In May, an outbreak of the Ebola virus was officially declared in the eastern Democratic Republic of the Congo. Aid groups are warning that it could become the deadliest Ebola outbreak in history.

On this episode, Dan Richards spoke with two experts about why this outbreak is uniquely concerning, what the global health community needs to do to respond effectively, and how U.S. international aid policy under the Trump Administration has affected the trajectory of this public health crisis.

Guests on this episode:

• Dr. Adam Levine is a professor of emergency medicine and international and public affairs at Brown University, who has led research and training on emergency medicine, including during the 2014 Ebola outbreak in Liberia.
• Dr. Craig Spencer is an emergency medicine physician and an associate professor of the practice at Brown University’s School of Public Health. He has worked around the world on frontline preparedness for health emergencies, including in Guinea during the 2014 Ebola outbreak.

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[BRIGHT MUSIC]

DAN RICHARDS: From the Watson School of International and Public Affairs at Brown University, this is Trending Globally. I'm Dan Richards. In May, an outbreak of the Ebola virus was officially declared in the Eastern Democratic Republic of the Congo for reasons having to do with biology, geography, and politics.

Aid groups are warning that this could become the deadliest Ebola outbreak in history. As of this taping, there have been over 1,000 confirmed cases and over 200 deaths. So why is this outbreak uniquely concerning? How should the global health community be responding to it? And how are changes to international aid policy in the United States affecting the potential trajectory of this crisis?

To help explore these issues, we have two guests on this episode. Dr. Adam Levine is a professor of emergency medicine and international and public affairs at Brown University, who has led research and training on emergency medicine, including during the Twenty Fourteen Ebola outbreak in Liberia.

Dr. Craig Spencer is an emergency medicine physician and an Associate Professor of the Practice at Brown University's School of Public Health, who has worked around the world on front-line preparedness for health emergencies, including in Africa. Adam, Craig, thank you for coming on the show.

ADAM LEVINE: Thank you.

CRAIG SPENCER: Glad to be here.

DAN RICHARDS: So before we get into some of the policy and the politics affecting this outbreak, I wanted to start with the virus and the disease itself. For listeners who maybe have spent a lot of time in the last six years learning a lot about respiratory illnesses like COVID, how does the Ebola virus work, and how is it different from a respiratory illness like the flu or COVID?

ADAM LEVINE: So the Ebola virus is a very simple type of virus, and it actually is only protected by a very thin lipid membrane, which means that it's very easy to kill the virus. It's very easy to disrupt it. Lots of different types of disinfectants that we have, from alcohol to chlorine, even dedicated sunshine and UV light can destroy the virus.

It's also not as transmissible as respiratory viruses like COVID. And so you can't walk into a room and somebody coughs and then you get Ebola that way. It's only transmitted by bodily fluids. And so one of the things that we know about the disease is that anybody who is coming into contact with the body fluids of sick people, which is not a large portion of the population, but it's a very specific group of folks, is going to be most at risk for getting the disease.

So that includes the obvious people like healthcare workers. I like to say nobody spends more time immersed in the body fluids of other human beings than nurses, for instance. But also, we can't forget that in many rural areas and rural villages, it's really families that take care of sick people. And it's especially the female head of household who often is taking care of sick spouses, neighbors, children, elderly people.

And so, not surprisingly, middle-aged women, middle-aged very broadly going from 20 to 40, 50 is a demographic that's also at high risk. And then lastly, Ebola is different than other infectious diseases, in that it can still be transmitted by a dead body-- so after death.

The vast majority of infectious diseases, even if they kill you, once you die, you can't transmit them to anybody else. But Ebola is one of the very few where if you are involved in burying or preparing a body that has died from Ebola, you're at risk for getting it if you're touching the body directly and connecting with its body fluids, et cetera.

DAN RICHARDS: And what's the fatality rate of Ebola compared to say, COVID? Is it a more dangerous disease to contract?

