Guest Host: Susan Page

Lt Susan Jeffreys checks medical equipment in the ship's hospital on board RFA Argus as it prepares to leave its home port of Falmouth for Sierra Leone on October 14, 2014 in Cornwall, England. The medical ship with a fully-equipped 100-bed hospital on board is currently being loaded to be sent to Sierra Leone, along with three Merlin helicopters to help in the fight against Ebola. The vessel, which is due to set sail on Friday, will not be used to treat Ebola-infected patients, but mainly to transport supplies and to ferry personnel.

Lt Susan Jeffreys checks medical equipment in the ship's hospital on board RFA Argus as it prepares to leave its home port of Falmouth for Sierra Leone on October 14, 2014 in Cornwall, England. The medical ship with a fully-equipped 100-bed hospital on board is currently being loaded to be sent to Sierra Leone, along with three Merlin helicopters to help in the fight against Ebola. The vessel, which is due to set sail on Friday, will not be used to treat Ebola-infected patients, but mainly to transport supplies and to ferry personnel.

Yesterday, the Centers for Disease Control and Prevention announced that rapid-response teams will be sent to any U.S. hospital with a new confirmed Ebola patient. The move is being made to better ensure the safety of hospital staff. This morning, there’s news that a second health care worker at a Dallas hospital who helped care for an Ebola patient has tested positive for the disease. Concern about Ebola is growing as efforts to contain its spread in West Africa have, so far, failed. The World Health Organization reports the total number of cases in West Africa will soon top 9,000, and that by early December there could be as many as 10,000 new cases each week. Guest host Susan Page and her guests talk about ongoing efforts to stop the spread of Ebola.

Guests

  • Dr. Michael Osterholm Director of the Center for Infectious Disease Research and Policy and director of the NIH-sponsored Minnesota Center of Excellence for Influenza Research and Surveillance; board member, National Science Advisory Board on Biosecurity.
  • Mvemba Dizolele Foreign policy analyst, writer, independent journalist, Johns Hopkins School of Advanced International Studies.
  • Jason Cone Communications director, Doctors Without Borders.
  • Kate Boulter RN and lead nurse for the biocontainment unit, Nebraska Medicine.

Transcript

  • 10:06:54

    MS. SUSAN PAGEThanks for joining us. I'm Susan Page of USA Today, sitting in for Diane Rehm. Diane is visiting station WCPN in Cleveland. The Centers For Disease Control now plans to send rapid response teams to any U.S. hospital with a confirmed new ebola patient. The move is in response to questions about how two health care workers in Dallas contracted the disease after caring for a patient there.

  • 10:07:20

    MS. SUSAN PAGEJoining me to talk about the CDC's new plans and the threat posed by the ongoing spread of the disease in West Africa, Mvemba Dizolele of the Johns Hopkins School of Advanced International Studies. Welcome to "The Diane Rehm Show."

  • 10:07:34

    MR. MVEMBA DIZOLELEThank you very much, Susan.

  • 10:07:35

    PAGEWe're joined by phone from Minneapolis by Dr. Michael Osterholm of the Center for Infectious Disease Research and Policy at the University of Minnesota. Thanks so much for being with us.

  • 10:07:46

    DR. MICHAEL OSTERHOLMThank you.

  • 10:07:47

    PAGEAnd by phone from New York, Jason Cone. He's with Doctors Without Borders. Welcome to the show.

  • 10:07:54

    MR. JASON CONEThank you for having me.

  • 10:07:55

    PAGEWe invite our listeners to join our conversation later in this hour. You can call our toll-free number, 1-800-433-8850. You can always send us an email to drshow@wamu.org, or find us on Facebook or Twitter. Well, Dr. Osterholm, let's talk -- start with you. We have news just this morning that a second health care worker in Dallas has tested positive for the ebola virus. What do we know about this? And is this alarming to you?

  • 10:08:25

    OSTERHOLMWell, first of all, I think we need to take a step back and realize that this had been almost predicted as a possibility when the first health care worker was discovered, that there were clearly issues that somehow transmission was occurring into that health care worker group. So I think that if we have one, two or three or more cases -- additional cases -- that's really a tragic situation for the individuals, but it's not really surprising in terms of the events.

  • 10:08:53

    OSTERHOLMI think we've learned a great deal since that first case was admitted into the -- in that Dallas hospital. And that we know realize that providing the kind of care for the patient and protecting the workers is a challenge. It can be done, but it's a challenge.

  • 10:09:11

    PAGEWe had -- after the first worker was diagnosed with the ebola virus, the head of the CDC was interviewed on television Sunday and said there had been a breach in protocol. That if the protocol had been followed these infections would not have happened. Do we know that for sure? I mean is it possible there's something about this disease that we don't understand so it's acting now in the ways we would have predicted?

  • 10:09:34

    OSTERHOLMWell, again, coming back to -- just from a perspective standpoint. You know, ebola virus is not pixie dust. It just doesn't magically appear somewhere. There has to be a documented route of transmission from an infected person to a susceptible person. We believe that when we mount this kind of protective cone around a health care worker, what we call personal protective equipment, that that is more than sufficient to keep that virus from infecting that person.

  • 10:10:02

    OSTERHOLMYou assume that if somehow the person gets infected that obviously there had to be a break in that cone of protection around the individual. And that's what they're referring to, is the breach in the protocol. None of us, I think, at this time know what that is. All the information coming from the CDC suggests surely, in fact, that something has happened.

