The Fight Against Ebola

Panelists discuss the Ebola virus outbreak in and around the Democratic Republic of the Congo, including the social, political, and medical factors that make the virus so difficult to treat and control.

ZBAR: Good afternoon. Welcome to today’s Council on Foreign Relations meeting, The Fight Against Ebola. I’m Brett Zbar and will be presiding over today’s discussion. Really happy to be able to introduce to you today three particularly distinguished discussants. We thank them for their time. You have their bios in your packet, so I’ll just do a brief introduction for you now.

First on our—on my right, Dr. Tom Frieden is an internationally recognized leader in public health. As a physician with advanced training in internal medicine, infectious disease, public health, and epidemiology, Dr. Frieden had led control over the largest outbreak of multidrug-resistant tuberculosis in the United States. He has launched an initiative that will prevent at least five hundred thousand heart attacks and strokes. And he’s accelerated efforts to address the opioid epidemic, among other accomplishments. From 2009 to 2017 Dr. Frieden was director of the Centers for Disease Control and Prevention, where he led the work that helped end the first Ebola epidemic in West Africa. And as commissioner of health in the city of New York, he led the transformation of New York’s restaurants by eliminating smoking and trans fats, for which I’m sure at least most of us in this room are still very grateful. (Laughter.)

On my immediate right, Michelle Gavin is senior fellow for Africa studies at the Council on Foreign Relations. She was previously managing director of the Africa Center. She served as U.S. ambassador to Botswana and is the U.S. representative to the South African development community, during which time Botswana launched the most ambitious HIV-prevention study in the world. Previously she was a special assistant to President Obama and worked closely with the National Security Council, conducting major policy reviews on Sudan and Somalia. She’s also served as staff director for the Senate Foreign Relations Subcommittee on African Affairs, director of international policy issues for Senator Russ Feingold, and LD for Senator Ken Salazar.

And joining us today by video conference, Dr. Jennifer Nuzzo is a senior scholar at the Johns Hopkins Center for Health Security and on faculty at the Johns Hopkins Bloomberg School of Public Health. An epidemiologist by training, she focuses on international and domestic bio-surveillance, infectious disease diagnostics, and disease mitigation strategies. Dr. Nuzzo also advises government and nonprofit organizations around the world on these issues. And she’s worked extensively on issues surrounding water security and has been consulted on pandemic planning efforts in Indonesia and Taiwan. Previously Dr. Nuzzo was a research analyst at the Center for Civilian Biodefense Strategies at the Hopkins Bloomberg School of Public Health. And she has also worked as a public health epidemiologist for the city of New York.

Thank you, again, very much to all of you for joining us today.

So of course we’re here today to discuss the fight against Ebola, against which much progress has been made but where so much more remains to be done. And since we have a number of members with some degree or some range of background on the issue, we thought it would make sense just to start with a little bit of context around what really has happened with Ebola in terms of new epidemics, control outbreaks, since the most significant outbreak in West Africa in 2014.

So maybe, Dr. Frieden, we can start with you.

FRIEDEN: Thanks very much. And it’s great to be here. Appreciate the Council’s interest in this issue. Very much in the news with a very long, ongoing outbreak in DRC. Your question is where have we come to? We had this massive, first ever, real epidemic of Ebola from 2014 to 2016 in West Africa, covering not just Guinea, Liberia, and Sierra Leone, but also exportations elsewhere. Since that time the world said: OK, we’re never going to let this happen again. And here we are again. There have been really three notable events on Ebola specifically before the current ongoing outbreak in DRC.

There were two small outbreaks in DRC that were controlled. And in fact, these were the eighth and ninth outbreaks that DRC has had. DRC is a—is an example of a country that has had relatively more functional surveillance and response systems. In fact, when we were fighting Ebola in West Africa and we needed more French speaking epidemiologists, we put out a global call. And fifteen Congolese epidemiologists ended up responding over a period of eighteen months in Guinea and providing wonderful help. I went to Guinea to talk to them after. I said: During the West Africa outbreak there was a large—there was an outbreak in Congo that was quickly controlled. Didn’t get much news coverage because it was controlled.

And I talked to the epidemiologists who had identified it and controlled it. And said, how did you know it was happening? They said, actually, it was very easy. The doctors and nurses in one clinic died, and then the doctors and nurses in the next clinic died, and then we knew it was Ebola. That’s not a good way to find out that a disease is spreading in your area. So what’s happened are one—two small outbreaks in DRC until the current large one. And also, during the outbreak in DRC, one export to Uganda of a person who had Ebola and was rapidly identified, correctly isolated, effectively treated or controlled. And I think one of the really important things that has happened since the last outbreak is a lot of outbreaks that haven’t happened, including Uganda not being a place where Ebola spread.

ZBAR: Yeah. So certainly resources are different, and we’ll spend more time on that. How about just in terms of the environment? What is different now relative to 2014 politically, and to what extent is that playing into this?