ADAM LEVINE: And so that is the negative side of it. Ebola is a lot more difficult to contract than COVID, but it is far more deadly than COVID and far more deadly than most diseases, most infectious diseases that we know of. And so it's hard to get exact statistics, because Ebola outbreaks often aren't always recorded, and there have been a lot in history that have not been recorded well.

But from the more recent outbreaks where we have pretty good numbers, depending on the strain of the virus, mortality can be upwards of 50%, 60%, which is incredibly high for an infectious disease. Even at its worst at the beginning of the COVID outbreak, before we had any vaccines, before we had any of treatments for it, mortality was still less than 1%.

DAN RICHARDS: Craig, while you were treating patients in Twenty Fourteen in West Africa, you yourself contracted Ebola. You became symptomatic in the United States and were treated and recovered in New York City. And it became a news story at the time.

I wonder what that experience was like and how really it changed how you think about this disease more broadly.

CRAIG SPENCER: Yeah. I had worked at treating patients in Gueckedou in Guinea and in an Ebola treatment center. I was probably taking care of 30 to 40 patients at any one point. There was not enough nurses. There weren't enough physicians. And a lot of it was, unfortunately, pretty brute triage.

If you think of the numbers, imagine 30 patients that you have to take care of, and you have maybe three to four hours a day inside the treatment tent in your personal protective equipment. So if you just do the math of 180 minutes divided by 30, you don't have that much time to take care of each patient.

And doing something as simple as putting in an IV, something Adam and I have done thousands of times in emergency medicine, becomes a really, really difficult task. It means you have to fumble with double pair of gloves. And it's really hot. And you know in the back of your mind that if you get a needle stick injury-- meaning that you put a needle in an Ebola patient and for some reason you get poked as an accident, like your mortality is like 100%. You get such a high viral load.

So this is all in the back of your mind as you're doing this. And it's also just in the context of Ebola is very scary. You see what it does. You see how in the span of a few hours, it can take someone from looking like maybe not great, but not horrible, to being dead.

And seeing that play out every single day and then being afflicted with the same virus despite being back in a place where healthcare was much better, you think a lot about your mortality. And people ask me, when I was infected, did I think about dying? Of course.

I just had seen Ebola indiscriminately it seemed take the lives of so many, despite everything that we had tried to do in the treatment centers to lower mortality. And so I look at my own experience of spending 19 days in a hospital in New York City being treated for Ebola as the best case of the worst case scenario.

It was the worst case because as Adam pointed out, Ebola is horrible. It has an incredibly high mortality. It's essentially a coin flip. But I was treated in a high class and very good quality facility in New York City. This undoubtedly increased the likelihood I would survive. And from that moment on, I've thought about the disparity between the 30 to 40 patients I would be taking care of at any one point and the 30 to 40 providers who were likely involved in my care at any point.

And what I keep coming back to, and I'm thinking about this now in the outbreak in Congo, is that in Guinea, Liberia, and Sierra Leone in Twenty Fourteen, there were probably as many doctors in those three countries combined as there were in the one hospital where I was treated in New York City, at Bellevue Hospital-- around 15 to 1,600 physicians.

And in the span of the outbreak in Twenty Fourteen to Twenty Sixteen, between 6% to 8% of physicians died of Ebola during that outbreak. And as you've seen, as Adam pointed out, this is a disease of compassion in that it affects those who care for others. We're seeing this play out similarly.

Now we see health care workers on the front in Congo being infected at much higher rates. And so I was lucky in that I had the best case of the worst case scenario. The question is-- and one of the questions we've had over the last decade is, how do we improve the quality of care to patients in Ebola outbreak, something we've done a bit better with.

But how do we make sure that we can stop people from being infected-- so vaccines-- as well as improve their treatment, some of which we've made some headway on, some of which we still have a lot to do.

