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West African countries continue to fight the largest outbreak of Ebola in history, which has now claimed more than 4,500 lives. A shortage of doctors in many of those countries continues to be a major challenge. Here in the U.S., two Ebola patients are recovering at hospitals in Maryland and Georgia, and a lab worker who had boarded a cruise ship tested negative for the virus. President Barack Obama appointed an Ebola “czar,” while the Pentagon readied a team of 30 military doctors to assist hospitals. In Congress, many lawmakers continue to call for a West Africa travel ban. Diane and guests discuss the latest international and domestic efforts to confront the Ebola outbreak.
- Dr. Malonga Miatudila Public health consultant; former public health specialist, The World Bank.
- Dr. Rajiv Shah Administrator, USAID.
- Lawrence Gostin Director, O’Neill Institute for National & Global Health Law at Georgetown University Law School; and director, World Health Organization Collaborating Center on Public Health Law & Human Rights.
- Congressman Tim Murphy Congressman, (R-Penn., 18th District).
- Nell Greenfieldboyce Science correspondent, NPR.
- Dr. Clifford Lane Deputy director for clinical research and special projects, National Institute of Allergy and Infectious Diseases at NIH.
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. The ebola epidemic continues to claim victims in West Africa. Now, more than 4,000. Here in the U.S., President Obama appoints an ebola czar and the Pentagon says it's training a dedicated 30 person ebola taskforce to assist healthcare workers. Joining me to talk about the latest developments in the fight against ebola here and abroad, Dr. Clifford Lane of the National Institutes of Health, Nell Greenfieldboyce of NPR, Lawrence Gostin of Georgetown University School of Law and public health consultant Dr. Malonga Miatudila.
MS. DIANE REHMBut first, joining us from his office here in Washington is Dr. Rajiv Shah. He's administrator for the U.S. agency for international development. That's for joining us, Dr. Shah.
DR. RAJIV SHAHThank you, Diane.
REHMI know you've just returned from West Africa, Dr. Shah. Talk about the situation right there now with ebola.
SHAHWell, I visited Liberia, Sierra Leone, Guinea and Senegal and the purpose of my visit to make sure that we were doing everything we could to help lead a strong coordinated and effective international response designed to stop ebola at its source in West Africa. And what I saw is that all three endemic countries have effectively the right strategy in place and the challenge now is to scale up their execution of that strategy so that contacts are getting traced, burial teams are reaching people who have died from ebola and removing those bodies before further people get infected and that you start to see a bending of the curve so that we're no longer in a situation of epidemic growth of the problem.
REHMHow much money is actually going to halt the disease?
SHAHWell, yesterday -- last week, I announced an additional $142 million in humanitarian assistance to projects and partners designed to reduce ebola's consequence in West Africa. That brings the total for U.S. humanitarian assistance to more than $250 million, but that's just part of a larger international effort. And over the last six weeks, we've worked aggressively to insure that partners, including the United Kingdom, France, Canada and local, other African countries are all doing more as well.
REHMSo how will that money be used specifically?
SHAHWell, a data-driven, evidence-based response essentially has three components. Number one, we build ebola treatment units so that people with ebola can seek care and isolation in a safe setting. I visited a 300-bed ebola treatment unit that's about to come online in Monrovia, as an example of that. Number two, we build out community care centers. These are small scale care facilities usually associated with a health clinic or hospital deep in a rural area.
SHAHThese are very important because they help provide oral rehydration and basic therapies to people who are sick and they get people out of their homes into a safe setting where they're isolated and not a transmission risk to others. And then, third, we try to reduce the vectors of transmission. So now, if you go to Monrovia or Freetown in Sierra Leone, everyone's washing their hands before they walk into a building. People are doing elbow bumps instead of shaking hands, which reduces transmission.
SHAHAnd most importantly, more than three-quarters of all people who have died of ebola and now have a safe burial team, a six-person team dressed in Hazmat suits coming out, removing the body in a dignified and safe way so that the main vector of transmission, which is touching and kissing the deceased, no longer contributes to epidemic spread.
