The Ebola Czar
INSIDE THE WHITE HOUSE, President Obama was not happy. By early October, a little more than six months after the World Health Organization (WHO) announced Ebola’s presence in West Africa and about two months after the U.S. government ramped up its own efforts, political pressure was rising rapidly. In Liberia, the Ebola virus had shifted from northern Lofa County south into Bong County, while the number of cases in Monrovia spiked to more than 1,000. Back home, Obama’s aides had worked hard to convey the impression of a federal government that had a handle on the crisis and could protect the American public from danger. But with an election just a month away, that impression was not sinking in.
Opposition Republicans seized on two concurrent crises—the Ebola outbreak and the rise of the radical Islamic State terrorist organization in Iraq and Syria—to sow unease among the American electorate. Public opinion polls showed that voters were pessimistic about the direction of the country to begin with, a trend borne of a deep economic recession from which America was only just beginning to recover. Throw in a killer virus and a pack of thugs rampaging through the Middle East with designs on harming Americans, and voter anxiety began reaching new heights. For an incumbent party, that anxiety can translate into a rout at the polls. Democrats held a narrow majority in the United States Senate, and party strategists tasked with preserving that majority warned the White House that anything less than an all-hands-on-deck response would cost them seats.
Already, Republican candidates, beginning in Michigan and North Carolina, started using the outbreak in West Africa to attack their opponents. Amplifying that message, Republicans in Congress criticized the Obama administration for being slow to react, and for taking what they characterized as a disengaged approach to protecting American lives. Slowly at first, then more rapidly, Republicans started calling for a total ban on travel between the United States and West Africa. Some Democrats, sensing the political danger, joined the chorus. (Virtually every Democrat who called for a travel ban lost their election bids anyway.)
The American response to the Ebola outbreak, both in the United States and in Africa, was anything but hands-off. But the impression the White House sought to convey—cool, collected, no panic—sometimes felt more blasé than Obama and his aides intended. They meant to demonstrate to the public that everything was well in hand, that the president was not panicking. It was an attitude that extended from the president himself, a cerebral man who depended on rationality and science to guide decision making, both his own and that of the emergency responders at the Centers for Disease Control and Prevention (CDC), the United States Agency for International Development (USAID) and the Pentagon.
It was also an attitude that caused Obama significant political grief throughout his two terms in office, from the eruption of an oil well in the Gulf of Mexico in 2010 to the rise of the Islamic State and the administration’s perceived lack of response; sometimes the public wants to see their president get angry and take action. George W. Bush grabbed a bullhorn on a pile of rubble in New York City in the wake of the September 11, 2001, terror attacks. That was not Barack Obama’s style.
Washington power circles were replete with stories about No-Drama Obama, a president in an egocentric town who wanted his top aides to put ego aside. During the Ebola crisis, Obama told his advisers again and again to be guided by science; he would handle the politics. His attitude struck people like Anthony Fauci, of the U.S. Institute for Allergy and Infectious Disease, as a welcome breath of rationality into the frenzied and irrational political arena. It struck others—increasingly those Democrats who had to face voters just a few weeks away—as maddeningly naive and out of touch.
So by early October, Obama asked his team for a new solution. The political pressure from Senate Democrats was mounting. Thomas Eric Duncan was dead, and two nurses who had treated him were infected. Airport workers in New York had gone on strike, mostly to protest working conditions, though they also cited the threat of an infected passenger spreading Ebola as he or she walked through customs. The White House needed some new way to approach the evolving crisis, one that would give Americans the sense that their government was taking swift and decisive action.
Two Republicans in Congress had suggested just such an approach—name one person to oversee the whole-of-government response to the outbreak. In Washington parlance, name an Ebola czar.
The two Republicans, Senator Jerry Moran of Kansas and Representative Frank Wolf of Virginia, recommended three people for the job: former secretary of state Colin Powell, former secretary of defense Robert Gates, and former Health and Human Services secretary Mike Leavitt. Their motives may not have been altogether altruistic; Moran led the Republican effort to reclaim control of the Senate, and all three people he and Wolf had suggested were Republicans.
Two were nonstarters: Gates had penned a blistering book scorching the Obama administration after he left the Pentagon, and no one in the West Wing wanted him back under their roof. Leavitt had been a top adviser to Mitt Romney, Obama’s opponent in 2012; he was in charge of building a Cabinet in the event Romney had beaten Obama. The third was Powell, Bush’s first secretary of state, who had endorsed Obama back in 2008, but Powell had been retired for a decade and showed no interest in coming back to Washington.
