WEBVTT - The End of Ebola 0:00:15.356 --> 0:00:23.276 Pushkin from Pushkin Industries. This is Deep Background, the show 0:00:23.316 --> 0:00:26.316 where we explored the stories behind the stories in the news. 0:00:26.716 --> 0:00:32.956 I'm Noah Feldman Today some good news. The Yubola outbreak 0:00:33.036 --> 0:00:36.196 in the Democratic Republic of Congo seems to be coming 0:00:36.236 --> 0:00:40.676 to an end finally. Since the outbreak started in August 0:00:40.796 --> 0:00:45.596 twenty eighteen, over two thousand people have died, but now 0:00:45.916 --> 0:00:51.916 infection rates are measurably slowing down. Plus, in other good news, 0:00:51.916 --> 0:00:55.036 a vaccine for yubola is likely to get approved by 0:00:55.076 --> 0:00:59.116 the European Commission very soon. That means that there is 0:00:59.196 --> 0:01:04.756 now a potential prospect of substantial reduction of future outbreaks. 0:01:05.476 --> 0:01:09.556 To learn more about these important developments, I spoke to Pardisa, 0:01:09.636 --> 0:01:11.956 who's a cutting edge biologist at Harvard and at the 0:01:11.996 --> 0:01:15.716 Broad Institute. Partis was actually in West Africa during the 0:01:15.716 --> 0:01:20.276 twenty fourteen Ebola outbreak researching the disease, on which she's 0:01:20.276 --> 0:01:24.716 made important scientific contributions. I started by asking her exactly 0:01:24.756 --> 0:01:29.076 how the ebola vaccine works. Ebola as an RNA virus, 0:01:29.236 --> 0:01:31.716 so some viruses are made of DNA and some are 0:01:31.756 --> 0:01:35.196 made of RNA. RNA is a less stable sort of 0:01:35.236 --> 0:01:39.516 the thing that makes copies of it is has more 0:01:39.836 --> 0:01:44.036 mutations in it. So RNA viruses mutate faster, and flu 0:01:44.196 --> 0:01:47.356 and ebol are both RNA viruses, but then those are 0:01:47.396 --> 0:01:51.476 even within them those there's differences. You know, HIV and 0:01:51.556 --> 0:01:54.276 flu are really hard to develop vaccines for because they 0:01:54.316 --> 0:01:58.156 have a lot of different versions of themselves and they change, 0:01:58.516 --> 0:02:01.876 you know, quickly, and ebola is not quite like that. 0:02:01.956 --> 0:02:05.396 It's actually not as difficult to develop a vaccine for. 0:02:05.516 --> 0:02:08.156 And that's sort of why we've seen such early, really 0:02:08.196 --> 0:02:13.316 good success. We're seeing really good, promising success of the vaccines. 0:02:13.676 --> 0:02:17.116 And why also, you know, so Murk has a lead 0:02:17.396 --> 0:02:19.916 vaccine that's being used in the DRC right now. A 0:02:20.036 --> 0:02:23.196 number of other companies like Johnson and Johnson and GSK 0:02:23.396 --> 0:02:26.196 had one. A lot of people are developing vaccines because 0:02:26.196 --> 0:02:29.156 they know that it's likely to be effective. Was there 0:02:29.156 --> 0:02:33.516 a single breakthrough or development over the last five years 0:02:33.556 --> 0:02:38.676 that made it possible for multiple companies to develop vaccines here? 0:02:38.716 --> 0:02:42.156 I mean, obviously was not really in contemplation when the 0:02:42.196 --> 0:02:46.756 disease was still poorly understood and when just basically characterizing 0:02:46.756 --> 0:02:48.916 it was still the name of the game. Is the 0:02:48.996 --> 0:02:50.916 process sort of what we should expect that over a 0:02:50.956 --> 0:02:53.596 course of five years there was time or is it 0:02:53.636 --> 0:02:57.716 more that there was some particular intervening event or discovery 0:02:57.716 --> 0:03:00.196 that made it possible to develop these vaccines. No. I 0:03:00.196 --> 0:03:02.676 mean the vaccine that Murk is using right now is 0:03:02.716 --> 0:03:07.236 based on VSV, which is a particular type of raptivirus 0:03:08.076 --> 0:03:11.236 that is really easy to engineer. And essentially what they 0:03:11.276 --> 0:03:14.716 do is they take another virus that's less dangerous and 0:03:14.756 --> 0:03:17.996 they put a protein of a bowl of virus that 0:03:19.356 --> 0:03:23.196 is presented to the immune system into that virus, and 0:03:23.276 --> 0:03:26.196 so it allows basically this other virus