FRIEDEN: Well, the—first off, ironically in February of 2014, while Ebola was spreading but before it had been identified, we launched something called the Global Health Security Agenda. And one of the things that we did with that was to encourage countries to go through a rigorous, externally validated evaluation process called the joint external evaluation. There have now been 105 joint external evaluations done around the world. And for the first time ever we have a sense of where the world is. It’s not perfect. It could be better. It’s going to get better. But the point is, if you get on our website PreventEpidemics.org, you can click on any country and see where they are in terms of epidemic prevention. That didn’t exist before. So that’s a very important component.

There have also been interests and various different mechanisms for dealing with epidemics, whether it’s an insurance-based model or research model. But the area that remains weakest is preparing countries by addressing everyday threats. What we’ve learned is that if you wait for the big one by keeping emergency plans in the closet, it’s not going to work. On the other hand, if you’re using your emergency operations center, your incident management systems to respond to everyday health challenges—whether it’s food poisoning, or measles, or typhoid, or cholera, which unfortunately these countries have in abundance, or HIV, TB, malaria—you’ll be much better prepared for whether it’s Ebola, or Lassa fever, or any other of the very dangerous pathogens. So I think politically there’s a much better understanding of the need to prepare. But unfortunately actual progress in the field at being better prepared is not nearly what it should be.

ZBAR: So that may be a good segue just a little bit into how some of the tools have evolved. When you step back, you know, up to 2014, we have now recently had the first ever approved vaccine for Ebola. We have two treatments that are now available in the form of antibodies for patients that are exposed or sick. First maybe on the prevention side, where have we made the most progress? Where is the greatest remaining need? I mean, we have a—maybe the bluntest way to put it is: We have a vaccine. Why do we still hear about Ebola? And this is for everybody, I should say, on the panel. And Dr. Nuzzo, I can’t look at you the same way I can our panelists in New York, so please jump in any time.

FRIEDEN: So I’ll start and then I’ll turn it over to others.

ZBAR: Great.

FRIEDEN: So the vaccine is a great tool. It’s effective. It’s safe. But it’s just one tool. It’s not like other vaccines of preventable diseases where you vaccinate everybody, and the disease can go away. In order to deploy this vaccine in Ebola you have to find the case, you have to isolate the patient, you have to identify who the contacts are, you have to gain the trust of the community, you have to ensure that the health workers are safe. If people die, you have to make sure they’re safely buried. So all of those fundamental, core public health functions continue whether or not we have a vaccine. In fact, you can’t deploy the vaccine effectively without them, because you don’t know who to vaccinate.

On the other hand, the vaccine is really important because it makes each of those things easier. Because there’s a vaccine, you may be more likely to have community trust. There’s been great interest in the vaccine. We were concerned that there would be a lot of suspicion. In fact, there’s a very high uptake by the community. You can help health care workers be safer so they can care for people more safely. Also burials can be safer for those who are providing the burials. So the vaccine is a really important tool, but it’s just one tool.

GAVIN: Yeah, if I could just jump in, you have to vaccinate people within a context, right, a political, and an economic, and a security context. And I think the fact that there’s been a measles outbreak in Congo that’s killed more people than Ebola has over the same period of time tells us something, that having a vaccine that works is insufficient, right, to address these public health issues. And eastern DRC is a politically complicated, extremely insecure context in which to be trying to get anything done. And so I really do think, and we can unpack that a little bit. There have been many reports of attacks on health workers who are there to fight the Ebola epidemic. I think the WHO has suggested there’s been more than three hundred such attacks. And it can be a bit confounding, right, to try and understand why people there to help fight this horrific disease would be the target of community ire. But I think it’s really important to step back and try and imagine the lived experience of people in eastern DRC.

So we talk a lot about what a challenging environment it is for health workers. And that is absolutely true. Extraordinarily poor infrastructure, right? There’s a huge security crisis. There’s been regular conflict in this part of Congo for a couple decades now, and particularly in North Kivu you have multiple armed groups—scores and scores of armed groups, often with murky agendas. It’s—there’ sometimes some collaboration clearly between the state security forces and police and some of these armed groups. So you have this very difficult, very hard place to work. It’s an even harder place to live. People have been dealing with this kind of insecurity for a very long time. Tremendous poverty in the area. And either an absence of governance or incredibly poor governance.

And these public health issues have been swept into this whole context. And here’s one great example. The people of Beni, where some of these most recent attacks on health workers have occurred, were not given an opportunity to vote in last year’s presidential elections. And the state said: It’s because of Ebola. It just wouldn’t be safe to have people come out to the polling place. This is an opposition stronghold and has been for a very long time. The way this interpreted on the ground, right, is that this is just one more tool for disenfranchisement, one more way in which the state will disregard our interests. And so it’s—when you consider the sort of totality of the context you see how difficult it is for a population that’s been coping in these circumstances to have any kind of faith or trust in an internationally led response to any disease outbreak.

