A nurse of the 'Doctors without Borders' medical aid organization examines a patient in the in-take area at a center for victims of the Ebola virus in southern Guinea.

A nurse of the 'Doctors without Borders' medical aid organization examines a patient in the in-take area at a center for victims of the Ebola virus in southern Guinea.

The latest Ebola outbreak is being called the worst in history. The virus has killed nearly 700 people since March in Guinea, Sierra Leone, and Liberia. The president of Sierra Leone has declared a public health emergency, and Liberia’s government is putting communities on quarantine. In the past week, the disease claimed Sierra Leone’s top Ebola doctor and the first American to die in this outbreak. While experts say a U.S. epidemic is unlikely, international concern is growing as the disease shows no signs of slowing its spread. Understanding the deadly Ebola virus, and the international effort to contain it.

Guests

  • Dr. Anthony Fauci director, National Institute of Allergy and Infectious Diseases at the National Institutes of Health.
  • Dr. Billy Fischer physician and associate program director for research in pulmonary diseases and critical care medicine, University of North Carolina School of Medicine.
  • Dr. Daniel Lucey infectious disease and public health physician; adjunct professor of microbiology and immunology at Georgetown University Medical Center.
  • Laurie Garrett senior fellow for global health, the Council on Foreign Relations.

Where Has Ebola Spread?

Last week, the Centers for Disease Control released this map of where the deadly disease has spread in Africa.

Outbreak: Guinea 2014 | Ebola Hemorrhagic Fever | CDC

Dispatch From Guinea

Billy Fischer, a physician and associate program director for research in pulmonary diseases and critical care medicine at the University of North Carolina School of Medicine, posted updates last month from Guinea, where he was treating patients.

Read some of his entries below.
Dispatch from Guinea: Containing Ebola

Transcript

  • 10:06:53

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. The ebola outbreak in West Africa is unprecedented in scope with more than 1,000 cases and nearly 700 dead. Here to discuss ebola, what's being done to prevent it from spreading further, Dr. Anthony Fauci of the National Institutes of Health and Dr. Daniel Lucey of Georgetown University. Joining us by phone from New York City, Laurie Garrett of the Council on Foreign Relations.

  • 10:07:29

    MS. DIANE REHMAnd from Chapel Hill, North Carolina, Dr. Billy Fischer of the University of North Carolina School of Medicine. And I'm sure many of you will have questions, comment. Join us by phone at 800-433-8850. Send an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. And thank you all for joining us today.

  • 10:08:00

    DR. ANTHONY FAUCIGood to be with you, Diane.

  • 10:08:02

    DR. DANIEL LUCEYThank you very much.

  • 10:08:03

    DR. BILLY FISCHERThank you.

  • 10:08:07

    REHMAnd good to be with all of you. Dr. Fauci, how serious is this outbreak?

  • 10:08:15

    FAUCIWell, certainly for the countries involved, the West African countries, it's really quite serious, as you can see. This is unquestionably, historically, the worse ebola outbreak that we've had in history. The first cases were recognized in 1976 and there have been several, almost two dozen outbreaks over those years in a variety of countries.

  • 10:08:35

    FAUCIThe total amount of people involved in those, cumulative, have been about 2300. This already, as you see, have over 1300 people with about 730 deaths so far. So overwhelmingly this is the worst. But also because it is going across countries, adjacent countries with porous borders. And now, unlike prior outbreaks, mostly in rural areas, it is now in a densely populated area.

  • 10:09:05

    FAUCISo all of those things conflating together make this quite a serious situation there.

  • 10:09:09

    REHMDr. Lucey, how did this outbreak begin? Do we know?

  • 10:09:15

    LUCEYWe're not certain, but most likely it began like other ebola outbreaks where there's an infection in one or more animals that people are exposed to.

  • 10:09:22

    REHMLike what?

  • 10:09:24

    LUCEYLike bats, like African antelopes called duikers, like nonhuman primates, maybe chimpanzees or gorillas. Sometime these animals are killed for food, so-called bush meat, and people can be exposed to the animal's body fluids that have the virus in it and then people can get infected and then they start to infect other people.

  • 10:09:44

    REHMAnd Dr. Billy Fischer, I know you recently spent three weeks treating patients in Cacadu in Guinea. Tell us what you saw there?

  • 10:09:59

    FISCHERIt was -- from a clinical perspective, it was an intense experience. There was a tremendous amount of both fear and despair around the surrounding community as well as within the population of patients that we were treating. But contrary to what is popularly portrayed in popular media, most of the patients were presenting with really nonspecific symptoms, so vomiting diarrhea and then about half of the cases, they progress to have hemorrhagic complications, such as bloody vomit, bloody diarrhea.

  • 10:10:33

    REHMAnd how are they treated?