REHMWhat about doctors to care for those patients in either large or small facilities?
SHAHWell, we're going to need more doctors. We know that and if anyone is interested, they can go to USAID.gov and register. We'll partner you with International Medical Corps and other NGO partners who are taking and seeking and recruiting medical support from abroad. But importantly, what I saw is the vast majority of the healthcare services are going to be provided by West Africans themselves.
SHAHI visited a facility where the World Health Organization and USAID are jointly training 120 Sierra Leonean community health workers, mostly nurses, in how to use the protective equipment, how to take it off safely so that they can be safe themselves as they provide care and support to members of their community who have gotten ebola. And I think it's important to highlight that they are very much, these local community health workers, are very much the front line of the response backed by international medical support.
REHMNow, Nigeria is declaring itself ebola-free after six weeks with no new cases. Are there any signs the outbreak is slowing down in the other countries. You mentioned Liberia, Sierra Leone, Guinea and Senegal.
SHAHWell, Nigeria and Senegal, as you know, have had specific cases and then had an effective contract tracing, disease control and medical services system in place to help mitigate the consequence of that. And I think both places feel they have been successful at preventing further spread of ebola. And that gives us real hope. In Liberia, I would note that over the last four weeks, it appears that the number of new cases, which is still positive, so the problem is still getting worse before it gets better in absolute terms, but the rate of growth appears to be slowing.
SHAHAnd we're never going to declare success until ebola is gone and that's gonna take months and months and months and it is going to get worse before it gets better. But it does prove that some of the things we've done to scale effort over the last four weeks, getting burial teams to more than three-quarters of all deceased persons with ebola, for example, does appear to be reducing the rate of transmission in specific areas and it provides a roadmap for how we can have an evidence-based, data-driven strategy to tackle ebola comprehensively over the next months.
REHMLast week, President Obama said he was going to send National Guard troops to West Africa. When and where will they be deployed and what will they be doing?
SHAHWell, they will be in support on an as-needed basis of the United States military mission. And I had a chance to spend time with Major General Darryl Williams in Monrovia who's working with the USAID and CDC teams that are helping to lead this effort. And what General Williams is focused on is doing what only the U.S. military can do right now, building ebola treatment units in difficult-to-reach areas quickly and efficiently.
SHAHStanding up a training facility that will train almost 4 to 500 Liberians every week on how to use the protective equipment and serve the fight against ebola and having that training facility up and running will greatly expand the capabilities to overcome this disease. And the military's also building a 25-bed hospital that will be ready for business in early November that will really provide world class care to health workers who get infected so that they can be safe and they know they're cared for and taken care of as they are the most courageous elements of fighting this horrific disease.
REHMAnd what about here in the U.S.? Dr. Shah, the Pentagon says it now has an ebola taskforce. It can deploy here a 30-person quick strike team. Tell me about that.
SHAHWell, you know, my remit is really in West Africa where I'm responsible for helping to coordinate an aggressive and effective response. I think what I saw there gives me confidence that in the United States, we can scale effort here. What I saw in West Africa is that once you train health workers and they know how to protect themselves, they have access to the right equipment, the actual treatment for ebola, for most patients, is actually pretty basic.
SHAHIt's making sure that they have fluids and nutrition and electrolytes are kept in check so they don't suffer electrolyte imbalances. It's insuring that they're in a safe and isolated environment as they're receiving either oral or intravenous fluids. And it's making sure that they have basically supportive care in that setting. And the truth is, I saw that care provided very effectively in Guinea through Medecins Sans Frontieres and, you know, they're doing that at scale for hundreds of patients over many months and they haven't had a single health worker infected because they're following the protocols carefully.
REHMDr. Shah, a little later on, I'm going to talk with Congressman Tim Murphy of Pennsylvania who has been calling for a travel ban on passengers from countries battling ebola. What is your thought on that?
SHAHWell, ultimately the Centers for Disease Control, you know, set the protocols on those types of issues. Right now, I can tell you that we are relying on people being able to come in and then go back and be part of the response in order to mount an effective large-scale evidence-based response in West Africa. And our immediate priority is to stop this problem at its source and to make sure we get the technical leadership and support in the region to be able to do that.
