people with malaria, other types of diarrheal diseases, pneumonias, et cetera, tuberculosis are not getting the care and treatment that they need.

So there's—there is a parallel potential for increased illness and death in these same countries because Ebola is overwhelming already weak health infrastructures.

I think we're going to talk more later about the impact that Ebola is having on the broader economic and social fabric of these societies that already had weak economies, but just to say that I think this is, for us as a development organization, another huge concern.

If you look at just everything from whether or not children are to continue to school, because schools have largely shut down out of concern about having people potentially in contact with Ebola to farmers unable to go and—and farm their harvest and farm crops and what that will mean for places that are already food insecure.

So I think there's a whole other downstream impact of Ebola on societies and economies that I think will be something that we may want to get into in our question-and-answer period.

So you know, again, I think we are mounting a increasingly effective response. I think there are challenges to that response, both in terms of adequate resources, adequate health personnel.

That said, I think the greatest focus is being put and should continue to be put at the source so that we can really do all that we know needs to be done on the treatment side as well as the prevention side and then looking at what are some of the corollary of both an overstretched health system as well as the downstream social and economic impact.

KASSALOW: Thank—thank you, Helene.

Before we get to some of the broader areas of economics and political and security, just one question for you and Steve, it's often the case where one of the most dangerous times of any epidemic is when people start to feel like they're starting to win the battle.

Can you talk a little bit about what needs to be ensured, what kind of vigilance needs to be ensured when we're getting a sense that maybe the balance is tipping in the right direction?

GAYLE: Well, you know, I mean, I think your—your question essentially, you know, points to, you know, the—somewhat obvious that—you know, and we can't declare victory until the battle is really won, and I think, you know, we have example after example of how we stopped too—too soon and didn't get the job done, and if we do that, I think we risk having a real potential resurgence or you know, moving back into the exponential direction that this was going in, and I just think, you know, we can't afford to do that.

And so I think, you know, there—there are resources that we need to continue to advocate for. I think we have to make sure that we don't put in place barriers for healthcare workers getting over to Liberia, Sierra Leone and—and Guinea and really think about all the ways in which we—we can't give a mixed message about how important it is to do what we need to do to, you know, end the chain of transmission at the source.

KASSALOW: Yeah, yeah.

Steve, you want to add anything to that or...

MORSE: No. I would emphatically agree.

And, you know, I would agree, there is a tendency, once cases start to wind down, that one gets complacent, and we can't afford complacency. The other thing is, this virus has been in this area, although we weren't aware of it, for at least 10 years, and I'm sure longer than that. And we're likely to see future outbreaks, as well.

KASSALOW: Interesting. Just...

GAYLE: Could I just—just a final point on that. I think what it does—and, again, that's why I mentioned the Nigerian response—you know, I think what it does point to is that, you know, we will continue to see, whether it's Ebola or the next very serious infection—you know, what—we've had HIV, we've has SARS, we've had, you know, Ebola, H1N1, et cetera. And at the end of the day, it all boils down to having an efficient and effective health system, including a public health system that allows for disease surveillance and—and detection. And I think, you know, it's the difference between why Nigeria was able to stop it fairly quickly—they had a strong surveillance system, they had ways of getting public health messages out—and why some of the other countries have not.

And so, I think the real message in all of this is, you know, while we need to do what we can to fight Ebola now, because it is killing thousands of people, we also need to continue our efforts in strengthening the health systems in countries where health—the health system is so fragile and so weak. Because if it's not Ebola, it will be something else. And in a global world, there really needs to be a concern, not only because we care about people in those countries, but because pandemics—epidemics become pandemics if we don't have the right systems in place.

KASSALOW: Thank you for that important message.

I know we have hundreds of members from around the country online. It is 2:30, so I want to make sure we turn our attention to you and answer questions that you have. Just if I could remind you of two things—one is, we are trying to focus our best attention on where the issue is greatest, which is the pandemic in West Africa, or the epidemic in West Africa, one. And two, is, I think we've had a nice conversation about the disease and the health aspects of—of the disease, and the ramifications to the health sphere. In our short half an hour, we haven't had a chance to extend it into those other areas of—of economics, political, security, and so forth, so we do welcome your questions in that direction.

And I will turn the table over to our first question from the audience.

OPERATOR: Thank you. At this time, we will open the floor for questions. If you would like to ask a question, please press the star key followed by the one key on your touch tone phone now.

