Klain, a lawyer and well-respected Washington insider, had done the unprecedented, serving as chief of staff under two separate vice presidents (Joe Biden and Al Gore). But the appointment drew criticism, not only from Republicans but also from those in the medical and public-health communities who wondered why a political operative was helming the White House response to a major infectious-disease outbreak.
Yet Klain's tenure was far from the disaster many predicted. Ebola cases declined in the United States and Liberia, the two countries Klain was focused on. (France and the UK took the lead on the Ebola response in Guinea and Sierra Leone, respectively.)
By mid-February 2015, with the number of US cases at zero, Klain was able to leave the post to return to his private sector job in Washington. But that still leaves plenty of questions: was having an Ebola czar actually helpful — or did the disease recede on its own? Did the United States learn anything from the pandemic? Are we any better prepared for the next one? To find out, I talked to Klain by phone about his experience — and why he's still worried about the next outbreak.
Why the politics of Ebola are trickier than the disease
Julia Belluz: The day after you started the job in October, we had an Ebola case in New York City with Dr. Craig Spencer. News broke that he had been running around the city in the days before — jogging and bowling. What was going through your mind?
Ron Klain: Everyone was very concerned. This is the nation’s most populous city. We want to make sure everything goes well. I mostly focused on getting a CDC [Centers of Disease Control and Prevention] team into Bellevue Hospital [where Spencer was diagnosed] to help them understand what would be required to take care of an Ebola patient, and working with the city on doing the contact tracing, doing the things we needed to do to have some confidence we would quickly find and isolate anyone else who may have been exposed. Obviously, you worry, too.
Julia Belluz: Shortly after that, public panic seemed to reach a new high: there was the debacle with the Ebola nurse in New Jersey, and Governors Chris Christie and Andrew Cuomo, among others, called for mandatory quarantines of returning health workers. What did you make of these overreactions?
Ron Klain: There was a lot of uncertainty at the time. And it was unfortunate that we got away from science-based decision making. We put out our own federal policy and tried to persuade states to follow it. Thirty-eight of the 50 states did. But it was obviously a time of a great deal of anxiety and it was unfortunate.
Julia Belluz: It was also the midterm elections, and it seemed the politicians were playing into public anxiety for political reasons.
Ron Klain: I don’t agree with that. I don’t want to characterize their motives or their decision-making. There was a great deal of public anxiety. We put forth a science-based policy and most of the states followed it, and some states didn’t. I’m not going to judge why people did or didn’t do that.
Julia Belluz: Were you surprised that Ebola became such a hot-button issue, with people taking shots at the science?
Ron Klain: No. Dr. Anthony Fauci [director of the National Institute of Allergy and Infectious Diseases], who was one of our top medical advisors throughout this effort reminded folks of some of the initial anxieties and misconceptions around the AIDS crisis when it first broke, and some of the overwrought and misplaced concerns then. New diseases, new threats, they make people anxious. We knew if we made the right choices, put the right policies in place, and could prove they work over time, we could prevail over that. You have to recognize, as Dr. Fauci explains, that people are nervous and anxious about new things and I think that was what was going on here.
Julia Belluz: As we were freaking out about Ebola here, people like Dr. Fauci and Dr. Tom Frieden (the head of the CDC) were reminding us that the real threat of Ebola was in West Africa and that resources and attention should be diverted there. How difficult was it to get that message across in America?
Ron Klain: I think those two things go hand in hand. We were able to persuade the Congress when they approved the president’s emergency funding request that the best way to protect the American people from Ebola here was to try to extinguish it in West Africa. So the concern the American people had about Ebola actually helped provide the basis to persuade the Congress to fund the efforts we were launching in West Africa to get the epidemic under control.
Why we're not ready for the next pandemic
Julia Belluz: You did not come from a medical background when you were suddenly at the helm of the White House’s response to this global epidemic. As a health outsider, what did you find most surprising?
Ron Klain: The most surprising and disappointing thing is the lack of global infrastructure to deal with this sort of thing. People have some sense, maybe from the movies, that in the event you have an outbreak there are some pre-existing global disease fighters that drop in with parachutes and helicopters and go on the attack. And there just isn’t. The WHO [World Health Organization] clearly admitted they missed the boat on this. President Obama had to make the hard and bold decision to get the military into Liberia to build infrastructure, do training, build Ebola treatment units. Our allies — the UK in Sierra Leone and France in Guinea — had to help. That’s not really a scalable or sustainable strategy for dealing with epidemics like this in the future. It can’t be our responsibility in the US to do this every time.
Julia Belluz: Having seen that we are ill-prepared to cope with pandemics, what most worries you about the future outbreaks we will surely have?