  • 10:10:37

    FISCHERThat's a great question. I know it was actually one of the concerns that I had upon being deployed by the World Health Organization to Cacadu. So there is not specific antivirals currently available and there's no specific vaccines that are licensed for use. There are a number of agents that are currently in the R&D pipeline, but just not ready for use.

  • 10:10:58

    FISCHERBut what is available is aggressive clinical care support. And what I mean by that is aggressive fluid hydration. So many of these patients are presenting with really low blood pressures due to volume loss through diarrhea and vomiting. And if we can get to them earlier enough, we can keep them hydrated and support them through it.

  • 10:11:16

    FISCHERAnd for my experience on the ground, I was actually able to witness that with this aggressive critical care support, we can reduce the mortality.

  • 10:11:26

    REHMLaurie Garrett, what about these particular countries? What does their history have to do with this current outbreak?

  • 10:11:38

    MS. LAURIE GARRETTWell, one of the features, Diane, that we're seeing as a key problem in this outbreak is the resistance of the general population to measures that could conceivably bring the epidemic under control, measures that worked in other outbreaks, including the one I was in in 1995 in Kikwit, Zaire. Pretty basic things, but scary things for populations, like removing the ill from the care of their loved ones and placing them in quarantine and denying public burials so that there's no contact with a cadaver.

  • 10:12:15

    MS. LAURIE GARRETTAnd what we're seeing here is that there's massive resistance to these efforts, even attacks on health workers because these are countries that have in recent time experienced the most brutal civil wars, the most heinous atrocities of human rights violations in modern history. I mean, Charles Taylor is one of the few truly convicted war criminals in modern time and he was the leader of Liberia.

  • 10:12:44

    MS. LAURIE GARRETTHis counterpart in Sierra Leone died of a heart attack when he was facing his own trial for war crimes. Almost every single family in all of these three countries, but especially in Liberia and Sierra Leone, has witnessed horrible atrocities committed against them by rival militias, by governance, by one invading child soldier group after another.

  • 10:13:15

    MS. LAURIE GARRETTAnd so nobody trusts anybody and there's no sense of confidence and belief in either government or health workers. And then, on top of everything else, these are three of the poorest countries in the world and they have 50 percent illiteracy rate.

  • 10:13:31

    REHMAnd Dr. Fischer, Laurie Garrett just said there's no trust even of the healthcare workers. Surely, that is compromising any effort to try to help these folks who might be infected.

  • 10:13:51

    FISCHERAbsolutely. That's a critical problem that exists. The first two patients that I actually took care of were brother and sister who were demonstrating symptoms within their village. Their village contracted Doctors Without Borders and when that group tried to bring them to the treatment facility, they fled into the bush. And the only reason we were able to get them into the treatment facility were because they became so weak, because their symptoms had progressed, that they couldn't run any further.

  • 10:14:19

    FISCHERAnd unfortunately, by that time, it was too late.

  • 10:14:24

    REHMNow, Dr. Fauci, I understand that three Americans, that we know of, have been infected. One has died, stepping off a plane in Lagos, Nigeria. What about the others on the planes in which he traveled?

  • 10:14:49

    FAUCISure. Well, what's going on right now is what we call contact tracing, Diane, which means that, first of all, to put it into perspective, it is extremely unlikely, not impossible but extremely unlikely, that individuals on the plane would be infected because...

  • 10:15:07

    REHMBecause...

  • 10:15:07

    FAUCI...because you have to come into direct contact with bodily fluids.

  • 10:15:10

    REHMDo we know that for sure?

  • 10:15:12

    FAUCIYeah. Well, you know, when you say for sure, if you look at the long experience that is now back until 1976 when the first interactions with patients that we know of with the first outbreak in 1976, that it is very, very clear that you have to come into direct contact with bodily fluids, usually vomit, diarrhea, blood or what have you.

  • 10:15:34

    FAUCISince the person, in fact, was not feeling well, but he was not openly vomiting or whatever on people in the plane so it is unlikely. However, to be perfectly careful and cautious about it, the authorities in Nigeria with the help of WHO and the CDC and others are doing contact tracing to make sure that the people who were on the plane are not coming down with symptoms.

  • 10:15:57

    FAUCIBut it is very unlikely that there was transmissibility because of the condition of the person while he was on the plane.

  • 10:16:03

    REHMOkay. But then we go back to Dr. Fischer's point. Suppose someone has contracted the virus, how would he or she know before symptoms actually begin? In other words, how quickly do symptoms appear after infection?

  • 10:16:28

    FAUCIWell, it's anywhere between two and 21 days and sometimes, you know, if you look at the mean, it's probably around five to 10 days following exposure, with the incubation period, where people start to get symptoms. But as Dr. Fischer said, the symptoms don't start off with bloody diarrhea. They generally start off with symptoms that you could maybe not confuse with malaria or bad flu or what have you.

