A crisis of leadership on Ebola
I’m sure Nero did not actually fiddle while Rome burned, but it makes a nice metaphor for the less-desirable qualities and actions of leaders and communicators during emergencies and crises. In the global/international response to the Ebola virus as it smoldered and then raged in West Africa beginning in the spring of 2014, and the inevitable importation of cases to the developed world, no single politician, public health official or virology/infectious disease expert has emerged as a reasoned, reliable voice. In my opinion, the leadership and communication provided during the current EBV outbreak has ranged from comical to ”A for effort”, to “Hey, who’s that on the fiddle?”
Drs. Margaret Chan, Joanne Liu, Tom Frieden – why isn’t at least one of these eminent officials a household name by now, giving interviews to the international media that are strong on scientific facts coupled with appropriate measures of alarm, reassurance and a credible plan to lick this thing? A public health crisis requires leadership. It also requires communication with the public through the media. Sometimes those two things can be done by the same person or persons, sometimes they can’t.
The faces of SARS
For Canadians, SARS provides a fairly recent and familiar comparison to the events we’re witnessing with Ebola. Many in the public and the media have paid tribute to my late husband, Dr. Donald Low and his colleague, the late Dr. Sheela Basrur for their calm, honest answers during the daily SARS news conferences in that spring when this emerging disease caught everyone off guard. Low and Basrur stated the science as it was known, and admitted what wasn’t known. Low might offer predictions about containing the outbreak, but when SARS 2 materialized at North York General Hospital, he publicly accepted the blame.
Low became one of “the faces of SARS” mostly by accident. Once it was understood how widespread Toronto cases were in several hospitals, the Ontario government sent its public health and public safety bureaucrats to daily news conferences to outline the measures being taken to contain SARS. Low was asked to sit in to answer specific questions about transmission, symptoms, and the progress in trying to identify the pathogen. Low had no official role with public health at the time – as the head of microbiology at Mt. Sinai Hospital, he didn’t have to answer directly to a minister as others (Dr. Jim Young and Dr. Colin D’Cunha) did. This gave him the luxury of being able to speak his mind and not fear for his job. Journalists appreciated that frankness, but they also understood that Low and Basrur had expertise in infectious diseases and public health, and they were credible sources of information in a way that no politician or bureaucrat could be. It didn’t hurt that they had a knack for taking complicated scientific information and making it accessible to the public – another challenge for politicians.
Laura H. Kahn looks at the Toronto SARS experience in her insightful book, “Who’s in Charge? Leadership during Epidemics, Bioterror Attacks, and Other Public Health Crises”. Kahn defines a leader as “someone who can make something happen that would not happen otherwise.” Obviously Kahn would hope the “something” is beneficial to healthcare workers, the public, the healthcare system and patients.
Leadership in times of crisis
Kahn describes two different models of leadership, based on the 2001 anthrax attacks in the US. In the Glendening Model – named for Maryland’s governor at the time, Parris Glendening – the government or political leader provides background support and resources to public health and safety officials, but lets the experts make decisions and do most of the public communication.
Rudolph Giuliani was mayor of New York City during the anthrax attacks. Having provided both able leadership and communication during the 9/11 terrorist attacks, Giuliani remained in control of decisions and the microphone when the weapon was anthrax rather than airplanes. In the Giuliani Model of leadership, the political leader is making the decisions and communicating them to the public, flanked by his scientific advisors at news conferences, who usually don’t get to say very much.
Kahn acknowledges that certain personalities in a crisis favour one model over the other, but her overall conclusion is that in a public health emergency, the media (including, increasingly, social media) is the major vector for disseminating information, and the media will seek credible experts for its stories regardless of who is addressing the microphone at the news conference. At least, that was true of SARS and anthrax and swine flu. I’ll leave it to others to critique the media/social media coverage of the current Ebola outbreak, but let’s look at leadership and communications thus far.
Who is in charge?
