With last week’s news of a baby born in the U.S. with microcephaly related to the Zika virus infection of her newly arrived mother, as well as the head of the Centers for Disease Control, Dr. Tom Frieden, once again having to plead with Congress for the necessary resources to deal with an emerging viral threat, many are wondering: What were the lessons learned from the Ebola crisis, and were they so easily forgotten?
To answer this question, I sat down again for a follow-up interview with Dr. Richard Wenzel, an infectious disease expert who has been on the frontlines for decades combating emerging diseases, such as the
2009 H1N1 pandemic, in both the developed and developing world.
Kara Elam: How have things changed at your institution, Virginia Commonwealth University Health System (VCU), since the Ebola outbreak?
Richard Wenzel: At VCU we are representative of a large number of hospitals that have spent at least a million dollars in response to the Ebola threat, and that money was to build the facilities to manage the case and do all the rehearsals and get the equipment, which included the Personal Protective Equipment (PPE), as well as some hospitals who bought the robots to clean the room with the UV light.
So I think the after part would be that we are a little more comfortable that we can manage the next highly contagious and serious disease. But again if you said, “Is there an everyday focus on that?” No. I think that is a general statement, and with all the stuff coming out about Zika I think we have moved on from concerns about Ebola, which isn’t always good, but it is what has happened.
KE: Do the healthcare administrators in the hospital still focus on infection control since it was such an important topic during the Ebola outbreak, or has this focus waned?
RW: Just like anything, the focus and attention and amount of resources that go into an acute epidemic are enormous, and then afterwards, and I would say this is both nationally and internationally, the difficulty is to maintain that same kind of vigilance and response until the epidemic is totally contained. So we always say in infection control, “Don’t let a good epidemic go unanswered” with all kinds of requests because I think administrators are ready. But I think in general, the hospital administrators appreciated the effort that the infection control team did certainly locally, and I think that is probably true across the country.
KE: What about the impact of our politicians’ waning interest on resource capacity to continue dealing with Ebola’s global threat as well as preparation for the next outbreak? Last year when we spoke about this, all the political soundbites referenced Ebola, and now they are telling President Obama to use the money set aside for Ebola to fight Zika.
RW: That was a horrible response to the Zika funding request, because what you really want is incremental money to handle the latest epidemic and not lose control of the money for the original one. Once attention gets below a certain threshold, as is the current case with Ebola in the U.S., because people forget, and it takes a certain kind of public health approach to maintain a sense of importance for resource needs after the control period than it does during the epidemic.
In other words, it is easy to respond, but it is hard to keep up the management afterwards — and you see this with almost every program in the past that we have had, like tuberculosis. We were doing well and then they took their eye off the ball and now there is a resurgence of TB, and you can say the same thing about yellow fever, and for a number of different complicated reasons, measles has resurfaced as a concern and it didn’t help that Chris Christie, Ben Carson, and Carly Fiorina spoke about the lack of need for vaccines.
KE: How can public health professionals better manage the short attention span of our politicians so that the importance of consistent vigilance and prevention efforts is not overlooked after the major networks’ cameras move on?
RW: That is a tough question, because if you are just talking to people in the field, I’ve seen this for years in infection control, we talk to each other as people in the healthcare field in terms of morbidity and mortality and sometimes costs. But administrators think of it differently — they are talking about avoiding costs, what is it going to do for the Joint Commission, are we going to get any good or bad publicity out of this — and politicians, as you know, want one thing, and that is a large number of votes.
So if you go to a politician and say, “This is a serious problem and we have to keep our guard up,” and particularly after that sort-of threshold that I talked about of controls — they are worried about getting elected and you can see it currently. They are so worried and afraid to use the word Trump when they are Republicans and they are trying to figure out how to get the votes.
There is not going to be, particularly in an election year, a lot of time spent on the Ebola issue. I think it is going to be enormously difficult and it will require, as most things in politics do, sitting down with the politicians and gaining their trust, and then educating them on the same value system that we have in medicine. And then it requires a skilled public health professional to recognize what the politician is looking for.
KE: Last time we talked you spoke often about the Lexicon of Uncertainty with Ebola and the importance of challenging our assumptions about this unforgiving virus. Do you think, looking back, as well as the current state, are assumptions being adequately challenged?
RW: I still think we haven’t learned enough and it will be tough now because in a way both the World Health Organization (WHO) and CDC are focused on medicine, but they are both highly political institutions and they are influenced by the politics.
Now, one thing they did with Zika was respond very quickly because they knew that they both made major errors and were very slow to respond in saying, “This was a problem” during the Ebola crisis. When you look back, Ebola didn’t become a U.S. concern until a case showed up in Texas, and then things exploded after that. The head of the CDC, Dr. Tom Frieden, took a lot of heat for that.