  • 10:10:20

    OSTERHOLMI think with one of the other guests you have on here, Jason Cone, from the MSF, can surely tell you that they have learned over the years how to do this very well and under very -- what I would call really dangerous conditions. Have done a very good job of protecting their workers. So we know it can work. It's just something happened in Dallas that we don't know what happened.

  • 10:10:40

    PAGEWell, let me go to Jason Cone, who joins us from New York. He's the communications director with Doctors Without Borders. What do you make of this? And the question about whether we know how to adequately protect health care workers.

  • 10:10:53

    CONEI think we do know what is needed. I think, as what Mike was saying about the way the virus is transmitted, it's, you know, it's a question of setting up a very clear set of protocols of all the people who are going to be involved in the care of people who are infected. And that's what we've done very clearly in the different countries we're working in West Africa and Liberia, Sierra Leone and Guinea, as well as other countries where we've been advising people, like in Nigeria and Senegal.

  • 10:11:21

    CONEAnd it requires a really good adherence to protocol. I mean, for example, in our treatment centers we use a buddy system where we have two of our clinical staff, are working together to insure that they're all -- that are maintaining all the safety protocols in place. We don't keep people inside the centers for more than an hour. In that case, they're working in very difficult conditions with all the heat and humidity that is apparent in the places like Liberia and Guinea.

  • 10:11:46

    CONEThat said, it's -- there is a very clear roadmap of how to handle these cases, the need to keep people separated, confirmed versus unconfirmed. The operating environments are very different, obviously, from the U.S. context and where we're working in West Africa, in terms of the type of treatment. But I think it is quite startling to see the number of people that were involved in the treatment of just one case. And how that can lend itself to the breakdown of protocol, in terms of safety standards.

  • 10:12:11

    PAGESo you assume also that there's been a breach in protocol that can be fixed so that U.S. health care workers -- we don't see this replicated in -- if there are other cases?

  • 10:12:21

    CONEI mean, we've treated I think close to 4,000 patients, I believe, in our centers over the last few months. We have lost staff who've gotten sick. Most of them have gotten sick because they're national staff who have gotten infected in their communities. We've had some international staff, basically I believe two cases that we've really dealt with. It shows that you can mitigate the risks. You just have to understand how to -- how the disease is transmitted and what safety protocols need to be put in place.

  • 10:12:51

    CONEAnd people really just have to rigorously adhere to those. And that's part of being a team and very clear about who's going to be in charge of treating what patients at what level, whether it's admitting them at the triage point, which is -- can be quite chaotic in the environments that we're working in where you have possibly up to 100 people showing up at the center in one day, whereas you might have a suspected case in the U.S. context where it's going to be a very much smaller case you're going to have a very different kind of admissions sort of situation.

  • 10:13:17

    PAGEIt makes you certainly admire the contributions being made by health care workers, both in the region and here in the United States. Well, briefly, Jason, bring us up to date on what is happening in West Africa. It sounds like there has been no success in trying to limit the spread of this disease.

  • 10:13:33

    CONEYeah, I must say it's quite shocking that on many of the issues that we were discussing in early August remain to be present. And that means really in the areas of a lack of scale-up, in terms of the provision of medical care in the three most affected countries, inability to really trace cases, inability to insure that there is proper and fast diagnosis, prevent infection control.

  • 10:14:01

    CONEA lot of the things -- even though we've had a lot of good political momentum, whether it's from the U.S. government, the U.K., the French, the Chinese, the Cubans, who have actually deployed the most medical personnel, I believe, on the ground -- is that a lot of these same issues remain. I mean, for -- and this epidemic is really unpredictable. So for instance, in Guinea, where we thought we probably had the situation under control, we have more cases today in the capital of Conakry then we've ever had before.

  • 10:14:28

    CONEAnd our centers are overwhelmed. And I'm just speaking about the Doctors Without Borders centers in that case. In Sierra Leone, every single district has reported a case and 85 percent of the calls that go to refer patients into a structure go unanswered by the health system, meaning people are having to stay at home, potentially infect their family members and others. And that's just talking about the impact of the ebola cases that are obviously continuing to rise.

  • 10:14:55

    CONEAnd it's lend us a lot of good, important questions, particularly about the U.S. government response, which has been quite a significant mobilization, in terms of the military personnel deployed. And we made that call back in early September for the very reasons I talked about earlier, which is that you need to insure a really good, strong command and control and adherence to protocol when you're running these centers.

  • 10:15:17

    CONEAnd what we have is a situation where many governments are going in and they're setting up centers, but they're delegating the responsibility to manage those to the private sector. The private sector being organizations like myself, Save The Children, International Medical Corps, all these private agencies. And the U.S. government hasn't deployed any of the medical and civil military medical personnel that we know are attached to many of their military branches.

  • 10:15:42

    CONEAnd that raises a lot of questions for us as to this considered sort of delegation of responsibility to what is really a volunteer response, in many ways, while we know that President Obama has called this a national security threat. So there's a disconnect between, I think, some of the resources that are being deployed to the emergency and the discussions at the sort of political level.

  • 10:16:06

    PAGEMvemba Dizolele, you were born in Congo, now a U.S. citizen. You study and teach African affairs. What does this -- what has this health crises meant in that part of Africa?