to bring in 0:03:26.636 --> 0:03:28.316 a piece of a bowl of virus that will allow 0:03:28.356 --> 0:03:31.196 our immune system to get a chance to see it 0:03:31.276 --> 0:03:35.876 and develop immunity to it. It's a pretty well understood 0:03:35.996 --> 0:03:39.236 way of developing a vaccine, and other groups like Johnson 0:03:39.236 --> 0:03:41.756 and Johnson I think, have one that are based on 0:03:41.796 --> 0:03:44.236 an adenovirus as well as another virus. So they have 0:03:44.316 --> 0:03:47.116 got some other things that they're doing to try to 0:03:47.116 --> 0:03:50.716 make vaccines even better. But even the very simple merc 0:03:50.956 --> 0:03:54.916 based vaccine that's based on just one virus engineer to 0:03:56.276 --> 0:03:59.076 carry a protein from e bowl is working very well. 0:03:59.276 --> 0:04:01.836 So I don't think that this is an instance like 0:04:01.996 --> 0:04:04.916 HIV or flu, where we need to do something very 0:04:04.956 --> 0:04:07.316 fancy to get it to work. This is really more 0:04:07.876 --> 0:04:11.196 of a situation in which there was no need to 0:04:11.236 --> 0:04:12.756 invest that kind of money. I mean, I think one 0:04:12.756 --> 0:04:15.916 of the really big issues that we have in vaccine 0:04:15.916 --> 0:04:19.076 development in general is that there's no incentive for big 0:04:19.116 --> 0:04:21.516 companies to put in a lot of effort to develop 0:04:21.596 --> 0:04:24.476 vaccines for anything that might possibly be an outbreak. No 0:04:24.556 --> 0:04:27.596 financial incentive. You mean, there's a there's a strong humanitarian incentive, 0:04:27.636 --> 0:04:29.716 but you mean that there's not. There are for profit 0:04:29.756 --> 0:04:31.476 companies and there's just not enough money to be made 0:04:31.516 --> 0:04:34.916 in a crisis. In a simplest term, Yes, but you know, 0:04:34.956 --> 0:04:37.196 but you could also say, well, we don't we don't 0:04:37.276 --> 0:04:39.476 know what the next big outbreak is, so we can't 0:04:39.516 --> 0:04:43.156 necessarily build vaccines for everything that might be possible. You know, 0:04:43.236 --> 0:04:46.996 before the West African outbreak, it wasn't like a lot 0:04:47.036 --> 0:04:48.756 of people were worried that people was going to be 0:04:48.796 --> 0:04:52.236 something that would infect them. So there's definitely not financial incentive. 0:04:52.276 --> 0:04:56.196 But there was not even necessarily of the universe of 0:04:56.276 --> 0:04:58.836 many viruses that you might want to be worried about 0:04:58.836 --> 0:05:03.476 and create a large scale vaccination program. People would one 0:05:03.556 --> 0:05:05.396 might argue which of these viruses are the ones to 0:05:05.436 --> 0:05:07.796 go after? So that's sort of really interesting because the 0:05:07.836 --> 0:05:10.236 point you're making, if I understand correctly, is that you 0:05:10.276 --> 0:05:12.916 know there's a cost benefit that goes into not only 0:05:12.956 --> 0:05:14.996 developing a vaccine, but also in spending all the money 0:05:15.036 --> 0:05:17.756 to go out and get people vaccinated. And to do that, 0:05:18.116 --> 0:05:21.236 you really need to think there's a relatively high probability 0:05:21.636 --> 0:05:25.316 of some event occurring that would have bad consequences. I mean, 0:05:25.316 --> 0:05:26.516 I guess really what you want to do in a 0:05:26.516 --> 0:05:28.836 cost benefit is figure out not only the probability of 0:05:28.876 --> 0:05:31.356 an outbreak, but also the consequences of that outbreak, and 0:05:31.396 --> 0:05:34.116 then multiply the probability by how bad it would be 0:05:34.316 --> 0:05:37.516 and get an expected value, and then that goes into 0:05:37.556 --> 0:05:39.996 your cost benefit analysis. And you're saying that, really, it 0:05:40.076 --> 0:05:43.596 wasn't clear before the twenty fourteen West Africa outbreak that 0:05:43.676 --> 0:05:46.436 ebola was that kind of a virus. Yeah, I mean, 0:05:46.716 --> 0:05:49.196 I mean, obviously it was that kind of a virus, 0:05:49.236 --> 0:05:51.436 But was it more that kind of a virus than 0:05:51.556 --> 0:05:56.876 machupo or judine or haunts of virus or lassa virus. 