On-the-Ground Views of the Ebola Crisis in Liberia and Sierra Leone

Nancy A. Aossey, president and chief executive officer at International Medical Corps, Laurie Garrett, CFR’s senior fellow for global health, and David Nabarro, the UN’s special envoy on Ebola, join Richard E. Besser, chief health and medical editor at ABC News, to discuss the panelists’ recent trips to West African Ebola-treatment units and the international response to the crisis. While the Ebola crisis in Liberia is greatly improved, the situation in parts of Sierra Leone remains dire. The panel credits safe burial practices, reduced physical contact with infected persons, increased laboratories and care, and coordinated work with the Liberian government as reasons for Liberia’s success in lowering the infection rate. The challenges in Sierra Leone include unsafe burials, the scarcity of health workers, and the rough terrain.

BESSER: Good afternoon, I'm Rich Besser with ABC News, and I'll be presiding over—over this session. I want to welcome you to this session. It's an Ebola update, an assessment from Africa. So, if you weren't expecting an Ebola update, you're in the wrong room.

(LAUGHTER)

BESSER: I want to welcome the CFR members around the nation, and world who are participating in the meeting through livestream, and through teleconference. We're going to be hearing more from them when we get to the—to the question and answer session. But today we're going to be hearing from—from three experts about this situation in—in West Africa. They all have extensive knowledge what's been—been going on in terms of the—the course of the epidemic, the efforts to control the epidemic, and they bring very different perspectives from—on—on that event. Hopefully, at the end of the hour we'll all have a better sense of—of what's going on and what it will take to knock this out of—of West Africa. I'm also thrilled that in the audience we have a number of people with—with firsthand experience in—in either working to contain the—the pandemic in West Africa, or reporting on that.

I'm going to briefly introduce our—our speakers. In materials that you have access to, you'll see their detailed bios. If I went through the long bios that would take half of our session, because they are extremely distinguished individuals. First is Nancy Aossey, who is the president and CEO of International Medical Corps. That's a global first responder organization that delivers emergency relief and training on the front lines of war, natural disaster, and disease. They're operating Ebola treatment units in both Liberia and Sierra Leone. And Nancy's sitting right next to me.

On the end is Laurie Garrett, who is the Senior Fellow for Global Health here at the Council on Foreign Relations. Author of many books, including most recently, Ebola: Story of an Outbreak. And she has recently returned from a trip to Sierra Leone, and Liberia, and is now two days past her twenty-one days. So, congratulations.

(LAUGHTER)

BESSER: And joining us via satellite from Geneva is David Nabarro, who is the Special Envoy on Ebola for the United Nations. He heads up the efforts by the U.N. to control the Ebola epidemic. He's had many visits to—to that region, and you can read his—his statements almost daily in terms of the progress that's been made and—and obstacles to—to—to getting this under control. I'll be asking questions for about twenty-five minutes, and then tossing it over it to you here in the room, as well as to—to people who are on email, sending in—sending in questions.

But I'll—I'll just set the stage from my own—own personal experience as a reporter with ABC News I've—I've now made two trips to—to West Africa. The first in—in late August, and I spent—I've spent most of my career in public health and I have to say that the situation I saw in—in Monrovia, in—in Liberia in August was unlike anything I've—I've seen in—in an outbreak in my career. It was—it was apocalyptic. Going to the largest hospital in Monrovia, and the hospital was closed. It was too dangerous to be open to see regular patients. And in the corner of the compound, there was an Ebola treatment unit in—in a building that had housed a cholera treatment unit. And outside of that unit, there were patients lined up along the wall, waiting for room—room in the inn, but there was—there was none. It was a unit designed for twenty that had sixty, and the next day had—had eighty. And until the trucks were bringing out bodies to take to the crematorium, there was no room for anyone to come in.

I went back a month later, to Monrovia, to the same place, and it had a very different feel. There was a feeling of hope in Monrovia, and in Liberia. I interviewed the—the president of Liberia, and she said that they were seeing the numbers starting to stabilize. That they were seeing a change. There was now room for patients who—who needed treatment. And in one treatment unit I saw a Liberian physician giving blood transfusions from a survivor to a sick patient. Same treatment that was being given here in the United States.

That trend in Liberia has continued, while in Sierra Leone the epidemic still seems to rage out of control. And so now I want to turn to our panelists and—and, David, I'm—I'm going to start with you. We'll test out our audiovisuals. And—and I want to ask you, has Liberia turned a corner on the epidemic? And, if so, how they accomplished that.

NABARRO: So, first of all, thank you very much indeed for the chance to be with you today. I would like to be sure that you can hear me, and I presume you'll—you'll interrupt me if you can't.

BESSER: Can you all hear him in the back?

NABARRO: Information...

UNKNOWN PARTICIPANT: Yes.

UNKNOWN PARTICIPANT: Yes.

BESSER: It's all good.

NABARRO: Yes, great. OK. The information from Liberia right now tells us that the numbers of new cases of Ebola infection, people with the disease, per day is stabilizing at around ten, and most of these are people in Montserrado County. This is cases confirmed by laboratory testing, and that's six times less than what was being seen in September, when the outbreak was really increasing very rapidly in Monrovia. I'm concerned that it's stuck at ten per day now for two weeks. I'm concerned that most of these cases are coming in Montserrado County, which is where Monrovia is. That suggests to me that we have some difficulties with further reducing the case load, and that an intensification of the response is needed.

