Lessons Learned After the Ebola Crisis

Tuesday, November 24, 2015
Baz Ratner/Reuters

Director, U.S. Centers for Disease Control and Prevention 

Richard E. Besser

Chief Health and Medical Editor, ABC News

Thomas Frieden, director of the U.S. Centers for Disease Control (CDC) and Prevention, joins Richard E. Besser, chief health and medical editor at ABC News, to discuss lessons learned from the Ebola crisis in West Africa. Friden reflects on the U.S. response to the Ebola epidemic and on the disease's progress in West Africa. He additionally analyzes the public reaction to Ebola, the CDC's response, and the challenges associated with treating Ebola.

The Darryl G. Berhman Lecture was established in 2002 and focuses on Africa policy. The series is held in memory of Darryl Behrman, who came to the United States from South Africa and dedicated himself to improving the prospects for international peace and cooperation.

BESSER: Welcome to the Darryl G. Behrman Lecture on Africa Policy: Lessons Learned from the Ebola Crisis. This is the annual Darryl G. Behrman Lecture of African Policy. And it’s held in Mr. Behrman’s memory. He’s originally from South Africa and had an abiding passion for Africa and international peace. The Behrman family is seated here in the front. And we thank you for your support of this.

I want to also welcome the CFR members from around the nation and the world who are participating in this meeting through live stream. You were told to turn your devices off, but as long as they’re silent you are free to tweet away to those who are following this conversation on Twitter. I’m going to be having a conversation with Tom for about 30 minutes, and then I’ll be turning it over and asking for questions from members.

The West African Ebola epidemic began in Guinea in 2013 and spread to neighboring Liberia and Sierra Leone. It was the first time that Ebola had been seen in that region of Africa. So far, more than 28,000 people have been infected, more than 11,000 have died. And the epidemic has slowed, but it hasn’t stopped. There was an announcement today of a 15-year old boy who died in Liberia, three cases in Liberia were reported out on Friday after months with no cases. And in addition to the incredible loss of life, the economic impact on that region has been staggering. And the epidemic revealed major problems in global response to health threats. And so we want to talk today about how do we ensure that the next heath threat is handled differently and isn’t allowed to grow to this level?

As is customary for CFR, I’m not going to go through Tom’s biography. It’s extensive and it’s in your materials there. And I couldn’t ask for a better person to be speaking with. I do want to make a disclosure, however. I am with ABC News, but I’m not an unbiased journalist. I worked at the CDC for 13 years and spent a number of those years in charge of emergency preparedness and response.

So the first question, Tom, has to do with the idea of lessons learned versus problems observed. Whenever there’s a health crisis, there is incredible efforts underway to identify what went wrong. And they’re always described as lessons learned. But if you look back in history, rarely are the lessons learned because the next time there’s a crisis we see a lot of the same problems occurring again. So I want to ask you, when you look at this health crisis, what do you see as the big lessons that should be learned from Ebola? And what needs to happen to turn them truly into lessons learned?

FRIEDEN: In the big picture, I think there are three key things that we had better learn from Ebola, because it could have been a whole lot worse, and the next one could be a whole lot worse. And whether it’s the next HIV or drug-resistant bacteria, or an intentional attack with an organism or another agent that can kill lots of people, there are three things we have to know. The first is that every single country has to be better at finding, stopping, and preventing health threats. That’s what the global health security agenda is all about, making sure that each country anywhere in the world, when a threat emerges, has the most likelihood of being able to find it and stop it.

The second real challenge is ensuring that when a country’s capacities are overwhelmed, the world can surge in effectively when a country can’t do it on its own. And for that, WHO reform is crucially important. And we at CDC are thinking about what we can do to surge in even more rapidly than we did this time. The third lesson has to do with health care facilities. Ebola, SARS, MERS, these are indicator diseases. They show what’s happening day in and day out in health care facilities. And what’s happening isn’t pretty. About 70,000 Americans each year are killed by infections picked up in the hospital in this country. And all over the world we see drug-resistant tuberculosis, measles, sometimes HIV, often Hepatitis C being spread through the health care system, formal or informal. We have to improve that if we’re going to protect ourselves.

But in the bigger picture, theoretically speaking, before Ebola we had a system of non-accountability and non-assistance. Countries weren’t accountable for having a system in place to find and stop threats. And the world was not assisting countries that didn’t have the wherewithal to do it. And the real challenge for the world is, coming out of Ebola will we have a system of accountability to know which countries are ready and a partnership to help those that aren’t?

BESSER: I want to dive into that a little further. In July of last year, Ebola was introduced into Nigeria when an infected man from Liberia arrived by plane. There were 19 people who were infected. Five died. It was an incredible contrast in terms of how quickly it was stopped there. There’s a new report out, came out Sunday, from an international group that is analyzing the response to Ebola. And one of the things they noted was that two-thirds of the world’s countries do not have systems in place to detect and respond to outbreaks. And that’s following a call in 2003 after SARS that countries all get ready. So your point that countries need to be ready to respond, how do we get there from where we are now so that response looks more like Nigeria? How did they pull it off?

FRIEDEN: You’re right to focus on Lagos because there isn’t a widespread understanding that if Lagos had gone the other way—and it could well have—the world would look completely different today. Lagos has the same population as Guinea, Sierra Leone, and Liberia combined. It has at least 10 times more travel in and out. And the control there was incredibly intensive, I’ll get to that in a second, but if it hadn’t been controlled there’s no doubt in my mind that Ebola would have been all over Nigeria and all over Africa for months or years. So we would have seen what was already a horrendous epidemic transformed into a global catastrophe. And it didn’t happen fundamentally because we had a polio eradication infrastructure in Nigeria.