  • 10:16:51

    FAUCIAnd then, when it progresses, that's when you get into the situation where it's clearly much more likely to transmit.

  • 10:16:57

    REHMAnd Dr. Lucey, suppose someone has been infected, is not showing symptoms? For example, these people on the various planes. Is there any preventive medication that could be administered?

  • 10:17:19

    LUCEYSo if someone has not developed any symptoms, fever, any kind of symptoms at all, diarrhea, vomiting...

  • 10:17:24

    REHMIn this 21-day period.

  • 10:17:26

    LUCEYYes. Then by day 22, they are out of the incubation period. They're out of the danger zone. They're not going to become symptomatic. They're not gonna develop ebola virus disease.

  • 10:17:37

    REHMOkay. But during that 21-day period, is there anything that can be done?

  • 10:17:45

    LUCEYNo. There's not specific treatment available.

  • 10:17:48

    REHMThat's pretty scary, Dr. Fischer. You must have seen that yourself.

  • 10:17:55

    FISCHERAbsolutely. It's terrifying with contract tracing to monitor people. The one thing that I would add, though, that amidst all this despair and this concern and high mortality rates, is the hope that if we can get to people early enough in their illness, so as soon as they start manifesting signs and symptoms of ebola, that we give them their best chance of survival.

  • 10:18:21

    FISCHERAnd so while we can't give them anything that will protect them from developing it, once they develop symptoms, it's critical that we get them into a treatment facility as soon as possible, both to help them and to prevent their chance of transmitting it to someone else.

  • 10:18:32

    REHMAll right. Dr. Billy Fischer, he's physician, associate program director for research. He is at the University of North Carolina School of Medicine. Short break, right back.

  • 10:20:01

    REHMAnd welcome back. We're talking about the outbreak of Ebola in three African countries. There have been thus far some 700 people who've died, some 1300 who may have been infected -- affected. And then is the question what a number of people are asking, Dr. Fauci, is this particular strain of Ebola different from that which we saw back in '76?

  • 10:20:38

    FAUCIThere -- well, no. Actually the first one was the Zaire strain.

  • 10:20:41

    REHMOkay.

  • 10:20:42

    FAUCIAnd this is very close to the Zaire strain. So when you look at the multiple strains that have been isolated at different times and worked on in the laboratory, this clearly is on the spectrum a very virulent strain.

  • 10:20:54

    REHMVery virulent.

  • 10:20:55

    FAUCIYeah, it's virulent but it's like the Zaire strain which is the most virulent.

  • 10:20:58

    REHMOkay. Dr. Fischer, once that patient has begun to develop symptoms, what is your role as a physician? To what extent can you prevent that person from dying?

  • 10:21:19

    FISCHERThat's a great question and we are limited with what we can provide for a couple of reasons. One, as I mentioned earlier, there's no specific therapy for Ebola. But two, it's -- this outbreak is occurring in one of the most under-resourced areas of the world. So we are further limited in what we're able to do. But what we're able to do is bring them into a treatment facility which effectively stops the chain of transmission to other people in their community and then aggressively rehydrate them and keep up with electrolytes as they lose them through their vomit and diarrhea. And provide aggressive critical support of care.

  • 10:21:53

    REHMAnd to what extent is that critical care successful?

  • 10:22:00

    FISCHERSo if you look back historically at the mortality rates associated with Ebola virus, it's about 70 percent. If you look specifically at the mortality associated with the specific strain that we're dealing with, as Dr. Fauci mentioned, Ebola Zaire, it's about 78 percent. We've been able, with aggressive clinical care, to reduce that substantially into the 40 to 60 percent range, depending on location of the treatment facilities.

  • 10:22:27

    REHMAnd Laurie Garrett, from your perspective, getting them into those treatment facilities has got to be pretty scary for those people.

  • 10:22:41

    GARRETTWell, it's terrifying for them and families resist it. The individuals resist it. If I may, Diane, I want to make a couple of points.

  • 10:22:48

    REHMSure.

  • 10:22:49

    GARRETTBecause one of the real concerns, every time we see an outbreak of this nature -- of course, this one is now by far the largest ever -- but anytime we see these things there's a tendency by the outside world, by the average American to start thinking, what a scary place. Let's just wall them all off and forget about them and hope that we don't get this virus. And it's a natural tendency for people to think of their own self interests, their own families and so on. But we're talking about three desperately poor countries.

  • 10:23:23

    GARRETTAll -- the two key leaders, the leader of both Liberia and Sierra Leone today announced that they're imposing a military support for quarantine. They've declared states of emergency in their countries. And both of them are cancelling trips to Washington, D.C. for the big Africa Summit called by President Obama at the White House.