0:05:56.956 --> 0:05:58.716 I mean, if there is a vaccine that you would 0:05:58.756 --> 0:06:01.756 have a bigger that would kind of hit the buttons 0:06:01.756 --> 0:06:05.836 of being both a really big global sort of pandemic 0:06:05.876 --> 0:06:09.396 threat and also a public health crisis there where veloping 0:06:09.476 --> 0:06:11.916 vaccine now would also help a lot of people. Loss 0:06:11.916 --> 0:06:14.156 of virus might be a better choice. And so it's 0:06:14.196 --> 0:06:17.436 not necessarily that one couldn't make an argument that they 0:06:17.436 --> 0:06:19.756 should have gone after ebola. It's just that there's I 0:06:19.796 --> 0:06:22.156 think of almost four hundred viruses that are known to 0:06:22.196 --> 0:06:25.116 infect humans, which one of those you would choose as 0:06:25.196 --> 0:06:26.916 hard to make a case for. And when you talk 0:06:26.956 --> 0:06:30.236 about the financials, so at least some of these vaccines 0:06:30.236 --> 0:06:33.476 were already developed when the West African outbreak hit, they 0:06:33.516 --> 0:06:37.116 just hadn't been tested in clinical trials. And that's really 0:06:37.116 --> 0:06:40.596 the hard part. The cost of developing a vaccine may 0:06:40.676 --> 0:06:44.636 be relatively reasonable, and then reasonable it means millions within 0:06:44.676 --> 0:06:47.556 the millions of dollars, But once you go to testing 0:06:47.596 --> 0:06:50.156 the first the safety and then the efficacy of the 0:06:50.236 --> 0:06:53.316 vaccines through multiple clinical trials, you're getting up into the 0:06:53.556 --> 0:06:56.556 sort of tens to hundreds of millions of dollars. And 0:06:56.596 --> 0:06:58.756 so when you start to think about that, that's where 0:06:58.756 --> 0:07:01.796 it becomes a whole different ball game. So in the 0:07:01.956 --> 0:07:04.156 when the West African outbreak hit, there were vaccines that 0:07:04.196 --> 0:07:06.636 could be employed, and one of the big things that 0:07:06.716 --> 0:07:09.036 was happening there. At first, people didn't even want to 0:07:09.036 --> 0:07:13.036 do vaccinations because they considered that research. To me is 0:07:13.076 --> 0:07:15.236 sort of to say we're not going to try anything 0:07:15.876 --> 0:07:19.796 is wild that that was such a big deal to 0:07:19.836 --> 0:07:23.596 say we're going to try something when anybody who is 0:07:23.636 --> 0:07:26.876 on the front lines, if asked, would you take a vaccine, 0:07:26.916 --> 0:07:30.076 even if experimental, as long as it's known to be safe, 0:07:30.476 --> 0:07:32.236 you would absolutely do it. But it took a long 0:07:32.276 --> 0:07:33.956 time to even get the community to say we're going 0:07:33.996 --> 0:07:36.276 to try some stuff. And it wasn't really until it 0:07:36.356 --> 0:07:40.636 sort of hit and probably hit Western individuals, that people said, okay, 0:07:40.676 --> 0:07:43.916 let's try these vaccines. And now now I think we 0:07:43.996 --> 0:07:46.836 understand more that we need to try things in real time. 0:07:47.676 --> 0:07:49.636 I want to unpack the many fascinating as you said 0:07:49.636 --> 0:07:54.356 there party. So one is that actually, some of these 0:07:55.156 --> 0:08:00.036 vaccines did exist in twenty fourteen, and we're not used 0:08:00.556 --> 0:08:05.996 because they hadn't been properly tested in a randomized, controlled experiment, 0:08:06.036 --> 0:08:08.156 And that runs very much counter to what the ordinary 0:08:08.196 --> 0:08:12.116 person imagines from watching the movies, namely that you know, 0:08:12.156 --> 0:08:14.756 when people are dying in large numbers in the field, 0:08:15.116 --> 0:08:17.556 that's the moment when you say, Okay, we have this 0:08:17.636 --> 0:08:19.716 untested vaccine, but it has a chance of working, so 0:08:19.796 --> 0:08:21.556 let's get out there and save some lives. I mean, 0:08:21.716 --> 0:08:24.036 there we have this sort of fantasy that when that happens, 0:08:24.796 --> 0:08:28.036 then emergency and measures kick in. And I hear you're 0:08:28.036 --> 0:08:29.916 saying that that's not exactly what happened, or at least 0:08:29.956 --> 0:08:31.756 