SHAHI also know in the region, where they have had travel bans between countries in West Africa, what's happened is people with ebola are still able to get through and what doesn't get through are the medical teams and the supportive resources and general economic activity so we're dealing with a generalized economic crisis and trying to do the best we can to help people push through.
REHMDr. Rajiv Shah, administrator of the U.S. agency for international development. Thanks for joining us, sir.
SHAHThank you, Diane.
REHMAnd short break, we'll be right back.
REHMAnd now to our guests here in the studio, Dr. Malonga Miatudila, tell us how you react to Dr. Shah's assessment. Do you believe we are making progress in the fight against ebola?
DR. MALONGA MIATUDILAI think we have to wait for that, the statistics, before we can say that we are winning because so far I think ebola has been winning and we have been losing. But hopefully, if we believe what Dr. Shah said, there are signs of turning back. But I can think that now we have also changed the strategies because let's remind everybody that this is the number 26th (sic) epidemic. We have been able to contain the 20 -- all the previous outbreaks by using the recipe that's worked for almost 40 years.
MIATUDILA...which is early diagnosis, early response and community empowerment instead of what we have been doing so far tendency to medicalize our approach. And then good contact dressing and isolation and emitting the international -- I mean external assistant to assist communities in dealing with the problem.
REHMWhat do you think is wrong with the current approach? Do you think it's simply a matter of more money needed?
MIATUDILAIt's not a matter of more money because it's a problem of strategy. We started on the wrong foot. First, we ignored the disease is the problem because the first case was in December -- December, 2013. And we didn't do anything. We waited more than 100 days before doing. Okay. Sorry, that we cannot correct. The second part is information and community empowerment. That I can see it's coming now. When I contact my friends in Sierra Leone and Liberia or Guinea I can feel that. Now they've at least come to the understanding that to contain the disease you have to empower communities.
REHMDr. Malonga Miatudila. He's former public health specialist at the World Bank. Dr. Clifford Lane of NIH, you were in Africa earlier. Is this current strain of ebola different from what has previously been the case?
DR. CLIFFORD LANESo at a basic scientific level, at a molecular level it's very similar to the other ebola's Zaire strains. It has its own unique signatures, but nothing that makes one thing that it is biologically distinct.
REHMWell, do you agree then with Dr. Miatudila that somehow we, number one, came to it late and number two, have not been employing the correct approaches to deal with it?
LANEI will completely agree with the importance of community empowerment and getting a handle on this. I had the opportunity to see that firsthand in the West Point community of Monrovia. And to see the pride with which the contact tracers talked about their work and how important it was for them to keep track of the people who might be exposed and get them the appropriate care and isolation if they developed symptoms. So I do think there's a very important effort underway at the local level, at the community level coordinated by the central government to try to do the things that have been outlined by both guests earlier today, to get this disease under control.
REHMAt the same time we heard this morning on NPR, Nell Greenfieldboyce, that some families are keeping their relatives hidden at home rather than having them transported to these health centers. And only when they're at the end stage of ebola do they call for help.
MS. NELL GREENFIELDBOYCERight. I think that's one reason to be a little cautious about any statistics that seem to show a slowing of the growth of the epidemic. It will be some time before we understand exactly what's happening with the numbers. But I do think the shift to sort of community care centers away from ebola treatment centers is a sort of recognition that we need to do something faster, something that can be put into place sooner than we can get these treatment centers up.
MS. NELL GREENFIELDBOYCEDr. Shah mentioned this 25-bed hospital. That was promised in early September, I believe, and he said it would be open for business in early November. So that's almost two months and, you know, that's supposed to be a fairly sophisticated hospital.
REHMWhat's taking so long?
GREENFIELDBOYCEYou know, people say, you know, the rains are complicating things. There's just all kinds of logistical problems. And so all of these treatment centers have been promised but -- and they are moving up. They're building them but the scale of the outbreak is so large that they need to do something faster.