Instead, on October 13, the phone rang in a penthouse-suite office about six blocks north of the White House. Denis McDonough, Obama’s relatively new chief of staff, was on the line when Ron Klain picked it up. Ron, McDonough said, stay by your phone this afternoon. The president is going to call.
Klain did not have the profile of Powell or Gates or Leavitt, but he was well-known among Washington insiders. He served as chief of staff to both Vice President Al Gore, during the Clinton administration, and Vice President Joe Biden, during the Obama administration. He is known in Democratic Party circles as the best debate coach around; he had coached everyone from Bill Clinton to John Kerry to Barack Obama on how to take a punch, and give one back, when they confronted Republicans on stage. Biden’s masterful performance against former Alaska governor Sarah Palin during the 2008 vice presidential debate—that was all Klain’s work.
Outside of Washington, Klain is best known as one of the lead characters in the 2008 movie Recount, which tells the story of the neck-and-neck 2000 election, ultimately decided by a handful of votes—and a Supreme Court decision—in Florida. Klain, one of Gore’s lead lawyers after the election, was played by Kevin Spacey. (The physical resemblance isn’t exactly spot-on: Klain is ebullient and excitable. He is a bit larger than Spacey, with a round face and flashing eyes, and he has quite a bit more hair than the actor does.)
Though Klain had not been a member of Obama’s original circle of trust, a cabal notoriously difficult to break into given that the president trusted few beyond those who had served him for years, Klain had ingratiated himself. As Biden’s chief of staff, he had spearheaded oversight of the mammoth $800 billion economic stimulus package, passed in 2009. Any government project spending that much money would be a natural target for waste, fraud, and abuse; Klain and Biden had worked hard to ensure there were no headline-grabbing stories about wasteful or fraudulent expenditures, an effort that largely—and improbably—worked. Klain had been present at another key moment in the Obama administration’s brief history, helping to convince a Republican senator to switch parties in 2009, a defection that led directly to the passage of the Affordable Care Act, Obama’s most significant domestic achievement. He had been asked to serve as Obama’s chief of staff in 2013, though he turned it down (McDonough got the job).
Now, Susan Rice, Obama’s national security adviser, called Klain to lay out what the White House wanted from him. A few hours later, Obama called, too.
The president told Klain he had confidence in the team at the White House at the moment, but that they were stretched too thin. Rice was overworked, juggling Russia’s intervention in Ukraine, the rise of the Islamic State in Iraq and Syria, and a hundred other crises that would have warranted front-page headlines but for everything else going on. Lisa Monaco, Obama’s top homeland security and counterterrorism adviser, also had too much on her plate. As a consequence, decisions that needed to be made quickly were being put off. The outbreak, and its interconnected parts, was complicated enough that the White House needed one point person to oversee the entire response. For all his work in politics and public policy, Klain had built a reputation as a master problem solver, making him the right person for the job. He would report to Rice and Monaco, though he would regularly brief the president himself.
“There was an implicit recognition that there were a lot of hard policy choices to be made, and that the pace of that decision-making needed to speed up,” Klain recalled later.
Klain called McDonough back the following day: He was in. On Friday, October 17, the White House announced that their former adviser would come back to take over the response.
He would start a few days later—even the Ebola czar needed to pass background checks and a drug test before reporting for duty. In those intervening days, he met with many of the younger staffers who would work for him, to familiarize himself with the scope of the challenge ahead and the faces of those who would help navigate them.
An expert at crafting the winning debate soundbite, Klain believed the key to tamping down the growing panic around the country was to communicate accurately, and honestly. They had to build public trust, and part of that trust was to convince Americans they were getting the unvarnished truth. Klain and Tom Frieden, head of the Centers for Disease Control and Prevention, agreed early on that the White House would neither review nor approve any science-based pronouncements that Frieden’s agency wanted to make.
That also meant recalibrating the message coming from Obama himself. In the early days of the outbreak, Obama had promised that Ebola would never come to American shores. Then Thomas Eric Duncan had arrived, and gotten two more people sick. Obama, Klain said, needed to assure Americans not that Ebola would never show up in the United States, but that if it did, the government would quickly find those victims and isolate them, for the public good. Some inside the White House argued with Klain that a firmer promise would do more for public confidence; Klain countered that providing assurances that were both unrealistic and untrue undermined the White House’s efforts. Obama sided with Klain.