So we took the deputy incident manager from polio and made him the incident manager for the Ebola response. We took ten of our top disease detectives from CDC and we said: Go there, do Ebola control now. There’s nothing in the world that’s higher priority. They got there within a couple of days. And in Nigeria we had trained over 200 Nigeria doctors and public health workers to do polio eradication work. And we said, we’re bringing you to do nothing but Ebola for the next few weeks.

In the course of the first few days they identified 894 contracts. Over the next three weeks they did 19,000 home visits. They measured temperature and asked about symptoms on every one of them. They identified 43 patients for suspected Ebola. They built an Ebola treatment unit in way too long a time—it took them 14 days—but that got built. Because it took 14 days, one person left Lagos and went to another city, Port Harcourt. And as the Lagos outbreak was being controlled, Port Harcourt started. They relocated the entire response to Port Harcourt, replicated it there, and stopped the outbreak.

But it could well have gone the other way. It really was touch and go. What every country in the world needs is the fundamental capacity to find, stop, and prevent. Those are the three capacities. That’s what IHR, the International Health Regulations are about. That’s what the Global Health Security Agenda is all about. And doing that means having laboratories in place, as they did in Lagos; having trained disease detectives, as we have in Lagos; having a surveillance system so you can track when things are happening; and having the ability to do rapid response, response capacity in emergencies.

BESSER: Some of the strongest criticism has been leveled at the World Health Organization. After several countries in the region notified the World Health Organization about Ebola it took months for the WHO to sound the alarm. In the end, the U.N. bypassed the World Health Organization and established a separate coordinating body reporting directly to the U.N. secretary-general, and in part in recognition of the fact that WHO wasn’t getting the job done. This isn’t the first time WHO has been criticized for global response activities. Do you feel that WHO can effectively be the protector of global public health during health crises? And if so, what needs to change?

FRIEDEN: Well, first let’s be frank the Ebola was unprecedented. It was the world’s first Ebola epidemic. It was the first epidemic that spread through multiple countries, the first time we saw urban Ebola. And I don’t think any organization—not CDC, not MSF, not WHO—can look back on the epidemic and say we did everything right.

That said, clearly there were big problems with the WHO response. In fact, I personally had to get involved both in March and in July to contact them because they were resisting having CDC staff go to assist. That’s extremely unusual. That, in my seven years as director, has only happened one other time where I had to get—

BESSER: They were resistant?

FRIEDEN: Yes. So they didn’t want us there. And it wasn’t Geneva. Remember, WHO is Geneva, it’s the regions, and it’s the countries. I think we have to help WHO get stronger. Many years ago Bill Fahey said to me, when we were struggling on how to run a program—Bill Fahey, former CDC director, led smallpox eradication, the Carter Center and the Gates Foundation—that we have to work with WHO. And if we work with WHO, we have to strengthen WHO. And I think that’s the core message. And that strengthening means above all—there are some great people in WHO. There are really good technical experts. They are sometimes overruled by politics. And we need to ensure that in WHO the technical, the science, always rules.

BESSER: In order to effectively response and gather resources to respond to an outbreak, it can be very helpful to know what it’s going to look like in the future. And so modeling is often used. In September of 2014, CDC put out a paper that suggested that without an additional interventions, Liberia and Sierra Leone alone could have as many as 1.4 million cases of Ebola. WHO issued their own estimates, not quite as high, but still staggering. To date, as I mentioned earlier, WHO estimates that, well, those two countries have had roughly 25,000 cases. Do you believe the difference was truly due to interventions, or is the ability to public health to predict the course of an outbreak really that bad?

FRIEDEN: Well, two different points. One, the modeling exercise that CDC did—that the CDC modeling team did, I think was very impactful and very accurate. They made four points. The first was that cases were increasing exponentially. And that was important to sound an alarm. I’ll come back to that in a second. The second was that time was of the essence. Every month delay resulted in roughly a tripling of cases. So we needed to see progress in hours and days, not weeks and months. The third was that if we got to 70 percent safe care and 70 percent safe burial, we would break the back of the epidemic and the exponential increase would stop. So there was a tipping point at 70/70. That set our strategy.

And the fourth observation was one that was counterintuitive to me at the time, which was when you got to that tipping point cases would fall just as exponentially as they had risen. And that’s exactly what happened. But if you go back to that first estimate, if you look at the numbers, there were actually two lines. One, what would happen if there was no action. The second, what would happen with rapid, effective action starting in September. In fact, that’s what happened. The estimate was that if there was immediate action that Liberia would have between 9,000 and 27,000 cases by the end of January. In fact, Liberia had between 8,500 and 24,000 cases. So it was almost exactly right on for a rapid response.

But the broader question is, can we predict where the next disaster is going to come from? And on that, I think we’re on much shakier ground. No one predicted that H1N1 would come from Mexico, or MERS from the Middle East, or that we would have this outbreak in West Africa. That’s why every country has to be prepared.

BESSER: In September of 2014, the president pledged troops on the ground and 17 treatment centers. But in the end, those treatment centers were not used. So do you believe it was the interventions that caused—these types of interventions? Or what type of interventions broke that back?

FRIEDEN: I think three things fundamentally made a difference. The first was safe burial. A lot of transmission was from unsafe burial practices and inability to ensure that bodies, people who had died from Ebola who are enormously infectious after death, because the number of virus particles is huge, were safely buried. The second were the hospitalizations in Ebola treatment units and others. And if you look at Monrovia, which had the worst outbreak, when one center, called the Island Clinic opened, they opened with 100 beds. They almost immediately had 200 patients. And shortly thereafter, the outbreak started going down rapidly.

The third real change was a change in behavior, that many communities all over Liberia saw what happened in Monrovia, and learned what was needed. And our staff had microplanning exercises with leaders from every county in the country in September. And we said, where are you going to put sick people? Where are you going to put contacts? Every community found places to do that. So community action was very important. And as we got into the fall, we learned to do what we called rapid isolation and treatment of Ebola, or RITE. We got out within days every time there was a new case. We found that if we got out quickly, we could cut the duration of the outbreak in half and double survival. But days made a huge difference. Getting out in two days versus five was the difference between two or three generations of cases with 20 or 30 total, and five or 10 generations with hundreds total.