not what happened. That's just not what happens. It's not 0:08:31.756 --> 0:08:34.356 what happened at all. I mean. And vaccines are kind 0:08:34.356 --> 0:08:38.596 of a you know, are one thing, which is they're preventative, 0:08:38.636 --> 0:08:42.356 and so one might argue, if you don't feel sure 0:08:42.396 --> 0:08:44.156 that it'll be effective, you might not want to take it. 0:08:44.596 --> 0:08:48.596 What's more shocking is treatments. Once you have ebola, would 0:08:48.636 --> 0:08:52.876 you rather take your chances on riding out ebola or 0:08:52.916 --> 0:08:56.676 trying a treatment that is not completely well vetted but 0:08:56.876 --> 0:09:00.116 you know, is confident in given that the fatality rates 0:09:00.156 --> 0:09:03.396 early in the outbreak were about eighty percent, you would say, 0:09:03.476 --> 0:09:07.196 you know, I'll try anything. But even there, I think 0:09:07.236 --> 0:09:09.516 that was the place that it was really even more 0:09:09.556 --> 0:09:12.436 remarkable to see that even there a lot of the 0:09:12.556 --> 0:09:16.476 international community wasn't willing to try treatments. There's some famous 0:09:16.516 --> 0:09:20.156 cases of places where there was battles over trying treatments 0:09:20.156 --> 0:09:24.756 on individuals that were infected, where organizations chose not to 0:09:26.356 --> 0:09:29.156 and the individuals died. They didn't do it until it 0:09:29.196 --> 0:09:32.396 was actually Americans that were infected that they said, well, 0:09:32.396 --> 0:09:34.036 oh now we'll try the treatments. But there were a 0:09:34.036 --> 0:09:36.836 lot of really prominent healthcare workers that were infected and 0:09:36.836 --> 0:09:38.556 they didn't even have it. They were not even given 0:09:38.556 --> 0:09:42.676 the opportunity to take a experimental drug. So willingness to 0:09:42.716 --> 0:09:47.076 try experimental treatments was actually higher when it was Americans 0:09:47.156 --> 0:09:50.596 getting sick than when it was Africans who were getting sick. 0:09:50.636 --> 0:09:53.236 And that doesn't seem intuitive to me. I mean, you 0:09:53.276 --> 0:09:57.596 sort of imagine that if anything, you know, Western professionals, 0:09:57.636 --> 0:09:59.676 they're not all Western, but many Western professionals would be 0:09:59.676 --> 0:10:03.116 more willing to try out something experimental in Africa. So 0:10:03.236 --> 0:10:05.356 what's the background to that, is that a case of 0:10:05.396 --> 0:10:08.796 bending over backwards to try not to appear to be 0:10:09.156 --> 0:10:14.516 ferimenting with an experimental treatment on people in poorer countries 0:10:14.916 --> 0:10:18.076 and then that's a kind of perverse reversal of our 0:10:18.716 --> 0:10:21.956 deep past and that leads to this kind of strange result. 0:10:22.116 --> 0:10:24.636 Or is it more a story of just valuing American 0:10:24.676 --> 0:10:27.476 lives more highly? Like what's you're deep inside this? So 0:10:27.516 --> 0:10:29.516 what's your theory about how that that happened? Well, I mean, 0:10:29.596 --> 0:10:32.356 actually I was part of the conversations, and I would 0:10:32.396 --> 0:10:35.396 say although I didn't get to I would I did 0:10:35.396 --> 0:10:38.356 not get to witness. So the one the one that 0:10:38.396 --> 0:10:40.876 I got to witness the early conversations and then didn't 0:10:40.876 --> 0:10:43.676 get to witness what happened at the end was with 0:10:43.996 --> 0:10:47.956 doctor Humar Khan, who's a Shikumar Khan, who's the head 0:10:47.996 --> 0:10:51.676 of the clinical ward at Kennema Government Hospital in Siri Leone. 