Klain first arrived at his office in the Eisenhower Executive Office Building on October 22. His office, EEOB 300, was larger than most others in the building; it was on the same floor as the rest of the National Security Council (NSC), but in a prime location overlooking the West Wing. He attended McDonough’s senior staff meeting that first day, in McDonough’s large conference room next to the Oval Office. Then his new team met for the first time, about sixteen people in all, including two strategists from the legislative affairs office, a communications expert, and a handful of NSC staffers. For hours, they built a matrix of issues they had to work through, both at home and in Africa.
On the domestic front, two significant issues were the top priorities: first, how would they treat travelers returning from West Africa, those most likely to have been exposed to the disease? How would those travelers be screened at airports, and how would health officials monitor travelers during the twenty-one days of the virus’s incubation period, when they might develop an infection? Second, what would happen if someone else got sick? Where would that person go, how would hospitals prepare for his or her arrival, how would the CDC respond, and how would top government officials be kept in the loop? Both questions required input and buy-in from a host of government entities, from the Department of Homeland Security, which oversaw agencies that controlled travel from foreign countries, to the CDC and the Department of Health and Human Services, which worked with hospitals.
Klain’s team had a different set of concerns about the response overseas: How many beds should the U.S. government, through USAID and the Army, build in Liberia? How would they track the disease in Africa, given the notoriously inaccurate numbers being issued by WHO? What role should American-run hospitals play in the broader battle against Ebola in Liberia? How would they go about testing vaccines and other possible treatments, given the medical ethical concerns involved? And how should they coordinate between the three West African governments and nongovernmental organizations (NGOs), as well as the British and the French, who were leading international recovery efforts in Sierra Leone and Guinea?
On its face, the scope of the outbreak and the government response appeared unmanageably large. Officials at Homeland Security were overwhelmed by the prospect of keeping tabs on thousands of passengers coming from overseas. Health and Human Services could not fathom training the nation’s hundreds of thousands of medical providers.
But to Klain, the crisis management expert, the perception was out of whack with the reality. And the reality was much more manageable. On any given day, only about 2,000 people who had been in Liberia, Guinea, or Sierra Leone over the previous three weeks were in the United States. Sometimes that number dropped as low as 1,400; during the holidays, it rose to about 2,300. So the question was not how they would track 300 million Americans, only how to keep an eye on 2,000 travelers.
Managing the passengers most likely to have come into contact with Ebola was a matter, Klain said, of “figuring out the right end of the telescope to look through.”
“When I got there, the perspective was, ‘We’re a country of 300 million people, we have 5,000 hospitals, we have 500,000 medical providers. How can we possibly manage this disease in this vast [country]?’ If I had any insight, it was, none of that matters. There’s only 2,000 people we need to manage at any given time. We are just going to focus on managing those 2,000 people and making sure none of those 2,000 people have Ebola,” Klain said later. “I think our team took a problem that had really taken the federal government, racking it with being overwhelmed, and helped reconceptualize it as a manageable problem. It’s 2,000 people. It’s manageable.”
What made the problem even easier was that, of those 2,000 people, about 85 percent lived or stayed in a very small number of places: the Acela Corridor, between Washington and New York; Atlanta; Minneapolis; Chicago; Seattle; and Los Angeles. Health and Human Services (HHS) did not need to race to train every ambulance driver and dentist in Tulsa or Tallahassee; they only needed to focus on a small number of hospitals in areas where an Ebola patient was most likely to walk through the door. Any possible Ebola patient would be sent to one of those few hospitals, which would be ready to handle them. Klain’s team, guiding efforts by HHS and the CDC, began to identify and prepare at least fifty hospitals across the country to handle a possible Ebola patient. Those facilities, which would be designated ETCs, or Ebola Treatment Centers, had to be within fifty miles of 90 percent of the population of travelers who returned from West Africa.
“We’re not going to let [the next] Thomas Eric Duncan walk into some hospital in Dallas again that’s not expecting him,” Klain said. “We severely limited the number of facilities where someone was going to encounter the medical system.… Someone with Ebola is only going to have 50 touch points with the medical system, and we’re going to get those 50 places ready.”
Even the question of finding, screening, and monitoring passengers could be broken down into easy-to-manage constituent parts. Instead of potentially exposing thousands of customs officials at every major airport in the country, the Department of Homeland Security (DHS) officials worked with airlines to funnel passengers from West Africa through five airports—John F. Kennedy in New York, Newark Liberty International, Atlanta’s Hartsfield-Jackson, Washington’s Dulles International, and Chicago’s O’Hare International. That allowed DHS to focus its training on Transportation Security Administration agents, and to build sophisticated screening facilities, at just five airports, rather than fifty.
