INSIGHT-How Trump's America First policy hit the Ebola response in Congo

When US doctor Patrick LaRochelle realized in May that he'd been exposed to Ebola in a mining town in Democratic Republic of Congo, he expected to be rushed home for treatment.

That's what happened to him during a previous outbreak in 2018. And this time, at least three of the 13 state-of-the-art US biocontainment centers had agreed to treat him and his infected US colleague Peter ​Stafford. Then the plan changed.

According to a senior administration official, once the White House heard US citizens had been exposed to the deadly virus in Congo, it delivered a clear directive: None would be coming home for treatment. The decision to pull down the shutters flew in the face of years ​of investment and preparation and set the tone for a US Ebola response focused more on border controls than fighting the disease, according to more than 50 people including current and former senior ‌administration officials, US doctors and ​nurses, people involved in this outbreak and previous ones, as well as public health and legal experts.

President Donald Trump's administration instead set up a 50-bed Ebola quarantine camp for US citizens on an air force base in Kenya and doubled-down on its closed-doors policy in July with a "do-not-board" order blocking citizens from taking US-bound flights if they had been anywhere in Congo within 21 days. The fallout from the administration's America First closed-borders philosophy is now playing out in an Ebola outbreak that's spreading at the fastest rate ever and has killed more than 4,000 people.

The threat of offshore treatment for exposed citizens and the 21-day policy have dramatically slowed the flow of American medical volunteers, increasing the strain on local doctors and weakening the overall response, 19 of the people said. Trump's shutdown of the US Agency for International Development (USAID) and withdrawal from the WHO also left a hole in the supply chain for medicines and equipment and disrupted medical work in a country almost six times the ‌size of California.

Medical missionary LaRochelle was transported to an isolation unit in Prague in the Czech Republic. He didn't contract the disease. Stafford went to Germany for treatment, and recovered. Both doctors said they were grateful for the US government's help and praised their care, but were sad they weren't flown home. "It seems like so much is motivated by fear and by the optics, rather than a true understanding of medical risk," LaRochelle told Reuters.

"It felt like decisions were patched together and reactive," said the 46-year-old doctor, who has lived in Congo for 11 years with his wife, a family nurse practitioner, and their three children. "It makes me sad that we're at that point, and there are times that I feel angry." Stafford said his evacuation was delayed several times for logistical reasons and when he heard he was going to Germany, he assumed it would be to a US military hospital. Instead, he went to Berlin's Charite hospital.

"I was disappointed and certainly sad that my home country was kind of rejecting us," Stafford told Reuters. "I would have loved to get treated in the US." QUARANTINE CHALLENGE

Traditionally, the US played a key leadership role during Ebola epidemics, alongside the affected countries, the World Health Organization and - since its inception in 2016 - the Africa Centres for Disease Control and Prevention. The US Department of Health and Human Services helped track and treat the disease wherever it spread, spending heavily ‌to develop vaccines fast and bringing sick Americans home for treatment. This time, Health Secretary Robert F. Kennedy Jr. – a longtime anti-vaccine activist – has taken little interest and deployed relatively few resources from his sprawling $1.8 trillion agency to accelerate vaccine development for the Bundibugyo virus, a rare Ebola species.

Instead, the US State Department chipped in $50 million to the Coalition for Epidemic Preparedness Innovations, a global partnership set up in 2016 to help develop shots for pandemics and epidemics. CEPI has allocated $100 million to fund Bundibugyo vaccine research but needs another $128 million for a large-scale trial in Congo, a spokesperson said. Since taking office last year, Kennedy has minimized the importance of ‌fighting infectious diseases, despite a historic measles outbreak. He has fired thousands at the US CDC, the Food and Drug Administration, and the National Institutes of Health, including disease and vaccine experts, and is focused on initiatives questioning the safety of vaccinations.

"This characterization of the US Ebola response overlooks the extensive work HHS and CDC are leading both at home and in Africa," Health Department spokeswoman Emily Hilliard said in a statement. "Protecting Americans from importation and combating the outbreak at its source are both essential parts of our response." In June, the health agency sent doses of an experimental drug to the region for use in clinical trials.

Kennedy didn't receive a formal briefing on the current outbreak for weeks after it was detected in May, two people familiar with his schedule said. Hilliard said Kennedy has received regular briefings from agency experts, including the CDC, and is deeply engaged in the US response. Kennedy's conspicuous absence during the second worst Ebola outbreak on record left a vacuum filled in part by Secretary of State Marco Rubio, and at the outset by top White House official Stephen Miller and his team, who pushed the closed-borders strategy aggressively behind the scenes.

Public health officials say stopping Ebola entering the US is a legitimate goal but the 21-day quarantine policy is having a tangible impact on staffing, and morale. "This is something that has been difficult and discouraging for these medical workers. They have traveled around the world to fight Ebola and they should be treated as heroes," said Franklin Graham, President and CEO of US faith-based aid organization Samaritan's Purse.

Graham told Reuters that Americans once made up 80% of staff at the charity's Ebola Treatment Centers in ⁠Congo. Now it's about 20%. He said ​the cost of deploying medical professionals, who typically go for month-long stints, had more than doubled because of the quarantine policy. "The most effective way to respond to an Ebola outbreak ⁠is to safely bring as many highly trained medical professionals as you can to the epicenter, but these quarantine requirements are making that a real challenge," Graham said.