  • 10:16:19

    DIZOLELEThank you, Susan. I think the, you know, my colleagues have discussed the medical side of it, but I think this a political management crisis, it's a leadership crisis, it's a governance crisis, you know. It's an urgency now. It's emergency that we're dealing with, but in reality we have to go deep. I mean, if you take the situation of Liberia, for instance, you know, the basics of what need to be health care delivery, public health care's delivery -- we're not there.

  • 10:16:47

    DIZOLELESo Liberia was not even equipped with the right number of ambulances to deal with its own population on any given day. So I think they had less than 1,000. Just two days ago Japan had to offer them four more ambulances. So then you ask, why is this? It's the same problem with the level of the A.U. The A.U. is a big organization, 54 countries.

  • 10:17:07

    PAGEThe African Union. Yes.

  • 10:17:08

    DIZOLELEThe African Union, yes. Sorry. And so where is the African Union in helping Liberia, in helping Sierra Leone? We're not talking about big countries, just put in perspective, Liberia is a country of 4.2 million people. That's less than the population of the Washington/Baltimore metro area. Sierra Leone is 6 million. Guinea, it's 11 million. Then you wonder why are these countries so poorly managed to allow the level of calamity that we're seeing now.

  • 10:17:40

    PAGEAnd we had the shocking predictions from the World Health Organization yesterday that there could be as many as 10,000 new cases every week by the time we get to December. We're going to take a short break. When we come back we're going to be talking to a nurse from Omaha, Nebr., who is the lead nurse for the Biocontainment Union (sic) at the Nebraska Medical Center, who's been dealing -- specially trained to deal with ebola.

  • 10:18:04

    PAGEWe're going to talk to her about what their protocols are, what you have to do if you're going into help care for an ebola patient. And we'll go back to Dr. Osterholm to talk to him about the CDC response of sending rapid response teams to U.S. hospitals. Is this a policy that makes sense and will help? We'll take your calls and questions. Our phone lines are open, 1-800-433-8850. Stay with us.

  • 10:20:00

    PAGEWelcome back. I'm Susan Page of USA today sitting in for Diane Rehm. And now joining us from Omaha, Neb. is Kate Boulter. She's an RN and lead nurse for the bio-containment unit at Nebraska Medicine. Thanks so much for being with us.

  • 10:20:14

    MS. KATE BOULTEROh, you're welcome, Susan, It's a pleasure.

  • 10:20:17

    PAGENow you've had one Ebola patient at your center and now a second, is that right?

  • 10:20:21

    BOULTERThat's correct, yeah.

  • 10:20:23

    PAGEAnd are these the first Ebola patients that you've cared for in this – in your facility?

  • 10:20:27

    BOULTERYes. Yes, they are.

  • 10:20:29

    PAGEAnd yet you've been in training for this for a long time. How long have you been preparing and training to handle Ebola cases?

  • 10:20:36

    BOULTERSince 2005. We opened our unit in March actually in 2005. And since then our staff has been training, writing protocols and planning for this very scenario.

  • 10:20:51

    PAGESo tell us about how it works. Is Ebola different from other infectious diseases that you might have to deal with?

  • 10:20:57

    BOULTERWell, it's definitely scarier for the staff to deal with. It's just something that's -- it's not easy to get. You know, I would like to emphasize that. We do know how it's passed on so it's passed on from body fluids. And you've got to get it, you know, into your body somehow. So, you know, like your earlier guest, you know, we put on our PPE to protect ourselves from that.

  • 10:21:19

    PAGENow PPE stands for...

  • 10:21:21

    BOULTER...personal protective equipment.

  • 10:21:23

    PAGEYes.

  • 10:21:24

    BOULTERAnd just like with the -- your guest from the Doctors Without Borders, we have a buddy system. We call them our dawning and doffing partners. So we have a partner who helps us put on PPE. They check to make sure that it's put on properly. They also check to make sure that everything is intact and that you're comfortable to go ahead. And then we have a strict policy on where that person can go after they're in PPE and they're going into the patient's room. They stay there really for probably about four hours until, you know, they can't take it any longer in the PPE or, you know, they're ready to get out or it's time to do a change of a staff member.

  • 10:22:04

    BOULTERAnd when they come out of the room there's a doffing partner who's going to go through every step of getting that PPE off them. And it continues on from there as well because we also are very strict about how that PPE is handled once it's been taken off the nurse of the health care provider. You know, it goes straight into an autoclave bag and then it goes to an autoclave where it then gets sterilized before it gets sent out to the community as trash.

  • 10:22:35

    PAGEAnd why is it important to have a buddy?

  • 10:22:38

    BOULTERWell, you get tired. And there's some parts of taking off the PPE at the level that we're at that makes it a lot easier for a buddy to do that for you. So we wear three pairs of gloves. And the middle layer of gloves is actually taped to the sleeves of your protective gown. It's much easier for your buddy or your doffing partner to take that tape off and put it in the trash. And then you take your gloves off after that. And there's a certain way that we do that.

  • 10:23:08

    BOULTERWe wear boot coverings that cover our feet and our legs. After you've been in the room -- and it gets pretty hot under all that PPE so, you know, you get a little exhausted by the end of it. Bending over is probably not a good idea to take those boots off, so you have your doffing partner do that for you. And, by the way, our doffing partner is dawned in the exact same level of PPE as the person that they're doffing.

  • 10:23:36

    PAGEYou know, I wonder -- you've been -- obviously this is a complicated process. You've been training for this very situation for nine years. It must be hard for a hospital like the one in Dallas. It is not -- doesn't specialize in this. I mean, obviously they deal with people who have infectious diseases but not in this extraordinary way. It must be so difficult to be thrust into this situation and try to handle it in a safe way.

