← Bulwark Takes
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Dr. Craig Spencer
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- [00:45]
Jonathan Cohen
Hey everybody. Welcome back to Bulwark Takes. I am Jonathan Cohen. We are here to talk about this Ebola outbreak. What's going on, why so many people are worried about it, why what the US Is doing in response or not doing in response. Our guest today is Craig Spencer. He is an emergency medicine physician. He is also a professor of public health at Brown University. If he looks familiar, if his name sounds familiar, that's because he was in the headlines in 2014. He was part of a Doctors Without Borders mission to go treat people in guinea during that year's 2014 Big, Historic West African Ebola outbreak. He came back to the United States, contracted the disease. Thankfully for all of us, he's here. He survived. He's here to kind of walk us through everything from Ebola 101, what is this disease? To looking at what the United States is doing is not doing, and so on. Dr. Spencer, really, thanks. I know everyone wants a piece of you. I'm so glad you are here with us today.
- [01:43]
Dr. Craig Spencer
Yeah. Thanks for making time. I'm looking forward to chatting.
- [01:45]
Jonathan Cohen
Yeah. Yeah. So let's start high level here for people just tuning into this Ebola. What is it? Where does it come from? How does it spread?
- [01:52]
Dr. Craig Spencer
That's a great question because last night I was Talking to my 5 year old in bed and he had heard me on NPR yesterday morning and he was like, dad, there's this disease. I don't know what it is. Where does it come from? So I had to explain to him, ebola, bad disease, high mortality, there are multiple different strains of it. So people might be hearing that there's this thing called bundebugio. Hard to spell, hard to say.
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Jonathan Cohen
Yeah. How do you say it One more time, how do you say it?
- [02:20]
Dr. Craig Spencer
Bundabudjo. Bundabudjo. Yeah, exactly.
- [02:24]
Jonathan Cohen
Keep going.
- [02:26]
Dr. Craig Spencer
So there are multiple different strains. The strain that we're dealing with now kind of looks the same. Clinically if you're a provider or you're a patient, it's gonna look the same or feel the same, but it's different than the strain that caused the 2014 outbreak and different from the strains that primarily cause most outbreaks. It's only the third time that we've seen a bull outbreak from Bundibugya. It is a virus that is transmitted. I've been calling it a disease of compassion because it's primarily transmitted between people taking care of other people when they're really sick. So think of a mom taking care of their kid, or a family member burying one of their loved ones who recently died, or a healthcare worker that might be taking care of someone and the maximum part of their contagiousness. We think that the reservoir for this virus is a fruit bat, meaning that the fruit bats can carry this virus doesn't get them sick, but maybe if they chew on a piece of fruit that you later eat, or if you come in contact with their droppings, you can be affected. My son told me yesterday that if that's the case, that I probably shouldn't eat any fruit after a bat has eaten it. And I told him that's probably a good set of life advice, whether you're in Congo or in Colombia. And so, you know, we've known about ebola outbreaks for 50 years. There have been dozens of them. In reality, there have probably been many, many, many, many more that we just haven't detected because the majority of the time, they end up fizzling out pretty quickly.
- [04:05]
Jonathan Cohen
So this one's getting. I mean, we've had a number of outbreaks that did make the news since 2014. This one, I'm definitely detecting more concern. As much as I've heard about any of the others. I mean, the others also generated concern. But what is it about this particular outbreak that has a lot alarmed who declaring it a WHO declaring it a crisis of international attention? What's going on?
- [04:26]
Dr. Craig Spencer
I was concerned as soon as I saw the announcement on Friday that this was going to be remarkably bad. And I know that as someone that's followed these outbreaks for the past decade, the thing that concerned me the most was that the case numbers when this was first reported was much bigger than most outbreaks when they end. And so even within the first day of this Ebola outbreak, it had already become one of the top 10 largest ever. Within the first 24 to 48 hours, it had joined the top five. And right now, I think it's probably the third largest Ebola outbreak ever. And again, we didn't know about this last Thursday. That's exactly why within a day we saw the World Health Organization come out and declare a public health emergency of international concern, which is essentially a global call to arms to say, hey, this is bad. There's potential for regional and international spread. We need resources to manage this now because otherwise this is definitely going to get much worse. We also saw on that first day cases not just in the Congo, but cases hundreds of kilometers away in Kampala, the capital of Uganda. This is concerning for so many reasons. One, we saw cases that were unrelated. So think about two cases of a disease in a place that don't appear to be connected to each other. That's worrisome because that means they're coming from some source somewhere, maybe multiple different sources. You don't know where that source is. Could it be back in the Congo? Could it be somewhere else? Could it be somewhere in Kampala itself? We're now five, six days in. We don't have that much more clarity on exactly how bad this is. But what I can say with confidence is that case numbers are undoubtedly a lot higher than what is being reported. And this has almost certainly been going on a lot longer than what was initially thought, which was a case sometime towards the end of April on a healthcare worker.