In my discussions last week with President Johnson Sirleaf, she made it clear to me that she's quite worried about the possibility that people will drop their guard and that physical contact will return as part of normal life, and that there will be, perhaps, a recrudescence of the outbreak in some of the counties. And so she is extremely keen to maintain the level of alert, and to ensure that there is surveillance and contact tracing everywhere.

My conclusion is that, yes, there is a marked reduction in the incidence of Ebola throughout Liberia. It's still stalled in Monrovia area. That there is always a chance that it will return again, and reinflame. And so a great deal of care is needed to ensure that we now move towards a situation where there is zero transmission throughout the country.

BESSER: And—and what is your sense in terms of the critical factors that have allowed them to—to see this reduction?

NABARRO: The most important factor in ensuring that the reduction has occurred is that communities throughout the country have recognized the actions they need to take to reduce their risk of infection. There has been much greater acceptance of the need for safe burial practices, and for reduced physical contact with people when they're sick, during healing ceremonies. There's also been widespread acceptance of the need for greatly reduced physical contact between people, especially during times of illness.

This has been supported by a big increase in the availability of beds, where people can be treated if they've got Ebola. A much better laboratory service, which enables the identification of—of Ebola cases and a widespread safe burial system which has been undertaken by a combination of the Red Cross and a number of NGOs. Altogether, it's been a very effective implementation of the different elements of strategy throughout the country.

BESSER: Thanks very much. Laurie, I—I want to pull you into the conversation with the next question. Why has Sierra Leone not seen the same level of improvement? What—what is the difference that—that you see between those two—two countries, and two situations?

GARRETT: The differences are profound. The only thing they seem to have—only two things they seem to have similar: that English is their official language and that they're in West Africa. But, otherwise, they are as different as two countries can be. Sierra Leone—those of you that have been in Monrovia know—this is a largely, flat, sort of muddy country that during the wet season, the rainy season, can be very hard to traverse mainly because the roads are so difficult. But the terrain itself is not terribly challenging. And it's an overwhelmingly Christian country, and they share, of course, the history of civil war.

Sierra Leone is by far majority Islamic. It is extremely rough terrain. You can't even actually get from the airport into Freetown without taking either a ferry or a high speed—speed motorboat, because there's no easy roadway to get from the airport into the city. And once you reach the city, it looks like Rio de Janeiro, with these fingers of steep hills, with buildings clinging to them. Getting anywhere in Sierra Leone is a very significant journey, especially once you're off of anything that's paved.

The other huge differences have to do with how the government structured their response, and what their international responding partners are. Liberia has really major partners, the United States government and U.S. based NGOs. And it really reflects a kind of American mobilization with an incredibly tight relationship between the U.S. ambassador and President Sirleaf. Literally daily communication and coordination going on.

U.S. military seemed to immediately know what they should do, and they charged into the ground and they bivouacked alongside Liberian military. No fancy accommodations. And in the process they're really effecting the quality of the Liberian military. Sierra Leone very different. It's a British dominated response. By and large it's the first time Britain's ever been engaged in anything like this. It's certainly the first time for their military.

And the government, by any measure of corruption, any corruption index you look at, whether it's from the IMF and World Bank, or all the way out to Transparency International and so on, Sierra Leone ranks as one of the most corrupt governments in the world. Had a long history of disappearing funds from GAVI, from UNAIDS, from a whole of list of global health programs, millions and millions gone missing. There's really no trust or respect between the masses and government, because every interaction with government has to involve payola. Often, many times, payola through a system.

So, one huge difference is that the response in Liberia, with America, a very civilian response. The response in Sierra Leone was officially turned over entirely to the Sierra Leone military, as the lead responders, the former minister of defense is running the campaign. They've been imprisoning critical journalists. They have gone out of their way to terrify reporters, both foreign and domestic, and make it very clear it's our way or the highway, but the—the our way or highway—is this is a country with a total 400 available Ebola hospital beds for the entire nation. Only about 150 for the Freetown area.

Their epidemic is completely out of control. There's—there's no semblance of control.

They—they have, you know, officially of the reported cases a relatively decent percentage, somewhere around 60 to 70 percent, are safe burials. But those are the reported cases. The vast majority of burials are still unsafe. They're hidden. They never get reported officially, and part of the whole corruption thing is that government officials are—are accepting donations to officially void Ebola death certificates and allow people to go ahead and have traditional burial ceremonies, which, in Sierra Leone, not only include cleansing the body inside and out, and the individuals that do that cleansing will be elders of the clan. But also involves sitting the deceased in the home and people come and pay homage to the deceased, including hugging and kissing and talking to the deceased, and this can go on for a couple of days before the actual burial.

BESSER: Well I will want to come back to—to solutions. How—how you effect change in—in some of those settings. But now I'd like to—to pull you in, Nancy. I visited the International Medical Corps treatment facility in—in Bong County. And you have treatment facilities in both Sierra Leone and Liberia. From your perspective, what—what is the—what has been the contribution of the treatment centers towards—towards the solution to Ebola in—in the region?