Ron Klain: As horrible as Ebola was — and still is — you can imagine the next scenario being much worse. These three countries [Liberia, Sierra Leone, and Guinea] are relatively small in population. The largest city in any of the three is Conakry with a population of about 1 million. If you had this scenario in one of the world’s largest cities, with 20 or 30 million people, it would be very different. Ebola is also very hard to transmit. It’s not airborne. You can imagine an epidemic of a highly deadly flu where the disease would be transmitted much more quickly.
The next epidemic could break out in a country where US troops wouldn’t be welcome. Liberia is a country that we have a great relationship with — our troops were welcomed as heroes in Liberia. But what if the next outbreak like this is in Pakistan or in Indonesia — or pick any other country — where sending in the 101st airborne is not an option? We need a global squad, an international unit, that can do what the US and the British military did in this case. So it’s hard to know what the next threat like this we will face could be, but it could be in a place where it’s much harder to fight the disease, with a higher rapidity of transmission, and a much lower ability to detect and isolate it.
Julia Belluz: Do you see any action on the horizon to suggest that we are learning that lesson?
Ron Klain: At the last G7 meeting last October, the Germans put forward an idea for what was called a "White Helmet Battalion." This would be a collection of troops from various G7 countries that would come in as rapidly deployed medics. It was kicked around, but not resolved. It’s something I’m hoping the G7 will take up in June when they meet again. With globalization, the ability of a disease to spread quickly is higher and the world needs to respond quickly to get epidemics under control.
Julia Belluz: What’s the biggest barrier to getting better prepared for the next pandemic?
Ron Klain: The barrier is we go through this cycle where you have an epidemic, everyone gets focused on it and says let’s do something about it. It gets under control, attention fades, we’re on to the next thing. Keeping the focus and urgency behind it is the hardest thing. In October, when the G7 last met, everyone was talking about Ebola. When they next meet in June, it’s not clear to me Ebola is going to be on anyone’s front burner.
Julia Belluz: Clearly the timelines of global health and short-termism of politics are not aligned, and I don’t feel very optimistic that they will ever be.
Ron Klain: I think the only way to deal with it is for people who are in the field to continue to try to press world leaders and institutions to do some planning in advance and to put the resources together in advance. Because this constant pattern of responding to these things after the fact is going to result in a disaster, a horrible disaster well beyond Ebola at some point in time in the future. There eventually will be a fast-spreading highly lethal flu that will get out of control and the world won’t have the time we had on Ebola to try to bring it back under control. We’re either going to get that message before it comes or learn after.
Julia Belluz: Who should the public look to for accountability on this? Who should take steps to improve our pandemic responses?
Ron Klain: The WHO needs reform. This is their job, and they’ve admitted they botched it this time and that has got to get fixed. The leader in our government is Dr. Tom Frieden, who serves on the executive board. President Obama put forward an aggressive global health security agenda, about $800 million that was funded inside the Ebola emergency funding request Congress approved in December. That will start to help build more global health security surveillance around the world and build in the kinds of epidemiological capacity in countries to make sure we’re finding these outbreaks before they get out of control.
What an ‘Ebola czar' actually does
Julia Belluz: Because of your lack of medical background, there was a lot of criticism that this was a purely political appointment, and there was some question about what you actually did during your term. How do you respond to that?
Ron Klain: As far as my appointment goes, we had a lot of great medical experts. We needed someone to coordinate the 14 federal agencies working on this. It wasn’t my job to be a medical expert. As far as what our team did: When I started we had three hospitals in America to treat Ebola; we now have 50. We had just a dozen labs to test for Ebola; we now have 45. We never before had a system to monitor returnees from a country that might have epidemic risk, and we built from scratch that system.
On the international side, we got our Ebola treatment units built in West Africa. We opened, operated and brought home two full rotations of teams who worked in the Monrovia medical unit. We trained thousands of health-care workers in West Africa now. We have worked with the African Union to get several thousand health-care workers in those countries. The US is better prepared and protected than it has ever been. We got the disease burden down from hundreds of cases a week in October to just two last week in Liberia. That’s obviously a lot of progress over the past four months. I was pleased to play a part in that.
The empty Ebola treatment units in West Africa
Julia Belluz: There have also been criticisms that the US responded too slowly, that you benefited from a drop in cases that was already happening in Liberia before you were appointed, and that the holding centers and treatment units came too late and now stand empty.
Ron Klain: The Ebola treatment units, the fact that they’re empty is a good thing. That’s the idea: you want them to be empty. The alternative is them being full, and that’s bad. I’m not going to apologize for the fact that we have a bunch of empty Ebola treatment units. That’s what progress looks like.
Julia Belluz: But isn’t it wasteful to have built the treatment units for nothing? Can they be used for other purposes?