- [06:25]
Jonathan Cohen
Yeah. So let's talk for a second about possible impact in Africa. And then we're going to broaden the lens. What are we looking at here? Without an adequate response? What does this look like in the continent?
- [06:35]
Dr. Craig Spencer
There was an outbreak of Ebola in 2018-2020 in exactly the same area, same region. There were thousands of cases. It was the second largest Ebola outbreak. It was super complicated, particularly because this is a tough place to work. I've worked in Eastern Congo. Road infrastructure is really, really bad. It can take a whole day to go 50km. Health infrastructure is incredibly limited. You also have conflict. So M23 other groups.
- [07:06]
Jonathan Cohen
That's like a Rwanda backed militia rebel.
- [07:09]
Dr. Craig Spencer
Yeah, and there's. Exactly. So there's, there's multiple different groups. We don't need to go back to 1994 and, and the genocide and the aftermath. But there have been. For decades, there's been instability and conflict along the border with Uganda, with Rwanda. And this has created instability in the region for healthcare, but also just on a daily basis for folks that are living there. There are refugee camps. What we have with Ebola is an acute humanitarian crisis on top of a chronic humanitarian crisis. All of that layered on top of the fact that within the Past year, the US and other countries have pulled out a lot of their humanitarian support, including support for places like Eastern Congo. Yeah. Yeah.
- [07:52]
Jonathan Cohen
Well, we're going to get to that in a second. Just before we get to that, for Americans watching this, they want to know, do I need to, like, start hiding in my house or whatever? I mean, I've heard most people I've talked to have said they are not at the moment certainly concerned of this becoming a worldwide pandemic. As things stand, what's an appropriate way to think about the level of concern? What should people be thinking in their personal lives?
- [08:14]
Dr. Craig Spencer
I think it's important for us all to be concerned. This is definitely going to get much worse. I don't have a whole host of optimism for how this unfurls in the next couple weeks and in months. Quite frankly, do I think this is going to become the next global pandemic? No, Ebola is not an efficient transmitter. Like I said, it's a disease of compassion in that it's the people who care for others that get infected. But what you actually need to prevent and stop transmission is not all that complicated. Washing your hands, gloves. Ideally, when you're taking care of people, you're in full protective equipment. But even just using gloves, washing your hands, basic sanitation can slash the likelihood of transmission pretty high. This is not airborne. This is not a respiratory virus. This requires direction, direct contact. And so I'm not concerned about this spreading far afield and causing hundreds or thousands of cases outside of Congo. That being said, I would absolutely not be surprised if we end up hearing about cases not only a lot more in the region, but also cases in other countries around the continent, in Europe, maybe in the US and in other places. That would not be surprising to me at all.
- [09:29]
Jonathan Cohen
I do want to get to the US Response, but just before we do that, you are one of the. You have a relatively unique experience of having both had Ebola and treated Ebola just for people to understand what it's like to go through this. I mean, what does this disease do to people and for healthcare workers? What's it like to try to treat it?
- [09:47]
Dr. Craig Spencer
I mean, what the disease does, unfortunately, is it kills half, if not more of the people that it infects. For the Zaire strain, the one that I was infected with, the one that's caused the majority of outbreaks, we have treatments and we have vaccines. Those created in the aftermath of the 2014 outbreak, those don't appear to work well for this strain, the Bendibugio strain. And we don't have vaccines or treatments. So that means we're gonna rely on good clinical care, good public health, end of contact tracing. The disease is pretty horrific in that it goes from kind of a non specific viral thing, you know, fever, headache, malaise, et cetera, to diarrhea, vomiting, some hemorrhage so you could have bleeding from your gums. One of the things that we saw that was really, really kind of concerning every time we saw it was hiccups. So people that had hiccups seemed to be a, you know, pretty high predictor of mortality. And you just, you know, you see folks that maybe in the morning look okay and you come back in the afternoon and they're dead. It is tough for providers who, you know, you're putting yourself in that position, which is really dangerous and really scary. But on top of that, you know, you're doing everything you can and still, you know, 40 to 50% of the people you're taking care of end up dying, particularly people that are older kids. And it just is really, really hard to repeatedly fail to do the one thing that you feel like you need to be doing, which is like saving lives.