AOSSEY: Well, so we've seen, as you mentioned earlier, and a couple of months ago in Liberia, things were much more dire then than they are today, and this has been the impact that treatment activities and treatment units in Liberia have had. So, as a result of opening up these treatment units, and providing proper and safe burial, as well as working with the local community, earning their trust, you can imagine the amount of fear that exists in Liberia. People think they're going to catch Ebola in a treatment unit. So, there was a lot of education around what the treatment units are, what they can do for the community, and—and why they—why they matter, and why they can be effective. So, a lot of our work in Liberia has been outreach to the local community, and education around Ebola, and what the—the impact these treatment units can provide.

Another piece of the—a very important piece, is training. As we know, the health worker situation in West Africa is really tragic. There's just not enough health workers. It's one of the reasons we are where are today. And so we have focused a lot on training health workers, and in training other NGOs that want a stand up Ebola unit so that people feel safe if they're going to be involved in Ebola treatment. These are rigorous standards around case management protocols, and around the proper way to—to treat an Ebola patient, and then hopefully not contact it—or contract it yourself.

So, the impact in Liberia has been primarily around the fact that there are treatment units where people can get the assistance they need, and that they can actually recover and go home again. And we've seen this in the early days when—when we first opened our treatment unit in Liberia in September. By the way, going to what Laurie said, thanks to the generosity of the U.S., and USAID's Office of Foreign Disaster Assistance. And then the U.S. military went in, and as a result of the quick testing that they were able to do, we were very quickly able to determine who needed to be isolated, and who didn't.

BESSER: So, you—you have testing available at your ...

AOSSEY: We—we have the—the testing that we are working—the testing we're doing is with the U.S. Navy, and what they do is they get our results back right away. So, in the beginning, in September, people were coming to our—our treatment units, most of them so sick they were dying right away. Over time, with supportive care, with rapid testing being done, where we can clear out the backlog. With the proper training, and we have very, very strict protocols around putting on—on a suit, taking one off, disinfecting constantly, the proper burial, and basically just training people to know what needed to be done. And a combination of this and then working with local entities, and working with, of course, the Ministry of Health, it's—it's required a lot collaboration and coordination. And at a time which has—where there's been a lot of fear.

And so these things, over time, have had a dramatic impact in Liberia. And when you operationalize these kinds of—of activities, you start to see the drop in Ebola cases that we see today. I just want to make the point, though, as—as David said, we're not out of the woods. We need to be at zero. Even though we're at ten cases a day, first of all some of the—the data is still changing a little bit on the ground in Liberia. We know the—we know the operational efforts are having an impact, but Ebola can resurge again, until it's at zero.

BESSER: Question—question to you in terms of the—the quality of treatment. Patients with Ebola in the United States, in Europe, most of them have—have survived. But in West Africa, in the treatment units, even in the good treatment units, the mortality rates are above 50 percent. Is this something that—that we have to accept? Or is there a way to bring the same kind of survival rates that we're seeing in the United States to West Africa?

AOSSEY: I think we always have to work on trying to improve the survival rates, one. Two, the supportive care is absolutely critical. So, in—in the U.S., the—the standard of care start at a much higher level. In Liberia, we are trying to catch up to this standard of care, and—and that's a part of the reason why more people are surviving in countries like the United States than they are in Liberia.

That—I just want to mention one other thing ...

BESSER: Yes.

AOSSEY: ... the other piece of this is, you know, and they're still looking at the data, but it depends on when we see the patient. The—the more quickly we see the patient after they have contracted Ebola, the more likely they are to survive.

BESSER: And why is that?

AOSSEY: And—but just because that the longer they have it, the—the more their body starts to break down and the less likely they're able to—to fight it. And so the healthier they are, and the stronger they are in the beginning, the more likely they are to beat it. As they have it for a period of time, they're less likely to beat it. And so these are a—these are number of factors that go into the death rate.

BESSER: David, let me—let me pull you in. One of the things we've heard about is treatment units that are built, that don't have healthcare workers to staff them. And Nancy was talking about their efforts to train healthcare workers. Has the international community met its responsibility in terms of providing healthcare workers? Clearly, there's been big efforts to—to build facilities, to send money, to coordinate, to do community activities, but it—it seems that for most countries there's been a big reluctance to send the number of healthcare workers that many feel are necessary to get this under control. What—what's your perspective?

NABARRO: Thanks very much indeed. A couple of quick things. Firstly, on Sierra Leone let's not forget that Eastern Sierra Leone, around Kenema, and Kailahun, there, which were very densely infected with rapid transmission, are now areas where the case incidence level is almost as low as it is in neighboring counties in Liberia. So, it's not universally a bad situation in Sierra Leone, as the western region, particularly Western District, and also Port Loko that are particularly bad. And, yes, we're worried about what's happening there. But, working very closely with government and others to get a response speeded up.

Now, in some of these treatment centers, the construction has been relatively straightforward, but staffing has been more difficult. Let's remember that the world has not ever responded to an Ebola outbreak like this before. Usually when there is an outbreak, say, for example, the one that happened earlier this year in Democratic Republic of Congo, it's quite a localized affair, and governments that have experience of dealing with Ebola, like the government of—of DRC, and the government of Uganda, very quickly able to institute a response of relatively small treatment center is set up, perhaps with 40 beds, and patients are admitted, and treated and contacts are traced. And then within a—a matter of weeks, or perhaps months, the outbreak is over, the recovery rates tend to be greater than 50 percent, and communities are the wiser now because they know how to respond next time it comes.