  • 10:23:47

    GARRETTNow, this has huge implications because already many of their neighboring countries, especially Nigeria, and many of their major trade partners, especially the UK, have started to impose certain kinds of concerns, border protections, talking about sanctions against these countries, all of which could drive them into ever, ever deeper poverty. Really leave them so deeply scarred that once the epidemic is over, they will have years and years of recovery from the economic impact of all of this.

  • 10:24:21

    GARRETTI think it's tragic that these two key leaders are not able to plead their case in Washington at this summit. And I really hope that the Obama Administration and the Cameron Administration in the UK and the Africa Summit recognize the very desperate need to not only support the battle against the virus, but to also be there to help build these countries back up, help them recover from this desperation and come up with decent health systems once this is all over with.

  • 10:24:57

    REHMWhen you talk about the Africa Summit on Monday, surely these leaders might be able to participate by Skype or some other means to plead their own cases, Laurie Garrett.

  • 10:25:15

    GARRETTWell, I would hope so but actually as of the last agenda I saw, the Ebola epidemic is not even on the agenda.

  • 10:25:22

    REHMWow. Dr. Fauci, in the past in the case of Zaire, in the case of the '76 outbreak, how long did the outbreak last?

  • 10:25:35

    FAUCIIt really varies. If you look at the multiple outbreaks it really varies from several days to weeks to a month or two. It usually breaks -- it essentially dissipates itself. But this is really important and it relates to the point that I made earlier on, Diane, is that they usually occurred in areas that were relatively remote. Which means it could be much more easy to contain in a population that's in a remote village and not really close to cities.

  • 10:26:03

    FAUCIOne of the confounding issues of this outbreak is the one, the porous borders between three separate countries here as well as the large populations in getting into the cities. So the earlier ones were dramatic but they essentially burned them out -- themselves out by the kind of infection control mechanisms that were put into place.

  • 10:26:24

    REHMAnd Dr. Lucey, you mentioned earlier that one of the causes here was the consumption of bats, for example, as one source of protein that these individuals are accustomed to eating. Have they been warned off those kinds of foods?

  • 10:26:51

    LUCEYSo I should defer to Dr. Fischer. Now there's been in the three countries but certainly that's my understanding from what I've been able to learn from internet information, that that kind of risk communication has been conveyed. The dangers of getting infected from exposure to animals that have this virus like many other infectious diseases that come from animals like Bird Flu, like the Middle East Respiratory Syndrome, like the SARS virus in 2003. So there are quite a few newly recognized infectious diseases over the last 30 years of humans that come from animals.

  • 10:27:24

    REHMDr. Fischer.

  • 10:27:27

    FISCHERSo education is a big part of this and there have been some efforts, in fact I was met at the airport when I arrived in Guinea by a large placard that announced how Ebola was transmitted. But I think that's one of the critical pieces that's missing in this outbreak, and particularly because this is in such an under-served area, is information infrastructure. So there is not a great way to disseminate a lot of information about how this virus is transmitted and how to protect themselves within all the villages that are affected.

  • 10:27:59

    REHMAnd Laurie Garrett, if you tell folks you cannot eat a particular food that they rely on, why should they believe you?

  • 10:28:11

    GARRETTWell, I think the lack of belief goes even deeper than that, Diane. I mean, first of all, these countries have an average adult illiteracy rate of 50 percent. Then you take in what's functional literacy versus the ability to read anything that actually tries to describe what a virus is, you're talking about a very small percentage of these populations.

  • 10:28:35

    GARRETTAnd for most people, the germ theory of disease is not a real concept. You know, Dr. Fauci has been doing battle against the HIV pandemic since the days before in the 1980s we even knew it was caused by a specific agent. And, you know, he can tell you that all over the world we have seen populations not understand really what a virus was and how it was transmitted. That's in it for a slow spreader, a slowly evolving pandemic.

  • 10:29:08

    GARRETTIn the case of Ebola, we're really up against cultural beliefs that when a disease hits a given family, it's because your ancestors committed some sin against some other family and they have leveled evil spirits against you. It's a kind of sense of an endless set of circles of retribution and revenge for deeds committed by someone against someone else. Well, now add to it, they just came out of these heinous civil wars where indeed evil deeds were done on almost every single family by somebody during the course of the 1985 to 2003 outbreak of violence.

  • 10:29:55

    GARRETTAnd so you have a situation where outsiders are trying to say to people, there's a virus. And this virus causes this disease. And we are outsiders dressed in space suits and we don't look like you and you should believe us. And meanwhile the average person doesn't even have a concept of what a virus is.

  • 10:30:17

    REHMThis happened even in this country when the HIV came here. I mean, there were people who said, you know, this is the result of your hideous behavior. And in Africa they're saying it's your relatives who did something wrong.