BESSER: I want to ask you a clinical question, a question about clinical care and health equity. During the Ebola crisis, there were major disparities in terms of the clinical care provided to foreign health workers and the care provided to local African health workers. Almost all foreign health workers were evacuated to America or Europe, many receiving high-tech, intensive care, experimental treatments. Not surprisingly, the mortality rates differed dramatically. In addition, in Ebola-affected countries, there were major differences in the quality of care provided by different nongovernmental organizations. Some felt it was too dangerous in fact to even give intravenous fluids. And again, there were differences in outcome. Is there a lesson to be learned here in terms of health equity and justice? And as we look towards the next health crisis, what should be the goal in terms of provision of clinical care?

FRIEDEN: Let’s remember where we were a little over a year ago. We couldn’t get anyone to go to West Africa because of the fear of Ebola. So one of the things that was a barrier to stopping Ebola was the inability to get foreign health workers to go in to help. I had specific conversations with President Sirleaf Johnson and others because I was concerned when we decided to build a facility for health care workers that there would be friction between the higher standard of care being given for health care workers, and those facilities are for American or national health care workers and others. And her response, and I talked to people from the community and health care workers, religious leaders and others, their response was uniformly the same. If people are coming to help us, we get that they need to have some assurance that they will be cared for if they become sick.

But the broader issue that you raised is how can we ensure that we don’t let the perfect be the enemy of the good, and we provide care that’s effective at saving people’s lives. I was in Monrovia when there was a single doctor for 120 patients with Ebola. And it was a horrific situation. It was traumatic for everyone. And the horror of not being able to provide standard intravenous care was awful. But it wasn’t that they didn’t want to provide it. It was that they couldn’t, because we didn’t have enough people. We had a series of vicious cycles there that were reinforcing. You had not enough beds, so you had more people dying unsafely. You had more people dying unsafely, and so you had more people infected. You had fewer health care workers willing, you had fewer health care facilities. We had to break those vicious cycles to turn it around.

I think there are important lessons for how to learn from the experience. If we look at what was one, we wish we had started some trials earlier, but there wasn’t enough product—with ZMapp, for example. But even good clinical care was challenging. So you have an intravenous line so someone doesn’t get dehydrated, but there are huge electrolyte imbalances. Took us a while to figure out how to measure electrolytes within the hot zone of an Ebola treatment unit. I think the challenge is understanding how hard it is and addressing action on the front lines where you have no electricity, no Internet, and limited number of staff. So it’s easy to sit back and criticize, but the more important issue is, next time something serious like this happens, how can we make sure that we go in robustly? And part of that means not waiting till it gets so far out of hand.

BESSER: One of the things that can impact on the U.S. ability to respond to a crisis overseas is public opinion in the United States. And while CDC and others were battling this outbreak in West Africa, there was an epidemic of fear going on in the United States. Some political leaders during that time took actions such as quarantining health care workers who were returning from Africa. Public health took action such as changing the monitoring of returning health care workers, screening of incoming personnel, limiting the movement of those who’d been to the area. And many of these steps appeared based less in science and more in politics. And so I have a couple questions, but the first question is: Looking towards the next event, how do you ensure that public health response remains science-based?

FRIEDEN: What we’ve tried to do always is tell the truth, give all information, not sugarcoat anything, and be clear on what we know and what we don’t know, and for things we don’t know how we’re trying to find them out. We think sunlight is the best disinfectant. And being clear about what the science shows and what is and isn’t a risk is crucial to gaining and retaining the public’s trust.

BESSER: It seemed like the policies that CDC had put out in terms of monitoring and self-monitoring were based on those facts that you were saying, and the science. But over time, as fear rose in the United States, the level of monitoring changed. And one of the things you’d mentioned earlier is that the thing that would keep people safest here was encouraging people to go overseas. Many viewed the treatment of people when they came back here as a disincentive to going over. And part of that disincentive were the limitations on movement. Were those science-based? Or were they more a response to—were they necessary in order to allow the response to continue?

FRIEDEN: Given the amount of interest, tension, and concern there was, our mandate was to get the risk in this country as low as possible. And that meant setting up a system that had never been done before. First, we screened everyone leaving the country. That was really important—each of the three countries, and Nigeria when they had countries. We ultimately screened hundreds of thousands of people. That was very important because someone with fever would know, I can’t get on this plane and get out of here. So they would be found if they had a fever. And it kept the airlines flying. They airlines were going to pull out. But by being able to say, you know, no one with a fever is going to get on the plane, that was helpful.

Second, we recognized that there was a risk, however remote, that in his country someone coming back from West Africa would become ill and cause a cluster of disease. So we put in a system that had never been done before to track every person that came back to this country, as you went through it, I went through it. It wasn’t highly burdensome. But we’ve tracked 25,000 people who’ve come into this country from West Africa, so that if they had developed Ebola we would have rapidly put them in the hospital and gotten them effectively treated, and prevented them from spreading it to others. I think it was a good approach. It was evidence-based. It worked. It wasn’t unduly burdensome to people. And it allowed us to keep flights going and not to isolate West Africa, so that we could stop it at the source.

BESSER: On Friday, there were three new cases of Ebola identified in Liberia, two months after the country was declared Ebola-free. It’s the second time the disease has reemerged there after supposedly being eliminated. We’ve seen Ebola reemerge in a British nurse nine months after she recovered from the disease, Ebola isolated from semen, from the central nervous system, even from the inside of the eye. There have been dozens of outbreaks of Ebola in the past, and this is the first we’ve been reports like this. So what does it mean to be Ebola-free? And what does this mean going forward?