Here we were in a situation where we had altogether an instance rate across the three countries of over 100 a day during September. The demand for beds was really very high indeed, especially as we didn't know where the next set of cases would come, so we were trying to put in place something in—in the order of 3,000 beds across the region, with at least forty, getting up towards fifty, treatment centers. This was far, far greater than the world has ever had to deal with it. Organizations that were experienced with doing this kind of work, such as Medecins Sans Frontieres, or Doctors Without Borders, were at their limit, and had said to the international community they could do no more.

And, so, IMC, Red Cross, Save the Children, others and a number of government groups, the International Office of Migration, all—Organization Migration-- all tried to set up the capacity to run treatment centers, and had to do this very much from scratch. So, it's taken time to set these treatment centers up. Typically, Medecins Sans Frontieres would open a treatment center, initially, perhaps, catering for twenty patients, and then would increase the number of patients each week, perhaps by an extra five or ten that they would receive, depending on the extent to which their combination of local and international staff, perhaps 250, 300 staff per treatment center were able to do so safely. And, so, yes, it's taken a bit of time to get the staff in place.

We have had situations, quite well reported, where there have been treatment centers created but they can't open fully because the staff are not yet ready to do so. But I'd much rather the treatment centers opened gradually, and staff were able to do so safely. They were also creating a situation where patients do not end up being a danger to others who might be inside the center, who are not themselves Ebola positive. I'd rather it's done gradually and safely, rather than rushed, and we end up with increasing numbers of health workers infected. We've already got too many who are.

So, I'm—I'm at the situation now where I believe that we are getting much more capacity in place. IMC has done brilliantly, as have many others, probably others represented in the room today. And it's going to be all right. We will have the desired level of treatment capacity in Liberia, in Sierra Leone, and in Guinea by, I believe, the end of January next year. And that will, I believe, ensure that we do get a reduction in incidence rates right throughout the three affected countries.

BESSER: Thank you. I'll be coming to your questions soon, so you can be thinking about those—those questions. I have a slew more, but I guess I have to share. Next question, Nancy, for you. Just to follow up on—on what David was saying. A lot of healthcare workers who have come back to the United States and to—to Europe have a stigma, have—have faced many different kinds of—of policies to—to protect the community from—from healthcare workers. How has this impacted your ability to recruit people for International Medical Corps, to—to work in the region?

AOSSEY: So, health workers that risk their lives in West Africa, trying to stop it at the source, should be celebrated, and we are very disappointed that they were marginalized or made into pariahs during this period of time when there was just a tremendous amount of frenzy and, frankly, unwarranted hysteria in our view. As far as the—the impact on health workers, so many of our volunteers went over not knowing that they would be required, many of them, to be in a twenty-one day quarantine when they returned, even if they weren't sick or if they asymptomatic. So, a number of them came back.

Of course, we work closely with the CDC, and local health authorities, and we felt whatever the mandatory requirements are around quarantines, but it had—it did have a big impact on health workers that we were talking to and were interested in going to Liberia. We saw about a 25 percent drop off rate fundamentally because people just couldn't add twenty-one days to their schedule. And, frankly, many of them felt it was unnecessary if they had no symptoms that they—that they should undergo this quarantine. We did—we did see that drop off, and we saw also saw less interest in going to West Africa.

So, you know, we had to do a—everything we've done all along, since our work in September, has been course correct. Situations changing on the ground, situation around health workers is changing constantly. It's absolutely critical that we send enough health workers to West Africa so that they can train locals and they can train other organizations as well, so that those organizations can start treatment activities. And so we've come up with a number of ways to make sure that we have the staffing that we do—that we need. And we do. We have, right now, we have about 800 people on the ground in West Africa, and all except about a hundred of them are local Liberian health workers, and our expats are there to provide outside expertise that is needed, and we expect by the end of December to have a total of a thousand.

BESSER: A thousand?

AOSSEY: A thousand. And that's mostly, I'd say, about 90 percent of them will be locals. I mean, we're a training organization, and so International Medical Corps' focus will always be on building a local health care capacity in a community. That's what we do all the time. And, certainly, in Liberia, it's an incredibly important aspect of what we do because they are the leaders in—in their community, in Sierra Leone they are the leaders, where we will be focused as well. People trust people in their own—in their own populations, in their own villages, in their own countries, and that's the only way that any efforts around Ebola will be sustainable over the long run. And, so, we will have about a thousand in West Africa, and about a hundred of those will be expatriates.

BESSER: All right, well, I—I want to open it up to members now, to—to join the conversation with their questions. A reminder that the meeting is on the record. If you could wait for a microphone to—to come to you, speak into directly, stand, state your name and affiliation, and limit yourself to one question, and—and keep it concise. If it goes long I may need to shorten it for you. And I want to remind members who are participating in the teleconference to email their questions to [email protected]. And I have an iPad here, and I'll be able to feed those—those in. Question here, and some questions here in the front. A microphone is—is coming your way.

