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“This will get worse before it gets better”

How America's top public health expert sees the Ebola crisis

Dr. Thomas Frieden is the director of the Centers for Disease Control and Prevention. That makes him one of the people in charge of America’s response to the Ebolaoutbreak — both how to slow the disease’s rampage in Africa, and how to stop it from spreading to the United States. We spoke on Friday about how Ebola has overwhelmed attempts to control it, why the CDC believes Ebola could infect up to 1.4 million people by January, and why even rich countries need to worry about poor health-care systems. A lightly edited transcript of our conversation follows.

Ezra Klein: It’s felt to me like over the course of this outbreak it’s gone from public-health experts saying, "Don’t worry, Ebola isn’t very contagious, and modern health systems can easily contain it," to "Oh shit, we are in an infectious disease firestorm." What’s happened?

Thomas Frieden: I think both of those things are true. An exponential increase in cases like this is truly unprecedented. But as far as we know, the virus has not changed.

What’s changed is the context in which we’re fighting it. It’s in urban areas for the first time. The tipping point was when there were more patients than isolation beds. At that point, it began to spiral out of control and enter an exponential increasing phase. So I think people totally get that the critical characteristic of our response now has to be speed. President Obama put it exactly right at the UN. He said that we have to act, even if imperfectly. An adequate action today is better than a great action in a week.

Ezra Klein: You hear stories about health workers in Guinea walking off the job because they don’t have the gloves necessary to treat patients safely. Why is it that we can’t get enough gloves and suits to the workers who need them?

Thomas Frieden: The quantity of the need is mind-boggling. Here’s an example: to pick up one body you might need nine full changes of PPE [personal protective equipment]. Four for the people to put the corpse onto the truck. One for the person to spray them down so they don’t get infected. And then again four to take them off the truck. The need is astronomical, and it’s increasing. I heard someone say in a meeting that we’re increasing our efforts arithmetically and the virus is increasing exponentially.

We had two exported Ebola cases, one to Senegal and one to Nigeria, within the first few thousand cases. Now we’re getting a couple of thousand cases a week. How many exported cases are we going to have? The World Health Organization has already raised the specter of the disease becoming endemic. That would mean it’s around and a constant threat. Anytime anyone comes to our country from a place where they’ve had Ebola, we’d have to see if they had a fever, and if they did, we would have to treat them as if they did have Ebola until we ruled it out. This is an amazingly fast-moving, serious problem.

But let me tell you what the CDC is doing. Take Nigeria. We put 10 CDC staff into Lagos with 48 hours. We redeployed 40 of our top polio eradication staff into Lagos in a couple of days. The team in Lagos was run by a Nigerian with experience in running emergency operation centers. They identified more than 850 contacts. They’ve identified 19 secondary cases. They’ve done 19,000 home visits to measure for temperature. One patient fled to Port Harcourt and ended up infecting and killing his doctor and his doctor’s wife. That created another cluster. So we’re not quite out of the woods there. But we were a hair’s breadth away from having Ebola all over Nigeria.

Ezra Klein: One thing that has been striking here is the degree to which weak health-care systems in poor countries can be a real threat to rich countries. How should we think about that?

Thomas Frieden: Yes. We are all at risk. But it’s not health systems so much as public-health systems. Do you have a system in place to find when there’s a cluster of unexpected illness, whether it’s Ebola or MERS or SARS or the next HIV? Do you have a system in place to get the lab tests done? Do you have trained disease investigators?

This is not going to come by creating some great global entity to do all this for us. We need to build the capacity of countries to find, stop, and prevent global health crises. We are all vulnerable to the weakest link in the chain. And it is not that expensive to strengthen those links. But it does mean you need to train public-health workers. It does mean you need a lab-reporting network. It means you have more than a public-health system you pull out in case of emergencies. It means you have one you’re using every day to fight disease, and so you can scale it up in the event of an emergency.

Ezra Klein: The CDC recently released a report suggesting we could see as many as 1.4 million Ebola cases by January. What needs to happen to prevent that scenario?

Thomas Frieden: I don’t think we’ll see that number of cases. But I think it’s important to know that we could. Look at figure 10. It’s worth contemplating that figure for awhile. The president said at the UN that the slope of the curve is within our control. He totally got what we were showing.

CDC model Ebola


The point he gets is that action now makes an enormous difference. So first, we have to make burial safe. There are still bodies being left overnight on the street. There are still burial services happening all over where people are going to die because they’re mourning in a way that’s unsafe. The other stream leading to transmission is unsafe caregiving, both in hospitals and in homes. What we have to do is urgently scale up safer caregiving and safer burials. If we do this we could cut it off.

This will get worse before it gets better. But we can turn it around. Look at what public health has done. We have vaccinated a billion kids against polio. We are treating 10 million people with antiretroviral treatment for HIV. We eradicated smallpox — including an effort that requires 100,000 workers for six days every three months in India going to every house in the country. We can do this. These are not huge countries. Five or ten or twenty thousand people to care for well is a lot of people, but when you put it in that context, it’s doable. But if we don’t do it immediately, it goes from 10,000 to 100,000. Every month delay triples the size of the epidemic. Triples. The urgency is beyond being able to describe.


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