  • 10:30:41

    FAUCIThis is nothing new. It's not new to HIV, it's not new to Ebola. History is replete with examples of when there are major outbreaks and plagues. The fear, the terror that is stricken into people has people almost intuitively look to someone to blame, someone, some group, some class, some religion, some country. There always needs to be a reason for things. And if you don't understand, as Laurie was saying correctly, the subtleties of the germ theory of infection, then you're looking to blame people and blame nations and blame groups that have nothing to do with it. So you're absolutely correct, it's a very difficult situation.

  • 10:31:20

    REHMDr. Fischer, from what you have seen so far, do you believe that this particular strain of Ebola and this particular outbreak does have the potential for spreading beyond Africa and into other countries? There is obviously, as you know, a great deal of concern about that.

  • 10:31:53

    FISCHERSure. I think that there is potential. We've seen that somebody who had the virus was able to get on a plane in Liberia and travel to Nigeria. And given the incubation period of 21 days, you can do a lot in that 21 days. The difference is -- and I would be more concerned about further spread into other pockets of Africa mainly because of the under-resource -- the lack of resources that exist in many of the areas, in many countries in Africa that would be able to respond to a virus like Ebola.

  • 10:32:26

    FISCHERIf it were to come to a place more developed or resource-rich place such as the United States, I think we have the absolute correct resources to be able to respond effectively and efficiently to isolate somebody who may have symptoms or have that virus so that it would not take hold in a place like Europe or the United States.

  • 10:32:45

    REHMDr. Billy Fischer. He is at the University of North Carolina School of Medicine. And you're listening to "The Diane Rehm Show." Sadly, Laurie Garrett, that's exactly what was said about HIV AIDS when it began. And the isolation, the quarantine, the fear of spreading was downplayed in this country. Do you see that same thing happening here?

  • 10:33:25

    GARRETTWell, we've already seen the UK government go on a special alert status advising physicians across the UK to be on special awareness of the possibility of Ebola arriving in the UK. I think the danger point politically for global solidarity and for the whole nature of how the world community deals with this problem, the flashpoint will be if we ever actually do see spread inside Nigeria.

  • 10:33:55

    GARRETTNigeria's the big Kahuna of the African continent. It's the most populace country. It's a major oil producer and economic powerhouse for the continent. It has two major international airports and a very highly mobile population that travels all over the world. Sierra Leone, Liberia, Guinea, these are very, very desperately poor societies. The average person has never traveled anywhere except walking distance to another country nearby. But Nigeria would be a completely different state of affairs.

  • 10:34:34

    GARRETTAnd honestly given the situation inside Nigeria right now politically, with Boko Haram having control of the northern provinces of the country with the country facing a national election, with the disgrace of the 300 missing girls never accounted for kidnapped by Boko Haram. And the history of the Islamic movement -- or Islamist movement, excuse me, of northern Nigeria opposing polio vaccination and at various points opposing other health interventions in the Muslim population in the north, I think we could be looking at a really serious powder keg.

  • 10:35:12

    GARRETTSo if I can read the tealeaves right now on this African Summit, while the Ebola epidemic is not on the agenda, I have to assume that the back table discussion will be, how do we contain this? How do we keep it from getting into Nigeria or into Senegal, another powerhouse economically in the region? How do we isolate these countries? And of course, the danger of doing so is if they become sort of national pariahs in the same stigmatized sense that the average HIV patient was stigmatized here in the United States in the 1980s.

  • 10:35:53

    REHMDr. Fauci, do you agree with Laurie Garrett that Nigeria could be a tipping point?

  • 10:36:00

    FAUCIWell, certainly. I mean, it would be terrible if it gets into the type of spread that we're seeing in the other three countries. Because as Laurie said correctly, Nigeria is the most populace nation in Africa. And it's a nation that interacts very much with the rest of the world. The fact that the Nigerians right now, even though they are -- don't have the kind of health care structure that we have or that the Europeans have, they are on very high alert now about the situation about making sure that this does not establish itself. But it could. And as Laurie said correctly, if it does that would really be a big problem because of the size and the population of the country.

  • 10:36:43

    REHMWould you see isolation as a result?

  • 10:36:47

    FAUCIWell, you've got to be careful when you start talking about isolation. There are things that one can do that are appropriate that are not infringing on people's literal basic human rights. The critical issue is what several of us have said throughout this dialogue here, is to try and get an as organized as possible infrastructure, whether that's help from other organizations, other countries or what have you to be able to do the fundamental protocols of isolation and care so that people don't spread it from one to another.

  • 10:37:19

    REHMDr. Anthony Fauci of the National Institutes of Health. Short break here and when we come back, we'll open the phones for your questions, comments. I look forward to speaking with you.

  • 10:40:02

    REHMAnd welcome back. Right now we're going to go straight to the phones, to Sarah, in Ann Arbor, Mich. You're on the air.

