Ebola czar — "This thing isn't over yet." And the next pandemic could be even worse.

Ron Klain. (Andrew H. Walker/Getty Images)

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.

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.

A health worker carries a child suspected of having Ebola in a treatment center in Paynesville, Liberia. (John Moore/Getty Images)

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.

Ebola search trends from January to December 2014. Interest peaked in the US following the Dallas, Texas case, when a Liberian man died and infected two US nurses who had been caring for him. (via Tableau)

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.

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.

Ebola cases before and during Klain's tenure. You can see that the drop in Liberia began before he took the post. (Joss Fong/Vox)

The empty Ebola treatment units in West Africa