  • 10:23:58

    BOULTERYeah, yeah, I agree. You know, it's -- you know, for -- you know, they didn't know it was coming to them before it got there. And they had to put in a lot of plans, you know, just on the minute for that. So, yeah, my heart goes out to them and to the staff members who have got the disease now.

  • 10:24:17

    PAGEIs it hard to get nurses and doctors who are willing to work with Ebola patients willing to care for them?

  • 10:24:23

    BOULTERNo, no. Well, not in our experience anyway. We've had our unit -- like I say, we've been practicing for quite a few years. When -- and we kept our staff to a minimum for, you know, cost reasons. But as soon as we got the call that we were being activated, now we had enough staff to get -- you know, to begin and keep going. But then we realized that, you know, we need more staff. And so, you know, we had staff from all over the hospital applying right away.

  • 10:24:56

    BOULTEROur director, you know, I think she's amazing, you know, the type of staff that she selects for our unit, because the nurses and the respiratory therapists and the care techs are coming to us. They work fantastically as a team. And I know other units may only use ICU nurses, you know, nurses who are trained for ICU care. But we use our nurses and our techs and respiratory therapists from all over the hospital. So we've got multi-disciplines. What that's really given us is a huge skill mix.

  • 10:25:30

    BOULTERYou know, we've got an L and D nurse. We've got med-surg nurses and we do have ICU nurses as well. And we all, you know, share our knowledge with each other. And it's just working really well actually.

  • 10:25:44

    PAGEKate Boulter, thanks so much for joining us. Thanks so much for your service here.

  • 10:25:47

    PAGEOh, you're very welcome. Thank you. Thanks for having us.

  • 10:25:49

    PAGEKate Boulter. She's the lead nurse for the bio-containment unit at Nebraska Medicine. Well, Dr. Osterholm, let me go back to you. Now the CDC has changed its approaches, as it will not deploy rapid response teams to any hospital in the United States that has a confirmed new case of Ebola. Does this make sense to you?

  • 10:26:09

    OSTERHOLMWell, I think it is part of a response situation right now that we need to look at. But I think we're all realizing that, in fact, just having expertise suddenly come on the scene with a case at a hospital is very different than an institution that has been preparing and planning for such an event. And I think you just heard the very, very -- a good example of that with the facility in Omaha and the level of preparation. You heard it from Jason Cone in terms of how MSF prepares for a considerable period of time before people enter the theater wherever Ebola is emerging.

  • 10:26:43

    OSTERHOLMAnd so I guess one of the things that we're all looking at right now, shall we change the system where every institution, every hospital, every medical clinic, every emergency room needs to be prepared to see an Ebola patient, meaning that we don't know where they'll show up. But once they do show up they should really be transferred to one of the very select number of hospitals that have spent a lot of time training on how to do this. They've already put the staff together, so this is not an in-the-last-minute kind of operation in where which CDC comes in.

  • 10:27:13

    OSTERHOLMSo I welcome the CDC's team wherever a case occurs, but even then I think there's more to do where we regionalize care in these highly specialized locations where people will practice every day right now. We can't expect 5,000 hospitals to be practicing every day for an Ebola case to arrive.

  • 10:27:30

    PAGEWell, the CDC had said that they were considering that as an option, taking Ebola patients to these four special centers, but they're not doing that at this point. Do you think that's what they ought to be doing?

  • 10:27:42

    OSTERHOLMWell, first of all, I'm not sure they have to go to the four centers. I think that, you know, clearly that they represent the state of the art. But I think that you could also begin to work with regional medical centers throughout the United States so they may not have to be airlifted to one of these locations. And I think that's still to be decided. I do believe that there are a number of facilities in the United States, not many but a number that could provide this similar kind of care where there has already been training in place for a disaster involving an infectious agent like this. And so I think you could still have more than just the four.

  • 10:28:17

    OSTERHOLMBut in terms of what's happening now, I mean, the conditions on the ground are, you know, something that many of us are not fully aware of. Clearly there's a lot of expertise at that hospital in Dallas right now. Whether that means that those staff members are fully prepared to handle this, that, you know, now they have more training in a sense in under live fire and therefore it's okay for these patients to stay there in terms of what care they're getting, I don't know. But it's clear that, you know, they're likely or possibly going to see more cases in Dallas. And I'm sure they're considering this point right now, where should these patients be cared for?

  • 10:28:50

    PAGEJason Cone, when you think about the situation in West Africa, which of course is so much more dire than the one we face here in the United States, what would make the most difference? What could be done in the short term to make the most difference in trying to stop the spread of this disease and care for the people who have it there?

  • 10:29:09

    CONEWell, I think as I was alluding to earlier is that we need that rapid scale up in terms of treatment facilities. That's still a huge issue. And if you can imagine the projection that the World Health Organization is having is that if we can't treat the number of cases we're dealing with today, how are we going to possibly deal with that scenario in the future?

  • 10:29:31

    CONEAnd after -- remember that we have a good -- a descent sense of how many people are being infected and dying from Ebola but there are also these diseases like malaria, diarrheal diseases and other things that are killing people and lack of emergency aesthetrical (sp?) care. Many of the medical facilities in these countries have really shut down and to treat, like, a pregnant woman who has a complicated delivery. So there are other things as well which is really critical is to sort of address the health system collapse.