QUESTION: My name is Joel Cohen. I'm from Rockefeller and Columbia Universities in New York City. I'd like to thank the panelists for excellent presentations. I'd like to ask them to take a slightly longer-term perspective. My understanding is that there have been Ebola outbreaks in West Africa over more than twenty years. If that's wrong, please correct the impression. And my understanding is that we don't really know fully what the ecology of the virus is, and its roots of infection into the human population.

And, therefore, I'm wondering whether we are underinvesting in the basic scientific and ecological research required to cope with this in the longterm. The gist of the question is is it really realistic, as the moderator said, to hope that we can knock out Ebola in West Africa? Or rather is it something we have to prepare to live with to understand and to manage with a kind of capacity that IMC is developing? That's my question.

BESSER: Laurie, will it become endemic?

GARRETT: So, I've written extensively the history of Ebola and I was in the 1995 epidemic in Kikwit, Zaire, and I've—I think it would be fair to say I know pretty much all the scientists who've been on the ground, dealing with the various outbreaks since the original in 1976 in Yambuku, Zaire. And what I would say about the ecology is a warning across the board that says this not the first, the last, or even perhaps the most severe outbreak of an incurable viral disease for which we have no vaccine, no rapid diagnostic, and we will require, or necessitate, mobilization of healthcare personnel willing to put themselves at great personal risk to provide assistance.

In this particular case, what we know about the ecology of Ebola is something that it shares with a number of hemorrhagic viruses which is that their natural hosts is fruit bats. And we know something is going on in the tropical rainforests, not only in Africa, but also in Asia, in fruit bat populations. They're very stressed. They are the—the bees of the rainforest. The pollinators. And they—we've seen the emergence now of Ebola, Marburg, Nipah, Lyssa, the list is huge, all bat-borne viruses.

As far as how humans get it, it's usually secondary. They're not in contact with the bats. But the bats masticate fruit, spit out what they don't want to eat, and animals further down the food chain are likely to grab that masticated fruit. That may include chimps, monkeys, and so on, which then are, in fact, hunted by humans. So, one of the mantras is get rid of the—the tendency to eat bush meat or wild animals. That would certainly help. But there's something much more going on that involves the encroachment of human population deeper and deeper into rain forests, and a chain of exposures and the stress on the bat populations.

What all this means is that, add to it tremendous increases in human mobility, in places that—the first time I was ever traveling around in Africa, it was almost impossible to get from point A to point B without going back to Europe. Now, one moves all over Africa, and that is true in Asia as well, places that were once quite remote. All of this means that the isolated outbreak can now become a much larger phenomenon fairly quickly. A real challenge, by the way, for Liberia right now is that the rainy season is ending, the dry season is commencing, it will now be easier to move around because the roads won't be muddy. And, indeed, it is a time when traditionally people really are moving around, and heading into Monrovia, in particular trading goods. This could bring Ebola back. That's a problem.

And I think the last point I would make on all this is that we have never, despite numerous outbreaks that we've looked at over the years—and David Nabarro played a key role very similar to one he's playing now with Ebola in the context of H5N1 avian flu, bird flu, whatever you want to call it, trying to coordinate and prepare a global response. We have never really said as a global community, look, you know, emerging diseases are a reality, and we're now a globalized planet and we need to really get prepared. And we need to have agreements in place that we can mobilize boom, boom, boom down the road. And each time we're reinventing the wheel.

So, here we are, once again, oh, gee, why isn't there a vaccine? Oh, gee, how do we get over the patent issues? Oh, gee, how do you do field trials? Well, we've had this conversation before, and before and before and before. And you could go down the entire list. How do you mobilize humans fast that have expertise? How do you break down—how do you keep the airlines operating? There's only one left that still services the Ebola-hit region. All of these issues we keep visiting on a crisis basis, and we never fundamentally resolve them, and set a permanent precedent so we have a template for the next outbreak, and the next, and the next.

BESSER: Let's—let's pull in the next question.

QUESTION: (OFF-MIKE) Thank you, my name is (inaudible), and I'm a project (inaudible) in (inaudible) medicine. And I'd like to direct this question to (inaudible) and it falls...

BESSER: Can you all hear? I'm not sure is that mike ...

GARRETT: I don't think your mike is working.

QUESTION: Let's try this. OK, so at the same that we need more data. We know there's ten cases in Liberia, we have little data, perhaps, reliable data from Sierra Leone and we know that the rainy season is over. At the same time, we have a long history of cover-ups. Guinea covered up the outbreak for several months. With Polio, the Syrian government covered it up. New York itself covered up the cholera outbreak here, 150 years ago. So, putting that together, the stigma, the unwillingness of governments, the multiple problems with the corruption, lack of transparency, and put that together with the absolute need for better data to guide this epidemic, I'm wondering how you perceive that future? Because that also brings me to somewhere like Sierra Leone, where we all acknowledge this outbreak requires clinical care and public health. Clinical care for treatment of cases. Public health for the contact tracing, the surveillance, the ongoing monitoring of rebuilding of a public health system.

BESSER: Nancy, do you want to start with that?

QUESTION: And, sorry, just to finish it, and then we have in Sierra Leone Save the Children, which is, you know, has led one of the international response which have no capacity in either health care, treatment, clinical care or public health. So, I'm interested on the macro level, and also on the micro level how you can see this playing out?