Ron Klain: This thing isn’t over yet. Even though we got cases down in Liberia, Ebola could come back so building the Ebola treatment units for future outbreaks of Ebola ostensibly is a very useful thing. When this outbreak happened, there wasn’t the isolation capacity.
Now there is. That said, some of them will be used for other purposes, other kinds of health screening, potentially to do vaccination. They aren’t hospitals — they were relatively inexpensive facilities to isolate and provide treatment to people.
Julia Belluz: The other preparations in the US and globally for Ebola, can they be applied to other infectious diseases now that Ebola is not as big a threat?
Ron Klain: Here in America, there are 50 Ebola treatment centers that have the capacity to treat other highly infectious and dangerous diseases. The ability to isolate patients — the protective gear for medical teams to safely treat patients — that will have usefulness not just for Ebola but other infectious diseases. This monitoring system we set up to identify people coming back from West Africa sets a precedent and we’ll be able to use it in the future. That’s good capacity for America going forward.
Globally, we’ve significantly increased capacity in these three countries to test for other infectious diseases. We’re leaving behind lab equipment and trained health-care workers to work in labs and what not that will increase their capacity to deal with other outbreaks in the future. We need to implement President Obama’s global health security initiative. We need to do that around the world, to make sure those kinds of capacities exist in other places, before future outbreaks.
The dangers of media hype
Julia Belluz: How much of this was media hype and what do you think was lost in the hype and anxiety?
Ron Klain: You have got to separate coverage from public anxiety. It was a new and scary threat, and so it got covered that way here in the US. And that’s understandable. If you look at a lot of the coverage, some of it tended to seek out the people with the most sensational views. I thought that the folks who were medical reporters did great work and were constantly putting out science-based points of view. But it’s not surprising that people reacted with anxiety.
One thing that continues to be a problem here in the US is that we continue to have a lot of fear and anxiety — and that really impacts the people who go fight the disease in West Africa. They are heroes, they are doing hard work, they don’t pose a threat to us, they aren’t dangerous to us.
One of the saddest things during my tenure was that we had a doctor who lived here in America, a green card holder, Dr. Martin Salia, who ultimately died from Ebola. He contracted Ebola in Sierra Leone while running a non-Ebola hospital. He had performed heart surgery on someone, got Ebola from treating a patient who he didn’t think had Ebola but who did. So understanding the risk to health-care workers, not in America but in West Africa where they’re doing this work, and making sure they’re protecting themselves, is important.
Life after Ebola
Julia Belluz: We’ve been hearing that beyond directly harming and killing people, the Ebola virus has indirectly affected the health of people in West Africa because many have not be getting their routine care. Was that a concern at the White House?
Ron Klain: The lack of vaccinations and lack of prenatal care: there’s no question that this remains a real crisis in all three of the most-affected countries. They all had very, very low levels of doctors before this epidemic happened, and they all suffered devastating losses of those doctors because of Ebola. That’s not a problem you’re going to fix overnight. It’ll be years before the health-care systems in these countries are back up to the low level of staffing they had before this started. That’s a very serious problem.
Julia Belluz: What you’re referring to are problems of poverty. These are difficult to deal with through health-related responses.
Ron Klain: Ebola is obviously a very, very dangerous disease, a fatal disease, but it’s not an accident that of the eight people in America who were promptly identified and treated, all eight survived. While the recovery rate in West Africa has improved over the course of this epidemic, and now it’s probably about 50 percent of people who get into treatment are saved, there’s a big difference between 50 percent and 100 percent, and so obviously it’s the resources and facilities and medical capacity that makes a big difference, no question about it.
Julia Belluz: Ebola, while under control, is still being transmitted in the three most-affected countries, and cases have actually been on the rise again in Sierra Leone. What stands between now and zero cases?
Ron Klain: I am confident we will get to zero but it will take time, and there will be setbacks along the way. It’s important to keep in mind that where we are today is very different from where we were four months ago. We had 100 cases of Ebola in all three countries in Africa last week combined. That number was well over 1,000 four months ago so you have to start with fact that it’s a lot better than it was. And the capacity to deal with this is a lot better than it was. So we do have Ebola treatment units to send patients when they are found now. There are testing labs and trained workers. We made a lot of progress in the fight and we have tools on the ground to finish the job. That said, getting from low to zero is the hardest part. You have to get all the way to zero. That’s going to take time: less time in Liberia but certainly several more months in Sierra Leone and Guinea.
Julia Belluz: What’s life like for you after being Ebola czar?
Ron Klain: I went back to my previous job as general counsel at venture capital firm in Washington. So life is a lot less stressful than it was when I was dealing with Ebola. It was enormously humbling work and it’s an experience that’ll always be with me.
This interview has been edited for length and clarity.