  • 10:29:59

    CONEWe do have some teams that are looking at, for example, in Liberia a mass distribution of antimalarials to try and -- you know, many of the symptoms can be somewhat similar in terms of like fever and things like that. And so it's very difficult to separate and diagnose the two rapidly and also not put our health workers at risk of trying to treat something like malaria when it could potentially be Ebola.

  • 10:30:25

    CONEAnd that said, we're trying to reinforce the health system in other creative ways. And there is other, you know, work that can be done by other NGOs in this light, whether it's malaria, distribution of oral rehydration salts for people who might have acute diarrhea could kill if untreated, if it's not stopped. So that's a very important part.

  • 10:30:43

    CONEThe other thing is that there's a lot of discussions happening around the development of curative treatments and vaccines for Ebola. And one of the things that we're really concerned about is that there are many different initiatives on the vaccine development front. But whether or not those vaccines prove to be safe and efficacious, needs to also be -- those trials that need to happen need to also be concurrently looked at in terms of what's the production capacity, the scale up?

  • 10:31:13

    CONEIf these vaccines prove to be safe and effective, how can you ramp up that production quickly in trying to get that incentive to the private sector to do that. Because they're not going to start doing something that they haven't proved to be effective and is going to be passed to regulatory authorities.

  • 10:31:30

    PAGENow Doctors Without Borders works in many places, difficult places with many terrible diseases. I asked Kate Boulter, the nurse in Omaha, if it had been hard to get volunteers among health care workers. She said no. Is it hard to get health care volunteers to go to a place like West Africa now where it is so dangerous and so difficult?

  • 10:31:52

    CONEOne of the things that's making it, I think, quite difficult, and it's very different from our staff at work in a warzone, let's say, in South Sudan or Central Africa Republic where they may be deployed for six to nine months, is that it's just a different kind of fear. You know, we're having to rotate people every four to six weeks to keep them fresh, to make sure that they're able to adhere to those protocols I was telling you about earlier. Make sure they stay safe.

  • 10:32:17

    CONEBut one of the huge issues is that, you know, we're in a position where we've had two staff have been infected and one has been cured and, you know, has fought through and the other one is under treatment still back home in Europe. But the medical evacuation system is completely nonfunctioning in the sense of it took us 50 hours to get our first staff member back to Europe for treatment. That is going to have some impact on people's willingness to go. And we have to be very transparent with our staff. We have 240 international staff on the ground in those countries. We need about two to three people for every one of those positions to keep the rotation going. So that's a good number of people right there just for our programs.

  • 10:33:03

    CONEBut if we can't fix this medical evacuation system and we can't with confidence tell those people that we'll be able to bring them back and get them treatment, that's definitely going to have an impact on the ability for their scale up.

  • 10:33:14

    PAGEI'm Susan Page and you're listening to "The Diane Rehm Show." We're taking your calls. Let's take our first call. We'll go to Nancy who's calling us from Jackson, Mich. Nancy, hi, you're on the air.

  • 10:33:26

    NANCYHi. Thank you for taking my call. I love the show. I have a family member who works for an international hotel chain. And she has expressed to me that they are very concerned because of international travelers, and they are taking extra measures. Do people need to be well and better even educated about measures to take for our own safety even on an everyday basis? Like at the supermarket I see now people wiping off the handles of the carts. And how careful do we need to be and do we need to raise the education level of people to prevent the spread of this disease?

  • 10:34:12

    PAGEAll right. Nancy, thanks so much for your call. Let me ask Dr. Osterholm what he thinks about that. What -- should Americans in their daily lives be doing anything different because of the threat of this disease?

  • 10:34:21

    OSTERHOLMYeah, and I think this show really highlights this very important point. Yes, we all should be very concerned in the United States but not about contacting Ebola. But it's about the fact of what's happening in West Africa. And I think you've heard from Jason a very articulate argument why the problem in West Africa is where we have to keep our eyes. You know, it's a tragedy what's happened in Dallas and it's become the media center of this debate or discussion or concern or scare.

  • 10:34:47

    OSTERHOLMYou know, I had a discussion yesterday with a taxi driver in Baltimore in which he was concerned about the issue of Ebola. And I shared with him, you know, his risk of having a bad thing happen to him is much greater getting in his cab, driving from downtown Baltimore to the airport than it ever was about Ebola. Nonetheless, this is a very critical international issue.

  • 10:35:06

    OSTERHOLMAnd so what we're trying to do here is really kind of titrate the response to say that, if this continues to expand in Africa as it could, it'll only destabilize potentially much of that continent. That is a dramatic impact on world security and all the issues we think of around a safer globe. And so what -- that's where we have to keep our focus. So let's be concerned about this. You don't have to wipe off handles on your carts in the grocery stores unless you're worried about the salmonella that dripped from the chicken that you were handling, things like that. It's not about Ebola. But Ebola is really important and we need to support this global response in Africa right now. And we're not doing that, as Jason has clearly articulated.

  • 10:35:45

    PAGEMvemba Dizolele, talk to us about what the potential repercussions are in West Africa and Africa. I mean, obviously this is devastating to an economy. It's got the potential to undermine governments there. Tell us what you think is happening.

  • 10:36:00

    DIZOLELEWell, it's an issue of human security, to start with. And public health is really the backbone of any health in any country. The risk of contagion is high, as our medical friends have said which means it affects your workers, it affects your school teachers, it affects your health care providers. Which means it's paralyzed the economy so you cannot trade within country because roads are being closed, access to certain markets are being closed. You cannot trade with your neighbors if they're closing the borders, if they're upset about or scared about what's happening in your country.