GREENFIELDBOYCEAnd so there's this shift to these community care centers which are sort of smaller, scattered more throughout communities and provide sort of more basic care. But it's a real question how those will be perceived by the local people, whether they'll be seen as something positive, a place that they can bring their loved one quickly if a treatment bed is not available or whether they'll be seen as a sort of place where people are just being held and maybe would be exposed to other people with ebola. So I think we'll have to see.
REHMTwenty-five beds does not seem like very much.
GREENFIELDBOYCEWell, that was a hospital that was specifically going to be for health care workers. That was going to be built to encourage health care workers to stay with the epidemic and be treating it. But Dr. Shah mentioned the need for more doctors.
GREENFIELDBOYCEYou know, I think there's a real question among some folks about if a doctor volunteers to go work in an area that's affected by ebola, what will happen if that doctor gets infected? Is there a promised guarantee of a ride home or is treatment going to happen in that 25-bed hospital? Is that 25-bed hospital just for ebola? What if a doctor or someone else goes there to volunteer and has a heart attack? What kind of health care facilities will be available? So I think a lot is happening but there's still a lot of questions.
REHMYou know, we have an email from Bob in St. Louis who says, "We've been assured from health professionals that the only way to get ebola is through bodily fluids. However, we still have not been told any solid reasons as to how Dr. Kent Brantly and the two nurses were infected. Can any of your guests say for sure ebola is not able to be transmitted through the air," Dr. Lane?
LANEThanks for asking that question because I think it's a critically important question. I can't comment on Dr. Brantly. I could perhaps make some comments on the two nurses from Dallas. If you look at the types of personal protective equipment that was used during the first few days of Mr. Duncan's admission, it was different than the type of equipment that was used subsequent to that. And the two nurses who became infected were using approaches with gowns and gloves that did not give full body protection. And I think it's quite likely that that level of protection was not adequate to protect them from the infected body fluids from the patient.
REHMAnd why were they just using gowns and gloves and...
LANEAnd masks, yes.
REHMAnd masks. Had they not been informed that they needed full body cover?
LANEThey were following the guidelines that were in place at that point in time and those were guidelines that were based on WHO guidelines based on experiences in the prior epidemics. In the U.S. we're dealing with a very different type of setting. We have different types of procedures that are being done. And I think very soon new guidelines will be issued to deal with these differences and these risks. So I do think there are some reasons that do explain why these two nurses and probably from around October 1 on, the likelihood of infection dropped considerably for the healthcare staff.
REHMBut Dr. Brantly, we don't understand why.
LANEI don't know. I don't have any specific information on his case.
REHMOkay. I want to turn to you now, Larry Gostin, and talk about the possibility or indeed the prospect of a worldwide travel ban or a travel ban from West Africa? What do you think about that? Does it make sense?
MR. LARRY GOSTINNo, it doesn't make sense and it also is deeply concerning to me. It doesn't make sense, one reason is what Dr. Shah said, is that if it's going to impede anybody it's probably going to impede the rescue effort. And so we're not going to be able to get doctors, nurses, medical supplies and other things in and out of the area. And that's in and of itself going to fuel the epidemic there.
MR. LARRY GOSTINAnd what we need to understand, I think, here in the United States, is that our risk is directly tied to the source of infection in West Africa. And if we continue to let that spin out of control, then our risk is increased. But beyond that, I think America is better than that because we would be creating a humanitarian crisis, at least exacerbating one. It would mean that the food supplies would be difficult. It would mean that people would feel trapped in there. And you're just kind of putting a lid on a boiling pot. It's really a bad idea.
MR. LARRY GOSTINAnd the other problem is is that other countries are going to follow us if we do it. When America does it, others will do it. So symbolically I think it would be just not the kind of compassionate response we want.
REHMWhat do you think, Nell?
GREENFIELDBOYCEWell, I think that that's going to become a question that we'll probably be hearing more about in the coming days. There certainly seems to be a political desire among many to see some sort of travel restrictions. But public health officials and the president have been clear that although they would consider anything to protect the health of Americans that they just feel that a measure like this would be counterproductive.
