In the growing public debate about Ebola, both sides are basically right. The administration is right that we are not witnessing an outbreak of Ebola and that such an outbreak is unlikely in our highly developed public-health system. But the administration’s critics are right that we are witnessing serious failures of that system that should be cause for serious alarm and major improvement.
Ideally, this unusual combination of circumstances — a genuine test of our communicable-disease containment and response system in which the danger to the public at large is actually quite small — would be an opportunity to learn some humbling lessons and make some meaningful changes. We have already learned, for instance, that in the case of a serious public-health crisis, our public officials will have a tendency to express vast overconfidence while relying on plans and procedures that demand an unrealistic level of competence from an enormous number of people in a wide variety of circumstances. The president should not have said that it was unlikely that anyone with Ebola would reach our shores, and the CDC director should not have said that essentially any hospital in America can handle Ebola — and more important, his agency should not have believed that and built its response plan on that premise.
This crucial process of learning lessons has been hampered so far by a peculiar attitude that often emerges in our politics in times of crisis and imbues our debates with the wrong approach to learning from failure. The attitude is premised on the bizarre assumption that large institutions are hyper-competent by default, so that when they fail we should seek for nefarious causes. Not only liberals (who are at least pretty consistent about making this ridiculous mistake) but also some conservatives who should know better respond with a mix of outrage and disgust to failures of government to contend effortlessly with daunting emergencies. But do we really expect (or even want) our government to have the power and ability to smooth all of life’s edges and be ready in an instant to address the consequences of, say, a major hurricane or massive oil spill or deadly disease outbreak? What do we think that government would be doing with that power the rest of the time? What we should want and expect is a government that can respond to unexpected emergencies by calling upon generally plausible prior planning, quickly building up capacity when it is needed, and learning from unavoidable early mistakes.
The most prominent of the arguments from nefarious causes has been the notion that what we’re witnessing now is the result of budget cuts—because surely an adequately funded government would also be omnicompetent. And it is especially appalling that this line of reasoning has been helped along by uncharacteristically foolish comments from NIH director Francis Collins. The director of the NIH would of course like the agency to have even more money, and he no doubt wishes his agency had directed more resources to this particular disease in the past. But his agency does have a $30 billion budget (which was doubled, in my view in a rather reckless way, in the late Clinton and early Bush years). And until this year the most severe known outbreak of Ebola had killed a total of 280 people—so it was perfectly reasonable not to treat it as a high priority in a world where, say, malaria kills 600,000 people every year, and it’s not likely that if the NIH had been given more money in recent years it would have directed it to Ebola research. This unexpected outbreak is killing thousands in Africa and could kill many more, and so we are turning our sizable resources to it. That we do not already have a vaccine is not a failure of government. It is a serious problem that our government (with its massive commitment to medical research) and our private pharmaceutical sector are actually pretty well positioned to help address now that it has arisen.
The response of our public health system is certainly another story, but there too there is simply no reason to think budgets are at issue, or that the failures we have witnessed are inexplicable. The Centers for Disease Control and Prevention is a public-health agency, and public health is an uneasy combination of two very different things: emergency disease containment and nannyist do-goodism. It is a field that exists to save us from the plague and to tell us to drink less soda. To expect the same agency, and many of the same people, to be very good at both of these missions is a lot to ask, and the CDC is much better at the second than the first. Since (thank God) we don’t experience many plague outbreaks, public health spends most of its time on that second mission: preaching the virtues of green vegetables and contraception. So the CDC is for the most part an agency engaged in a kind of low-grade, often silly social activism much of the time. When we confront a disease outbreak or similar public-health emergency, the CDC turns to the other part of its mission, and has an impressive core of experts and resources to call upon in doing so. But the turn is no simple matter, and the fact is we (thankfully) just haven’t had much experience with public-health emergencies on American soil, so the people charged with handling them haven’t had much practice here. It is not hard to imagine how all of this could lead to failures of the sort we have seen.