FRIEDEN: We’ve had at least 20 times more cases of Ebola in this epidemic as in all prior outbreaks combined. So we’re going to see things that are rare here occasionally that maybe never occurred before or maybe we didn’t notice before. In fact, all of the last clusters in each of the countries have to do with unusual modes of transmission. We haven’t worked them all out yet. Some appear to have been sexual transmission. We documented a case where a woman who had no known Ebola history gave birth to—a miscarriage, actually—had a miscarriage and the fetus was Ebola-positive. So she’d had Ebola without knowing it, and had delivered, and could have spread that to those who attended her during the miscarriage. So we’re seeing many different aspects of this which we anticipate will continue potentially occurring in small clusters for months to come.

The good news is that twice in Sierra Leone, three times in Liberia now, at least once or two in Guinea, they’ve been found rapidly and stopped rapidly. So this is the aftermath of this massive epidemic, but it’s also the new normal because we don’t know when the next animal-to-human spread of Ebola will happen in West Africa that started the whole outbreak, probably, in December of 2013. We have to be ready for not just Ebola, but other health threats as well. That’s what Global Health Security is all about.

BESSER: If an individual who’s recovered from Ebola can, in a sense, reactivate or it can reemerge, what does that mean in terms of behaviors these people should follow? And how do you avoid a situation where they’re ostracized, stigmatized as they try and reenter their lives?

FRIEDEN: The nurse in Scotland was deathly ill from Ebola, far sicker than anyone who survived in West Africa. And whether that had to do with the risk of reactivation, we may never know. But it may be that that type of situation is unusual. We are undertaking a series of studies in survivors to look at how long Ebola remains viable in semen and other body fluids. And we do see a steady decrease in the amount of virus in body fluids after survival. So we don’t think this will be indefinite, but we continue to be surprised by it, to learn from different aspects of this disease.

BESSER: On July 1st, an article in The Lancet provided results of an Ebola vaccine trial conducted in Guinea during the crisis. The vaccine was highly effective of stopping disease transmission to people who’d been in close contact with known Ebola patients—an astonishing result, not just because the vaccine was so effective, but because of the hurdles both ethical and logistical that had to be overcome to conduct a vaccine trial during a crisis. Is there a lesson to be learned here for the next event in terms of how you conduct research during a crisis?

FRIEDEN: It’s important to learn as we go. For no disease do we know everything we need to know. We always need to be learning and applying that learning to use it. In fact, yesterday we began doing ring vaccination for Ebola in Liberia around these three cases, based on the protocol established in Guinea, using a National Institutes of Health protocol that’s in place in Liberia.

BESSER: Ring vaccination?

FRIEDEN: That means you vaccinate around the case, the contacts, and the contacts of the contacts, so that if there are secondary cases they won’t continue to spread. This is how smallpox was eradicated. And it’s the strategy being used in Ebola. The vaccine for Ebola is a really important tool, but it doesn’t change the basics. You have to find the cases, find the contact, isolate people, and make sure they’re isolated as soon as they’re sick, and if anyone dies bury them safely. But it’s an important new tool to control Ebola. It was used in the last cluster in Sierra Leone and it’s been used in this cluster in Liberia.

BESSER: Many question the ethics of doing research during a crisis. How is that overcome?

FRIEDEN: They’re tough issues. First off, you always have to get informed consent. And you always have to be transparent. So there are—were actually three vaccine trials. The one in Guinea that was done by WHO and the Norwegians and the European consortium. And that’s the one that came up with the result of efficacy. The NIH began a randomized controlled trail of two different vaccines and a placebo in Liberia, but the control happened so quickly that they weren’t going to get a result. We did a vaccine trial in Sierra Leone of health care workers, since they’re at higher risk. And we vaccinated 8,000 health care workers, some earlier some later. If the virus had continued to spread, we may have been able to document the effectiveness there.

But for all of that transparency, open information for the public, making sure that whatever you do is very, very clearly understood by all so there are no misunderstandings, you never want to be doing something that you don’t want people to know you’re doing. That’s a pretty good hint that if you’re doing that you’re not doing that right thing. So we said, we’re going to provide treatment, care to health care workers. We’re going to provide a vaccine. We don’t know if it works. But here’s what we’re going to do. And we got very high participation rates.

BESSER: I’m going to have one more question and then I’m going to open it up to members. And this has to do with countermeasures, and the fact that when this started there were no licensed drugs, vaccines, diagnostic tests for Ebola, even though there had been dozens of outbreaks of Ebola over the decades. Going forward, is there a better way to prepare countermeasures and tests for deadly diseases that seem to be limited in their geographic scope, diseases for which there is clearly no market incentive for industry to get the job done?

FRIEDEN: We have to do better. We have now a vaccine that works. We have some promising drugs for Ebola. But there isn’t a market for them. And that’s a market failure. That means we need for the public sector to step in and say let’s figure out how to protect people by having the right incentives and doing the right studies so we have good tools. We have for Ebola now a new diagnostic. It’s like a pregnancy test. Twenty minutes, and we get a result. It’s in use in Guinea. In fact, it identified the last case diagnosed in Guinea faster than we would have been diagnosed otherwise. That’s something that our laboratory and a private company were able to develop together. We need a way to work together to develop new tools, new ways—

BESSER: So if that has been available at the start of this, it may have been a different picture.

FRIEDEN: It would have been much easier to control. But there’s no magic bullet here. Even a vaccine isn’t a magic bullet. But better diagnosis, better treatment, better vaccines, not just for Ebola but for other conditions as well. And as you were indicating, being able to try those out, to research them under emergency-type conditions, is very important. Otherwise we may never learn what works and what doesn’t. And it’s tricky, because some of the medications can make people worse. So you really have to be very careful about what gets done and how it gets done. Often it won’t be possible to do research on certain things in an emergency. That’s why laboratory tests and animal models may always be very, very important.