  • 10:40:15

    SARAHHi. Thank you for taking my call.

  • 10:40:16

    REHMSure.

  • 10:40:18

    SARAHI have two comments. Well, first of all, I recently had to postpone a trip to Liberia that I was supposed to take in two weeks. So I've been following this outbreak since the beginning, back in March. But since I'm -- so there's sort of been two things that I've found a little disheartening. The first is this outbreak sort of shows the fragility of a lot of the hospitals in places like Liberia. I mean, recently they had to close one of the more important hospitals in the capital of Monrovia, St. Joseph's Catholic Hospital.

  • 10:40:49

    SARAHAnd then, also, you see a lot of the doctors, the major doctors who have been affected from this. So I was hoping the panelists could sort of talk about that. And then also the other disheartening thing that I have seen is that from the beginning I heard the World Health Organization talk a lot about how reduced funding has sort of affected their ability to deal with the Ebola outbreak. And so I was wondering if the panelists could talk about that.

  • 10:41:14

    REHMAll right. You have quite a number of questions there. What about the fragility of hospitals, Dr. Fischer?

  • 10:41:25

    FISCHERAbsolutely. I think the caller hit on a number of key issues. One is that there are such -- it is such an under-resourced area. So they don't -- so the lack of basic health care infrastructure essentially sets up this area to be overwhelmed by an outbreak. So that's a key point. And actually, I would say, that even the resources that we're able to bring in are not sufficient. I think we need to increase the amount of resources, both on the material -- from a material perspective, as well as a human perspective to -- in order to be able to combat this outbreak.

  • 10:42:01

    REHMLaurie Garrett, do you want to jump in?

  • 10:42:05

    GARRETTQuick thing is the average per capita spending, according to the World Bank on health care per person in these countries is a high of $18 a year, a low of $7. So there's not a lot of health care delivery available if you're spending $7 per person per year on all health services combined. And as far as the question -- I'm very glad the caller brought this up -- from Ann Arbor. Thank you. Funding and WHO -- WHO is in severe budget crisis. Has been now for almost four years.

  • 10:42:41

    GARRETTThey've laid off 20 percent of total personnel of the institution. And their disease response capacity has seen its budget slashed. I know that the average listener imagines that there's this huge SWAT Team of health providers sitting in WHO Headquarters in Geneva. And at the snap of a finger the director general deploys them where needed. This is absolutely untrue. In fact, WHO goes around begging for people like Dr. Fischer to -- at the expense of somebody else, the U.S. government, for example -- to go in under the WHO flag where needed.

  • 10:43:25

    GARRETTAnd our own CDC has seen our budget cut for international response capacity, pandemic response and surveillance. So actually we're less prepared today then we were perhaps 10 years ago, in terms of the budgetary constraints of the major responders.

  • 10:43:44

    REHMDr. Fischer, do you want to comment?

  • 10:43:49

    FISCHERI totally agree. That was exactly my experience. I think my contract was for $1, but there are -- there is hope. There are people who want to go there and help out. And so the work that WHO does and is able to do -- even with a slashed budget -- is Herculean.

  • 10:44:09

    REHMWe have several tweets and emails on this question. "Please ask why doctors are dying, even with all the precautions being taken." Dr. Fauci?

  • 10:44:25

    FAUCIWell, as we say, the predominant way of transmitting is by direct contact to body fluids. Okay.

  • 10:44:34

    REHMBut don't the doctors have uniforms?

  • 10:44:37

    FAUCIIndeed, they do. But you've got to understand -- and Billy Fischer will, I'm sure, verify that for me. If you look at the conditions under which you have to put on these suits, these masks, these goggles, these gloves, when it's 100 degrees out…

  • 10:44:54

    REHMJust like Hollywood.

  • 10:44:56

    FAUCIYeah, just putting it on and taking it off -- I mean I worked in isolation facilities where it's an air-conditioned room when you put on those space suits and it's uncomfortable, even when you do it for 20 minutes. Could you imagine three, four hours at a time, having to put it on and take it off? And in fact, it's not only the doctors and the health care providers who are at high risk of getting infected, but even the people who assist them in putting the personal protective equipment on and off.

  • 10:45:26

    FAUCISo when you're exposed and when you're there and getting into direct contact with the bodily fluids, that puts you at risk. And that's exactly the reason why doctors and health care providers are getting infected.

  • 10:45:38

    REHMDr. Fischer?

  • 10:45:41

    FISCHERAbsolutely. I'd echo all of those comments. It's not just the protective equipment, which is critical, as Dr. Fauci mentioned. But it's how you put it on and more importantly how you take it off. And so -- and in addition to that…

  • 10:45:55

    REHMWhat do you mean, how you take it off?