The question, then, is whether our public-health system, and our political decision makers, are learning lessons from their poor performance so far. It remains to be seen if senior officials from the president on down will be able to stop saying more than they know. But it does seem as though the CDC is backing off from its expectation that the competence required to deal with Ebola will be very widely available in our health-care system. They’re saying publicly that they will begin to send specialist SWAT teams to any hospital with a likely case of Ebola, but in practice they’re actually doing something better than that: they’re moving patients to a few select hospitals (so far Emory University hospital, which works closely with the CDC in Atlanta, and the NIH’s own specialty hospital in Maryland) where they know the expertise exists. That should continue. There aren’t many such hospitals, but there won’t be many patients at this point either and this should be a sustainable model for the time being.
A second lesson, which I suspect is being slowly internalized by the administration, concerns the importance of containing the disease. But the exact implications of this lesson for policy are not as clear. I agree with NR’s editors that the United States should impose a travel ban (with ample room for case-by-case exceptions) to our shores from Guinea, Liberia, and Sierra Leone, and should have done so weeks ago. The chief argument of opponents of such a ban, which the NR editorial didn’t really take up much, is that a ban would further undermine the economies of the stricken countries and so make it more likely that people, including people with Ebola, would flee those countries and make it more difficult to contain the disease. That’s a serious argument, and a serious worry that policymakers have to balance against the need to close off direct routes of potential transmission into our country. It’s particularly serious because containing Ebola and fighting it where it is must be the top priority of public-health officials. Allowing the disease to spread into densely populated parts of the world beyond the three nations now affected by it would ultimately be at least as dangerous to the United States as keeping passenger travel from those countries open at the moment. Conversations with a variety of public-health officials and journalists and others who have kept a close eye on this crisis have left me persuaded that the pursuit of this balance ultimately points to imposing a travel ban, and that it would be useful and important to do so now. And I think the administration will impose that ban. But it’s not a simple or easy call.
And all of this points to one further lesson that encompasses the rest, and which we probably haven’t really learned yet: not to underestimate this disease and this outbreak. This is really the original mistake, made by public-health officials throughout the world who worked to help the West African nations affected. It, too, was understandable. Past outbreaks of Ebola have all involved a very limited number of people in very contained zones. It was becoming apparent by the beginning of the summer that this one was different, but that’s much easier to see in retrospect than it could have been at the time. And no one really has any experience dealing with an outbreak of this particular disease that begins to grow exponentially as this one has. It is out of control in parts of West Africa, and is going to get much, much worse before it gets better.
The very nature of the debate we are now having, including the debate over the travel ban, is evidence of the fact that we probably have not yet learned not to underestimate this outbreak. We are still thinking about it in terms of a crisis in Guinea, Liberia, and Sierra Leone that could reach our shores by the various means that connect us to them. But the real danger, to us and to others, is probably far greater than that. Our greatest worry should not be that the disease could get to the United States from those West African nations but that it will get to Nigeria’s larger population centers or to, say, India or other places with massive population density and weak public-health systems, and from there will become an epidemic throughout the third world. The scale that this outbreak is now likely to reach in West Africa will make it rather difficult to prevent that, raising the risk of a far more colossal human catastrophe than the nightmare we are already witnessing and of a greater threat to the U.S. population.
That has not yet happened, and so it is likely preventable, but what the world is doing at this point in West Africa is probably not sufficient to prevent it. The travel bans imposed by many African nations have been effective (and again, I think we should have a similar one) and the increased commitment of resources and expertise by the United States will surely help, but it does seem unequal to the scope of the task.
We must work to see that our domestic public-health authorities learn lessons from the relatively modest problems they confront. But ultimately, the work of containment and prevention in West Africa, combined with intense efforts to develop treatments and vaccines, is what matters most. We are likely still making the original mistake of this crisis — still underestimating the outbreak.