  • 10:36:38

    DIZOLELESo it affects all layers, all steps of interstate relations. And this is a cost. I think some economists have already calculated up to date maybe bout $32 billion waste -- I mean, what's the term again, loss. There will be a loss of about $32 billion in terms of just a business cost. And this is based on what they saw with the avian flu in Asia when, you know, you scare people. And then people, they come to measures to quote unquote "protect" themselves from a potential scare.

  • 10:37:14

    PAGEWe're going to take a short break. When we come back, we'll continue our conversation about what's happening with the Ebola virus both in the United States and in West Africa. We'll go back to the phones and take more of your calls and questions. Stay with us.

  • 10:39:59

    PAGEWelcome back. I'm Susan Page of USA Today sitting in for Diane Rehm. And joining me in the studio, Mvemba Dizolele of the Johns Hopkins School of Advanced International Studies. By phone from New York, Jason Cone, he's with Doctors Without Borders and from the University of Minnesota, Dr. Michael Osterholm, he's director of the Center for Infectious Disease Research and Policy.

  • 10:40:22

    PAGEHe's also director of the NIH-sponsored Minnesota Center of Excellence for Influenza Research and Surveillance. You know, we have a lot of emailers who are expressing skepticism about some of the things they've been told, some of the reassuring things they've been told about the ebola virus so let's just go through a couple of them. This first one, maybe Dr. Osterholm can address.

  • 10:40:45

    PAGEWe have Rudy asking us, "we regularly hear that ebola cases are not contagious until they become symptomatic. How do we know this?" What would you say?

  • 10:40:56

    OSTERHOLMWell, actually, this is based on the historic records of outbreak investigations over the past 40 years. There have been 19 such naturally-occurring outbreaks. We've had some isolated cases and some lab-related situations in addition involving about 2400 individuals. And there is no evidence to suggest that someone is infectious before that time and clearly, we need to continue to look at that, but, you know, the data are pretty clear from these outbreaks that that hasn't happened.

  • 10:41:25

    PAGEAnd here's another caller who says that, let's see, this person says, "why is there not a massive effort, at this time, to get as many people as possible vaccinated against the flu? If we do get outbreaks of ebola in this country, the last thing we want is to have our hospitals trying to sort out ebola patients from flu patients." This is from Tim who writes us in College Park.

  • 10:41:48

    PAGEDr. Osterholm, do we expect a number of ebola patients to make this a real factor?

  • 10:41:53

    OSTERHOLMRight. Well, first of all, let's make it really clear we're not gonna have an outbreak of ebola virus in the United States. It's simply not going to happen. We have the tools to identify cases like the one in Dallas and stop them. Now, if someone is suggesting that you're gonna consider this a major community outbreak if two or three healthcare workers become infected from caring for a patient, I surely can understand that and, yes, that really is, in a sense, an outbreak.

  • 10:42:17

    OSTERHOLMBut it's not the kind of community-wide outbreak, the regional-wide outbreak, the countrywide outbreak that you're hearing from us this morning talking about West Africa. So yes, I always encourage people to get the flu shot, absolutely. This is the time of year to start thinking about that. We should get that, but don't think that this somehow going to then mitigate what we have to do in terms of the issue with ebola.

  • 10:42:41

    OSTERHOLMWe will still likely and potentially see more cases in the United States coming from West Africa, but that is not going to be the big community problem.

  • 10:42:49

    PAGEAnd here's one from John, an email from John who writes, "I'm wondering why the ebola-infected man's family has not tested positive for ebola. Presumably, they had unprotected contact with him, yet it's the healthcare workers who did get infected." Can you explain that?

  • 10:43:05

    OSTERHOLMWell, first of all, we do know that people tend to get more infectious as they are ill longer, meaning that the more severely ill they get they may have more virus. We also don't know -- and while public health authorities in Dallas do know, but I, for one, do not know just exactly what happened inside that apartment in terms of containing any of his body fluids, if he had vomiting or diarrhea, you know, what contact was had with bed sheets or things like that.

  • 10:43:30

    OSTERHOLMAnd so surely that is still a real concern for us and, you know, they're not completely out of the potential incubation period yet so that those cases might happen. We really hope they don't. But again, remember these nurses were caring for the patient when he was at his sickest, when he was likely the most infectious.

  • 10:43:47

    PAGEAll right. Here's a question for Jason, I think. This comes from Brian. He asks, "can a cured ebola survivor contract the disease again or could they safely help in dangerous areas?"

  • 10:44:01

    CONEI don't think we have any evidence of someone getting ebola twice and, in fact, we do have some staff who've been cured and I've heard of this also with, I think, the International Federation of the Red Cross, working with people who've been cured, who've survived and then they have been working in some of the treatment centers in different capacities. It can vary. I think just back to the point of what Mike was saying about this, I think we have to keep -- while it's very important that the CDC and health departments prepare hospitals and prepare the public for information about the ebola virus, I think we just have to keep everything in perspective.

  • 10:44:40

    CONEI think about some of our staff and our patients in Sierra Leone, for instance. One family, in particular, that lost their father. Five out of eight siblings died. Three of them survived. They pushed through. That's a family that's lost almost everything. They're going to rebuild their lives and they've lost more than any of us have ever experienced in this outbreak in the United States or any of the other countries outside the region. I think it's important to keep this perspective of how devastating this epidemic has been for these communities.