  • 10:45:57

    FISCHERSo it's a great point. So when you put on all of this equipment, it can get as hot as about 115, 116 degrees on an average temperature day inside your suit. And then you work for as long as you can before you start being -- coming very dehydrated and then you have to exit. But you have to take off your equipment in exactly the same way every single time. So Doctors Without Borders, MSF, has established these rules, these routines that really provide a safe way of removing these clothes, which have potentially infectious bodily fluids on them.

  • 10:46:34

    FISCHERBut there's one other thing that I wanted to comment on, is that not only do you have these incredibly hot and restrictive suits, but you also have the emotional and physically fatigue of trying to provide care with incredibly limited resources to a large number of people who are dying. And that should not be underestimated, in terms of its effect on the person, because fatigue and time that you're in a facility and that you're taking care of people can weaken your ability to do all of these rules the right way each time.

  • 10:47:04

    REHMLaurie Garrett?

  • 10:47:05

    GARRETTOne point I saw in the '95 Ebola epidemic is that of course all the foreigners are also taking anti-malarial drugs to protect themselves from acquiring malaria on site. Some of those drugs have the impact of affecting your psychological outlook rather severely. And you add that on top of this whole business of trying to deal with the emotional atmosphere -- it's easy to make a mistake.

  • 10:47:36

    GARRETTWe now know, in the SARS epidemic in 2003, in Hong Kong, the difference from one hospital to another in the rate of infection and death in health care workers was almost 100 percent about -- exactly what Dr. Fischer was talking about -- how you get out of your protective gear and whether or not you touch in the wrong sequence your mask, your gloves, your own face and end up actually contaminating yourself from your own equipment.

  • 10:48:05

    REHMDr. Lucey?

  • 10:48:07

    LUCEYYes. I'd like to follow Dr. Garrett's comment. I went to Hong Kong during SARS and then worked in a SARS designated hospital in Toronto, Scarborough General, in 2003, in June. And in both places there were very strict rules about the sequence of putting on your personal protective equipment, but, again, as Dr. Fischer said, even more importantly taking it off so that you don't inadvertently expose yourself and infect yourself to a virus that's on the protective equipment itself.

  • 10:48:36

    LUCEYAnd so there's always at least a two-person team when you had to put on your protective equipment. Someone to not just guide you, but to stop you if you're doing the wrong thing. You're not following the exact sequence.

  • 10:48:48

    REHMBut couldn't those two people -- once you're starting to take the uniform off -- couldn't they be affected by your bodily fluid?

  • 10:49:01

    LUCEYWell, certainly. I think as Dr. Fauci was alluding to, that -- they are at risk as well. And so you have to be very, very careful to follow very strict written criteria. And often there's a senior nurse or doctor or sort of a safety officer who would watch the process of putting on and taking off the personal protective gear.

  • 10:49:18

    REHMHow many health officials -- doctors, nurses -- do we know have died? Dr. Fischer?

  • 10:49:29

    FISCHERIt's -- that's a tough statistic to get a hold of because the majority of health care workers that become infected and die actually do so in the beginning of an epidemic, before it's recognized. And so I actually don't know the actual number of…

  • 10:49:43

    REHMDo you, Dr. Fauci?

  • 10:49:45

    FAUCINo. No, I don't.

  • 10:49:46

    REHMOkay.

  • 10:49:46

    FAUCIBut what Dr. Fischer is referring to is that when you start in the epidemic people are not on high alert the way they are right now.

  • 10:49:54

    REHMRight.

  • 10:49:54

    FAUCIAnd people come into the emergency room. You think somebody has malaria or a bad case of diarrhea and you're the emergency room physician. You put yourself at very high risk before the high alert comes out.

  • 10:50:04

    REHMLaurie Garrett?

  • 10:50:05

    GARRETTWell, the best estimate I've heard is 60, with the majority of them actually being the Red Cross workers who perform the heroic duty of trying to actually remove ailing individuals from their families in village level, and bring them into a quarantined facility. They're the ones that face attacks, resistance. They may get into a scuffle. Their protective gear may be compromised in the process. I know we're all very focused right now two heroic American physicians that are fighting for their lives right now with Ebola on the ground.

  • 10:50:43

    GARRETTBut their demise was preceded by the top physician from Uganda, who came into offer his services, having been in the Ugandan outbreak years ago. The number one physician for Sierra Leone passed away due to Ebola just this week. And, as I say, the best estimate we've got is about 60 health care workers…

  • 10:51:11

    REHMWow.

  • 10:51:11

    GARRETT…in an area that is very, very, very deficient in health care worker talent to begin with.

  • 10:51:18

    REHMAll right. To Zac, in Silver Spring, Md. You're on the air.

