POLITICS
10/22/2014 06:00 pm ET Updated Oct 22, 2014

The Ebola Outbreak And The Void Left By The Absence Of Government

WASHINGTON -- Few epidemiologists are as publicly lauded as Don Francis. The longtime public health worker has toiled on multiple continents in efforts to eradicate some of the world's deadliest diseases, from smallpox in South Asia to cholera in Nigeria to hepatitis B in the United States and China.

Most famously, Francis worked to track and identify AIDS in the 1980s as an official with the Centers for Disease Control and Prevention. The 1993 movie "And The Band Played On" chronicled that chapter of his life, with actor Matthew Modine playing Francis in one of the film’s leading roles.

But before all of that, Francis was a member of the World Health Organization team that was dispatched to Africa to investigate the first outbreak of the Ebola virus. That was in 1976. Thirty-eight years later, he is crestfallen to see the virus spread in West Africa to the extent it has.

In an interview with The Huffington Post, Francis compared the epidemic to a forest fire, in which the flames weren't hidden "in the roots of the trees," but rather, "blazing at the top of the forest." It was all very preventable, he added. Certainly, the world community shouldn't have been caught off guard. "This outbreak should have had major international effort at least six months ago," he said.

Having witnessed public health crises at their most severe levels, Francis said he wasn't necessarily surprised by the degree of fear that Ebola has provoked within the United States. When a disease has a short incubation period like Ebola, he said, "people do panic." And the fact that virus was still relatively new to the public consciousness means that people aren't familiar with its characteristics.

Still, he cautioned, perspective was important.

"It is interesting that we have a much more dangerous virus with HIV circulating around, with millions of people, and we do the opposite of panic," said Francis. "We tend to say, ‘Oh well, we will take our chances.'"

Perhaps Francis' most pointed argument, however, had to do with the role of international institutions and government in crises like this. During a roughly 30-minute conversation, he argued repeatedly that a link in the chain of the international health care system had broken. Somewhere, he suggested, a World Health Organization official was probably screaming, trying to get the world's attention to the burgeoning medical crisis at hand. "We have Ebola. We still have Ebola. We still have Ebola here," Francis imagined someone saying. The lingering question was why no one listened.

And Francis added that the Ebola outbreak also underscores the need for strong government institutions, if for no other reason than because no other entity can play its role.

"If nothing, we learned that all this anti-government stuff -- that we don’t need government infrastructure -- is what causes this," said Francis. "If you don’t have a good CDC at the federal level in the United States, and state-level health departments or local-level health departments, this is what happens."

Below is an edited transcript of our interview.

What have been your thoughts and impressions watching this Ebola outbreak?
If you think about what’s happened in West Africa, the situation is very different than previous Ebola outbreaks. This one has, for a variety of reasons, become huge. I was just looking the other day at all the previous outbreaks in the last 20 years. If you add up all the cases of those outbreaks, which is one about every other year or so, it is about a third ... compared to what this one year has seen.

What happens in this disease is that if it is not taken care of early in rural areas, it starts getting out of hand, especially if you have societies that have been decimated by civil wars and political unrest and economic issues, which these three countries [Liberia, Sierra Leone and Guinea] clearly have. It is a bit like having a fire in your neighborhood where the fire department starts getting overwhelmed and doesn’t have the structure to respond.

Was the main problem in West Africa a problem of medical and political infrastructure?
Yes. I hate to say this, but in those areas where we’ve had outbreaks before -- and even though they’ve had all the challenges of being in Central Africa and Eastern Africa -- once they had their first or second outbreak, they get quite good at responding. Here you have virgin territory in West Africa. This is new.

How worried should we be about burnout among health care workers or workers declining to go to West Africa?
I think you see that for the local folks. But at least you see the opposite now, with the massive outpouring of literally hundreds of folks going over from international groups to take care of them, which is good. It is unfortunate that they can’t do it locally, because then you’ve got all the issues of your hospital structures. You’re going to get these essentially military pop-up hospitals being built. All this takes a huge effort.

Is one of the problems that the local population distrusts foreign workers?
I don’t know, to be honest. But that usually is relatively superficial. If there is a decent structure there, you find they will do their best for their family members to get them in. You always hear that kind of a thing. But in all the work I’ve done around the world, ultimately a trusting relationship gets built with the local folks.

What is the nightmare scenario?
The fact that it has got, really, into three countries majorly, the nightmare would be that lots of people will die. But look, even if you go to the cases that have come to the United States or Nigeria or wherever, people with experience in isolation have not transmitted very much. If they are not identified then you can get in trouble. But if they are identified with Ebola, than people are very careful with it because it is remarkably easy to transmit in a health care setting.

Has the panic here been overwrought?
I’m not sure it is a panic. But it is interesting that we have a much more dangerous virus with HIV circulating around, with millions of people, and we do the opposite of panic. We tend to say, ‘Oh well, we will take our chances.' And that’s true, interestingly, of a long incubation phenomenon compared to short incubation, where people do panic. Short incubation is much easier to deal with because you can see it in front of you -- whereas HIV, you’re infectious for a decade.