AOSSEY: So, thank you for your question. I want to go back to something we were talking about earlier. In order for governments, people, international agencies to—to want to share information, for them to be open and transparent, which we want, which we need if we're going to manage a disease, we have to remove the fear and the stigma around those diseases. If—when we don't do that, it—it forces things underground. People, if there's a travel ban, they're going—they're going to cheat. If there's an outbreak, they're going to suppress it. If they—if there's perceived punishment for—for a disease, or—or some kind of a global health problem, then that is an incentive for whether its governments or people just in general, to try to hide that outbreak.

So, it's really important that we get it out openly. Out on the open stage. As Laurie was saying that—that we have things in place so that we know what to do, and that we—we put knowledge out there to help combat the fear. Because so much of our reactions, both in the U.S. and—and around the world have understandably been around fear. So, what do you do about fear? You get information out. You have a plan. You talk about a way to manage it. When you start shutting borders, or you start penalizing or punishing the very health workers, or the country that, you know, where there's a terrible outbreak... We can't stop these diseases from traveling, so we need to get them out there, so that people want to be transparent and open about it. And that's just human behavior. So, I think that's a critical piece toward getting information out, and—and for there being an incentive for governments and organizations.

QUESTION: (OFF-MIKE) I'm talking about the governments who are behind it and ultimately responsible. We support the government, and yet the Ghanaian government (inaudible).

GARRETT: It's very difficult because all the people that are online cannot hear her, and she won't use a microphone. So...

BESSER: David, let me—let me throw that to you. The question is is focused more at the governmental level, how do you—how do you support transparency? How do you support earlier identification and sharing of information, so that outbreaks can be identified faster and the impact can be—can be curtailed?

NABARRO: So, of course, everybody is really nervous about these kinds of outbreaks, because of the reactions that can happen, individual stigmatization, or isolation of whole nations. I think that over time as the international response becomes more efficient, and also as an understanding of the true risks posed by the outbreaks become clearer, then fear will diminish and the reaction to a disease like Ebola will be much less profound. We had to do the same with HIV. We've had to do the same with some of the influenza outbreaks. So, all I would just urge to everybody is to try to mainstream this kind of debate into foreign policy, into international development discussion so that we can better enable countries to be confident that if they declare that they've got an outbreak of a disease, a hemorrhagic viral disease like this one, that they know that they will get prompt support, rapid response, and they will not end up being isolated or treated in an unfair way.

BESSER: David, but given that many countries have isolated West Africa, have implemented travel bans, is it in some way a rational decision to—to hide what's going on at the country level?

NABARRO: As we look at the economic costs of all outbreaks, and pandemics, we see that about 75 percent of the cost is due to actions that people take that don't have a basis in public health reasoning. So, of course, there will always been reactions that are, perhaps, based more on anxiety and fear, than based on an analysis of risk. Our job internationally is to do everything we possibly can to help ensure that everybody, everywhere has true information about the nature of infectivity of any kind of viral disease, and also the options for bringing it under control.

We really have to be clear with everybody that you only get Ebola through contact with body fluids of somebody's who's got the disease, who happens to be secreting the virus, and that if you're, say, two meters away from that person you won't get ill. But, most people would, I think, be forgiven for believing on the basis of information that's been made available in recent months that perhaps it's an airborne disease, or perhaps it's a disease that's got just simply by being physically close to someone who's got it, perhaps having been in the same room. And that's just not the case. So, our job internationally, our job as public health people, is to try to ensure that the correct information is made available and that—that information then guides public health policy.

BESSER: Let me pull in a question here from the members who are not here. This question from Paul Auerbach at Stanford School of Medicine. And he wants to know what's the appropriate role for the U.S. government to take in terms of manpower and funding to combat this epidemic? Should it work independently with respect to the WHO and the NGOs? Or should its support come through them? Or—or both? Laurie, do you want to start on that?

GARRETT: I don't think it's ever wise for the United States to offer it unilaterally, or in a direct bilateral, without—ignoring a superstructure. And, I'm very happy to say that, indeed, the response in Liberia was very deeply enmeshed and connected with what was going on by—from the Liberian government, what was going on in the NGO and humanitarian sector, and what other countries. And, indeed, one—one of my favorite moments, when we were talking before about healthcare workers failed to applaud Cuba for its extraordinary contribution of 165 physicians coming to all three countries.

And, in—in Liberia, I was with U.S. military, and I visited the military facility built specifically at your taxpayer expense for infected healthcare workers in Liberia. And, I said, well, would you take in Cuban physicians and treat them if they contracted Ebola here in Liberia? And they said absolutely. We would see it as one of the most exciting things we'd ever encountered, the—the thought of possibly creating a diplomatic bridge with Cuba over—over treatment of a selfless individual. And, as you all saw, thankfully the Cuban physician who contracted Ebola in Sierra Leone was released from hospital yesterday.

BESSER: Very good. Here in the front? And those who are working the microphones, if I—if I'm missing somebody who's had their hand up longer, please jump in. Yes?

QUESTION: I'm Craig Charney from Charney Research. Some of our work has involved health projects in Africa. We heard the rather contrasting images of Sierra Leone from Laurie, and from Mr. Nabarro. Laurie seemed to suggest things may still be in the exponential stage there. Mr. Nabarro seemed confident that with the establishment of treatment facilities things will be under control by January or so. I'm wondering, Laurie, if you agree with his perspective? And if he might want to respond, I'd be curious if we could have a bit more of a dialogue on the outlook in Sierra Leone and what the potential risks are?

