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MIT Technology Review

The lessons we didn’t learn from Ebola

An interview with Christopher Kirchhoff, who wrote a post-mortem of the US Ebola response for the National Security Council.

Christopher KirchhoffChristopher Kirchhoff
David Vintner

What steps did the US government take after the 2014 Ebola outbreak?

An emergency spending bill that was passed by Congress in December 2014 included $1 billion that the administration used to address some crucial weaknesses. Many nations around the world didn’t have testing capabilities to be able to notice when a novel or really lethal pathogen emerges. Using that money, we partnered with more than 60 countries to introduce much more widespread testing capability to detect pathogens when they first emerge. Then we conducted a country-­by-country assessment of how strong their emergency response and public health system is and worked with each country to strengthen their preparedness and response capabilities.

We also established a network of Ebola treatment centers: 35 hospitals across the United States, plus a number of labs that were designated by the federal government. If somebody were to come down with Ebola or another highly lethal pathogen, they wouldn’t be more than two hours away from a hospital that was designed to treat them.

Another thing that was really important was the creation, toward the end of the Obama administration, of a new office in the White House called the Global Health Security Directorate.

This new office within the National Security Council had two functions. The first was to coordinate the response in the event of a future crisis. The second purpose was that it would be responsible for seeing through substantial structural changes in many departments and agencies. These were the kinds of reforms that wouldn’t happen on their own, without organized follow-through from the White House.

Can you go into a little bit more detail on what those structural changes were?

On the domestic side, the very small number of Ebola cases that we had in the US showed major gaps in how federal, state, and local authorities responded together. Because the US has a federal system where most public health authorities are actually at the local levels, but most capability is at the federal level, we had to have tighter coordination in the future to respond.

On the international side, we discovered whole new doctrines for how to respond to an outbreak abroad by using different capacities in government. Never before had the military been used to support civilian health responders in the way it was in West Africa.

Do you think the existence of an office like that would have made a substantial difference to the prevalence of the novel coronavirus in the US today?

Yes. The office was dissolved in May 2018. But Ebola taught us that there’s an incredible penalty for inaction, because epidemics grow exponentially: every day you delay responding, you end up facing a steeper exponential curve that makes the situation quickly transition from what would have been manageable to something that’s unmanageable. This is where we are today. You have to imagine that the presence of an office well staffed with professionals in emerging infectious diseases would have been able to help the US government be more nimble in those crucial early days, when more capabilities could have been brought online and could have been ready to help us get ahead of the curve.

What do you think might have happened had the Obama administration not sent nearly 3,000 military personnel to West Africa?

I think you would have seen the epidemic continue the way that it was growing in August 2014, when it was doubling in size every three weeks. Although the three countries where the outbreak was concentrated don’t themselves have high rates of international travel, there are land routes to other African nations. One scenario that people worried about tremendously was Nigeria—not only having the mega-city of Lagos, but in the north of Nigeria having insecure conditions with an Islamic insurgency that might well have prevented international health responders from accessing those who needed care, which could have resulted in Ebola becoming endemic in Africa.

Has the role the current administration has given to scientific research limited the effectiveness of the US government response?

I think it’s unavoidable to talk about the fact that the CDC [Centers for Disease Control] budget has been significantly decreased, that administration budgets have continually advocated for dramatic cuts to research and development. Programs oriented to delivering therapeutics and vaccines have been affected in this process. And in an emergency like this, you want to have more of them.

What role did the private sector play in 2014, and what can be done today?

There were tremendous contributions during the Ebola outbreak from both the private sector and the philanthropic sector. Paul Allen pledged $100 million to fight Ebola, and his foundation developed an ability to safely transport people infected with Ebola on airplanes so they could be medically evacuated. This was a capability that the US military didn’t even have. We’re seeing the same thing today, where the Gates Foundation stepped up in Seattle and rolled out test kits before the government was able to.

At Schmidt Futures, the philanthropy I work for, we’re doing a lot of thinking about the role technology can play. One of the efforts we’ve already funded is using online education tools to train people to use ventilators. It turns out that we have very few ventilators, but we have even fewer people able to operate them.

Another example: there’s a great race among technologists in Western countries to be able to do location-based, smartphone-enabled contact tracing in a privacy-protected way. There are several different architectural approaches to this. It could be an enormously powerful tool—particularly toward the latter stages of an outbreak, when you revert from a situation with widespread community transmission to just a few carriers who nevertheless still infect others. Just like in Ebola, contact tracing is the only way, at the tail end of an outbreak, to ensure that an outbreak is stopped in its tracks. This gives technologists an important window to experiment with different capabilities that could be enormously important if they were to come online two to four to six months from now.

How optimistic are you that we will learn lessons from what’s going on now that will enable us to be much more effective in fighting epidemics in the future?

What we are living through now will be hard to forget. So I think there will be an intense focus on how to prevent an outcome like this in the future, but there will be no substitute for leadership to see through the very significant changes that are necessary if we want to grow our capacity on all fronts for outbreaks.

I think there’s an enormous opportunity for Congress to lead on making investments that not only will help us respond today, but will help us grow the capacity of our response systems in the future. Investments in helping hospitals all across the United States be able to surge capacity in the event of an emergency; investments in our ability to rapidly produce diagnostic testing; investments in our public health infrastructure at the state and local level; investments around the world, particularly in nations that are not themselves well equipped to confront the outbreak of novel diseases. And that work can begin now.

This interview has been condensed and edited for clarity.