BESSER: All right. At this time I want to open it to members to join the conversation with their questions. A reminder that this meeting is on the record. If you could wait for a microphone and speak directly into it, stand, state your name and your affiliation. Please limit yourself to one question and keep it concise so that as many members as possible are able to speak.

All right, Laurie Garrett here in the front, I will give you the first question.

Q: Thank you very much. And thanks to both of you for joining us today. As always, Richard, great job pooling the questions. And Tom, it’s an honor to have you with us.

You twice used the term health security. And of course, the White House promulgated the Global Health Security Act and we’ve been pushing the initiative. But as you well know, many of the countries that have not complied with the International Health Regulations and not built up precisely the sort of infrastructure, surveillance, and response capacity that you’ve been addressing, have stated suspicion of our intentions as Americans, and why do we use this word security. And we’ve seen a lot of intellectuals in even Western Europe refer to the Americans securitizing global health response, securitizing epidemic response, as if this is a very bad thing and implies some evil intent. How—from a foreign policy position, with a sense of the urgency that we feel about all this—how do we get past this roadblock and gain a kind of mutual trust in the world about what our intents are?

FRIEDEN: Our goal is not to securitize health, but to give people health security, and to take that security to the health field. Now, whether you call it IHR, or global health protection, or global health security, I don’t care. But what does matter is that every country in the world can find a threat promptly when it emerges, respond to it effectively, and prevent it wherever possible. At CDC, we have been working to build that capacity for decades now. And the global health security funding from the U.S. Congress allows us to scale that up more than we’ve ever done before.

So we’ve got now between ourselves and USAID about a billion dollars more to put into building laboratory networks around the world. We’ve identified 30 initial countries that we’re working in. We’re training thousands of epidemiologists, like the ones we trained in Lagos who were able to stop Ebola there. We’re helping countries around the world strengthen their tracking systems. This isn’t about us setting up installations elsewhere. This is about us helping other countries get better at stopping disease outbreaks so that we don’t have to stop them there. It’s good for them. It’s good for their neighbors. And it’s good for us.

BESSER: You know, just to follow up on that, Tom, I think a lot of people think of CDC as a domestic public health organization. What is the scope of the international activities, and why?

FRIEDEN: CDC has 2,000 staff working in 60 countries with an annual budget of about $2 billion for global health. We cannot protect Americans at home unless we are able to stop threats overseas. And we’ll do that through WHO in many cases. Sometimes we’ll do it bilaterally with other countries. Often we work multilaterally as well. But fundamentally, our job at CDC is to work 24/7 to protect Americans from threats, whether they’re infectious diseases or noninfectious, whether they’re intentional manmade or naturally occurring, whether they come from this country or anywhere in the world. And the only way we can protect Americans at home is by identifying how to stop threats wherever they emerge around the world.

BESSER: Over here. I’ll work my way around the room and them back to the front.

Q: Thank you. I’m Tiffany Clay with the Texas Pacific Group.

Most of our experience with Ebola was through the media coverage. I’d be curious to hear your reflections on whether you thought the media coverage here and overseas helped or hindered your efforts, and kind of more general reflections on responsible journalism in the context of outbreaks.

FRIEDEN: I think in general the coverage was fair. However, there was a massive misunderstanding of what the level of risk was, where you have half of Americans thinking they’re at risk when there were at most a handful of people at risk. It was frustrating. How can you make that clear? And yet, when we had cases diagnosed here and we had infections in nurses in Texas, I think there was a degree of concern that brought Ebola to a very different level than health risks usually get the attention of. Some of that is understandable. It’s the first Ebola case in the Western hemisphere. Ebola’s had a very exiting movie done on it. And it was a month before the elections.

So all of that led to kind of a perfect storm of media. I think by and large the media tried to cover it responsibly. And I think by and large the coverage was helpful in galvanizing the world’s interests. But it would have been maybe a little easier to do our jobs with a little bit less interest.

BESSER: Were you surprised at all by the level of public reaction and fear and media attention?

FRIEDEN: You know, the truth is that we were working so hard that other than doing press briefings I wasn’t really paying attention to what was going on in the media. This has been the largest response in CDC history. We’ve had close to 4,000 staff worked on the response in the last year and a half. We’ve had 1,400 people in West Africa. We still have 140 people—130 people in West Africa today. They’ll spend Thanksgiving there later this week. We spent 66,000 workdays—person-workdays in West Africa. It’s the largest, most sustained response in CDC history.

BESSER: Here and then over there. Yes.

Q: I’m Joel Cohen from the Rockefeller University and Columbia. Thank you for your presentation. Thank you for your excellent questions.

Is the statement Ebola-free meaningful when we don’t apparently seem to know the ecological origins of the infection, and are we investing enough in understanding how this gets into people?

FRIEDEN: Thank you. Two years ago—in fact, when Ebola was first starting to spread in West Africa, I walked through our Viral Special Pathogens Branch, that’s the branch that works on Ebola, and they showed me proudly a picture of the group of them dissecting bats in the late-2000s. There’s an Ebola-like virus, called Marburg, it has a very similar mortality rate; it just didn’t have a movie written about it. And they were able in Python Cave Uganda to identify the Marburg virus in the cave bat that roosts there. I looked—I’ve been to Python Cave. It’s, as you might imagine, a cave with a very large python in it, about 10,000 bats.

And I asked the team, weren’t you kind of scared to go into this cave? You got 10,000 bats. You’ve got Marburg virus. You’ve got the python. And they said, well, we weren’t afraid of the bats. We were wearing those space suits. And we weren’t afraid of Marburg because we were in the full protective gear. And we weren’t afraid of the python because we could see it and avoid it. But we were afraid of the cobras—(laughter)—because there were cobras all at the bottom of the cave. And so under our space suits, we wore leather chaps so that if there was a cobra strike we would not get bitten—get the cobra venom in us. This is the kind of folks we have at CDC. There were people—more volunteers for the effort than could be accommodated by the work. And we’ve begun similar studies now in West Africa to look for the ecological reservoir of Ebola.