GOSTINAnd there are other things we can do and I think the CDC is considering it, which are enhancing screening procedures. We might do that for our Visa requirements, requiring more medical checkups before you can get a visa to come to the United States. We might do more active monitoring of people coming from the West African region. Once they come into the United States makes really, really sure we know where they are, we follow them up. And we have more intensive follow up.
GOSTINAnd so what I'm hoping is that we can broker a reasonable political compromise between congress and world and public health experts in the United States so that we can try to make -- be as sure as we can to make sure ebola is not imported here while not doing something that would really be self defeating and also demoralizing to the region.
REHMLarry Gostin. He's at the Georgetown University School of Law and you're listening to "The Diane Rehm Show." And joining us now is Congressman Tim Murphy. He represents Pennsylvania's 18th district. He's chair of the House Oversight and Investigation Subcommittee. Thanks for joining us, Congressman Murphy.
REP. TIM MURPHYGood morning. Great to be with you.
REHMThank you. You've said dealing with ebola is like dealing with terrorism. Explain what you mean by that.
MURPHYWell, I said that in terms of we need to understand that we have to put up our highest level of defense and be right 100 percent of the time. Ebola only has to get in once. This is a pervasive insidious disease which seeks hosts to kill. And along those lines we need to be taking strong efforts and understand that the scientific and medical community, our biggest enemy is not ignorance. Out biggest enemy here is arrogance to think we know it all.
MURPHYThere's a great deal we don't know and also we don't even know what we don't know. So along these lines I believe, as we're moving forward in this, we're best to take more of a defensive perimeter stance, lots of controls on this and gradually open them up as we learn more. But I think there's been a lot of missteps.
REHMWhat kind of false information do you think the CDC has put out that's really inflamed the concern on the part of the American people?
MURPHYWell, they said, for example, you can identify people just by their fever. A study in the New England Journal of Medicine said 13 percent of the time that's wrong. They assume that travelers will be honest about their exposure in travel and that's not true, including some things of Mr. Duncan. They said the travelers would be honest and know about their symptoms. But there's a 21-day span here in which a person may not have symptoms and so they may have nothing to report. They said that the proper temperature to detect ebola is 100.4 degrees. The young woman who began to develop symptoms had 99.5 and Mr. Duncan had a lower threshold than that.
MURPHYThey said that virtually any hospital can -- who can deal with isolation can deal with ebola. That turned out to be false. They first said that no quarantine was needed for medical personnel. That turned out to be false and they've modified that. They said you didn't need full body suit covering. That turned out to be false. So far they're saying it only spread through bodily fluids. There's some suggestion that that may not be totally true. They said that the airport screening is going to be sufficient. I don't agree with that.
MURPHYAnd I think they have a number of false premises about this travel ban or the travel restrictions, which your last guest was also, I think, restating some of those false assumptions. And this is where the American public will only get more fearful if they don't handle this right. This idea about demoralizing Western Africa...
REHMSo you believe that...
REHMSo you do believe that a travel ban for individuals coming to and from West Africa ought to be in place, even though...
MURPHYI believe that we need travel restrictions. So when your last guest says we don't want to demoralize Western Africa, heck, they're already demoralized. They have a terrible disease killing thousands of people and likely tens of thousands more. But here again where we get into this, our biggest enemy here is hubris, that we know what to do and we have these assumptions. And when that is our enemy we need to have a strong perimeter defense.
MURPHYSo let me talk about this travel ban issue. They say, well, people will sneak out of their infected countries to get to the U.S. First of all, people will lie to protect their family and themselves, I understand that, in order to get to the best hospitals. This is human nature. The other idea they say we can't trace them. Well, we can look at their passports, we can find out why they're coming. We'll say, if you're coming here for tourism, no.
MURPHYWe can screen them for very specific legitimate needs to go in and out. No one is saying to keep doctors and nurses out. That's fine, that should be happening. People also say that people would travel throughout Africa to escape. They're doing that now...
MURPHY...and this is the season where the migrant workers are leaving Eastern Africa to go to Western Africa. And this idea we can't get supplies in, that's absurd. We can get massive amounts of supplies in.