  • 10:45:13

    CONEEntire families being wiped out, children being orphaned. It's really quite striking. And having been in Liberia about 10 years ago after the end of the civil war and seeing what that country faced in the years after trying to rebuild, you just get a sense that this is really -- there's a human imperative to get involved in this. And while we want to protect ourselves and our own communities, keep in mind the devastation that's being wrought by this disease in the places where it's being most effective.

  • 10:45:41

    PAGEWell, and the fact that it's not under control yet means it's just gonna get worse, at least for awhile and a situation that will need rebuilding for years and years. I mean, it's hard to imagine how long it will take to help this region recover.

  • 10:45:58

    CONEYes. And I mean, we were right in the thick of things. I mean, there's really, as I said earlier, there's been some improvements in terms of deployment of resources, in terms of money flow and things like that, but a lot of the same things we've been talking about almost 10 weeks ago, very publically, in late July/early August still remain similar challenges. And that means, not enough's being done. We don't really have a good sense of the predictability of the epidemic.

  • 10:46:25

    CONEAs I was eluding to earlier, places where we thought we had put out the fire, it's burning back up again in like, Guinea in Conakry, which is a very large capital city, very densely populated, not unlike Freetown, which is experiencing a quite similar situation to what we saw unfold in Monrovia and Liberia. So we are really in the thick of the things and if the models even in the lower end of the prediction models, we have cases that we cannot treat and we cannot admit.

  • 10:46:53

    CONEAnd then, we know from experience that when you're able to get people in early, at least they will give them supportive care. You can drive down the mortality rate. It's, obviously, still a catastrophic disease, but you give people a better chance and we can't do that if the treatment centers aren't operational and we don't have people in there who actually can adhere to the protocols. And that's why we've said before, we have serious questions as to why not deploy some of the medical military personnel who've been attached to different emergencies, whether they have been Haiti or the tsunami in Thailand and other places in past years.

  • 10:47:27

    CONEWhy those personnel aren't being brought into the fight -- and it's mostly a military logistical support that's coming from the U.S. government at this time in addition to the work, obviously, of the CDC that has been very instrumental in training and also surveilling the epidemic.

  • 10:47:41

    PAGEWell, I'm sorry we don't have a U.S. government official on to whom we could ask that question. But let me ask you. Why do you think that you have not seen the deployment from the U.S. military that you hoped to see?

  • 10:47:53

    CONEI think it's really a question that needs to be addressed to them. We don't have the answers. Obviously, we know there are a lot of risks in this deployment and I think it just raises very important questions as to about the privatization of the response in terms of, you know, set up of centers that will largely be staffed by volunteers working for NGOs like Doctors Without Borders and like Save the Children, International Medical Corps and others.

  • 10:48:20

    CONEAnd it really has exposed, I think, a really gaping hole in our global, you know, our capacity to respond to global health threats. In this case, it happens to be ebola. It might be others in the future. I think Mike can speak extensively to those gaps. He knows and examined those issues quite extensively.

  • 10:48:35

    PAGELet's turn to Mvemba Dizolele first.

  • 10:48:38

    DIZOLELEYeah. I just want to add to what the doctor was saying. I think the privatization of the response is -- it had to happen this way simply because the systems in those countries have collapsed. So even when -- the reason that we have Medecins Sans Frontieres, Doctors Without Borders, do such a great job is because there's a void in the first place. There's been a void with the government public health service structure. So then, you have to get the outsides to do it.

  • 10:49:03

    DIZOLELEIf you're gonna give aid, what is the best way to give aid? Do you give aid to the government that is collapsing or to a state that is almost paralyzed, or do you give it to an organization like the  Medecins Sans Frontieres or the Marines or organization that are outside that system, but that can work. This is where I was saying, this actually a governance and public policy issue as well and this is kind of the crux of that.

  • 10:49:28

    PAGEMichael Osterholm -- I'm sorry. Go ahead.

  • 10:49:29

    OSTERHOLMSusan, can I add a point to this right now? This is Mike. And you've heard from us about the impact right now in the three effected countries. But as some of us have written about recently, we're beginning to see the annual worker migration out of these three countries, which occurs every year, particularly in young men and boys, into other Central African countries, moving from west to east. And one of the things we haven't entertained yet, is as bad as it is in West Africa, imagine if this gets into the slums of Lagos or into Kinshasa or in (word?) or any of these other areas.

  • 10:50:02

    OSTERHOLMAnd we're having a hard time fighting it now and Jason has made that really very clear today. This is what we're trying to stop from happening and the only way we're going to stop that is to try to actually, really improve what we're doing on the ground in these three affected countries because if we have to fight it in these other countries, I can't even imagine what we're going to do.

  • 10:50:21

    PAGEWell, Doctor, so when you think about the performance of the World Health Organization in this crisis, what have we learned about the state of our ability as a globe to respond to these health crisis, these medical crisis that cross national borders?

  • 10:50:37

    OSTERHOLMIt is seriously broken. You know, Doctors Without Borders, were trying to warn us months and months ago about this and the global public health community just did not listen. They did -- once they started to listen, they didn't have the tools to respond. And so I think, if nothing else, this is the global public health's 9/11 where we're gonna have to finally understand we don't have the global system that we need to respond quickly.