Part of it is we have lived with HIV for several decades whereas Ebola is still new to us.
Absolutely. The newness is always [a factor], and appropriately so. People aren’t familiar with it. I mean, those of us who have worked on it for years certainly are familiar with it. We don’t get so excited. But for the general public and elsewhere in the world, it is appropriate that it's in the news and you’re doing these stories and such. But I think, for Americans, as far as dangerous viruses around, HIV is a much greater threat. Look at the tens of thousands of people who get infected a year here.

Why hasn’t there been a breakthrough on a vaccine and therapy?
I think it is very simple. Unless it is a government or military or some not-for-profit organization that would drive it through, [it won't get done]. Because it is expensive to make vaccines and therapies, especially for these bugs where you work in a laboratory where it is very, very dangerous. And so, frankly, the public market or private market has been relatively small until this one.

Now that the U.S. soldiers are going over there, will that change?
Yes. You get the U.S. Army working on this and they’ll do a fine job of getting a vaccine. It is a bit of a challenge, mind you, because you really are stuck with a primate study. Because if this outbreak is taken care of relatively rapidly by the time you get a candidate vaccine, there is going to be no way to test it out in the real world.

You don’t think we can push it and do a human clinical trial?
You could. And by the time you get it hopefully this outbreak will be gone and then you’ll end up having another little outbreak [in the future, where this vaccine could be used].

Should we have been so caught off guard?
The answer is no. This outbreak should have had major international effort at least six months ago. And I don’t know all the reasons why it didn’t. It is difficult to get these countries that have real infrastructural challenges. It is hard to get in there and find out all this early on so that teams can go in. But this should have been -- literally, there should have been large international efforts if people knew about this. And we will find out in the coming months who knew about this and who didn’t do anything or who tried but couldn’t and why did that happen.

What are your thoughts on a travel ban?
The reason you don’t do one is because they don’t work. You would love to do that. Now, you can have travel bans within the outbreak where you keep people who want to get out, they have to at least show they haven’t had exposure for weeks. Unfortunately, you look at the fellow who came to the United States. He actually admitted he had exposure and was still sent home from the hospital. That is not a travel ban issue, that is having the emergency room people in the hospital know what’s going on so that they don’t send people home.

The devil’s advocate claim would be that none of that would have happened if Thomas Duncan never came from Liberia in the first place.
Well, that’s nice. But there are probably half a dozen other people who came in who are doing important business or personal things from Liberia. You just can’t turn that off. The cost of things like that is huge. You’ll end up causing more problems than helping with Ebola.

How do you see this playing out?
Now you see all these teams going in to work on it. And hopefully it will be large, and enough people where you actually can get the appropriate isolation and stop transmission. We will know in the next month how effective that is. So let's take a look at the epidemic curve now, it is going up, up, up. Hopefully in the next month or two we will be able to see a shoulder on that, and then you know you’re doing the right thing. If it continues to go up, we have got to reassess.

Is part of the problem a lack of good intelligence on the ground in Liberia?
Usually, it is the lack of personnel to get out there and do it. If nothing, we learned that all this anti-government stuff -- that we don’t need government infrastructure -- is what causes this. If you don’t have a good CDC at the federal level in the United States, and state-level health departments or local-level health departments, this is what happens. And you get these people who don’t want government. They don’t want government getting into the system in the United States. But there is no private sector filling of that if you take it away.

Were you surprised that the outbreak that happened was Ebola?
I was surprised that it went this far. We always have periodic outbreaks of diseases but you don’t have ones that are such high mortalities as this. It was not until it gets to be a huge fire that the local folks said, yes, please bring in all the force. It’s too bad it takes that much time.

It is proving to be a lot more costly dealing with it later than earlier.
Oh, if this were 200 cases in two rural areas that got contact with bats, then you would do just what the other outbreaks had -- which is, you’d stop it at 200-300 cases, and maybe one export to the capital city or another city. But you’d catch those.

So why didn’t that happen here?
That’s the story, to be honest. I would love to get that. That investigation will ultimately happen and fingers will be pointed. I’m sure there are plenty of WHO notes on this: ‘We have Ebola. We still have Ebola. We still have Ebola here.’ I would hope that the WHO person on site was screaming. But usually Geneva will respond very quickly to Ebola. That will be very interesting to see why this was left ... because if you look at the curve, it was, gosh, not until ten months or 11 months into this outbreak that the epidemic curve started rising rapidly. And now, if you look at that map, you see these large outbreaks in half a dozen to a dozen sites around the country. Gee whiz. That’s really hard to deal with.

Should Americans be nervous about this?
No. You’ll see a few cases like we’ve seen already. And generally there will probably not be too many secondary cases like it. We will not have these giant outbreaks. You go to these villages -- there is no gloves, no gowns, nothing to protect people. It is very different. Now you can bet if you have a fever coming from West Africa, we will have gloves and gowns around, even though they might have influenza.

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