DAN RICHARDS: Well, and you both have done a lot of work to help treat people and help us figure out better ways to respond to this crisis. That said, a lot of experts warn that this could be the deadliest outbreak, as I mentioned, of this disease, for a variety of reasons.

And I wonder, when did you both start to sense that this particular outbreak might prove exceptionally or uniquely difficult to contain and devastating? Maybe Adam, we'll start with you.

ADAM LEVINE: It was the day I first heard about it in May, honestly.

DAN RICHARDS: And why was that?

ADAM LEVINE: Because typically in the past, Ebola outbreaks have been first declared with a handful of cases, less than a dozen. This was declared with hundreds of cases, suggesting that there were already multiple chains of transmission that, by definition, weren't being followed up on because the outbreak had just been declared.

And there are so many reasons for this. It was a different strain. And so the diagnostic testing they were looking for was set for the old strain or the other strain and didn't pick up on this strain until many, many cases had already presented. And then we can go into far more detail in the policy section about breakdowns in the healthcare system and the ongoing conflict and geopolitical situation in DR Congo, but for a variety of reasons, this outbreak got caught very late. And so that means that it's much, much more difficult to bring under control.

DAN RICHARDS: And as you mentioned, this outbreak is being fueled by a different rarer strain of the virus, the bundibugyo strain, that was not seen in Twenty Fourteen and is not one that we have a treatment or a vaccine for.

ADAM LEVINE: That's correct. Yeah. So the Zaire strain has been the most common over the last 50 years since Ebola was first discovered. And it was the cause of the main outbreak in Twenty Fourteen, Twenty Fifteen. That was the largest on record and then also the cause of the second largest on record, which was in Twenty Eighteen, Twenty Nineteen, in DR Congo.

And so I was involved in the PALM trial back in Twenty Eighteen, Twenty Nineteen that identified the first treatments for Ebola that were effective-- a couple different monoclonal antibody cocktails that showed a very significant reduction in mortality. And unfortunately, as far as we know, those don't work for this particular strain. So we're almost back to the beginning of where we were in Twenty Fourteen without an effective vaccine or effective treatments that are directed towards this virus.

DAN RICHARDS: Craig, what has stood out as most concerning to you about this current outbreak?

CRAIG SPENCER: As Adam pointed out, the moment I heard about it, I was concerned because it was bigger at the beginning than most outbreaks are at the end. It also was detected the same day, hundreds of kilometers away in Kampala, the capital of Uganda, the most populous city.

And also you saw very soon the number of cases along the Eastern border with DR Congo. And I've learned the hard way of working a bunch in Eastern Congo, this is an incredibly difficult place to live and work. It is beset by conflict, as has been mentioned. It's really hard to get from point A to point B. The span of 20 to 30 miles can take a whole day, given the quality of roads.

So the fact that you had so many cases so far away and in so many different places all at once, particularly along the Eastern border, in a place where it's really hard to move around, made it clear to me at the outset this had already been spreading for months.

And having in the ensuing days spoken to folks that were working on the ground, many organizations were already using their PPE protocols for Ebola. They had sensed that something was off. Healthcare workers for some organizations had already been getting sick for a couple of weeks, if not longer.

And as Adam has pointed out, they did the testing for the Zaire strain, which kept coming back negative. And part of the problem is that the bundibugyo strain has only been seen two other times before. And so it's something that we knew about and were certainly concerned about and should have been on our radar, but wasn't ultimately tested until much later than it should have been for a whole host of reasons.

And because of this, you're now trying to catch up to an outbreak that would have been really hard to manage in ideal conditions. And Eastern Congo is anything but ideal in terms of trying to manage an Ebola outbreak. It is like the worst case scenario in many respects.

DAN RICHARDS: Well, and another issue is that there is an armed conflict going on in the Eastern Democratic Republic of the Congo that's been going on for a long time, but has really escalated in the last year or so. And it has forced millions of people out of their homes in the region. How does an armed conflict like this affect-- obviously, it has its own medical emergency consequences, but how does it affect the spread of a virus?