  • 10:51:02

    OSTERHOLMWe can't put this on the backs of NGOs like we've done. We have to have a much more comprehensive rapid deployment capability for public health, which doesn't exist. And I think that we are far from seeing this played out yet. I mean, in some ways, we're only in the first chapter of a 10 chapter book here on this situation. And I think this is going to be a long haul and we can't let NGOs be the way that the world has to respond from a public health crisis standpoint.

  • 10:51:31

    PAGEWell, you called it the world health's 9/11, which is so dramatic, but there was a big response after 9/11. A lot of things changes. You know, the resources here in this country against terrorism just exploded. Do you see that sort of thing happening now in response to this crisis?

  • 10:51:47

    OSTERHOLMIt has to. I think, again, just think about what's going to happen here in terms of Africa if this moves further eastward and begins to destabilize other countries. This is the very heart and the belt of many of the terrorist concerns that we have. And failed states, you know, are the real source of where we worry about these kinds of terrorist activities taking off and being supported by. So I mean, the international security experts are very concerned about this.

  • 10:52:17

    OSTERHOLMSo we have to see that public health is the underpinning of a secure world and if you don't have that, we won't have that. And so this is why we have to take a step back and say ebola, as we know it today, is obviously a crisis, but it really is a symptom of a much bigger problem with global public health.

  • 10:52:35

    PAGEI'm Susan Page and you're listening to "The Diane Rehm Show." We're taking your calls. Let's talk to Bill. He's calling us from Dallas. We've talked so much about Dallas this morning with the ebola crisis. Good morning, Bill.

  • 10:52:47

    BILLGood morning, Susan. I also work at a nonprofit agency that works providing health services for our refugee population. My question is that there's something that hasn't been made clear to the public, to us in general and I don't say -- I don't believe it was intentional, but it's when we think about it, HIV/AIDS is transmitted through bodily fluid contact, the same way that we hear that ebola is transmitted. But we don't see doctors and nurses treating HIV positive patients with Hazmat suits.

  • 10:53:18

    BILLWe don't hear about hundreds of medical professionals in Africa coming down with HIV, even though the plethora of patients there. So there are just some little thing that's not being told about how dramatic the transmission is. There's obviously a drastic difference and that was what I'm interested to hear.

  • 10:53:35

    PAGEAll right, Bill. Thanks so much for your call. Dr. Osterholm, do you want to take that one?

  • 10:53:40

    OSTERHOLMYeah. So first of all, the transmission of ebola is very different than HIV. Any person with HIV infection can walk into a room, you can give them a hug, you can touch them, you can sit next to them. You don't worry about their body fluids. It's basically a sexually-transmitted or blood-borne transmitted disease. With ebola, unfortunately, is the patient is very sick. They actually -- their feces, their vomit, their blood and a small proportion of these people will actually bleed outside of their body through their body orifices.

  • 10:54:10

    OSTERHOLMThey are highly infectious and so this is a different situation. And I think the caller's concern is well placed, meaning how do we proportionately respond to this so that we don't over react to this. But as you've seen with the two nurses in Dallas where we not have infection among them and what is confronted every day in West Africa, this is a dangerous situation if these patients are not handled very, very carefully. We don't have that same level of concern about AIDS patients or, for that matter, almost any other infectious disease we deal with.

  • 10:54:40

    PAGEThanks for your call, Bill. Here's an email from Clem who writes a question I think perhaps Jason could handle. He said, "following the hospitalization of an ebola patient in Lagos, there was extreme fear that the virus would spread rapidly in this densely crowded city of 20 million residents. Fortunately, this did not happen. What can we learn from that case?"

  • 10:55:00

    CONEI think, in that case, I mean, you see the Nigerian government was able to very quickly do a lot of contract tracing, following the patient's -- anyone who had become in contact with that specific case. It's something that we had some teams who were working directly with the ministry of health, but they really took the illness and were able to kind of do some things in the way that, you know, other governments in the region weren't in a position to do as well.

  • 10:55:26

    CONEAnd, again, it was a limited number of cases, right, to trace. And as Mike has said, you know, the modes of transmission allow to sort of really identify, potentially, who's gonna be in contact with that person when they're actually infectious, track them down, monitor them for the 21-day window, incubation period and they've done that and they've been able to successfully contain it.

  • 10:55:51

    OSTERHOLMI think...

  • 10:55:51

    PAGEYes, go ahead.

  • 10:55:51

    OSTERHOLM...if I could just add here, too, it's very important to note that when this happened, it was in a government worker who was taken to some of the best healthcare in Nigeria and most of the thousand contacts that were followed up, which was an incredibly intense activity, were among higher socioeconomic status individuals who worked in healthcare or family members thereof. If this same virus had gotten into the slums of Lagos and had gone through one or two generations of transmission, it would've been a very, very different picture. And that's what we're concerned about.

  • 10:56:19

    OSTERHOLMSo I give the Nigerians and the CDC from the United States, who helped, great credit for this. It was an amazing piece of work. But that can't be duplicated when this starts out in the slums of these cities. It won't be.

  • 10:56:30

    PAGEA disturbing story. This is a story we're clearly gonna be returning to again and again on "The Diane Rehm Show." I want to thank our panel for being with us this hour. Dr. Michael Osterholm, Jason Cone, Mvemba Dizolele, thank you so much for being with us this hour.

  • 10:56:44

    DIZOLELEThank you.

  • 10:56:45

    CONEThank you.

  • 10:56:45

    OSTERHOLMThank you.

  • 10:56:46

    PAGEI'm Susan Page of USA Today sitting in for Diane Rehm. Thanks for listening.

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