REHMOne more quick question, Congressman. Should Speaker Boehner call House members back to vote on a travel ban, yes or no?
MURPHYThe president can do this much faster than congress can if necessary. But I believe the president can move forward on this and screen passengers much more carefully and put up a level of travel restrictions here.
REHMAll right. Thank you so much for joining us. Congressman Tim Murphy of Pennsylvania.
REHMAnd welcome back. Time to take your calls as we talk about what's happening in West Africa and other parts of the world, including the United States, in regard to ebola. Let's go first to Steve in Plano, Texas. Hi, you're on the air.
STEVEHi, Diane. Thank you for having me.
STEVEYou know I -- there's a lot of sentiment that the Congressman said and I agree with it, with a little bit of hubris. One thing that we're being fed is that ebola is something that's difficult to catch. But we have some people who have been exposed kind of treating their travels rather cavalierly. And I'm afraid that's bad precedent. So given the light that Americans are who we are and we do what we do and we're given the information that we have, I'd like to ask your panel what kind of risk are we putting ourselves at?
GOSTINWell, I think we need to put all this in perspective. In West Africa, we have an exponential spread of the disease. We could have hundreds of thousands of cases. There's been one case imported into the United States and it's resulted in two transmissions. So we really have to put this into perspective. We don't want to overreact. One thing, you know, that we tend to -- we believe in the rule of law and we believe in science. Scientists tell us that a travel ban wouldn't work and would be counterproductive. The WHO states that. Almost -- I think it's a virtually unanimous conclusion of most public health experts.
GOSTINAnd the law -- we're a signatory to the International Health Regulations, which really would prohibit a travel ban. So if the United States did this, I think it would be symbolically terrible, and other -- there would be a cascading effect around the globe.
GOSTINI just think it would be counterproductive.
REHMLet's go to Beth in Tamworth, N.H. Hi, Beth. You're on the air.
BETHGood morning. Thank you. My question is less about the travel ban and more getting back to the logistics of containing the disease. And I've read some information and know from working in hospitals that dealing with all the hospital waste is a big problem. In the U.S. there's a little bit of confusion not only about how -- not confusion, but differing opinion about how Ebola is transferred, what you can do to protect against getting it, but also then about proper procedures for dealing with bodily fluids that need to be disposed of and also all the protective gear that needs to be either cleaned or disposed of. And I'm just wondering what the plan is for that, as far any of your experts (word?)
REHMAll right. Dr. Lane, an easy question.
LANENo, it's a very important question. And I have to say, as we brought our first patient in as a rule-out, we were facing this challenge. It really does require a lot of forethought. It requires procedures for removing material from the room in a secure way, taking it to autoclaves to inactivate any virus, using the right chemicals to inactivate virus that might be in the body fluids. But it is something that can be done. It does take a lot of effort. It does take expense, particularly with the personal protective equipment. But there are ways to handle it.
REHMNow, there is, I gather, one patient at NIH, is that correct?
REHMHow is she being treated?
LANESo, as one knows, the specifics of any particular case are protected by patient confidentiality. And in a facility like the NIH, a federal facility, also by the Federal Privacy Act. However, we can say that she is in fair condition. She's comfortable and we're hopeful that things will continue to go in the right direction.
REHMAnd Dr. Miatudila, in West Africa, dealing with the question of waste that our caller referred to, cannot be an easy topic.
MIATUDILAI don't know. I've not been in West Africa during the crisis. But I can talk about -- can speak about the previous outbreaks. Again, let me put that into perspective. I think now, in the U.S., we are dealing with two diseases -- ebola and fear ebola. Now, let me talk about just ebola, the ebola virus. The first outbreak occurred in 1976. 1976 and 2013 we have had some 25 outbreaks. During those 38 years, ebola has been able to kill 1,326 people. Now, compare that to flu. Canada -- in Canada, they are 1,500 people died from flu in -- just in Canada, in two years. I'm not going to talk about the death in the U.S. for other diseases.