0:10:51.916 --> 0:10:55.036 That's where my lab had worked for many years before 0:10:55.076 --> 0:10:58.676 the Bola outbreak hit. And he was very prominent, very 0:10:59.516 --> 0:11:02.756 heroic Siri Leone in doctor on the front lines of 0:11:03.036 --> 0:11:06.316 first loss of virus and then ebola and of yours 0:11:06.356 --> 0:11:08.996 and a friend of mine and he was he was 0:11:09.156 --> 0:11:11.796 infected and it was actually the first time that the 0:11:11.796 --> 0:11:16.196 international community said now, well, so we were actually banging 0:11:16.236 --> 0:11:19.476 down the doors trying to get experimental drugs and vaccines 0:11:21.236 --> 0:11:24.036 tested early in the outbreak, and that was sort of 0:11:24.076 --> 0:11:26.876 like there was just like not no discussion of that. 0:11:26.996 --> 0:11:28.716 It was it was that was that no one even 0:11:28.756 --> 0:11:31.676 wanted to do it. And then finally actually when doctor 0:11:31.756 --> 0:11:34.156 Khn became ill and people recognize he was very prominent 0:11:34.436 --> 0:11:38.276 and this would be really devastating, there was discussions, but 0:11:38.356 --> 0:11:42.596 even there it was interesting. So I think a lot 0:11:42.636 --> 0:11:43.756 of it has to do with the fact that they 0:11:43.756 --> 0:11:46.396 want to be perceived as testing on Africans. A lot 0:11:46.436 --> 0:11:48.276 of it is see what if something goes wrong, what 0:11:48.316 --> 0:11:50.276 if he gets the drug and dies, would they blame 0:11:50.316 --> 0:11:52.316 the drug? So I think a lot of us around 0:11:52.356 --> 0:11:55.276 that political perception, and some of it is this idea 0:11:55.436 --> 0:11:58.356 that this kind of paternalistic view of like we have 0:11:58.436 --> 0:12:02.316 to protect them, them being being Africans. Africans, yeah, they 0:12:02.636 --> 0:12:05.596 like you know, when I do ethical protocols in Africa, 0:12:05.876 --> 0:12:07.756 I've taken a lot of ethics courses. I got really 0:12:07.756 --> 0:12:09.556 invested in it because I wanted to under stand how 0:12:09.636 --> 0:12:12.116 are we doing these things and thinking about how to 0:12:12.156 --> 0:12:14.396 do things ethically right. And there's a lot of like 0:12:14.436 --> 0:12:16.356 we must protect them or we must be you know, 0:12:16.356 --> 0:12:18.956 their vulnerable populations. We don't want to exploit them, but 0:12:19.076 --> 0:12:22.516 sometimes it's almost infantalizing the way we describe their ability 0:12:22.556 --> 0:12:24.876 to interpret it. And in the case of doctor Khan, 0:12:25.516 --> 0:12:28.476 it was an extreme case of in fact, he's more 0:12:28.516 --> 0:12:30.796 informed than I am to make this decision than any 0:12:30.876 --> 0:12:32.476 than And you know, even though I have an MD 0:12:32.556 --> 0:12:35.356 as well, he's still probably the most informed person on 0:12:35.396 --> 0:12:37.476 the planet to make a really good decision as to 0:12:37.476 --> 0:12:38.876 whether or not he should take the start or not. 0:12:39.156 --> 0:12:40.836 It's like it is like the scenario for a movie, 0:12:40.876 --> 0:12:42.316 isn't it. You know, like the person with the most 0:12:42.356 --> 0:12:44.716 on the ground clinical experience in the disease is now 0:12:44.756 --> 0:12:46.596 infected with the disease and who's going to make the 0:12:46.596 --> 0:12:49.116 decision about his treatment? Yeah, And so out of a 0:12:49.156 --> 0:12:51.956 lot of those conversations that seemed pretty obvious that he 0:12:52.076 --> 0:12:53.956 was the right person, it made a lot of sense, 0:12:54.076 --> 0:12:56.356 and this is the time to try it. You know, 0:12:56.356 --> 0:12:57.996 I wasn't in the situation room. I was just in 0:12:58.036 --> 0:12:59.836 the kind of pre conversations. But when it got to 0:12:59.956 --> 0:13:02.476 the situation room, they got cold feed. And I think 0:13:02.516 --> 0:13:05.836 for these other reasons, these sort of like larger implications, 0:13:06.356 --> 0:13:08.876 And then that part that you asked before, Like I said, 0:13:08.876 --> 0:13:12.956 I want to speculate, but obviously things changed when it 0:13:12.996 --> 0:13:16.076 was Americans on the ground affected. And I think um 0:13:16.916 --> 0:13:19.476 parties before you tell us that what actually happened to 0:13:19.556 --> 0:13:23.196 doctor Khan. Oh, he passed away. He passed away. So 0:13:23.236 --> 0:13:25.636 they chose not they ultimately chose. I mean, I just 0:13:25.676 --> 0:13:28.516 want to make sure that we get the depth of this. 0:13:28.636 --> 0:13:31.396 So he there, he was, and in the end, the 0:13:31.476 --> 0:13:34.236 relevant people in the room were not prepared to try 0:13:34.276 --> 0:13:37.996 