KE: According to the Associated Press, there was a report released saying the WHO had dragged its feet in declaring Ebola a public health emergency of international concern. Dr. Sylvia Brand, head of the WHO Pandemic and Epidemic Disease department, responded that what she had seen in the past was that for developing countries it is sort of a death warrant you are signing if you declare that too soon. Do you think that was a good reason for why the WHO waited?
RW: I think that is a terrible statement. You have a public health crisis, you respond to it, and any delays, as you know, can only make things worse. If you go back to SARS, and I often compare and contrast what the Chinese government did with SARS with what the Mexican government did with H1N1: For SARS it took almost six months of ongoing recognition in Southern China and the Guangdong Province before the Chinese government really admitted that they had a really serious problem and they only took action after there was a threat in Hong Kong, in contrast with H1N1, the Mexican government knew right away.
Once they got confirmation from both Canada and the U.S. that this was a new virus, it took them 10 days from the time they knew about the first patient who had died from H1N1 to declare that this was a brand new problem and epidemic, even though they knew this was going to be a financial burden. And people often say, “Well, the Chinese did it because they were worried about the economics of declaring that their country has a problem, or that they had to save face.”
None of those are appropriate rationale for not reporting an epidemic early, and for a health agency like the WHO to suggest that they would hold back responding to an epidemic because it might be perceived poorly in terms of the country that is involved, I think is a terrible statement. It is unethical, and medically it doesn’t make sense.
KE: A recent Lancet Report, “Will Ebola Change the Game?” offers 10 reforms for the international community in preparation for the next pandemic. I have a few questions in regard to this paper:
1) They stated in the report that the WHO should insist on a director general with the character and capacity to challenge even the most powerful governments when necessary to protect public health and they give an example that “they must be able to confront governments that implement trade and travel restrictions without scientific justification.” Do you think that is too idealistic, because I am sure that one of the countries they are referring to is the U.S., but could the WHO realistically challenge the U.S. response?
RW: It is idealistic and I don’t think that is so bad, and I think what they are saying is that when the WHO elects a new director, I think they are suggesting that the vetting process improve in terms of strength of character. Now if you said if you have a strong country with a lot of resources in it and influence, the real question is, suppose you challenge them and nothing happens, then what is your next step. And I think you can’t force a country unless you get a body like the U.N. involved.
2) Do you think this recommendation was made because the current director may have been a bit weak? They don’t clarify it in the report.
RW: I am sure they put that in there between the lines — I can’t say that for sure because I don’t know anyone in that working group, but between the lines, it is an obvious assumption.
3) Another recommendation they made was, “Effective governing of this complex global health system demands high level political leadership and a WHO that is more focused and appropriately financed and whose credibility is restored through the implementation of good government reforms and assertive leadership.” Do you think this is possible with such a massive top-down bureaucratic institution like the WHO?
RW: Again, I think they’re really focusing on leadership at the WHO and I think they are again looking for character and strength, and a strong focus on the medical issues, as opposed to just purely the political issues. You have to know about both, and I think also they need to be able to continually work as any institution does with the leaders in the world, those small countries and larger countries with more resources. So that is how I would read that.
Again, the problem is how are they going to do it? My sense is that the WHO desperately needs more funding and they can’t respond as well to local problems without funding. It is a relatively small organization and I don’t know how strong their links are to other institutions which might be useful, such as the International Monetary Fund (IMF), the World Bank, and the United Nations. I think more teamwork there would add political strength and even financial resources, particularly for countries that should be rewarded, such as Mexico with H1N1, for early reporting of epidemics with the financial resources to try to control it. For if you don’t do that, then the concept of worsening the spread seems logical, and if you could give them resources early to contain it, my hypothesis would be that you are going to save money and lives and morbidity in the long-term.
KE: As a public health professional who was on the ground in Mexico during H1N1, what are your thoughts on the theory that there is so much central control with global health by organizations like the WHO and U.N. that not enough local control is given to the countries of origin? Did you witness this during H1N1, and could it have been a contributing factor to the initial mismanagement of the response to Ebola?
RW: When I was in Mexico at the time, in Mexico City, of course, where there was a huge population, a large number of hospitals that I visited had more resources than those in the rural areas where they actually ran out of oxygen, respirators, and mats. So if you stayed only in the top hospitals in Mexico City, you might not learn that there is a huge disparity of resources throughout a country like Mexico. They had, I thought, pretty good leadership at the central area, but they didn’t have the expertise in the countryside to really carry out the objectives that they needed to accomplish, and of course they didn’t have the resources in the countryside either.
The other thing I noticed was that again, the WHO didn’t send anyone right over there to look at the patients and understand what was happening on the ground. Neither did the CDC. So when I was there I never saw anyone from the WHO or CDC, although I heard the CDC people were in buildings going through papers, but there is no substitute for what I thought in my experience was so invaluable, and that is making rounds in the hospital out in the wards and particularly the ICUs.