ADAM LEVINE: Yeah. We actually did some research in Twenty Twenty-One and Twenty Twenty-Two, in the same region of Eastern Congo. It was funded at the time by the US State Department. And we did interviews with community members and key informants, specifically looking at the security situation and how it impacted the prior outbreak at that time-- the Twenty Eighteen, Twenty Nineteen outbreak of the Zaire version of Ebola.

And one of the things that we learned is, firstly, it's an incredibly complex situation. It's not just like two separate warring parties fighting each other. There are multiple different militia groups that are fighting with each other and also fighting the armed forces of Congo, as well as police forces of Congo at that time as well. And still now to a certain extent, there was a UN peacekeeping force which was involved in various ways as well, though not to the extent that the population would have liked them to be.

And so you had, on the one hand, multiple different forces that were fighting each other, causing multiple different internal displacements in the region. So one village would be displaced to another village, and then later that village would be displaced to another village.

And so you layer an Ebola epidemic on top of that, where now all of a sudden these same actors that are failing to protect the population from violence are being asked to be trusted with treatment and vaccination campaigns and so forth for Ebola, and you have a population that's just distrustful from the beginning. They distrust their government. They distrust the UN. And so that's going to make it a lot more difficult. And so you had a very complex situation.

DAN RICHARDS: Craig, you also mentioned that cases have been reported in Kampala-- the capital and largest city in Uganda. For a disease like Ebola, that as I understand it, is usually found in more rural areas and small towns, what does it mean to see cases pop up in a major city? And does that change how you think people are thinking about the trajectory of this outbreak?

CRAIG SPENCER: Yeah. Obviously the spread to big cities is remarkably concerning. This was one of the big issues in the Twenty Fourteen outbreak, is that you had Ebola pop up at the confluence of three different countries-- Guinea, Liberia, and Sierra Leone-- despite the fact that Uganda has a very long history of managing Ebola outbreaks, and I think so far in this outbreak is managing quite well.

If you look at the numbers, their contacts, their cases, what they're doing in terms of trying to prevent further spread, it's quite remarkable. On the other side, you have big cities in Eastern Congo. Goma, for example, is the biggest one that I'm concerned about, has hosted many Ebola outbreaks before.

But as Adam pointed out, this has been a place for decades. It has been one of intense instability, and this has made it difficult for responders to come in. And so you have this challenge, but layered on this challenge, USAID and many of the organizations that had been supported by USAID have lost a lot of their funding, have pulled back their response capacity essentially overnight pulling out a lot of humanitarian support. That was the backbone of healthcare in Eastern Congo.

DAN RICHARDS: Well, and let's look more at this role the US has historically played and how it's changed, as you both have already been bringing up. And you mentioned USAID, which had long been one of the largest funding sources of international humanitarian aid, which the Trump administration dismantled last year.

The Trump administration also withdrew the United States from the World Health Organization. Maybe let's start with USAID, though. What role did the agency historically play in responding to outbreaks like Ebola? How important were they to response to these types of crises?

CRAIG SPENCER: USAID was great, one, as a trusted partner. So it would work on behalf of the State Department, on behalf of CDC and others in creating relationships and maintaining them long before outbreaks occurred, which is essential. But USAID, in the midst of an Ebola outbreak, would do the unsexy work of making sure lab facilities were in place and were able to transport around a country, for example.

They would work with the country to make sure that screening was set up at the airport, which is sometimes expensive and labor-intensive and may not be the number one priority of a country. But for people like the US to make sure that this didn't lead to regional spread, they'd make sure that people are getting screened before they got on a plane in Entebbe or in Kigali.

USAID also was really important for a very long time of helping support things like PEPFAR, which not only saved tens of millions of lives for HIV, but helped establish capacity in labs and surveillance in many, many, many countries so that they were capable of not just responding to the HIV pandemic, but also detecting and responding to things like Ebola or hantavirus or other outbreaks.