GARRETT: Well, of course, I always honor Dr. Nabarro's opinion and—and he's been at this game much longer than I. But, what I—there's a very curious situation which he alluded to in Sierra Leone. The original outbreak there was in the eastern part of the country, coming in from Guinea, and down into Kenema area, which has—is also where Lhasa fever typically is a hot spot. So, fortunately there was a Lhasa treatment center there that immediately was able to raise alarms to the world, and take on an enormous response right on the spot.

But what's happened is, since September, the whole epidemic has shifted to the west. And while, as of yesterday's report, there is still Ebola in every single county in Sierra Leone, the vast majority of it is in two districts, both called Western, the main Western where Freetown is, and then Western rural, which comes down to Kerry Town. And, these are—what's—what's striking in it when I was trying to describe the geography, it's—it's easy as the crow flies to be quite close, one village to the next, or one neighborhood of Freetown to the next. But, geographically, it can be extremely difficult to get from one place to the next, and you can hit neighborhoods that are truly pockets the way old New York was, where people don't even know the folks in the next neighborhood over and you're all in Freetown. And the—and Freetown, as of yesterday's numbers—David can correct me if I'm off a bit—only had about 150 Ebola beds available, and it's not all in the city limits. That includes going all the way down to Kerry Town, and that doesn't even come close to meeting the patient load.

So, yesterday, Connaught Hospital, which is the largest hospital in Freetown, the doctors and nurses went on strike, and they have lost quite a number in their ranks to Ebola. When I was there they had—they were still continuing routine medical care, which is a big difference, by the way with Liberia, where most of the health facilities ended up being either all Ebola facilities or no Ebola, you know, trying to keep them separated. But, Connaught Hospital still does cardiac surgery and whatever. And as you would enter, they've set up a triage. If you have any symptoms that might be coincident with Ebola you would go to a pen, which is out on the street, and there's nothing there, it's a holding pen.

BESSER: Laurie, let me pull—pull David in so we can get a little more back—back and forth. Are you seeing signs in Sierra Leone that—that—that give you a—a sense of hope? Or does the strategy need to—to change to—to see progress?

NABARRO: Thanks very much. I just want to stress that the situation on the west side is a real concern for—for everybody, where Laurie is talking about Western rural, Western urban, which is Freetown and Port Loko. And, so, yes, yes, we—we are worried, and we want to see more beds opening up quickly. There are beds on stream, but they're just not open and receiving patients. The—the lady who asked the question earlier on referred to some of the challenges that have been reported from Kerry Town. So, please don't think that I am complacent about this. It is one of our two big worry areas, and there are many good people, experienced people, working with the government of Sierra Leone, the president himself deeply involved, to try to get this situation better. And all the points that Laurie has mentioned about communications challenges and also some of the very limited local organizations in—in this area is something to be worried about. Yes, we are going to, all of us I think, face some challenges between now and the end of January in getting the situation in the western part of Sierra Leone under control. We can't fully explain to each other why it's so tough, but what I'm saying to everybody is that the strategy as has been designed, when fully implemented in other parts of Sierra Leone and in Liberia, works. And we have no reason to believe that we have to change strategy, Richard. I think—I think it's the right strategy, and with everybody pulling together, which is the style that's going on Sierra Leone right now, it will come right. It just will take a bit of time. Thanks.

AOSSEY: Yes, I just wanted to add one thing. You know, a couple of months ago, when we were looking at Liberia, the big challenge there was the outbreak was outpacing operational efforts on the ground. That's what we see happening in Sierra Leone. There can be measures put into Sierra Leone. More beds. More health workers. More community mobilization. More of all the things that worked in Liberia, and we can start to catch up with it in Sierra Leone as well. It's not too late, but it is, you know, quite shocking that the numbers are growing at the rate they are. If you really look at it, though, and you consider the amount of operational efforts there over the last couple months, I guess it's not so much of a surprise. And so we can catch it there, like we are doing, and trying to do in Liberia, but it's going to require the same kinds of things that worked in Liberia, knowing, of course, that it's different to work in Sierra Leone than it is in Liberia.

GARRETT: Can I ask David a quick question? David Cameron, the prime minister of the U.K., said in—in a meeting with the E.U. that he wanted the E.U. to come forward, supplement U.K. contributions to Sierra Leone, reaching a total of 1.2 billion, was the target. And, last I looked, it was around 235 million, something well below that that had come through. You're in charge of all this mobilization of resources. That's your piece of the pie for the U.N. Where are we compared to all the original commitments and the bravado that came forward in September? Where are we with the actual amount of dollars and human commitment that was made? How much is really out there?

BESSER: Easy question for you.

NABARRO: Thanks very much indeed. Actually the situation cash wise is not bad in that the first appeal that was formally produced was for nearly $1 billion in mid-September. The amount requested was raised to $1.5 billion in the middle of October. In relation to that appeal, the amounts that have been received are nearly $900 million, perhaps coming into a billion, depends on which figures were used. So, we're not bad in terms of cash receipts, and there have been other contributions outside the appeal which have been very promising as well, particularly to help the countries keep their economies going.