Questions will be taken in the order in which they are received. If at any time, you would like to remove yourself from the question in queue, press star two.

Again, to ask a question, press star one.

Our first question comes from Nancy Aossey with the International Medical Corps.

QUESTION: Yes, hi. So, thank you, Stephen. Thank you, Helen, for your comments.

I was curious—as you know, International Medical Corps is offering treatment units in Liberia, and we're scaling up. One of the concerns we have, which you talked about, was the sense that we're really not quite ahead of this disease yet, and that the focus will be taken off of getting ahead of the disease.

I'd love to hear your comments a little bit about—you know, observations around the issue of the health workers. And also, a little bit about the economic impact that you see happening, or that you fear happening in the very near future.

GAYLE: Well, first, let me say thank you, Nancy, in the work of the IMC—International Medical Corps—and your incredible and heroic work. You know, you've been one of the first in the field and in these countries. You know, even when there wasn't the commitment that I think there is now. So, thanks for all that you all have done.

You know, you alluded to the issue of health—health care workers. I think we have to do everything that we can to incentivize, and not disincentivize people to get over. You know, these are countries that have incredibly low health care worker to population ratios already. There is no way that just by the workforce within these three countries, that this epid—these epidemics are going to be controlled. So, it is going to take health workers from outside of those countries in order to have the kind of workforce that's necessary. It just is—you know, I think people probably have all seen what it takes for a health care worker to go in and be safe and have the right kind of protective garb on. You can't, in tropical climates, stay in those for hours. You know, you can't do 12-hour shifts. There is a need for people to—to be able to cover each other. So, I mean, the health care worker needs are—are incredible, and we can't underestimate that. So, I think that's—you know, I think that's huge.

You know, there have been—there have been—on the economic issues, there have been estimates—and I think right now, they're—they're, you know, estimates at best—about what is going to happen in terms of economics. But, you know, as an example, as I—you know, as I mentioned, in a lot of work that—that we do with helping small holder farmers in these countries—farmers are not able to—you know, are not going to go and work their fields. Working their fields is a cooperative, you know, multiple-people activity.

In countries—you know, in most of these countries, people have taken work holidays because of the concerns of people congregating, and what the potential of people congregating means for the spread of—of Ebola. So, you know, basic things, like being able to harvest crops, are on hold.

There are—getting things into these countries has been slowed down. So, basic essential goods are not in the—in grocery stores, in, you know—in shops, et cetera. So, you know, there's already a feel of, you know, economic challenge within these countries.

So, clearly, as this evolves, there's huge concern about what this means. And I think it's—you know, the downstream impact of this is going to be much greater. It's tearing apart families. We're seeing already orphans similar to what we saw with the AIDS epidemic, where children are now faced with one or more parents who have died from Ebola.

So I think all of these things point to the potential for, you know, real economic impact.

MORSE: Very definitely. I think Helene has put it very eloquently, but I also want to add thanks for all the work that you're doing there, and very, very bravely. It is amazing how much social effect Ebola is having on the people there, everything from closing schools and as Helene mentioned, the effect on food security. There's speculation that it may have an effect on cacao prices, which come from the same area.

And we're not even finished yet. So I think, you know, if this had gotten into Nigeria or into—into Senegal, each of which had one case and was able to control it, but Nigeria, of course, had several secondary cases as a result and was a good example of controlling it. If it had gotten in there and not been controlled quickly, I think it—we would have seen a really devastating scenario, which is not to worry anyone, but you know, it's an indication that we missed a real bullet there and through good public health work.

QUESTION: Thank you.

OPERATOR: Thank you. Our next question comes from Joel Cohen (ph) with the Rockefeller University.

QUESTION: I'd like to thank all three speakers for clarity and directness. Would you please comment on the sending of 3,000 U.S. military to Liberia from two points of view? One is the perception on the part of the people in the countries who receive the military, that the U.S. response is to send in the troops. And secondly, on the point of view of the U.S. military themselves: Are these people trained to deal with infectious agents or are we putting our young military people at risk in a situation they're really not equipped to handle?

MORSE: Well, thank you for that question. I think it's a very intriguing one.

My understanding notwithstanding—you know, putting aside any health care personnel, is that most of the military people who will be going in there will be doing construction, logistics and other things that I think fall very well within the area of military specialties and which they can do very well.