I will give you an example: In a very short period of time after being in several hospitals, it was clearly obvious that these were young patients, mostly in their mid-20s, who were high-risk due to obesity, and over-represented due to pregnancy, and I was reporting this to Larry Altman in The New York Times and confirmed it later when I went to four countries in South America. So you need to do that. Then I got a call from the WHO and they asked me to go on a conference call the following week with some of their people who were primarily in Geneva, to say what the patients looked like, and I was pleased and excited to do so, but it also meant that there was something missing. If you have this enormous responsibility, you need a clinician on the ground, particularly one maybe with some skills in epidemiology to visualize things and get some hypotheses going, and then begin to try and confirm them.
I thought the WHO was even slow with H1N1.
Obviously they were slow with Ebola, and I think they took so much heat for that that they really responded much more quickly with Zika. Although there are even people in Brazil saying that they were too slow with their response to that country.
My thoughts are that in regard to Brazil they probably were too slow to respond. One of the things that people talk about is when you have these epidemics it is often the poor, lower socioeconomic class people who are disproportionately affected, and people don’t respond as quickly, even here in the U.S. with the problem of lead in the waters in Flint, Michigan. So I think that probably should be examined to see if that was a factor.
KE: Do you think there should be an independent U.N. accountability commission created to do system-wide assessments of the worldwide response to major disease outbreaks epidemics?
RW: I think reviews are good. We used to call them post-mortems: How did we do on the medical response? And the idea would be mostly to learn something. It was not necessarily to punish anyone. I’m not sure punishment works in public health; I think rewards might, rewards for early reporting and jumping on things and disease management in any country should be rewarded with resources, including money.
I thought about in the past how can you punish a country that deliberately hides an epidemic. You could do things like refuse to let them be involved in the Olympics next time, but again I doubt any punishment would work.
KE: That seems to go along well with the adage “you are always fighting the last epidemic.” Do you think there will ever be a time when we will actually be prepared for a present or future epidemic?
RW: To do that it would take a global preparedness and a global commitment to controlling epidemics and a global awareness that no matter where you live, even in the wealthiest part of the U.S., that what happens in a remote village in a third-world country oceans away can have enormous impact on everybody, including you and your neighbors in a very wealthy area of a developed country.
Part of that, I really think, is that we may need more than what the WHO is doing now. One of the things that I thought we should really do is to develop several rapid response teams. Some hospitals have them now to look for patients who are at risk of getting into trouble by looking at their vital signs early and then eyeing the patient early so you don’t wait for them to have a cardiac arrest. So what you would do is have a team of volunteers — these would include microbiologists, infectious disease specialists, epidemiologists, and logistics people, aided by WHO, IMF, and Google, because I think the mapping is important, and the U.N. — and agree that if the call is made there will just be this team that is dispatched to the area, something sort of like the Green Berets of epidemiology and infection control, if you will. They would be on a plane in a short period of time and meet wherever the current threat is occurring. And you would obviously need back-up teams. I think that kind of response could be even more rapid than a bureaucratic operation like the WHO.
KE: But isn’t the CDC’s Epidemic Intelligence Service (EIS) supposed to be a rapid response team? Or is it failing in that capacity?
RW: They are and often they do. If you remember when Ebola started it created a dilemma for the CDC because their EIS are the newest people in the CDC and they didn’t have any kind of training on the management of a very contagious disease like Ebola, and I think wisely the CDC sent a large number of them, 20 to 30 initially, just to do some epidemiological work. But you also realize that you are going to need people that have been through something like this before. So if the next hemorrhagic fever comes up you really would like experts who have been around to be part of the rapid response team. You can’t send a team in there that is inexperienced or put them at enormous risk because then the whole program would fail very quickly.
KE: What do you think the world can learn most from the Ebola outbreak?
RW: I think what you learn is that if you look at Ebola, it is just the last of about 30 pandemics, all of which are zoonoses, and as people and animals are in contact there is going to be that one spark and a lot of conditional situations, which will set off a local cluster of cases and then move into a larger population, such as capital cities, and then it’s a national problem and with the ease of international travel, it becomes international.
So I think we have to recognize that these are not exceptions. We shouldn’t be shocked with every pandemic, we should see it as part of life and then say, now we have to develop systems to deal with these ongoing, predictable epidemics — predictable in a sense because they are going to occur not in terms of which epidemics they will be — we have had SARS and Ebola, and now a totally different virus, Zika.
We have to know that we are part of a global family and this is never going to end, the threat is always going to be there, and we shouldn’t be shocked and we should have ongoing systems to manage this.
For more information on Dr. Richard Wenzel’s extraordinary career, please click here.