the experimental treatment and he died. Yeah, And the experimental 0:13:37.996 --> 0:13:39.956 treatment was at the site, so there it was just 0:13:40.036 --> 0:13:43.716 you know, feet away Frore it was, he was, it was, 0:13:43.756 --> 0:13:46.876 it was there, it was ready, it could have been used, 0:13:46.916 --> 0:13:49.196 and it wasn't. And when they tried that treatment later 0:13:49.396 --> 0:13:53.116 on others they took that exact that exact dose, and 0:13:53.116 --> 0:13:56.516 they gave it to two Americans, Nancy Warble and Kent Brandley, 0:13:56.556 --> 0:14:02.916 and they both survived. Wow. Wow. Yeah. So I mean, 0:14:02.956 --> 0:14:04.716 when you can never say with one hundred percent certainty, 0:14:04.756 --> 0:14:07.916 but there's very very strong reason to believe that had 0:14:07.956 --> 0:14:10.956 doctor Khan received that treatment that was right there in 0:14:11.076 --> 0:14:15.836 the in the building with him, he would have lived it. Definitely. 0:14:16.356 --> 0:14:19.356 That was the risk I'm sure he know, his family knows, 0:14:19.476 --> 0:14:23.436 and I know if he was never given the choice. 0:14:23.636 --> 0:14:25.556 If he was given the choice, he certainly would have 0:14:26.116 --> 0:14:30.036 he would have ruled the dice with the drug. Can 0:14:30.076 --> 0:14:31.756 I ask because this is a bit opaque to the 0:14:31.836 --> 0:14:34.156 ordinary person. Definitely to me, And I'm not asking you 0:14:34.276 --> 0:14:37.876 to name any names, of course, but institutionally, who gets 0:14:37.916 --> 0:14:39.636 to make that call? You mentioned that you had only 0:14:39.676 --> 0:14:41.836 been in the preliminary conversations. But when the decision is 0:14:41.916 --> 0:14:46.276 ultimately being made. Are we talking about international organizations? Are 0:14:46.276 --> 0:14:50.316 we talking about local government? Are we talking about US government? 0:14:50.396 --> 0:14:52.756 Is at the who like who is at the private 0:14:52.756 --> 0:14:55.116 companies that control these things? Who is in the room 0:14:55.156 --> 0:14:57.676 when the decision is made. In this particular case, it 0:14:57.716 --> 0:15:00.156 was the MSF, And they have talked about it themselves. 0:15:00.436 --> 0:15:04.956 That's the med Sandstone Frontier, the International NGEO, Doctors Without Borders. Yeah, 0:15:04.996 --> 0:15:07.236 and and they I have a lot of sympathy for 0:15:07.436 --> 0:15:10.316 them and their decision, So I often say it's not 0:15:10.356 --> 0:15:12.756 the decision I would have made. But I do think, 0:15:12.796 --> 0:15:14.876 at least in the early conversations I was part of, 0:15:15.316 --> 0:15:18.196 they're being thoughtful, They're being mindful, and there's a number 0:15:18.236 --> 0:15:19.756 of things that kind of came into play, and they 0:15:19.756 --> 0:15:23.756 made a choice, and they certainly regretted that choice. So 0:15:23.836 --> 0:15:26.916 in that case, it was, yeah, it's this particular organization 0:15:26.956 --> 0:15:28.996 and they were in charge of his care and they 0:15:28.996 --> 0:15:31.956 are making a choice about what to do with his care. 0:15:32.636 --> 0:15:37.076 So I wrote a book called Outbreak Culture, and it 0:15:37.116 --> 0:15:41.996 talks about sort of what can become a toxic culture 0:15:42.076 --> 0:15:46.156 that emerges amidst the crucible of an outbreak. And the 0:15:46.276 --> 0:15:49.836 reason I wrote it, and I wrote it with Lara 0:15:49.916 --> 0:15:55.276 Salahia journalist, a fantastic journalist, was that I'm not trying 0:15:55.316 --> 0:15:58.396 to blame a particular person. I have deep sympathy for 0:15:58.476 --> 0:16:00.876 MSF and deep respect for everything that they're trying to do. 0:16:01.276 --> 0:16:04.076 I'm trying to understand the different the kind of complexity 0:16:04.156 --> 0:16:09.996 of considerations that these matter organizations have. It's the suspicion 0:16:10.036 --> 0:16:13.836 and paranoia and you know, perverse incentives that emerge in 0:16:13.876 --> 0:16:18.196 the middle of a completely banana situation. Is how do 0:16:18.236 --> 0:16:22.676 we make better decisions given the many, many complexities