In that case, I think there's very little risk, you know, virtually no risk of their coming in contact with the patients and becoming infected. I won't comment on the irony that we do send troops into Afghanistan to face IEDs, improvised explosive devices, for which we have no counter-measures. But we do know how to protect people against Ebola.

GAYLE: Yes...


GAYLE: Yeah, no, I would—I would—yeah, I would agree. You know, much of the DOD support is logistics. On the other hand, you know, the DOD has a history of dealing with dangerous infectious agents throughout the world and the DOD has some of the finest research institutions around dangerous infectious agents because troops are often exposed to, you know, medical dangers around the world.

So, you know, the troops that are—military that are—that are being deployed for Ebola are getting the appropriate training, have the, you know, the background to do this. But a lot of the work is around logistics and helping to, you know, set up things like, you know, field deployable hospitals and things that help with the logistical side that the military does incredibly well. And as Steve pointed out, we put our troops and young women and men at incredible risk around the world. It is part of the, you know, what people sign on for and why I think we owe them a lot for what they're doing, you know, in this situation.

QUESTION: Thank you very much.

OPERATOR: Thank you. Our next question comes from Richard Garwin (ph) with IBM Corporation.

QUESTION: Yes, in regard to rehydration. With cholera, the mortality rate can be reduced to less than 1 percent, I understand. But what is it with Ebola? And of course, it's easy in a hospital environment in the West where there's good source of power to provide rehydration. And in the field with oral rehydration, but this seems like a very big lever and ought to be pursued rapidly. What is the potential?

MORSE: Helene, have you see it being used in the field? You might want to comment on that?

GAYLE: Oral rehydration? You think oral rehydration?

QUESTION: Yes, oral rehydration.

GAYLE: Yes, it is being used in the field. And there is—there is more and more because there aren't enough hospitals and hospital beds. You know, there are community care clinics that are being set up in these—in these three countries in order to be able to do care that is care outside of the hospital setting, of which oral rehydration is part of that. So that families can actually survive hydration (inaudible).

QUESTION: That's input, but what's the output?

GAYLE: We don't—yeah, I'm not sure that there's statistics yet available to see how much of an impact it's having. Some of these community care centers are just being set up. But we do know that it is the supportive care which is what will allow patients with Ebola to have the time to mount enough of an immune response themselves. So the expectation would be that in fact aggressively administered oral rehydration should start bringing down mortality for people with Ebola.

And, you know, it will vary. How sick were they when they came in? And, you know, how soon, how aggressive, how well is it tolerated? So there aren't good data yet because this is really still evolving.

QUESTION: Yeah, it's important to carry out research on the epidemic while it is happening, rather than to go into each of these with the accumulated knowledge from before. Thanks very much.

GAYLE: Yeah, and I would just say to that, you know, that is obviously very, very true. And people are working to get the kind of data to support—you know, in a real-time way. On the other hand, in such a crisis, such an overwhelming situation as is going on now, you know, it's hard sometimes to be able to extract all the data.

But yes, that is, you know, people are monitoring, people are trying to get real-time data on what's working and what's not, feeding that back so that people can continue to improve the care and support that they're doing. And I don't know, there may be people on the phone who are, you know, who have some of those sort of data, but it's not as if people are ignoring the need to collect real-time data.

OPERATOR: Thank you. Our next question comes from Margaret McWinn (ph) with the International AIDS Vaccine Initiative.

QUESTION: Hi, and thanks to all three speakers, very helpful commentary.

I'm curious as to whether any of you have a perspective on something I've heard talked about a lot. We've all seen it in the press, but I've heard it a lot in the global health product development space. That—that drugs and vaccines directed at Ebola were just sitting on the shelf and never been fully tested. So, you know, that's the rhetoric that you hear, but I'm wondering if any of you have a sense of how much truth there really is to that and whether there are any lessons learned that we can apply to future global health threats.

MORSE: I think it's partially true. There hasn't been much economic incentive to develop Ebola vaccines, of course, because these have usually been sporadic and unpredictable, and obviously in very low-income populations. And even in the United States, a disease like Lyme disease, for example, it's very hard to get vaccines developed.

There were some initial technical difficulties which were overcome and I know that Frank Collins, the director of NIH, has remarked I believe that it might have been useful to take those candidate vaccines once they were developed and at least bring them through the first stage of testing for safety and phase one trials on humans so that we would know they were—we had some track record with them.