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- [12:43]
Dr. Craig Spencer
Yeah, yeah.
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Jonathan Cohen
So my recollection of 2014, there was a bit of a slow, slow ramp up to figure out what to do. But by the time we were done, we had kind of gotten pretty good at addressing this, at least in theory we knew what to do. And then subsequent outbreaks, I mean, first of all, am I right about that? We've learned a lot since just from having done this a few times. And in an ideal world, what would the response look like? What should the communities of the world. You said it was a call to arms to the world. What should the response look like? Broadly speaking, should we be saying people supplies? In an ideal world, if you were in control, what would we be doing?
- [13:15]
Dr. Craig Spencer
So we learned a lot from the 2014 outbreak. We learned that we needed a more operational WHO and those more flexible, more nimble. We put in place some of those things to make that happen. We recognized that we needed better detection architecture all around the world to pick these up so early. That 2014 outbreak wasn't detected for months after it had been spreading, which is part of the concern, pretty similar to what we're seeing now. We learned that we needed sustained investments and they couldn't just like surge into a region when there was a problem and leave. We learned that all the lessons that we'd learned in the past, we had already forgotten and we can't forget them again. And so what do I think we would need here? Look, we're flat footed. The US would normally have been very aware of what's going on well before the rest of the world. The CDC said on a press call a couple days ago, I think they said they found out Friday, which is the same day probably you and I found out. That's concerning the fact that we weren't kind of held close enough to be able to work with the Congolese Ministry of Health, others during this earlier phases of testing, something that we normally would have been able to do. But because of the cuts we've made over the past year, we don't have those relationships. We're not as close, we're not as trusted, we're not working in collaboration as we have had in the past. What do I think we need to do now? We need to surge people, supplies, resources, support everything that we can. We need to make sure the airport in Goma is open. We need to make sure the lab that the US helped set up with the CDC three years ago in goma, is functional and is able to help with the backlog of tests. We need to make sure that we can get in as much personal protective equipment as possible because supplies are remarkably short for many of the providers and clinics of the region. And we also need to recognize that this is gonna be really, really tough. This would have been a tough response in ideal conditions. And the conditions right now are anything but. You have conflict, you have distrust of outsiders. You have a place where healthcare infrastructure is remarkably weak. There are things that we're just not gonna be able to patch over in a couple days or a couple weeks. In 2019, I think one of Doctors Without Borders at bullet treatment centers was burned down because the community didn't trust the organization. That's despite the fact that MSF had been in the region doctrine lab boarders had been working in the region for decades. And so it just goes to show that this is going to be really, really complicated. It's going to be really, really tough to get this under control even with a perfect response. And we haven't shown ourselves capable of setting up a perfectly responsive decade ago. I'm not sure that we're capable of doing that right now.
- [16:04]
Jonathan Cohen
Yeah. Now, I was listening to a CDC press call yesterday. This is second consecutive one where they said, hey, we are surging resources. We're acting. State Department put out a statement saying they're acting. Is that not true? Are they not reacting?
- [16:19]
Dr. Craig Spencer
They are. I've spoken to people. The problem is that similar to the lessons we learned in 2014, we're learning the lesson all over again that it's really hard to coordinate interagency at the US Government. Over the past decade, we've put in place multiple structures that have then either been shuttered, taken apart, or just kind of left to wither. Things like our Office of Pandemic Preparedness and Response, the NSC Global health folks at the White House. None of those things do we have in place now. Those were things that we built up in the aftermath of 2014 to say, hey, it was really tough to coordinate across the US Government to get State and Defense and Homeland Security and. And USAID and all these people on the same page. We should have a coordinating mechanism to do that, and we built one. But that has since been taken apart. We also have in the US kind of a new approach to how we do global health, which is less support to multilateral organizations like who, more bilateral deals with countries, some of which are causing countries to kind of walk away over concerns about data sharing and the problem with that is that we have kind of new infrastructure to do this America first global health approach.
- [17:39]
Jonathan Cohen
And that's the new Trump. They took down usaid. We're getting drawing from these organizations and they're putting in this new, we're going to reach agreements with different countries, bilateral agreements that put America first. Right?