of 0:16:22.676 --> 0:16:26.116 an outbreak. In your book that you just mentioned, Outbreak Culture, 0:16:26.316 --> 0:16:31.516 you go through in a lot of systematic detail things 0:16:31.556 --> 0:16:34.796 that went wrong in the West African outbreak and in 0:16:34.836 --> 0:16:38.316 the response to the outbreak. And I'm wondering, as you 0:16:38.436 --> 0:16:41.556 look at the responses that are happening right now in 0:16:41.676 --> 0:16:44.836 the Democratic Republic of Congo, which is obviously a different 0:16:44.916 --> 0:16:50.516 geographical location, different political circumstances, do you think to yourself, Oh, 0:16:50.556 --> 0:16:52.516 my god, here we go again. You know, here are 0:16:52.556 --> 0:16:54.916 the mistakes that I just pointed out in a book, 0:16:55.316 --> 0:16:58.716 you know, published just last year, you know, for everybody 0:16:58.756 --> 0:17:01.876 to see, like, don't do this wrong. People could die, 0:17:01.996 --> 0:17:05.196 and then those things are happening. Or maybe there are 0:17:05.276 --> 0:17:08.076 examples where there are lessons learned that you pointed out 0:17:08.076 --> 0:17:10.436 that are being taken into acount WHI would be more optimistic, 0:17:10.556 --> 0:17:12.276 we're thinking better, or maybe it's both. I would really 0:17:12.356 --> 0:17:15.396 love to hear from your perspective, how are we doing 0:17:15.476 --> 0:17:18.276 this time relative to the last time. The thing is, 0:17:18.436 --> 0:17:22.236 these books have been written time and time again. In fact, 0:17:22.356 --> 0:17:25.156 when Laura and I kind of talk about these are recommendations, 0:17:25.196 --> 0:17:29.276 we actually don't give specific recommendations because so many people 0:17:29.316 --> 0:17:32.156 have given them before. What we try instead to do 0:17:32.316 --> 0:17:35.076 is to give a framework of how we should think 0:17:35.116 --> 0:17:40.276 about responding to outbreaks, and specifically we talk about organizational justice. 0:17:40.756 --> 0:17:44.396 You know, the idea of organizational justice is that people 0:17:44.516 --> 0:17:49.236 believe that there's due process, there's a meritocracy, there's cooperation, 0:17:49.316 --> 0:17:53.556 there's transparency, and you know there. I think we're getting 0:17:53.596 --> 0:17:57.076 better at recognizing that we need to work with the 0:17:57.116 --> 0:18:00.476 communities allow them to understand what we're doing. But I'd 0:18:00.516 --> 0:18:02.796 say that there's a move towards that being important, but 0:18:02.836 --> 0:18:04.956 not necessarily that we've learned how to do it right, 0:18:05.356 --> 0:18:08.076 because there's still a challenge of getting people vaccinated when 0:18:08.076 --> 0:18:10.436 there's a lack of trust. A lot of the treatment 0:18:10.476 --> 0:18:14.556 centers are being burned down because we haven't effectively communicated 0:18:14.596 --> 0:18:17.276 with the communities in which we're working, and so we 0:18:17.756 --> 0:18:20.396 haven't given them a sense of organizational justice, even if 0:18:20.436 --> 0:18:23.956 we may be developing it ourselves. And how much of 0:18:23.996 --> 0:18:26.396 that is dependent on the government that's in play. I mean, 0:18:26.396 --> 0:18:29.156 in the case of Democratic Republic of Congo, you're working 0:18:29.156 --> 0:18:34.196 in a place that has a history of serious civil 0:18:34.236 --> 0:18:38.796 war autocracy of a totalitarian type before the civil war 0:18:39.316 --> 0:18:42.836 disorder that arguably was even worse than the totalitarian dictatorship. 