National security agencies that had been beefed up in the years after the September 11, 2001, terrorist attacks helped too: “Customs and Border Protection are getting information about where someone has traveled and who they are, well before they actually get to the port of entry,” said Amy Pope, the deputy security adviser. “We kind of used that same model here.” American officials knew who was entering the country from West Africa, even if those travelers did not speak up themselves.
Despite calls from Republicans—and increasingly from nervous Democrats—to quarantine those returning from West Africa, scientists like Frieden and Fauci argued strenuously against locking people up. The science, they said, did not merit such an extreme reaction; in fact, requiring quarantine would have had a broadly negative influence on the fight against the outbreak at large. At a time when so many medical professionals were needed in West Africa, erecting barriers to them coming home would have a stifling effect. Even Kent Brantly, finally making his recovery, testified before a U.S. Senate committee against blocking passengers or creating quarantines.
“What the science says is that if you can really stay on top of the people that have been exposed to Ebola and get them just as they’re starting to get a fever, the risk of infection to other people is very low. So science said there was really no reason to quarantine people if they were asymptomatic.” Klain said. “Obviously, there was a lot of anxiety, and science couldn’t say there was zero risk of transmission of the disease, but putting in place measures that weren’t needed to address remote fears could really have slowed the overall response—which, ironically, would have made us less safe.”
Klain’s days started at 7:00 a.m., when he would arrive at the White House after driving through the slowly stirring streets of Washington. By then, two reports were on his desk—one, a domestic situation report, would detail the number of passengers who had arrived from West Africa the previous day, the total number of travelers who were within the twenty-one-day tracking cycle, and progress toward the goal of establishing the fifty Ebola treatment centers. The other, an international report, detailed the state of the outbreak in West Africa, updates on what the British and the French were doing in Sierra Leone and Guinea, updates on the Ebola Treatment Units (ETUs) that the American military was building in Liberia, and how many patients were in each ETU.
Klain would then walk across the small alley separating the Eisenhower Office Building from the White House itself, to attend McDonough’s 7:45 a.m. meeting. An hour and fifteen minutes later, he met with his team. The rest of the morning and early afternoon, Klain sat in on a rotating series of meetings, either in person or by phone with top officials in London and Paris, the American ambassadors in Monrovia, Conakry, and Freetown and the NGOs working so diligently on the ground.
In the afternoon, Klain would meet separately with his domestic team and his international team. Any interagency problems, issues of jurisdiction or stepping on toes, would be worked out through phone calls between Klain and the various agency heads. Together, Klain, Health and Human Services Secretary Sylvia Matthews Burwell and Homeland Security Secretary Jeh Johnson worked hard to maintain good relations. (Klain’s tenure overseeing stimulus spending made him the right man for a job heavy on greasing the wheels of interagency cooperation. At his going-away party several months later, the CDC’s Frieden offered a toast: “Before Ron came, it was a long painful process to get documents clear that had to be cleared across the interagency [task force]. After he came, it was no longer long,” Frieden joked.) After a wrap-up meeting at the end of the day, Klain would spend his evenings writing policy memos that would find their way to Rice, Monaco, McDonough, and President Obama.
As if the constant stress of rushing from one meeting to the next weren’t enough, Klain had to keep tabs on any possible Ebola case that emerged inside the United States. And though the White House was working hard to tamp down paranoia, every day at least a few possible cases emerged. Every time public health officials discovered a possible case, an e-mail raced up the chain of command, eventually to a small handful of top officials—among them Klain, Burwell, the CDC’s Tom Frieden, and National Institutes of Health’s (NIH) Tony Fauci.
Even false alarms could be instructive; each one taught the feds ways to tighten up their screening processes.
One traveler arriving at New York’s John F. Kennedy Airport, bound for Minneapolis, scared Klain’s team when he disappeared for three days, only to surface back in New York with a fever. It turned out the man had missed his connection, then visited a dentist to deal with a toothache. The dentist had performed an invasive procedure; his patient did not have Ebola, he had an infection at the site of the dental work. Still, the close call convinced Homeland Security to proactively monitor arriving travelers, to make sure they got to their destination so as not to lose them in the bustle of a busy airport.
Days later, another man who had recently traveled from West Africa arrived at a hospital showing possible symptoms of Ebola. The hospital was one of those certified to handle an Ebola case, but it was the smallest, least experienced Ebola Treatment Center in the country. Rand Beers, a senior White House counterterrorism adviser who had served as acting secretary of Homeland Security, called Atlanta’s Hartsfield-Jackson International Airport to stop a commercial plane at the gate so a team from the CDC could get on board and fly to the hospital.