- [17:48]
Dr. Craig Spencer
Yeah. And I think there are certainly weaknesses of this approach. I don't think it's all absolute crazy. There are things that needed to change. I think their things certainly could be better. Regardless, anytime you close out something well established and turned to something completely new, there are going to be hiccups in terms of how you coordinate, stand up, make sure that it's working effectively. And I think we're seeing that right now. If the US response, the US announced yesterday that they're going to put $13 million into the response, which might sound like a lot of money, but I think it's an absolute pittance compared to what is needed. Particularly when you think about each one of these Tyvek suits that a provider needs to use one time to go into an Ebola treatment center can be probably 100 bucks, if not more. And so we're doing this thing where we're trying to catch up to something that we should have been dramatically in front of. I think the cuts over the last year undoubtedly have played a role here. You know, normally USAID would be helping, you know, coordinate logistics around the country, testing, making sure PPE was in place, making sure that the countries were standing up surveillance at the airports so that cases didn't get on planes.
- [19:06]
Jonathan Cohen
And just to be clear, there's no more USAID to do that. That's right.
- [19:11]
Dr. Craig Spencer
Right. And so in previous outbreaks of Ebola over the past year, you know, countries have had to do it, WHO has stepped in to do it, but we've pulled a big chunk of WHO funding. They're short staffed due to cuts as well, largely because of the US pullout. And so we're seeing Ebola on top of hantavirus, on top of surging measles cases in the US like the international failures and the abdication of leadership, how it's impacting the response, but also I think how unprepared we are here at home as we leave a lot of our infrastructure to whether we don't have a permanent CDC director. And we haven't for 15 of the last 17 months. We don't have a surgeon general, we don't have anyone in the Office of Pandemic Preparedness and Response. We don't have a permanent FDA director now. It's just. Yeah, our leadership has been hobbled and we're seeing the impact of that, I think, all too clearly.
- [20:08]
Jonathan Cohen
Yeah, yeah, I want to let you go. But just a couple real quick things. This travel ban that they announced yesterday, any foreign travelers, any foreigners who have been to those countries, your thoughts generally?
- [20:19]
Dr. Craig Spencer
I think that these are usually more performative than anything. I don't know that they make much of a difference. You know, obviously this administration has already made it nearly impossible for folks from any of these countries that are affected to get to the US Anyways. I don't know the actual impact it's going to have. I worry that they're stigmatizing all those other things. I also realize that it's not just this administration. If there was a Biden, White House or another, they probably would have done the same thing. We've done this over and over in every single outbreak, particularly of Ebola. I think there's some aspects that help with some things that have fallen away in terms of CDC's monitoring capacity and funneling over the past year. But at the end of the day, I don't think this is going to make it's going to do anything more than performative to make it seem like we're doing something as opposed to surging the real supplies, resources and people to make sure we're able to manage this on the ground so that we don't have to worry about trying to pick up cases in the air before they get on a cruise ship. We need to stomp this out exactly where it's at right now.
- [21:22]
Jonathan Cohen
Last question. American watching this. Why do I worry about this? This probably isn't going to affect me directly. I'm not going to probably get Ebola.
- [21:29]
Dr. Craig Spencer
Why should I care? Because this reveals pretty massive gaps in our ability to respond to not just Ebola, but any other concerning outbreak like we've seen over the past couple of weeks that, you know, the cliche is diseases don't respect borders, but they also don't respect planes, they don't respect cruise ships. I think most Americans or a lot of Americans can probably relate to the idea of taking a vacation and getting on a cruise ship. And I think that's probably why hantavirus resonated so much with so many people that even if it wasn't at home, it kind of felt like home. We are rolling the dice. We're rolling the dice with our pretty slow, the US Slow and imperfect response to Hantavirus. We're rolling the dice here with Ebola. I don't think this is going to be a massive outbreak in the US by any means. But if you roll the dice so many times, eventually you're going to come up snake eyes and you're going to get bit. And I worry that what we're seeing here is our inability to think about what happens when we roll the dice, when it comes up snake eyes and what we're going to do about it. Because I'm pretty concerned that we don't have the infrastructure needed to be able to respond well. Yeah.
- [22:34]
Jonathan Cohen
Well, Dr. Spencer, thank you so much. I'm going to let you get back to your work and everyone watching listening to this. Thanks for staying with us here at the Bulwark. We're going to keep watching, talking, writing about public health issues. So I hope you'll think about continue to read us. See you next time.
- [22:51]
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