MIATUDILASo, really, ebola is there. It kills. But if you take the mathematics, the maths, you'll see that the number of deaths due to ebola are very minimal. I'm not going to say that we are going to have risk zero in the United States, yes, but compared to other diseases. Fear ebola is what is going to create problems, more problems for us. And that I don't have an answer to do with that.
REHMAll right. Nell Greenfieldboyce, tell me about Ron Klain, who has been chosen by the president as the new ebola czar.
GREENFIELDBOYCEWell, that was a choice announced at the of the week, last week. He, as I understand it, is a lawyer who's seen as a very competent administrator, someone who can manage things, get things done. He's been chief of staff for vice presidents. He's been criticized by some Republicans who say they would have liked to have seen an ebola czar who had some medical or public health background. There was also some criticism that he apparently wasn't at a couple of meetings -- President Obama held some meetings on Friday and Saturday to talk about the ebola situation -- he was not there. But the White House has said he's actually wrapping up other activities and will start his new job this coming week.
GREENFIELDBOYCESo, we'll see. Certainly in the response to Ebola, there are a number of different government agencies involved. You have the Department of Defense. You have the Centers for Disease Control and Prevention. You have the National Institutes of Health. You have the State Department. So there's a lot of big agencies all working on this thing. And so I think there was a sense that there needed to be one person to coordinate all of those activities.
REHMLarry Gostin, how do you feel about Mr. Klain?
GOSTINWell, I think we want him to succeed. And we want to -- we all want to rally around him. I think there are still a number of questions that I think we need to understand about it. One, if you want to coordinate by having another boss, does that do it?
REHMYeah. What does he do? That's what I'd like to understand.
GOSTINAnd what's his line of authority? What funding does he have? All of these things were unclear. And the idea was first posited by the president, almost off the cuff. And then within 12 hours, the appointment was made. And so there's a lot we still don't know. But here's what we need to do. We need to rally round the new ebola czar. We need to make sure that he actually is listening to his key public health informers and doesn't delay things by sending every public health decision up through the chain in the White House. That would be a bad thing.
REHMDr. Lane, how do you feel about the appointment of a czar. What do you see him doing?
LANESo, as a federal employee, I always have to be careful how I answer a question of that particular type.
LANEI would say that we're looking forward to working with him. I know that he has reached out to get briefings, certainly from the NIH.
REHMWhen's he going to start?
LANEI had heard Wednesday as well, so.
GOSTINHe should have started right away.
REHMNell, do you know when he's scheduled to start?
GREENFIELDBOYCEI believe Wednesday. But presumably, he had other activities that he had to wrap up. So that's what he was doing.
REHMSo what do you expect him to do?
LANEFrom my perspective, at the NIH, we have quite a few programs that we're putting in place and are conducting. And at times, there are some logistical administrative challenges in getting those done. And we're hopeful, by having at the White House level, somebody full time focusing on this, this may be a way to help us move some of those things even quicker.
REHMA lawyer rather than a doctor?
LANEI think what -- I think someone who's a good manager, who knows how the federal system works, can actually make sure that a Department of Defense, the USAID and HHS joint project doesn't run into obstacles that sometimes are put in place just by the way our systems are built. They can cut through some of that red tape quite effectively with the authority of their offices.
REHMDo you believe that?
GOSTINWell, and I think if the new czar has direct authority from the president, reports to the president, and actually takes care of bottlenecks, not creates them, then it will be worth it. But I think, really, the jury is out. We -- there's so much that we don't know. And this idea -- remember, you began the show, Diane, talking about delay. That's the last thing we want to do now. If we needed an ebola czar, we need an ebola czar now.
REHMLarry Gostin of Georgetown University School of Law. And you're listening to "The Diane Rehm Show." I know you wanted to add something.
MIATUDILAI wanted to say that, in the field, we need an Eisenhower -- somebody who's going to coordinate the assistance coming from all the countries. Because now, in West Africa, we have Chinese -- we are like an invasion of people. We have Chinese, we have Cubans, we have British, we have French. Who is going to be the conductor? Who is going to be the maestro?
GREENFIELDBOYCEShould that not be the World Health Organization?