It's important to add on top of that is that with the loss of USAID, what the US has been moving towards over the past year, and it's America first global health strategy, is less an approach of multilateral engagement with WHO, more towards these bilateral deals with individual countries, one of which is the DR Congo, another which is Kenya, and many others on the African continent, where in return for, it may be massive amounts of data, unrestricted access to data or mineral rights, the US is giving some global health assistance in return.

This is the approach of the administration and how they want to streamline global health support and security. What this does, unfortunately, is it gets rid of that multilateral and that multi-country aspect and understanding of the way you respond to outbreaks is not just in an individual country. It's more of a piecemeal approach to global health security that I think is probably a losing strategy when what we need is a more comprehensive approach to surveillance, detection, and response.

ADAM LEVINE: Yeah. Just to add on to what Craig's saying, I'll make two points. Number one, as we all know, prevention is always better than cure. But more importantly, prevention is always cheaper than cure. And so by breaking down the surveillance systems that USAID had been funding previously in Eastern Congo, it led to the ability for this outbreak to get out of hand quickly and will lead to the ability for other outbreaks to get out of hand all over the world over the coming years, unless we find ways to rebuild those health care systems.

Our global health security, as we call it here in the US or anywhere in the world, is only as good as the knowledge of the front-line provider on the ground in whatever setting the virus is emerging, whatever virus it is. And number two, once we do wait for the response, response to Ebola in particular is very expensive.

The Ebola treatment center that I ran in Liberia cost $1 million a month to run, and that's partly because you have to literally burn through hundreds of thousands of dollars of PPE every month - of personal protective equipment - and you need all sorts of structures in place to make sure that your staff aren't getting sick.

And so those types of costs are not things that typically humanitarian organizations can fund on their own or with funds that they receive over Facebook or through their own advertising campaigns. A lot of those are funds that they receive from governments, and particularly USAID in the past, to be able to afford the high cost of running those types of responses. And without those funds in place, the humanitarian organizations that know how to respond to this outbreak are not going to be able to do it well.

DAN RICHARDS: Do you think if USAID had been operating over the last year, like it had been in prior years, that this strain of Ebola, this outbreak would have been detected earlier?

ADAM LEVINE: Obviously, it's impossible to for certain, but I would say it is much more likely that it would have been detected earlier and that there would have been a more rapid response to it.

CRAIG SPENCER: I would say I fully agree with Adam. I don't know if it would have been detected a day earlier or a week earlier or a month earlier. I think it's highly likely that it would have been detected earlier. In an Ebola outbreak, getting delayed by two weeks can be incredibly problematic because it may double or triple the number of transmission chains.

It makes it that much harder to find out where the virus has been and where it's moving. And so even if it was a day or a week or a month, having detected this earlier would have been highly beneficial in terms of managing the overall outbreak.

I think we're at a point now where based on the epidemiology, looking at the situation reports that are coming out, talking to people on the ground, I think the actual case count of just over thousand cases is a dramatic under-count. I suspect that it's much, much higher than that, probably at least double.

I also suspect that a lot of the numbers that we're seeing that we're following, like the number of contacts that are being followed up, is not reflective of the actual reality, which is that we're probably following maybe a small fraction of the number of people that have been in contact with an Ebola patient.

The result is that you have multiple transmission chains that are continuing to spread the virus into unknown corners, into communities that may not be aware, and that just makes it that much harder to get a full visibility on where the epidemic is at, how big it is, and what are the resources that are needed to put it to bring it under control.

DAN RICHARDS: You both have painted a really vivid portrait of the importance of preparation and stopping this disease before it spreads. But I want to argue on behalf of the way the Trump administration has changed this type of international aid in their administration.

And they claim that by shutting USAID and reducing international aid funding, they've been eliminating a bloated bureaucracy that inefficiently funds groups around the world. And we have to be more efficient with our resources, something like that. And I wonder, what do you both as doctors and as just experts of public health, what do you make of that argument?

