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America's Ebola Command: Just Who's In Charge Here?

The Ebola crisis has Americans asking who’s leading the response, and the answer might surprise many.

Ebola spreads in the United States, first killing a patient who went days without treatment because of a hospital error and then infecting at least two of his nurses. A Cleveland wedding store closes because one infected nurse shopped there.

Members of Congress call for travel from West Africa to be banned. The heads of the Centers for Disease Control and Prevention, Customs and Border Patrol, and the National Institutes of Health are called on the carpet.

And Americans, jumpy and nervous, are asking: Who’s in charge of America’s Ebola response?

"There has to be some kind of czar," Arizona Sen. John McCain said on CNN this week. "I'd like to know who's in charge, among other things."

U.S. Sen. John Cornyn, a Texas Republican, called on the administration to "designate an experienced, proven leader to coordinate a national response involving local, state and federal agencies to contain Ebola in the United States, including considering temporary restrictions on travel from impacted West African nations.”

And President Barack Obama did get the message, canceling a fundraising trip and holding a high-level meeting on Ebola at the White House. On Friday, a senior administration official said Obama would appoint Ron Klain, Vice President Joe Biden's former chief of staff, to head up efforts to address the threat.

But the public health system is designed specifically so that no one single person or agency is in charge.

"The states have got to be involved.”

“The current administration is, essentially, playing out the playbook that was developed over a period of time,” says Mike Leavitt, a former Utah governor who was Health and Human Services secretary from 2005 to 2009.

Tommy Thompson, a former Wisconsin governor who headed HHS before Leavitt, helped set up the current disaster response system after 9/11 and the anthrax attacks that followed. It’s not a top-down system, Thompson told NBC News.

“It was never set up that way,” Thompson said. “It was always set up that public health is really a joint effort. The states have got to be involved.”

In fact, public health preparedness starts at the state and local level, Thompson said. “You have to do it in conjunction with the states,” he said.

“If you have a quarantine, it requires the involvement of the city. It cannot be done from the top down.”

States wouldn’t stand for it any other way, said an HHS spokesman. “We can’t just come in and take over a state,” he said.

“We can’t be everywhere. Everyone has to do their part,” CDC director Dr. Thomas Frieden told a hearing Thursday of the House Oversight Committee.

Leavitt and Thompson, both Republicans, could be critical of a Democratic administration’s response to the crisis. But they aren’t.

“Anything is going to seem inadequate,” Leavitt said.

“We can’t be everywhere."

“The thing that is unique about a disease emergency is that, in its full manifestation, it happens everywhere at once,” Leavitt added. “It is one thing to have a case in Dallas. But if it begins to spread beyond that and we lose the battle of containment, then you are fighting a war on every front and it requires that state and local governments step to the front.”

Many critics are blaming CDC. But few understand the agency doesn’t have much authority and must be invited by states or cities to intervene. “We have no regulatory authority, so we make guidelines and then facilities follow those guidelines,” said Abbigail Tumpey, a CDC spokeswoman.

Dr. Irwin Redlener, a disaster preparedness expert at Columbia University’s school of public health, says it’s unfair for critics to blame the CDC. “The problem is not so much at the CDC level. It is really at the local level,” Redlener told NBC News.

One problem is that it’s hard to keep up an effort year after year. There have been bumps in interest in public health — after the 2001 anthrax attacks, after the SARS pandemic in 2003 and when H1N1 swine flu hit in 2009. But budget cuts have hit hard and public health has lost 50,000 jobs since 2006, Redlener said.

“I have been looking at the appropriations process, which has allowed this erosion of funding,” he said.

“People are berating the president for not having an Ebola czar, and we do need some organized federal structure. But this plays at the local level.”

In 2003 and 2004, Congress appropriated $500 million a year to help get hospitals ready for a health emergency such as a pandemic. That’s been cut by more than half, Redlener said.

“That’s the money that is used to train hospital personnel for them to be ready for all kind of threats,” he said. “The ability to stop the epidemic has been scorched by these gradual but continuing funding cutbacks.”