GOSTINThat's exactly who it should be. And that's -- and it's curious that we're actually having to ask that question. Because under their constitution, they are the coordinating global health organization of the world. They just haven't stepped up to do that.
GOSTINWell, I think they see themselves as a technical agency. Their funding has been gutted. They've lost -- their member states haven't really supported them. They actually have about one-third the budget of the CDC. And they only control one-third of an already insufficient budget.
REHMAnd what do you think about the performance of the CDC thus far, Nell?
GREENFIELDBOYCEWell, the CDC is being pulled in a lot of different directions. I mean, you know, believe it or not, ebola is not the only disease they're having to grapple with right now. There are other things they're watching in this country. And then they're also intensely involved in this outbreak overseas. They've provided aid, to example, for Nigeria, in containing their imported case of ebola. And so, you know, the agency has really been pulled in a lot of different directions, you know, with the arrival of ebola in the United States. And I think that, you know, some people have felt that there have been missteps.
GREENFIELDBOYCEI think that's perhaps one reason why you saw President Obama appointing this new czar. But I think, as a public health agency, the CDC has really been out in front in dealing with the response, both here in the U.S. and overseas.
REHMFascinating to me to learn that Cuba is going to be sending so many medical experts to help. How is this czar going to deal with members of the medical profession from Cuba?
GREENFIELDBOYCEIt's not clear to me if Ron Klain would be dealing with the coordination at that level. I mean, I believe his job is to coordinate the U.S. government's ebola response.
GOSTINI think that's right.
GREENFIELDBOYCEAnd so, I mean, medical representation from Cuba would be something that would fall to the effected countries or the World Health Organization.
GOSTINYeah, I mean, you really raised a good point. Because if we did need coordination, it's really much more in West Africa...
GOSTIN...than we do now. And that -- and on the ground -- I mean, it's even been segment -- the United States is mostly in just Liberia. And most aid is going through colonial ties, where we had those colonial ties. But you have Cuba, you have China, you have got Europeans...
GOSTIN...Russia, so who's in charge?
REHMWho's in charge, indeed. Is the NIH in charge?
LANEDefinitely not. But I would say -- I would reiterate the point that, at the local level, the local ministries of health, the local governments have to be looked to as the coordinating body within their own country. And WHO can help facilitate some of that coordination. The U.N. is present in the countries as well to help them to coordinate. But it really does become a primary responsibility of the host country.
REHMI want to go finally to Kevin in Huntington, Ind. Hi, there. You're on the air.
KEVINHi, Diane. I know you're limited on time, as usual. So I'll just -- I'll bang out some points of view and then I'll get off the line.
REHMJust one. Just one, please.
KEVINOkay, then. I guess the -- one of the things that people don't seem to mention is that in the beginning there was a lot of resistance from the locals in Africa as far as taking Western assistance. They were very wary of it, very untrustworthy of it. And I think the West is getting a lot of heat for not responding quick enough. But I think that that resistance definitely played against them. They kind of were their own enemies. And it's, you know, regrettable, but I don't think that that's being mentioned, so.
GOSTINYeah, you know, you have to put yourself in their position. They are in fragile states, post-conflict states. They have deep distrust of government. They have deep distrust of foreign intervention. And they're scared. And so it's a dual problem. One is the problem of community empowerment, which is where we began. That's so crucial. We learned that with AIDS. And the other is, there is no excuse for the delays and inadequacy of the international response. Don't lay that on the West African people. That is -- that was our failure to recognize this soon enough and do enough.
GREENFIELDBOYCEI think there was a general reaction early on that this outbreak would be like other ebola outbreaks, you know? As has been mentioned earlier, we've had a couple dozen and they've always been contained and were relatively small. Now, what you have though, is the disease has found its way into a much more populated area -- cities and places where people are moving around a lot more than they ever had before. And so I think that the international community's initial response was, Oh, we know ebola. We just didn't know ebola like it is here.
REHMNell Greenfieldboyce, Dr. Clifford Lane, Larry Gostin, Dr. Malonga Miatudila, thank you all so much. Let's hope that this virus is contained soon. Thanks for listening, all. I'm Diane Rehm.
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