Be that as it may, I think we'll have the opportunity to do that now, even if it's a little bit faster. With some of the therapeutics, it's actually interesting. Some of those that have been used like Brinsidovivere (ph) have only been tested in cell culture, not against—not in animal models and certainly not in humans, until very recently. Others are in the early stages, but have shown efficacy in animals.

So I think right now we're seeing an attempt to accelerate development considerably.

GAYLE: Yeah, and just to, you know, back to an earlier point. You know, I think it's probably safe to say that there are a lot of, you know, pharmaceutical agents sitting on shelves that there's not an economic incentive to develop for uses in non-lucrative settings. And we all, you know, we all know that and know that, you know, a lot of the drug development that occurs, you know, is—is developed for markets that can better afford it. And, you know, there are a lot of organizations like the one that you head, IAVI, that were founded in order to come up with solutions for things that—that better address the needs of—of poor countries.

You know, that said, and I think there needs to be continued focus on how do we shift that balance a little bit more—the issue of how do we make sure that we have stronger health systems to begin with, including good surveillance that is key to getting a jump on things like Ebola, is also going to continue to be important. We can, in fact, predict that there will be something like Ebola, just like we had with HIV, SARS and other things, that if we had strong surveillance systems in place, we would be able to get a jump on some of these types of epidemics early on. So, I think, you know, we need to do both.

OPERATOR: Again, if you would like to ask a question, press star one.

Our next question comes from Joshua Busby with LBJ School of Public Affairs.

QUESTION: Yes, thanks very much for your comments. I wanted to follow up with the other question about U.S. military mobilization. I heard some pushback and critique that perhaps the emphasis on construction and building and beds may be overdone, that—that perhaps this isn't the best us of our overseas deployment. That we're may be possibly building too many beds. And I'm wondering if you've got a sense of that, and whether or not President Obama's request for $6 billion to support ultimate rebuilding and preparedness for the health systems in the region is likely to find success in the new Congress.

GAYLE: Well, it's probably anybody's guess on what will find success in the new or the old Congress. You know, I do think that the request for the—for the $6 billion is an important request. And, you know, I think it will need to be continually—continually reevaluated, what's the best investment.

Right now, it does seem like there is a lack of just physical space to treat very, very sick people, and to get facilities in place quickly enough so that the kind of care that somebody with Ebola, who is very sick, needs fluids and other supportive measures, can be put in place.

So, right now, where we are, that does seem like an important part of the equation. It's not the only part of the equation. And I think it is going to be important to make sure that we look at this holistically, looking at surveillance, contact tracing, treatment, isolation, community mobilization—all of the things that are very, very necessary.

But I—you know, I think this is one of those times where we could be penny-wise and pound-foolish and not do enough, and really suffer the consequences long-term.

You know, back to one of the earlier questions about the economic value—you know, the modeling that's been done says—you know, kind of—there's a whole very, very wide range. But, you know, if this is kind of quickly—and I guess it's already too late to say "quickly"—but if it's more rapidly brought under control, the economic impact is estimated to only be somewhere around $100 million. But if, in fact, this continues to escalate, it's estimated that, you know, the—the economic impact in the West African region could get to $33 billion.

And so I just think that again, not just the immediate health consequences, but the longer term economic impact, including the fact that if it's not kept under control in these three countries, other neighboring countries are going to start to feel the brunt.

And Steve mentioned cocoa. A third of the world's cocoa comes from Ivory Coast, which is, you know, right there in that region. So, you know, $6 billion, big number, it's always tough to make these trade offs. But I think if we are putting in the kinds of resources that are necessary to mount the appropriate response, we're going to pay later.

KASSALOW: I think this is also a good example of how health can quickly become a national security concern, and when you start talking about these kinds of billions of dollars, it is also to protect failed states from occurring, which are wonderful vacuums for terrorism, which is already taking root in West Africa.

GAYLE: Right.

MORSE: Yes, and these are very fragile states indeed. And getting back to you, just to mention something about your earlier point on the troop deployments, I hope that they'll be able to do quite a bit more, you know, given their level of expertise as you suggest, quite a bit more than just building hospital beds, there's a need for a lot of logistical support and personnel support, including protective equipment, supplies, water, everything you can imagine, and hopefully they can help with delivering those as well and making sure those are utilized properly.