CRAIG SPENCER: I'm happy just to start by saying, the amount of money that we spent on USAID was famously quite small, particularly in return for what we got, which was kind of eyes and ears in clinics all over the world to detect these Ebola outbreaks early. As a kind of tangible impact of this, one of the Marburg outbreaks in Tanzania a few years ago was detected by a community health worker that had received support from a CDC training program but also with support of USAID for these surveillance networks and places.

You detected those things early, and that's great. There has been this argument that there has been wasteful spending in things like USAID, and I am certainly not here to defend USAID fully. There are obviously things that could have been improved, as with any other government organization, I think we can all argue.

USAID was not perfect, but it was remarkable at what it was capable of doing with disease surveillance, with creating those relationships, with supporting programs like PEPFAR. The problem is not necessarily that the administration wants to change these relationships. I think there's a whole host of things that can and should be changed.

The problem was is that we did all of these things essentially overnight. We withdrew funding for so many programs that had been in place for decades. And so within just hours, many clinics had shut down. People were unable to access HIV medications. The number of deaths from HIV has gone up over the past year. People have lost their jobs. Anti-American sentiment has followed in the wake.

And so now what we're trying to do is after tearing down systems that had been in place for decades, trying to put in place new ones that may not be as effective, may not be cost effective, and may not be able to do the things that we need them as the US to do, which is detect diseases and outbreaks earlier and help put an end to them.

ADAM LEVINE: There is no question that USAID had multiple levels of bureaucracy in it, and a large portion of the funds went to that bureaucracy and to various middlemen. Now, a big reason for that was because it was incredibly important for us to ensure that none of the money ever went to organizations that it shouldn't and that none of the money ever was pocketed or used in a corrupt way.

And if you want to be absolutely certain of that, you need multiple levels of bureaucracy. But I would also say, do you know what other government agencies are inefficient and bloated? The Department of Defense. And nobody would ever think that you would throw the Department of Defense into the chipper in order to eliminate that inefficiency and then rebuild it from scratch. You would come up with a plan for how to step by step figure out where the inefficiencies are and how to improve them, and that is not what they did at all.

DAN RICHARDS: Just briefly, I'm curious also how you think about the US's withdrawal from the World Health Organization. I think a lot more has maybe been made, at least among non-experts, on the dismantling of USAID. But what does it mean for the United States to not be part of the WHO?

ADAM LEVINE: It means that the US is not getting access to information as it should about not just Ebola, but every single disease around the world. When there is flu in Argentina, and we're trying to plan out what our flu vaccine is going to look like the next winter here in the US, we're not getting that same information that we would have as part of WHO.

So it's not just that we are not contributing to the health of the world in the way that we were before, we are undermining the health of our own people. We're shooting ourselves in the foot, essentially.

CRAIG SPENCER: Yeah. I think that over the past month, we've seen the WHO do a really remarkable job in Eastern Congo, in Uganda. Yes, this was detected later than it should have been. But you saw Dr. Tedros, the director of the WHO on the ground, speaking to communities.

You saw him similarly just weeks before with the hantavirus outbreak, on board the Dutch cruise ship, helping manage that. The reality is it's not just Ebola outbreaks that are increasing in frequency, they are, but it's other concerning outbreaks that have worldwide potential for global spread.

And we need an organization like the WHO to help coordinate that response globally. We can't do this bilaterally with every single country. And I think the more that we cut down on these relationships and kneecap something like the WHO, the more vulnerable we're leaving ourselves to concerning outbreaks as we go forward.

DAN RICHARDS: Do either of you think there is a risk that this outbreak could make it beyond its geographic region right now. It could make it even into the United States?

ADAM LEVINE: I mean, absolutely it can spread beyond the geographic region where it is now. And there are a number of countries. South Sudan was mentioned, which is right across the border and has an even weaker healthcare system in some ways than Congo. But plane rides are very easy. And this could also spread to other countries in Africa especially and become even bigger. One case in Lagos, for instance, could spread to millions of people there.