We’ll begin with the World Health Organization (WHO). The medical charity Medecins Sans Frontieres (MSF) headed by Dr. Joanne Liu has been outspoken in its criticism of the WHO for its slowness to accept the enormity of the Ebola outbreak in Guinea, Liberia and Sierra Leone in the early days, when the virus might have been contained. The reasons for this failure of leadership are multi-factorial: a shrinking budget thanks to funding cuts from member countries, including the US and Canada, African bureaus appointed by local governments with no requirement to take orders from Geneva, and an inability to provide “boots on the ground” medical aid, even in public health disasters. Leaked documents suggest WHO Director-General Margaret Chan was kept in the dark about the extent of Ebola’s spread, but publicly she has defended her agency, asserting that the responsibility for containing infectious diseases lies with the governments of affected countries, and that the role of the WHO is to provide “technical advice.” That was August 8th, five months after MSF sounded the alarm before the WHO declared the West African outbreak a public health emergency, when 1,000 people had already died.
In late August, Dr. Tom Frieden, the head of the US Centers for Disease Control (CDC), visited West Africa and witnessed first-hand the devastation wrought by Ebola. He flew home and had a 15-minute telephone conversation with US President Barack Obama. Frieden held news conferences and made the rounds on Sunday morning political talk shows, warning “the outbreak was spiraling out of control, that stopping it would require an enormous and immediate response from the global community, and that it was inevitable that cases would surface in the United States until Ebola was stopped in West Africa.” Within weeks, the US promised $750-million to fight the outbreak, sending military, engineering and medical experts and equipment to the epicenter.
Frieden had articulated what the WHO had so far failed to grasp: that only an aggressive, international, well-resourced mobilization of front line aid in West Africa could contain this epidemic, and time was running out. Frieden tried to remind Americans of all that is known about the low transmissibility of the virus, and the unlikelihood of it gaining a foothold in the US (note: as of this writing one imported case has infected two nurses. Only one infected health care worker who treated patients in West Africa is still in hospital. Hardly a foothold). Frieden provided leadership AND exemplary communication and, along with MSF’s Dr. Joanne Liu, will deserve much of the credit if (and it’s still a big if) Ebola does not become endemic in Africa.
Still, Frieden has been sidelined and scapegoated since two nurses contracted Ebola while providing intensive care for Thomas Duncan, the Liberian man who was initially turned away from a Dallas hospital when he sought care. Obama’s political adversaries were quick to blame the administration and the CDC for putting Americans’ lives at risk. Some say Frieden and Obama were sending out mixed messages to the public: on the one hand, you can’t get Ebola by sitting next to someone on a bus. On the other hand, we’ve got guys in Hazmat suits sanitizing a parking lot. Fair enough.
Yes, we’re in somewhat uncharted territory here, and no health official should ever say “never” when it comes to a virus like Ebola. But we do know enough about the virus to know that recent mandatory 21-day quarantines imposed by the US military and some states for anyone returning from an Ebola zone are not science-based. Rather than protect the public, they will put more non-Africans at risk as they dissuade healthcare workers from volunteering to go fight the outbreak where it matters most: in West Africa.
I think Frieden would say that and say it strongly if he wasn’t being brought to heel by political forces. President Obama is trying to better communicate the science in White House press conferences, but he ignites so much political rancor, the message gets lost in the din. The Giuliani model is being employed over the Glendening model, and I think it should be the other way around. Frieden has everything Don Low had to be a great leader and communicator in a global pandemic: expertise and superior communication skills. Unfortunately, he doesn’t have the same freedom.
A failure in Ottawa
And now we have evidence that our present government in Ottawa is shamefully putting politics over science and public health by refusing to issue visas to travellers from the three African countries where Ebola is still widespread. This, despite all evidence that such travel bans don’t work. This, despite our collective Canadian outrage when the WHO imposed a travel ban on Toronto during SARS. The visa restrictions were announced by the Minister of Immigration and there’s been no response – supportive or otherwise — from Dr. Greg Taylor, the newly-appointed head of the Public Health Agency of Canada. I know that Low and Basrur, if they were here, would call the federal government out on its hypocrisy and use their communication skills to explain to Canadians that the best way to protect our nation from Ebola is to put more resources into fighting the virus in West Africa. We need the right decisions, communicated through the media by the right people. Right now, that’s not happening.
Maureen Taylor is a physician assistant in Emergency Medicine at Sunnybrook Health Sciences Centre and an Editor of Healthy Debate. Follow Maureen on Twitter @MaureenTaylor31