On Friday, October 17, the White House named Ron Klain the new Ebola czar. This move followed a storm of criticism in the media, on Capitol Hill, and elsewhere. The criticism focused on the multiple mistakes made by the U.S. agencies and Texas Health Presbyterian Hospital in Dallas in the weeks since Thomas Eric Duncan, infected with Ebola, arrived in the United States on September 19. Duncan set off a disturbing train of events that included secondary infections of two nurses, Nina Pham and Amber Vinson, along with the lingering threat of additional infections.
That threat widened rapidly over the course of this past week. Dozens of health workers in Dallas remain under some form of quarantine or very close monitoring. Contact tracing revealed 300 persons who had possibly come in contact with Vinson during her Columbus Day weekend travel from Dallas to Cleveland and back. Schools were subsequently shuttered in Ohio and Texas.
Most remarkable, within a month the controversy surrounding the threat of Ebola to Americans had mushroomed into a political emergency for the Obama presidency itself, only a few tense weeks before the November 4 elections. Calls escalated for the appointment of an Ebola czar and a travel ban on persons originating in Liberia, Sierra Leone, and Guinea, the root sources of the Ebola emergency. A special measure of criticism was reserved for the Obama administration’s lead face in the U.S. response, Dr. Thomas Frieden, head of the U.S. Centers for Disease Control and Prevention (CDC). In the words of one observer, this week became full of “recriminations, political showboating… and panicked overreactions.”
There is no question that public- and private-sector leaders involved in the Ebola response, including Frieden, made serious mistakes. Frieden, Texas authorities, the President himself and others were overconfident – at times cocky – that the U.S. health system could handle infection control, contact tracing, isolation, and containment responsibilities if faced with an Ebola case. That proved drastically wrong for Texas Health Presbyterian Hospital, a 900 bed, highly respected institution that fumbled badly at several turns. Frieden and others in the administration were slow to reverse course and admit they had underestimated the need for intensive training of hospital staff, better protocols, faster dispatch of CDC ‘swat teams,’ and far more stringent oversight of those who had been exposed and possibly infected.
Politically, Frieden and other officials failed to appreciate just how swiftly a small number of Ebola cases in Dallas could ignite fear across the nation, raise the risk of panic, and begin to erode public trust. Sadly, that fear built upon Americans’ surprisingly high skepticism that their public health institutions are in fact capable of competently protecting them.
Learning The Right Lessons
Were these mistakes principally a failure of Frieden and CDC, as reflected in the disproportionate, ritualized, and largely partisan scorn heaped upon Frieden at an October 16 House subcommittee hearing? I hardly think so. (For the sake of full disclosure: In my role at Center for Strategic and International Studies (CSIS), I have over the past five years cooperated closely with Frieden on numerous global health topics. He is a friend and professional colleague.)
Far more, these mistakes are rooted in the fragmentation of the U.S. health system itself, a honeycomb of public and private interests, built upon a complicated array of federal, state, and municipal authorities. CDC’s 7,000 experts are a valuable national resource who operate in close partnership with state and municipal authorities, providing guidance and technical expertise, in the prevention and control of infectious disease outbreaks. The United States’ far-flung distributed system, over which CDC has in practice very limited real authority, is innately ill-equipped to train and ready thousands of staff in hundreds of facilities across the country to cope effectively with the sudden, unexpected arrival of Ebola — a highly lethal, alien, and scary disease that is inherently difficult to manage and control.
Moreover, recent years have not been kind to our public health resources. State and municipal governments operate with 50,000 fewer public health experts than they possessed when the severe recession hit the United States in 2008, triggering sharp cuts in budgets and staff.
The solution to our structural public health problems will not be found at CDC or any other single agency, and responsibility should not be laid at Frieden’s door. Any solution to the short term problem of better readying U.S. hospitals for Ebola has to come from the Presidency itself, with bipartisan congressional support. Perhaps that is what Klain’s appointment implies — that the White House is now taking fuller ownership of the problem. If he is to be successful, Klain must seriously strengthen high-level coordination, in the President’s name; systematically calm the public’s nerves; think carefully and concretely about how CDC and other parts of our public health system can be empowered to function better; and protect Americans as best as possible from further importation of Ebola cases, without resorting to ill-conceived travel bans.
Assessing Tom Frieden’s Role
In the wake of this week’s unsettling sturm und drang, it is a mistake, and fundamentally unfair, to vilify Frieden. It is far more appropriate to underline just how invaluable he has been — and remains — in driving forward the administration’s response in this two-front war, at home and in West Africa. In the five years that he has led CDC, he has brought a passionate insistence on evidence and better data, and boundless energy. He has raised CDC’s morale and its sense of special mission. He has rallied over 1,000 CDC staff to respond to Ebola, including 150 who agreed to deploy on the ground in West Africa. He has drawn systematically on his exceptional experience in earlier public health battles in New York City and India.
Frieden’s visit to West Africa in August was a turning point. He spoke truth to power in Monrovia, Sierra Leone, and Guinea, where leaders were still deep in denial. Upon return to Washington, he spoke forcefully to the President of the strategic threat, in security and ethical terms, of the burgeoning Ebola epidemic, and the imperative of strong U.S. leadership, including the use of the U.S. military. Those messages were not welcome in many senior quarters of the White House and cabinet departments, but Frieden delivered them, undeterred.
As the U.S. mobilization in West Africa began in earnest, following President Obama’s announcement at CDC headquarters on September 16, Frieden was the lead personality encouraging an unusual collaboration across U.S. agencies, civilian and military, and encompassing vitally important non-governmental groups. Though he may have erred on occasion, his statements to the American public were overwhelmingly lucid, consistent, powerful, and closely echoed by the President and other senior officials. He has been the most forceful voice arguing the case that travel bans are dangerous, on public health, ethical, and political grounds.
Now, and into the future, we will continue to rely on Doctor Frieden and other gifted, competent, passionate, and committed American public health leaders. Frieden will remain essential to advancing U.S. national interests, at home and abroad. He like all of us will make human mistakes, and he will struggle with the deficiencies of our system. What we cannot possibly afford as a country is to sacrifice him to our fears and differences.