In terms of coming to the US or Europe, there's no question that it could. It did in the Twenty Fourteen outbreak. The likelihood of it spreading widely in the US or Europe, though, is small, mostly because of the fact that, again, it's not a very transmissible disease, when you have protections in place, places where people have good sanitation and water and so forth. But certainly it's very possible that if it spreads more widely in Africa, that eventually it'll find its way to our shores.

CRAIG SPENCER: The US has said our number one priority is keeping the ball out of the US, which sounds great at face value, but our number one priority actually needs to be making sure we take care of the outbreak where it's at, because the larger we allow it to get, the more we allow it to spread, then the risk of regional outbreaks become higher, and the risk of a case getting on a plane and coming to the US only grows.

And there is absolutely no way we can build a wall tall enough or thick enough to keep either Ebola or other viruses out. Even if we put in place a whole host of measures on travel restrictions, et cetera, I still don't think that's going to be 100% effective. I worry what that signals about how seriously we're taking this and how we're managing this.

The number one priority needs to be managing this at its source because doing anything other than that just dramatically increases the risk over the longer term of a bigger outbreak and greater likelihood of transmission here in the US.

ADAM LEVINE: Yeah. I mean, we learned during COVID pretty much the vast majority of countries on the planet put up travel restrictions to the vast majority of other countries on the planet, and none of it did anything because every country got COVID at the end of the day.

So those sorts of travel restrictions are not the way to protect your population. The way to protect your population is to make sure that the disease doesn't spread any further than it has to.

DAN RICHARDS: So looking ahead at the most important steps for stopping this crisis, as you said, both it's one part is clearly investing in containing it where it is right now. Another component, I'm curious about your thoughts on, is finding a vaccine or a treatment for this disease. How important is that as part of the path to containing this crisis, or might it not be?

ADAM LEVINE: Well, I think it's incredibly important because this will not be the last outbreak of bundibugyo.

DAN RICHARDS: Of course.

ADAM LEVINE: And it'll be very important for us to contain future outbreaks. And that's why I think research is also an underappreciated part of the humanitarian response, because if we don't learn from the crisis that we're in, then we're going to be doomed to repeat it again in the future because these crises will keep happening.

There is an effort now, similar to the PALM trial that I was part of in DR Congo in Twenty Eighteen, which discovered the first effective treatments for the Zaire version of Ebola. There is an effort now to get a similar trial up and running of a monoclonal antibody to actually be able to treat not just the bundibugyo version, but also all Ebola versions. So it's trying to target a part of the genome that is common among all the Ebola viruses.

I also know that there are trials planned for vaccine as well, which would be ideal to have if not during this outbreak and future outbreaks.

DAN RICHARDS: Because often, or it has at least been the case in the past, that the vaccines aren't ready and have gone through their trials until after the peak of the outbreak. So it may not be that important in the moment.

ADAM LEVINE: Yeah. But MSF worked to develop the vaccine against Ebola in Guinea in Twenty Fourteen and Twenty Fifteen. And then that vaccine was available in future outbreaks in Congo to be able to contain it. And probably those outbreaks would have been much bigger without that vaccine.

CRAIG SPENCER: My suspicion is that this outbreak is going to last quite some time. I think a year to two years is probably likely. And in that time, hopefully, we can get those trials up for these vaccine candidates, which will, as Adam said, be really important. This is not the last bundibugyo outbreak that we're going to have.

But I want to go back to something else that Adam said, which is that those treatments that we have for Ebola Zaire, the US, was the main funder of these treatments. So the US put in somewhere like $800 million. These are essentially owned by the US and by pharmaceutical companies, despite the fact that they were created from the blood of a Congolese survivor.