But I have to stress that this is an expensive operation. It's expensive when you consider the cost of bringing in the militaries, it's expensive for the national governments. They've had to divert their economies to put huge amounts into their health responses, and their incomes are much, much lower because of down reduction in economic activity. And the international community does continue to need finance. So, I do need to continue to remind the donor governments that continued financing is needed and will continue to be needed, especially for the next phase which is case finding and contact tracing, which is super expensive and involves painstaking work by lots and lots of epidemiologists and contact tracers on the ground. So, we need to continue, Laurie, to sustain the financing. We need, certainly, another half a billion now, and we will continue to need more next year. Our—our governments are paying their share as well. It depends. Some are fantastic, and your own government has been quite exemplary. But, also, Europe has done pretty well. We go to Brussels on Friday to—to converse with them some more. We just have to keep everybody continuing to come in with further contributions, third waves, fourth waves, fifth waves, because this continues to be an expensive response.

BESSER: Question over here.

QUESTION: My name is (inaudible) from Sierra Leone. Can the panel comment on the economic business impact of Ebola? And what needs to be done to address this alongside the humanitarian effort?

BESSER: The economic impact of—of ...

GARRETT: I got you. The World Bank and IMF just released last week some new guestimates, reckonings, of the economic impact, and that's all they are, because, of course, there's so many unknowns, how long will this continue and so on. But, certainly, Liberia is very possibly going to be in negative GDP growth for 2014, by the end of December. And Sierra Leone had been forecast to be in the ballpark of 12 percent GDP growth, as I recall, positive. And as—and that has plummeted way down, not into negative yet, at least. Guinea, also, very hard hit.

I think the biggest problem for this region is not going to be the impact of the epidemic directly, and the direct costs of—to these governments of the epidemic, but the pariah states that they have become for the rest of the world. I mean, when you're down to only one commercial air carrier that will service an entire region, that's going to be a huge economic impediment. And a lot of the big companies that had been in these countries, the non-extraction companies, have gone. And when I met with our ambassador to Liberia, she told me the thing that she loses sleep over every night is how will we get business back in Liberia.

And it's, you know, how much further away from disease state do you have to get before the world community comes back and says, OK, hang out the shingle and say open for business. I think this is going to be really a long time. I will not be at all surprised if we go out well over a year unless—and I mean a year after you say zero cases, unless Jim Kim can push the World Bank and its partners to step up to the plate really big time ...

BESSER: Well...

GARRETT: ...with huge development investment post-epidemic.

BESSER: We're nearing the end of the hour, and so I want to hit this last question that came in by email. And this is—is addressed to each of you in—really in brief. But it comes from Katherine Ward, from Coronado, California. And it's really that—given that the challenges—given all of the challenges that have been pointed out, what are some possible solutions? And what I'd like—like from each of you, really, is—is one thing. One thing that you see that either isn't being done, or isn't being done enough that you think could have a significant impact on the course of what's going in—in West Africa. I'll give you all, like five seconds, and then I'll ...

(LAUGHTER)

GARRETT: I'll say mine and ...

BESSER: Laurie ...

GARRETT: ... real quick.

BESSER: OK.

GARRETT: During the SARS epidemic we set up an enormous infrastructure for cross communication between technical experts so that the F.E. people were talking to their epidemiologists, the virologists, the virologists (inaudible). Nothing like that has been set up that allows Africans to talk to Africans. It's all going up to Europe and back again, and I think that's disrespectful. It's wrong. There's real expertise that's been developed in Liberia. Real expertise developed in Guinea, and so on. It needs to get shared in a collegial fashion, and the platform to make that happen, it's shameful it's not already there.

BESSER: Nancy?

AOSSEY: I think the U.S. especially has provided tremendous leadership. We see now in Sierra Leone that the U.K. government is doing that. Certainly others are jumping in. But it's not contained yet. We still have to stop it at the source, and I still believe that we need to shift our thinking and our attitudes towards seeing this outbreak in West Africa as our problem together in the world, and that we not do anything based on fear that would in any way isolate, penalize, or drive—or make those efforts more difficult.

One of the reasons why we've seen some of the fear subside, at least say in the United States, is we haven't had recent cases that frighten the American public, which I understand. But if we do have more, we can't go back to the kneejerk reaction that we've had in the past. We really have to look at the science, and look at it rationally, and determine what is our role as—as part of the global health community, and what can we do about it regardless of the, perhaps the—the fear that we have around the—the disease. And I don't—I don't think we're out of the woods on that, and I think it's important to sustain that effort.

BESSER: David, I'll—I'll give you the last word.

NABARRO: Thank you so much. We must be relentless. We must help communities and governments of these affected countries to deal with the current outbreak. We must empower governments of countries like Mali that are close by, to help them to prevent the outbreak getting settled in their countries. We must vow never to let it happen again. We must, all of us, who are involved in science, in communications, in international development, in global politics, just recognize that the threats posed by these diseases are frightful, and we have to get the world strong, so it can deal with them, anytime they reoccur. Thank you.

BESSER: Well, that concludes today's session. I want to thank all—all three of our panelists for sharing their expertise and—and their perspective. Thank all of you for—for your questions and—and discussions, as well as those who are participating through livestream. And thank the Council on Foreign Relations for—for covering such an important topic. Thank you all very much.

(APPLAUSE)

END