The US facility in Kenya, built for an estimated $70 million, is currently empty and has only housed seven people. Its tents and converted shipping containers, Starlink Wi-Fi, air conditioning, catering services, along with more than 100 staff, all stand ready to welcome US citizens, a US official said. A State Department official involved in the response said "first and foremost", the government doesn't want any cases in the US.

The WHO said that while it couldn't assess the overall impact of US policy without evidence, any measure that made it harder to deploy or retain responders risked slowing the response. It also said funding withdrawals and supply chain disruptions had complicated the response. "The ⁠decisive work is in affected communities: finding cases early, following up contacts, providing safe care and protecting health workers. International measures should support that work, including the timely movement of responders and supplies," Dr. Marie Roseline Belizaire, WHO Africa's regional emergency director, said in a statement.

Some of the US measures are unlikely to hold up if challenged in court, three legal experts said, and run against decades of precedent. When Trump locked down the US during COVID, citizens were still allowed to return. "All past administrations have brought US citizens home for medical monitoring and treatment," said Lawrence Gostin, director of the O'Neill Institute for National and Global Health Law at Georgetown Law School. "US citizens have a right to return home."

FASTEST SPREADING EBOLA EPIDEMIC The diminished US role in the ​global response coincides with a fast-spreading epidemic in a conflict-hit region. Bundibugyo is distinct from the better-known Zaire species, for which vaccines and treatments were developed after the 2014 epidemic in West Africa.

The US CDC said that 139 days after Ebola was detected in May, there were 8,224 confirmed cases in Congo. After the same number of days in West Africa in 2014, there were 1,766 cases and during a 2018 Congo outbreak only 543. It said this outbreak - the 17th in Congo - was challenging due to many factors including violence against health workers, a lack of personal protective equipment and ⁠misinformation. Without a stronger response, the CDC has warned that deaths could surpass the 11,308 seen in 2014.

While transmission in Congo's Ituri province is slowing, Bundibugyo is now spreading fast in other regions. Salim Abdool Karim, a leading South African epidemiologist and chair of the Africa CDC emergency committee, said the lack of a US presence was palpable.

"Traditionally, USAID is often given the task of logistics. They can find trucks, drivers, they can find warehouses," said Karim, who was in Bunia in eastern Congo as recently as July. "They will find the stuff and get it into the country, and get it out to where it's needed." He said the organizations on the ground fighting Ebola - many built up over the last decade - were getting on with the job despite the diminished US presence, though everyone was struggling with funding shortages.

"Their hands are tied because they ⁠don't have ​big money," Karim said. A July report from the US Office of Inspector General said the State Department had allotted only one-third the staff requested by the new African Affairs division to deal with the work it inherited from USAID. In Uganda, a US health security hub for the region, only one out of five people there previously are left, according to a former USAID staffer there.

The State Department said it has allocated $780 million to its Ebola response - mostly to NGOs to operate health facilities and procure supplies - from funding already set aside by Congress for global health and international disaster and humanitarian assistance. That's the largest contribution by an outside country. The White House has requested $1.4 billion that includes funding for prevention and detection of Ebola, as well as the Kenyan treatment camp and medical evacuation costs. The request is part of a broader government supplemental funding bill stuck in Congress.

The CDC, meanwhile, has said it has $113 million in emergency funds that could be spent on the outbreak in the US and overseas. While the CDC's role as a leader in the response has waned, on-the-ground staffing is about the same as in 2014. The agency said it has more than 120 people in Congo and Uganda doing disease surveillance, contact tracing, laboratory testing and other guidance and training.

FEWER US VOLUNTEERS The 21-day policy has created almost punitive measures for US ⁠volunteers, dissuading many from going to Congo, US and Congolese officials said.

Davin Ambitapio Musungufu, director of the Centre Medical Evangelique Hospital in Bunia - which is supported by Samaritan's Purse and Serge, another US faith-based charity - said the restrictions had hit their staffing. He said there were six US doctors in Bunia and Nyankunde - two of the hardest hit spots - before the quarantine policy came in. Now there's just one in Bunia.

A 31-year-old American nurse who worked for Samaritan's Purse in Congo in July said she quarantined for 21 days in the Kenyan camp and that it was mentally challenging. The nurse, who asked not to ⁠be named, hasn't decided whether to return, but said the quarantine requirement would weigh on her decision. She said a number of friends would be willing to go but the policy made it ⁠impossible for them.

Helping the Congolese was a religious mission and it was "heartbreaking" to leave them without their support, she said. In the face of a 2019 Ebola outbreak, Trump's then-Health Secretary Alex Azar jetted into Congo with top US health officials and kicked off an aggressive response focused on deploying people and medicines.

When Ebola broke out in 2014, former US President Barack Obama said the best way to protect Americans was to stop the virus in West Africa and sent some 3,000 troops to help contain it. Still, 11 people were treated for Ebola in the US during the outbreak. Two died. That's why the US then invested hundreds of millions of dollars to build biocontainment centers to offer better treatment for medics returning from Ebola zones, or Americans exposed to other rare diseases.

But, like the Kenyan facility, the US biocontainment centers have no Ebola patients. Benjamin Martin, a lawyer in Florida, said his daughter deployed as a nurse in Congo for July.

When she tried to ‌fly home, she was stopped before boarding in Kinshasa and asked to quarantine by Congolese authorities. After 11 days in ‌a hotel there, she quarantined for another 21 days in Europe. "To be told by her own government that 'Hey, we don't want you', it was very difficult for her," Martin said. "When this happened, she literally told me: 'I feel abandoned by my country.'"