They were trialed in Congo, but in recent outbreaks in the Congo, it was hard to access this treatment because essentially you need to beg and plead with the US government to deliver doses and to donate them. And it's essential that we don't get to the point in the aftermath of this outbreak where we have these great treatments that are largely inaccessible to the populations that created them, that trialed them, that need them at the time when they're most in need.

DAN RICHARDS: One last question as we wrap up. If the United States, through USAID or through other types of international aid, is no longer willing to really be the kind of backbone, the anchor of so much of this type of international public health work, who or what do you both imagine could fill that vacuum?

If a new administration doesn't come in and reinstate all of it as it had been before the Trump administration, what might this look like going forward?

ADAM LEVINE: So I think here there's both a short term and a long term answer that are probably very different. So in the short term, there aren't a lot of other options to fill this gap, unfortunately, because the usual suspects that you would turn to, like the European Union and Japan and maybe China, Gulf countries, those countries that have the money to put into this are not stepping up.

And in fact, many of them are actually similarly cutting back and following the US trend. And it's not noticed as much because they weren't as big a part of the funding. But it is being noticed. My hope is that there will be a wake up call. Perhaps this Ebola outbreak will be, and both the US and other countries will start to step in and fund humanitarian response, if not at the levels that we were before, but at least at a higher level than we are now.

In the future, I think the future of humanitarian response is going to be regional, and hopefully we'll be at a point where the Africa CDC and the Africa Union will have the capabilities to respond to crises like this within the borders of Africa. I think humanitarian crises often overwhelm the capacity of an individual country.

But at the regional level, there's the ability to have a robust response that's going to take many, many years to train up a sufficient number of responders at the local level and also to have the infrastructure and the funding and mechanisms in place. But I do see that as the future.

And we do have some examples of that future already today. The AHA Center, which is based in Jakarta in Indonesia, is the disaster Response Center for the Association of Southeast Asian Nations. And they are actually already quite effective and able to tell the US and Europe often, we don't need your help because we're responding within our own region.

In the Caribbean, there's a similar center that is also well functioning. And so we do have some examples of this. The EU, of course, has its own regional response mechanism within the EU that's very effective. And so I do hope that within the next decade or two, we will have that sort of system in places like Africa.

DAN RICHARDS: Craig.

CRAIG SPENCER: I would add that there's opportunity in entropy. And I would argue that in fact, don't want to put back in place USAID part and parcel, nor do we want to rely solely on these bilateral agreements that the Trump administration is putting in place to protect us from infectious threats or to make sure that the surveillance that we need is in place in places all around the world.

But the reality is that the US is going to need to play a big role because none of these things are going to ever stay hyper local. Ebola outbreaks are only increasing. Other outbreaks are only increasing. We have an incentive to not only be aware, but I think for a long term-- and I do strongly believe that the majority of Americans at their heart believe the apocryphal Tocqueville saying of America is great because America is good. And when it stops being good, it stops being great.

And we know that we have long had a role in providing security, responding to outbreaks, ensuring surveillance systems are set up. I suspect that we're going to get back there. But what that future looks like and how we do that in a way that's both respectful to other countries but also responsive here, I think that's still to be seen.

[BRIGHT MUSIC]

DAN RICHARDS: You both have given us a tremendous amount to think about, both in terms of this current outbreak and the future of global public health. So, Craig Spencer, Adam Levine, thank you both so much for coming on to Trending Globally.

ADAM LEVINE: Thank you for having us.

CRAIG SPENCER: Such a pleasure. Thank you.

DAN RICHARDS: This episode was produced by me, Dan Richards, and Juliana Merullo. Our theme music is by Henry Bloomfield, with additional music by Blue Dot Sessions. If you enjoyed this episode, leave us a rating and review on Apple, Spotify, or wherever you listen to podcasts.

And if you haven't subscribed to the show, please do that too. If you have any questions or comments or ideas for guests or topics for the show, send us an email at [email protected] Again, that's all one word, [email protected]. We'll be back soon with another episode of Trending Globally. Thanks.