0:18:43.396 --> 0:18:46.516 It's not credible or realistic to think that the government 0:18:46.956 --> 0:18:52.116 would have popular legitimacy as delivering justice and in those 0:18:52.156 --> 0:18:55.076 places definitely where the outbreak is occurring. So given that, 0:18:55.676 --> 0:18:59.556 is it at all credible to even imagine that local 0:18:59.636 --> 0:19:01.676 people will say, oh, well, you know that might be true, 0:19:01.676 --> 0:19:04.476 but this international health organization that's looking to help us, 0:19:04.796 --> 0:19:07.756 they're you know, full of justice. You know, absolutely agree, 0:19:07.756 --> 0:19:10.636 And I think that that's a major shoe is obviously 0:19:10.676 --> 0:19:13.436 that in a society in which there's always been corruption 0:19:13.476 --> 0:19:15.676 and injustice, it's really hard to get anybody to believe 0:19:15.676 --> 0:19:18.556 in anything. At the same time, I don't like kind 0:19:18.596 --> 0:19:20.556 of pointing to that being in a shoe because it's 0:19:20.596 --> 0:19:25.116 so easy. We're so good at anthropomorphizing other cultures and 0:19:25.156 --> 0:19:27.876 sort of saying that's that's their problem, that's not us. 0:19:28.236 --> 0:19:30.596 That we don't look to see what we're doing, what 0:19:30.596 --> 0:19:33.036 we could be doing better, and essentially we kind of 0:19:33.076 --> 0:19:35.036 throw everything up to oh, those are corrupt governments, so 0:19:35.356 --> 0:19:38.236 you know, so there, But ultimately, like you know, I 0:19:38.276 --> 0:19:41.676 witnessed it personally, we are bad actors ourselves. We can 0:19:41.756 --> 0:19:44.476 be what's an example of where you saw we in 0:19:44.516 --> 0:19:46.956 the sense by which I assume you mean the international 0:19:46.996 --> 0:19:50.396 community of scientists and healthcare workers who are trying to 0:19:50.436 --> 0:19:53.316 help What's an instance where you saw that that we 0:19:53.796 --> 0:19:56.316 being bad actors. Oh, I mean a million different ways. 0:19:56.596 --> 0:19:58.276 And again I'm not going to name any names, but 0:19:58.316 --> 0:20:00.716 I'll say that there are a number of people there 0:20:00.956 --> 0:20:02.636 in the West effering an outbreak that we're all. I 0:20:02.636 --> 0:20:05.836 mean you, We actually saw public fighting between number of 0:20:06.156 --> 0:20:09.516 major international organizations. People were trying to throw the people 0:20:09.556 --> 0:20:11.436 out because they wanted to be the ones to like 0:20:11.756 --> 0:20:14.236 do the first diagnosis or get the first paper out 0:20:14.396 --> 0:20:17.156 or they We got kicked out of multiple sites. I 0:20:17.156 --> 0:20:19.756 got kicked out of participating. They said you have no 0:20:19.836 --> 0:20:22.396 business being here. And so there you are on the ground, 0:20:22.436 --> 0:20:24.596 the person who's been doing the most groundwork in the 0:20:24.596 --> 0:20:28.516 field scientifically for the previous several years, and they're like, leave, 0:20:28.556 --> 0:20:30.116 we don't want you here. Yeah, my team was told 0:20:30.116 --> 0:20:32.196 to leave. They were told they were not to return. 0:20:32.316 --> 0:20:35.116 We had no business here. And you know, our colleagues 0:20:35.116 --> 0:20:38.036 were the only ones doing diagnosis. They had a you know, 0:20:38.676 --> 0:20:40.676 a diagnostic that was working, and they're the only ones 0:20:40.756 --> 0:20:43.596 doing diagnosis in a particular site, and an individual for 0:20:43.676 --> 0:20:46.276 a major organization kicked us out because they didn't want us. 0:20:46.476 --> 0:20:47.996 We were doing it for free. We weren't doing it 0:20:47.996 --> 0:20:49.996 for credit, but they didn't want us doing it, and 0:20:50.196 --> 0:20:52.756 our partner there and our African partner there kind of 0:20:52.756 --> 0:20:54.956 fought with this person and said, but you recognize that 0:20:55.116 --> 0:20:56.596 we're the only ones that can do it. If we leave, 0:20:56.636 --> 0:20:58.876 there's there's nothing, and he said, I don't care. I 0:20:58.916 --> 0:21:01.916 want you, I want you out. And then the amount 0:21:01.956 --> 0:21:04.236 of libel that gets thrown out and everybody gets it. 0:21:04.316 --> 0:21:07.996 Like essentially, I had multiple ceases and assists. I had, 0:21:08.356 --> 0:21:10.596 you know, before my paper we got published in a 0:21:10.596 --> 0:21:13.796 major journal, got out, we had somebody send a basically 0:21:14.076 --> 0:21:16.596 a scathing letter to the journal to say that we 0:21:16.596 --> 0:21:20.596 were criminals. I mean, it's endless. It's literally eighty percent 0:21:20.636 --> 0:21:23.196 of my time during that time was fighting off attacks, 0:21:23.316 --> 0:21:28.476