OPERATOR: Thank you.

Our next question comes from Molly Anders with Dibex (ph).

Well, at this time, I'll be turning the call back over to Jordan Castleow (ph) for closing remarks.

KASSALOW: Thank you very much. Thank you everyone from joining. Before I give closing remarks, would Helene or Steve want to say anything? Because we have about five more minutes, and I'll be glad to wrap it up. But if one of you or both of you would like to just give a closing thought, this is a great time to do it.

GAYLE: Well, I mean I guess I'll just reiterate, you know, the points that I made earlier that you know, one I think we have begun to mount a sizable response, but the needs are much greater. They need to be holistic and we need to make sure that you know, we're focusing on the things that can really make the biggest difference. And particularly, making sure that we're looking primarily at what can we do to halt transmission, you know, at the source currently in the three countries that are most affected?

I mean, it is important that there is support for this funding request for $6.2 billion. That's the range that is in the right range of the kinds of resources that are necessary not only to fight this immediate epidemic, but to really do it in a way that strengthens the fragile health infrastructures that will allow for better prepared when the next Ebola-like epidemic comes along, and that we also in that, and part of the resources will also go to looking at how to mitigate some of the economic impact that is going to come from people who are having to stay away from doing the things that are necessary for the economy and you know, we've mentioned whether it is kids staying out of school or farmers not harvesting crops et cetera to slowed commercial airlines coming in and out of those countries, I think we've gotta make sure that we're thinking about all of these things in a holistic way.

KASSALOW: Thank you, Helene. Steve, any last thoughts?

MORSE: No, I absolutely agree with everything that was just said. And you know, I agree, it shows the importance of having functional public health systems for not just Ebola, but everything else. And I think the other thing is that, you know, we shouldn't be afraid of Ebola the way, you know, we were.

In many ways, our reaction resembles the way people first perceived HIV, something that Dr. Gayle will know well. You know, it was a mysterious thing that somehow seemed frightening, and that may have been true of Ebola in 1976, but we've had almost 40 years of experience with it. And at this point, I think that although this is a large and unprecedented epidemic and requires a lot of activity and a lot of people on the ground, nevertheless, you know, we shouldn't really be pretending that we don't already have some knowledge of it and know how to control that.

KASSALOW: Very good. And I would just add one last thought, and that is the—what both of the other speakers have said is that the importance of bolstering the fragile health systems not only so that in the future, if another Ebola outbreak occurs, we're better prepared to stem it at its root.

But also if you put things into perspective, as Dr. Morse has said, about 5,000 people will have died of Ebola this year. But over 1 million people will have died of HIV/AIDS. Over a million people have died of respiratory infections. Over a half a million will have died from malaria. So, that investment in those fragile health systems as a baseline will help many hundreds if not millions of more people and also be well-prepared if there is another outbreak of Ebola.

So, I think that's a really important point, and I just think the other important point that I think the speakers want to leave you with and us with is the importance of staying vigilant as the tide starts to be turned in the favor of controlling the disease. It's—that's the time in these outbreaks that are most critical to make sure that we don't lose focus and don't give up on the tension and keep the resources coming during those times.

So, that...

GAYLE: Could I one more point before we?

KASSALOW: Yes please.

GAYLE: I'm sorry, I think we have one more minute.

KASSALOW: We do have another minute.

GAYLE: Which we—you know, a couple of times we've likened this to HIV in some ways. I would just say one other way in which I would liken it to HIV that I hope we will also continue to fight, which is the stigma, and as we know, you know, there has been incredible amount of stigma attached to Ebola, as well as now to the countries in which Ebola is—has its highest impact. And I think we also want to be fighting, you know, which is—does come from fear, fighting the stigma that comes with it as well.

And, you know, when I think about these countries in West Africa that are already fighting uphill battles in so many ways, two of which are still recovering from very severe longstanding civil war and other issues, you know, we can't afford to be isolating and stigmatizing regions and countries in the world. It doesn't help them. It won't help us ultimately.

KASSALOW: Excellent point. Well, thank you, Dr. Gayle, Professor Morse for enlightening our membership. I think for those who have been with us for the last hour know more than they did an hour ago and can represent the realities of Ebola better to their friends and families than they could have if they weren't here for the last hour.

So thank you again. Thank you, members, for joining, and we're signing off. Thank you so much.

MORSE: Thank you very much.

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