  • 10:51:25

    ZACOh, awesome. Thank you for taking my call. I just want to ask Dr. Fischer -- I read -- I've been tracking this whole thing. And I went to -- and I was in the hot zone before this happened so I have a really small idea of what ebola is. My question is that they said that it's related to ebola-Zaire. Could it still be possible spreading through the air that way? Or is it just only through direct contact with the fluid?

  • 10:51:51

    FISCHERSo thanks, Zac, for that question. It -- all of the epidemiologic studies that I've looked at transmission of Ebola, and including this virus, suggests that it's only through direct or indirect contact, but that it's not airborne.

  • 10:52:05

    REHMAll right. And, Dr. Fauci, I'm wondering about a vaccine.

  • 10:52:11

    FAUCIRight. Well, right now there are several candidates that are in development for a vaccine for Ebola. Some of them looking really quite promising. It's very interesting that years ago we began the development of a vaccine for Ebola and looked pretty good in a non-human primate model. One of the problems we faced is that it was very difficult to get pharmaceutical company interest in the development of that because of the fact that there were these mini-outbreaks since 1976. And up to the present time there were only, you know, about 2,200, 2,300 total cases.

  • 10:52:42

    FAUCIBut now we're seeing an intensive interest in it. There's a few candidates, one of which I might mention very briefly, Diane, is really looking good. It was -- a candidate was developed at the Vaccine Research Center at the NIH. We've done it in animals and it is very protective in animals, the challenge. And now we're getting ready to go in the early fall, likely the first week or two of September, in what we call Phase 1 testing in humans, to make sure it's safe and that it induces an immune response.

  • 10:53:14

    FAUCIThat, by necessity, will take several months. So that probably by mid-January we'll know if we have a vaccine that's safe and that can induce the response that we want. If we do, then pharmaceutical companies will get interested in gearing up and making it available, predominately to health care workers.

  • 10:53:31

    REHMAnd you're listening to "The Diane Rehm Show." Dr. Lucey, I want to go back to the bats. Have bats always been known to be carriers of the ebola virus?

  • 10:53:50

    LUCEYNo. They've been suspected for quite a few years. But it's only now with this outbreak that World Health Organization, U.S. Centers for Disease Control, and other organizations have really put a high likelihood that they are a source of the infection. But, again, along with multiple other animals, African antelopes, the chimps, gorillas, other animals that are often eaten as bush meat by people. And therefore, people can get infected.

  • 10:54:15

    REHMSo what I'm wondering is, is this something new in the atmosphere? Is this something new in the soil? Is this something new or is it one of those -- I mean, why these outbreaks, Dr. Fauci?

  • 10:54:36

    FAUCIWell, first of all, we don't know for sure. But if you look at outbreaks of new human diseases, about 70 percent of them are what we call zoonotic, Diane. They come from an animal to a human. So it is very likely that this virus has been around for a very long time, and it is only a -- circumstances of what likely happens is that there's human encroachment on environments that they were not in before, where people get in close proximity to different animals and that's how you get the spread.

  • 10:55:05

    FAUCIIt could be related to a mutation or not, that makes it more likely that it would then infect a human. But in direct answer to your question, it is likely that these viruses have been around for a very long time. And we just happened to notice the first outbreak that we were able to identify in 1976.

  • 10:55:22

    REHMLaurie Garrett, at this point, would you discourage yourself or anyone else you know from traveling to Guinea, Sierra Leone or Liberia?

  • 10:55:37

    GARRETTWell, personally, I go everywhere. So I'm a bad example, perhaps.

  • 10:55:41

    REHMWith a bad cold, I might add.

  • 10:55:46

    GARRETTYes. And apologies to the listeners for my fog-horned voice today and coughing.

  • 10:55:50

    REHMOh, listen, no apology necessary.

  • 10:55:54

    GARRETTBut, you know, what I would like to add is something that -- to what Dr. Fauci just said. You know, it's very interesting, Diane, that we see a long list of relatively newly recognized diseases, starting with ebola, Marburg, Nipah, Lissa (sp?), MERS, SARS. It's a long list, all of which seem to be associated with migratory fruit bats. And these are very shy animals. They live high in canopies of rainforests. They're the great pollinators of planet Earth, like bees to flowers, the bats are pollinating our rainforests.

  • 10:56:32

    GARRETTWithout them, we would have no rainforests. And yet, they're clearly stressed, these populations. I don't think the answer to your caller's question something intrinsic in the soil or of that nature. Rather, the question is are we so stressing these populations of bats that they're taking risks which these shy animals, these nocturnal animals would never normally take, coming closer to human habitation, coming closer to human agriculture because they're basically starving.

  • 10:57:07

    REHMAll right. And we'll have to leave it at that. Laurie Garrett, Dr. Billy Fischer, Dr. Daniel Lucey, Dr. Anthony Fauci, thank you all so much. We'll keep an eye on this. Thanks for listening all. I'm Diane Rehm.

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