But Ebola-free is a complicated term. Until we know what’s happening with survivors and recurrences and how long Ebola remains infectious in different body fluids, we’ll have to remain on the alert in West Africa and even afterwards because we don’t know the natural reservoir, and because we know there’s more encroachment into forest lands, more people eating bush meat as a major source of protein in the tri-country forest area in West Africa. There is the possibility that it will come back. The new normal is that we have to be ready for Ebola in West Africa.

BESSER: Right back here.

Q: Hi. My name is Priya Jain. I’m one of the residents at Columbia University in Pediatrics. And I’m currently working in the medical unit at ABC News on an elective.

Question that I had for you was, you mentioned several times that safe burial practices were really important in containing the disease. And I want to know if you could comment on some of the cultural or educational barriers that were there to implementing some of these practices. What was learned from that and what could be, you know, used were this to happen in another places like this again?

FRIEDEN: To many of us in the West, the burial practices can seem very strange. And yet, if they look at ours, they seem very strange. We sanitize death. In West Africa, they don’t have undertakers so when sometimes dies the family is responsible for respecting the body. And there are traditions of dressing the body, having ceremonies, people touching the body before the burial. Those ceremonies unfortunately are tailor-made to spread Ebola. And getting people who—70 percent of whom are non-literate, don’t trust the government, don’t trust modern medicine, have never seen Ebola before—to deviate from what is a very deeply held cultural practice has been very challenging. And even to this day, safe burial is the exception rather than the norm in many communities throughout West Africa.

What we began doing as a world was sending anthropologists in with the disease control teams to better understand what could be done to make the burial safe, but still dignified and respectful. And that’s a core lesson, that you have to work with communities to come up with a solution that’s acceptable to communities.

 BESSER: Question here in the front.

Q: William Haseltine, ACCESS Health.

The question I have to do is with—the follow up to one that you talked about, which are preemptive methods for preparing for future epidemics. We know there’s a number of agents out there that are likely. We actually have process that were developed for homeland security through the BioShield programs to allow us to develop and the government to stockpile for natural or manmade disasters. Are there plans that the CDC and others in the government are making to prepare for other epidemics? Say, Marburg, something you mentioned, Lassa, another possible threat. Laurie has, I think, probably a very good list of things that could upset us.

And in that effort, there are now emerging China for Africa, big programs where they’re planning to do fundamental research on medical problems in Africa, India for Africa. Are we cooperating with those programs in these kinds of preventative measures?

FRIEDEN: So on the one hand we have the strategic national stockpile, which was in Rich’s unit when he was there. This is $6 billion of preventive, curative, treatment, supportive countermeasures that can be delivered to anywhere in the U.S. within hours. We don’t have everything that we would like. And there are diseases for which we don’t have good treatments. So there is both the readiness and the development of new countermeasures. But beyond all of that, I would go back to the issue of global health security. We don’t know what’s spreading in many parts of the world. With the global health security resources we’ve begun doing studies of what’s causing fever in some countries. And we’re finding disease that we didn’t know where there. We’re finding new diseases.

So we need systems in place to find, stop, and prevent health threats wherever possible. And that’s something that’s going to take many years and consistent investment. And for that to happen, there has to be not just enlightened leadership from the government, but pressure from the public to say let’s make sure we’re finding out what’s threatening us from around the world, because if we don’t, we’re at risk from the next Ebola. Whether it’s drug-resistant bacteria—just last week we heard of new plasmid-mediated colistin resistance from South China in animals and pigs.

This is the last thread, basically. Our antibiotics are hanging by a thread. And China, they’ve identified one plasmid that can spread widely that can cut that thread. We’re at risk of living in a post-antibiotic world. In fact, for some patients in this country already, we have untreatable infections. That’s not just a problem if you got pneumonia or a urinary tract infection. Six hundred thousand Americans a year get cancer chemotherapy. We just presume we’ll be able to treat their infections and prevent them from dying from them. But if we don’t stop drug resistance, we have the risk of undermining modern medicine. So what we’re talking about is the need to strengthen our systems in this country and around the world to find and stop health threats, as well as develop new tools to address problems like Marburg, or MERS, or SARS.

BESSER: I want to just ask a follow up on that. Given that the budget for health expenditures is relatively fixed, is the balance right currently in terms of addressing those health problem that are affecting people today, and those health problems that potentially could affect people in the future?

FRIEDEN: Globally, we definitely need more investments in tracking and stopping emerging threats because they’re happening all over the world, and we’re not able to see them to stop them, and the next Ebola could be around the corner. Within the U.S., I’m particularly concerned about drug resistant bacteria. We’re seeing more and more drug resistance. We’ve seen that in communities, even with new antibiotics—which we hope we will have at some point—even without new antibiotics by implementing good public health control measures, we can cut the most resistant infections in half. And we want to be able to do that in communities throughout the U.S. So that’s a major budget need now.

BESSER: And I know that you do not have much in the way of budgetary discretion. But if you did, would you shift the balance of what CDC’s working on?

FRIEDEN: To protect Americans, we need to invest more in disease tracking systems around the world and we need to stop drug resistance from spreading in this country.

BESSER: Any over there? I don’t want to ignore this side. We’ll go here and then over here.

Q: Vicky Hausman. I’m with Dalberg.

Dr. Frieden, the three lessons learned that you outlined start to imply a global health security architecture with country, global, and facility-level capacity. The one thing I just wanted to question was the role of WHO and whether we truly need to work with WHO, or whether there are alternative models or organizations we should consider, given everything that we’ve learned through the crisis.