But when they arrived, hospital administrators didn’t let the team in. They did not want the federal government interfering in their hospital. We know what we’re doing, the administrators said.
While the CDC team cooled their heels in the hospital parking lot, Klain called the governor. Look, Klain said, I don’t have any authority to order you to allow the CDC team in. But if something bad happens and four CDC experts were waiting just outside the front doors, do you want to take that political heat? The team was quickly shown into the hospital, though they determined that the sick man was another false alarm.
On one cold January night, Klain got a call at midnight: a woman had shown up at a California hospital that wasn’t among those trained to handle an Ebola outbreak. She had symptoms very like Ebola, including vomiting and a fever. She told doctors she had just returned from her honeymoon to Guinea. What scared Klain the most was that the woman was not in the government’s database of returning travelers; where had she come from? How had she slipped through the surveillance efforts?
Klain spent a restless night trying to answer those questions in his own head. But another question nagged at him—who spends their honeymoon in Guinea, at the height of an Ebola outbreak?
The next morning, arriving bleary-eyed at the White House, Klain found that his suspicions were well-founded. The woman knew she had been in an African country that started with a G. But she got the actual country wrong; she had been in Ghana. And her symptoms were easily explained too: She was pregnant.
In all, during the 130 days Klain oversaw the American response, he got more than 300 warnings of possible Ebola cases. Every one turned out to be a false alarm.
By the time Klain arrived at the White House, the Obama administration had already spent more than $350 million—most of it through USAID—to fight the outbreak. The Pentagon planned to spend $1 billion more. The legislative specialists in Klain’s office got to work on a new challenge: convincing Congress to appropriate billions more necessary to fight off the Ebola virus, both at home and abroad.
The White House announced its new request on Wednesday, November 5, the day after Democrats suffered the election losses they feared. In a letter to House Speaker John Boehner—one of those Republicans who had called for a travel ban—Obama asked for $6.18 billion in funding, most of it to USAID and the CDC, and about half of which would be spent in Liberia, Guinea, and Sierra Leone. With spendthrift Republicans in charge of the House, and having just won back the Senate, such an amount could have set off serious objections on Capitol Hill.
But the White House targeted a few key members of Congress: Senator Lindsey Graham, a South Carolina Republican who had built a career as a foreign policy expert, and Representative Jack Kingston, a Georgia Republican who would retire from Congress just weeks later, became critical players. Both warned the White House they could have trouble selling a bill that would spend so much overseas.
Even in an era of hyperpartisanship, some of the old rules of politics still applied. The legislative experts at the White House made sure funding was included for every state to stock up on basic preparedness items, and for equipment for emergency medical services teams that might have to deal with an Ebola patient. Every member of Congress, in other words, could claim credit for helping his or her state prepare for a possible outbreak. On the contrary, if Congress voted down a measure to fight Ebola and an outbreak did occur, suddenly the onus would be on those members who voted no.
Still, Klain, cognizant of the battles he had fought over the economic stimulus package in which every member of Congress, even those who voted against it, wanted money for their states included, was leery of creating what is known in Washington political circles as a Christmas tree—a piece of must-pass legislation on which members of Congress hang their own pet projects. Klain pushed back against members who wanted special goodies added to the bill, yielding for just one: The final package contained money that would help foreign countries establish their own versions of the CDC, long a top priority for Senator Tom Harkin, an Iowa Democrat who would retire at the end of the current Congress.
The combination of carrot and stick—the ability to claim results for a member’s home state, coupled with the risk of doing nothing and owning political responsibility for an outbreak—focused Congress’s attention. And while the White House didn’t get all it wanted, on December 16, as one of its final acts of the year, Congress passed a $5.4 billion funding measure.
The White House and Congress had sent two messages: first, the American public had evidence that their leaders were doing something to protect them from a deadly disease. Second, and perhaps more important, foreign governments once again got the message that the United States was leading the charge. Money invested by the United States yielded billions more in international commitments, both to the West African governments themselves and to the NGOs working on the ground.
“It was critical in the international dialogue about the response in West Africa because we were able to dog other donor nations and other NGOs [with] the fact that we were putting a lot of cash up to fund these things,” Klain recalled a year later. “Our money yielded a lot of money from other countries.”
Spurring action, both at home and abroad, remained an urgent priority. On October 22, the day Klain began his assignment in the White House, WHO reported 9,911 confirmed Ebola cases. By December 17, the day after Congress passed the funding bill, that number had almost doubled: 18,569 Guineans, Liberians, and Sierra Leoneans had been infected.