FRIEDEN: If WHO didn’t exist, we would have to invent it. It exists, let’s make it better. One of the things that I think will be very important for the sustainability of better tracking systems around the world is an independent assessment process. And through the global health security agenda we’ve started that process. Half a dozen countries have gone through it. Another dozen are on the way. And what we’re finding is we can have objective, measurable documentation of whether a country is able to find, stop, and prevent health threats. And that should be available transparently, ideally through WHO. But if not through WHO, than otherwise so that whether you’re thinking about opening a business in the country, or you’re an aid agency and want to close a gap in preparedness, there’s an objective view of what the problem is and then, a year or two later, an objective review of whether that gap was addressed.

BESSER: Over here.

Q: Hi. Marine Buissonniere with the Open Society Foundations.

Voices of African scientists and researcher, West African scientist and researcher were by and large absent from the media and the public debate as for the Ebola crisis. And I wonder if you could comment as to why, and also what’s being done to associate them to the next phase.

FRIEDEN: We worked very closely in each of the three countries with national experts. For example, the vaccine trial that we are running in Sierra Leone was done with a Sierra Leonean lead. And that helped not just for us to understand how it can be done with cultural sensitivity, but also to strengthen the capacity that was already there. In each of the countries, we’re working to strengthen the public health and medical systems so that they’re better able to respond to Ebola and other health threats. There’s always the challenge of do you move quickly or do you move together with some of the national entities. And we’ve tried to do both.

We’ve begun what is called the Field Epidemiology Training Program. This is perhaps the single most important thing the CDC does around the world. We train disease detectives. We train epidemiologists, similar to the Epidemic Intelligence Service of the U.S. We have trained over 3,000 disease detectives from more than 50 countries around the world. More than 80 percent of them stay in their home countries, usually in leadership positions in public health. And that kind of capacity development is crucial for ongoing progress.

BESSER: I’m going to throw a question into the mix. A year ago Ebola was all people wanted to talk about. It was the conversation. Now, no one wants to talk about it. No one wants to think about it. We’re in the middle of a presidential election campaign, and not one of the debates has raised the issue of health security. Not one has raised the issue of Ebola, and response, and preparedness. How do you get a topic that’s important like this into the political conversation?

FRIEDEN: Well, I think all of us have to never forget just how bad it was how much worse it could have been. And we have to hold the public sector, you have to hold us responsible for continuing to make progress keeping people safe because in health our core responsibility is to protect people, keep people safe from threats, whether they’re from this country or anywhere in the world, whether they’re infectious or non-infectious, whether they’re manmade or naturally occurring.

BESSER: I’ll come back to the members for questions. (Laughter.) Any hands? Yeah, the girl right here. Please wait for the microphone. Thank you.

Q: Yolanda Barbera from the International Rescue Committee that has been active in Sierra Leone and Liberia.

Following on Richard’s question, I wanted to know: What is your take about the commitment and the uptake of sustained engagement in global health security in developing countries around senior leaders? And how do you think—I mean, if this is already happening in domestic politics, how do you think that sustained commitment, being able to ensure that this is just not a two-year effort that will just wane as the Ebola just gets out of the media?

FRIEDEN: Well, first, thanks for the group that your work has been doing in West Africa. It’s been very effective. Actually, this is an area where we see a lot of interest from governments around the world. They get it. They get that if they’re not able to stop a cholera, or measles, or meningitis, or Ebola outbreak, it undermines their credibility as a government. So we see a great deal of interest and commitment from governments all over the world. In fact, there’s almost not a country I’ve visited that hasn’t asked me how can we start our own CDC?

The challenge is getting rom that interest to getting it done. And that’s what the funding that we have available through the global health security agenda, that’s what the G-7 commitment to do this in 60 countries is important for. That’s why it’s key that Korea and Japan, other countries around the world are committing to this, because there is interest, there is commitment.

I don’t have to convince a head of state in an African country that he’s got a problem with infectious diseases. He or she knows it. And they know also what’s needed. That’s why all over we see really an eagerness to establish tracking systems, to build laboratories, and to make sure that they have their own staff who can find and stop outbreaks. And that’s what we want to be able to scale up and do in a sustainable way.

BESSER: One of the—one of the key steps in taking a problem that’s observed and turning it into a lessons learned is something called an after action review. And it’s been part of CDC’s culture for a long time. As CDC has done an after action review or an ongoing review during the action, what are some of the key things that you found in terms of the response at any level, that you’ve decided as an agency we don’t want to do it that way next time, we’re making a change?

FRIEDEN: Well, as you point out, it’s not after action yet. We’re still—we’ve got over 120 people in West Africa today. But one thing we’ve already done is to create a new unit called the GRRT, the Global Rapid Response Team, where we can surge in within hours to put more people anywhere in the world with a multidisciplinary team. On July 9th, when I activated our emergency operations center last year, I committed to putting 50 people—50 of our top disease detectives in West Africa by the end of July, within three weeks. That was a stretch goal. We had never done anything that big before. In fact, we had them in West Africa within 11 days and we had 100 in West Africa by the end of the month, and there still wasn’t nearly enough.

So we’ve looked at ways that we can move much more rapidly in. We also are very engaged with the World Health Organization on reform efforts because they have to get better. And there are some very good structures that they have that can be used. There’s something called the Global Outbreak Alert Response Network, or GOARN. It’s a consortium of organizations that’s a little bit too loose currently. And making that most structured and more effective, more multidisciplinary, more multilingual—we had challenges getting people into Guinea because they’re French speaking—are things that we’ve already begun to do to strengthen. And of course, infection control. We’ve worked with hospitals around the U.S. so that we would have infectious disease specialty facilities ready for people with rare diseases.

BESSER: That was a change during the outbreak, from a strategy of every hospital could handle to regional hospitals. Can you explain a little bit about that decision process and what things would look like for the next event?

FRIEDEN: The challenge of caring for Ebola in this country, where you have intensive nursing care, you have waste management issues. And it’s not West Africa. You can’t put people in gum boots and spray them down with bleach. That’s what we do in West Africa. So it’s very challenging to do that in this country. At CDC we had a longstanding arrangement with Emory for a biocontainment unit. That’s why they had the room that could be used with anterooms, with trained staff, with staff who had drilled. And now working with others within Health and Human Services we plan to have that regionally around the country. We already have sent our top teams out to close to 100 hospitals, 55 have been readied to care for an Ebola patient. We’ve established a laboratory network to diagnose Ebola rapidly. But this is important to have in place not just for Ebola, but for other health problems as well.

BESSER: Are there questions in the room? I will come back to the front here. One and two.

Q: Thanks again for being here. Laurie Garrett.

So we just released our report—the Ebola Independent Panel at Harvard London School of Hygiene Council on Foreign Relations this week. And we struggled with exactly what you were just getting at, how do you strengthen a semi-autonomous entity inside of WHO that’s GOARN or whatever we want to call it, as a rapid global response entity, give it its own capacity to respond, its own board, its own financing so that whatever the heck is going on in the craziness of WHO doesn’t affect the ability to move rapidly? And the bottom line is that the legal constraints that WHO operates under and its own international health regulations ultimately leave the director-general in the driver’s seat over, and over, and over again. And anything you create still has to depend on the politics of that individual. So the whole world is vulnerable based on who is the director-general of WHO. Do you see any way past this?

FRIEDEN: Well, I think, first off, the independent assessment process for global health security, IHR, is crucially important. It’s unacceptable that we don’t know which countries have claimed that they’re ready. We need to know for every country what their core capacities are. That needs to be transparently available. That will help. That will generate more progress.

In terms of rapid response, I think GOARN has a lot of potential because it’s not beholden to WHO, because it can work independently as well. Whether it should have an independent director—executive director of GOARN, I don’t know. I fear that with all of the discussion of change, there’ll be more discussed than changed. And we need to really focus on the capacity to respond rapidly by responding rapidly.

One of the things that our staff at CDC are doing is rather than going into a country and saying, we’re going to help strengthen global health security, say let’s stop outbreaks now, learn lessons from stopping them, because you’ve got them, and in the process of doing that get stronger. You don’t built systems—you don’t build strong, resilient systems by going out there and building a system. You go out there and do things. And in the process of doing things, you build a better system.


Q: Bill Haseltine, ACCESS Health.

We have gone through a number of different global disasters in health. When HIV was first realized to be a disaster that it became, the same call went out. Detection, surveillance, action. When SARS happened, the same thing. MERS to a lesser extent. Series of epidemics—flu epidemics. Why is this going to be any different? And I would like you to address the issue that I raised in the first question, which is, is the U.S. prepared to work with China in its major efforts that are getting underway to help address health problems in Africa?

FRIEDEN: Well, we have a close collaboration with China. The U.S. CDC and the China CDC have a partnership. In fact, we helped them get created and strengthened. And if you look at what happened in China with H7N9, bird flu, you had the harvest of 10 years of collaboration. SARS, you had non-recognition and non-transparency. H7N9, they recognized it relatively quickly, and immediately after recognizing it made it publicly available. We were able to download the genome, make a diagnostic test, begin work on a vaccine within hours of them finding it.

So we do have a good collaboration. We worked together in Sierra Leone with the China CDC, as identified as the area that they’ll do the most. They’re serving at the National Referral Lab there. So we’ve got good collaboration with China and we’re eager to do that elsewhere as well, including the creation of an Africa CDC which President Obama and the Chinese leadership have agreed to work on together. So I do think we have a collaboration there.

Whether this will be any different only time will tell. I’m not certain if we have learned the lessons. I certainly hope we have. And I think our maximum likelihood of learning the lessons is to implement programs to work, establish independent assessments, so that the world has a report card of how we’re doing in different countries, keep WHO accountable and supported, so that we can go from the prior existence of non-accountability, non-assistance, to the new world of accountability, and cooperation, and partnership.

BESSER: I’m going to ask you one last question and then—and then conclude. I want to come back to what you’d said about Nigeria, and how Nigeria responded so well because of the polio infrastructure. As you know, so many of the programs around the world through global health are vertical programs, like the polio program, the malaria program. Nigeria was one of the last countries to be able to knock out polio, and as such had a lot of resources coming in. If 10 years ago Nigeria had been able to wipe out polio and that infrastructure was no longer present, would the picture have been different with Ebola?

FRIEDEN: So I serve as the chair of the Polio Oversight Board. It’s an organization of CDC, UNICEF, WHO, Rotary International, and the Bill and Melinda Gates Foundation overseeing the polio effort. And we’re trying to get to zero. We’re closer than the world has ever been. Only Pakistan and Afghanistan continue to have polio spreading, as far as we know. Nigeria appears to be polio free. All of Africa may well be polio free. But we’re trying to make sure that in polio eradication we’re not just eradicating a virus; we’re establishing systems around the world. We’re establishing immunization systems, disease tracking systems, laboratory networks. And if done right, eradication efforts and so-called vertical disease control efforts should not only achieve what they’re trying to do, but strengthen the broader system.

And they can be done right. There’s a way of doing it that does that stronger strengthening activity. And polio is an excellent example of it. It was that infrastructure that could be repurposed for this. But it’s not a foregone conclusion that they will be. It can be done right or it can be done in a way that’s not building capacity in the medium and long term. And that’s what in all of our global health programs we have to try to keep in mind, not just addressing the individual problem, but establishing the context so that you can repurpose that for the next health threat.

BESSER: Well, I want to thank Dr. Frieden for an outstanding conversation. I think you’ve given us a lot to think about in terms of what needs to happen to make sure that there are lessons learned. And I want to thank you for the work that CDC has been doing in this area. And to the members who asked questions, thank you all very much. This concludes our session.

FRIEDEN: Thanks very much. (Applause.)


This is an uncorrected transcript.

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