ZBAR: Maybe just to dig into that a little bit, because it’s maybe hard for some of us sitting on East 68^th Street to imagine that lived experience, you know, and to read about the attacks on health workers that are going on. Maybe can you give us a little more of historical examples or contexts where really there has been such suffering at the hands of external elements?

GAVIN: Sure. Well, that’s basically the history of Congo, right? From one of the most heinous examples of colonialism at the hands of the Belgians, to, you know, an era in which Patrice Lumumba was assassinated, certainly with the complicity of the United States where, for Cold War reasons, we supported a dictator, Mobutu Sese Seko, who as incredibly rapacious and corrupt. Then to the era of war, which for the people of eastern Congo does not really seem to have ended, where you’ve had actors from Congo’s neighbors invading the state using proxy forces on the ground both to confront each other and to establish control over very lucrative mining and timber interests.

So it really is the case that for a lot of people there, when external forces come on the ground they are there for their own interest—their own economic interest. They are there to take something, to manipulate in some way. And authorities—and there’s often a conflation between the state, sometimes the U.N. forces on the ground and others—authorities do not have your best interests at heart. And they’re also very difficult to hold accountable. So when you have people actually on the ground in these places, these frontline health workers, or in some cases peacekeepers as well, here is someone finally one can see. And so it does not surprise me at all that the result is demonstrations, protests, and attacks.

NUZZO: So if I could jump in, if I may. And I agree with everything that’s been said. And just hello, everyone. Greetings from Stockholm.

You know, I think it’s really important to also consider opportunities for intervention that we could have had. Obviously the security situation is an important context to view this outbreak, epidemic, through and to consider that. And clearly the most recent attacks on health care workers I think will potentially have devasting impact on the important recent momentum that’s been gaining in terms of driving down transmission. And, you know, we had been sort of on an optimistic path towards containment.

But I do think that when we hear these stories, I think it sometimes give the impression of hopelessness, that there’s this larger context that we absolutely can’t fix, and we can’t address, and sort of, you know, this perhaps maybe lends a sense of fatalism about the trajectory of the outbreak, and perhaps maybe makes people think that there’s nothing that can be done.

You had asked the question about, you know, why if we have a vaccine do we still have Ebola. And Tom had raised some very important points about the kind of public health resources that are needed in order to, you know, mobilize the use of this important tool, which is the vaccine. But, you know, there, in my mind, has been a deficiency is some of the response that particularly in perhaps the first six months of the outbreak, had those been addressed, we possibly could have had a lot more gains.

And so from the very beginning of the outbreak there’s been a real challenge in not only identifying contacts of cases, who are the ones who should be offered the vaccine, but to monitor those individuals for signs of illness and to promptly isolate them when they become ill. There’s also been challenges in terms of protecting health care workers. So while health care workers are offered vaccine as a priority, there’s been really significant numbers of health care workers who have become sick in the treatment of Ebola patients and transmission happening in health facilities.

So while the larger security context is important to consider, and clearly has been an enormous challenge in the response to this outbreak, there are also other things that I think warrant our attention because those are things that potentially we can push on when we do have periods of quiet, when we do figure out a way to protect health workers through enhanced security, that we can, you know, make some gains in terms of further limiting transmission and mobilizing the very important resource of vaccine.

ZBAR: Just one follow up question on that. You mentioned contact tracing as a—as a hurdle in the early intervention. What was driving—what was impeding that contact tracing?

NUZZO: You know, it’s a really—we talk about it like it’s a thing. And it’s obviously something that is a routine practice in public health. But it’s more of an art than a science, in the sense that it’s very nuanced work. It requires very experienced management teams who can keep track of all of the staff and make sure that the work is being done. It requires delicate conversations with cases about, you know, individuals they may have had contact with, some of whom they may not want to identify to protect those individuals or perhaps not wanting to admit to having been in contact with those individuals. It requires repeated conversations, incentives. It’s work that really requires an experienced team.

And I had been quite alarmed in the first six months of the outbreak that some of our most, you know, experienced experts on this, the U.S. Centers for Disease Control, were really, you know, essentially shut out of the outbreak zones, from—by the U.S. government. Clearly the security situation is, you know, in a different state than it was then, but there was sort of this, you know, blanket statement that it was too dangerous for U.S. personnel. And so I think that really—we really missed an important opportunity to put the contact tracing path on an important, and productive and, you know, effective trajectory.

I still haven’t actually seen an analysis of the deficiencies of contact tracing and what is being done to address them. Clearly now we’re in a situation where a lot of the response operations have been interrupted. And so you know, we’ll have to think about that when hopefully they resume. But, you know, I think that there are some important levers that we can still push on before we declare the current situation hopeless.

FRIEDEN: Contact tracing is really core public health work. And it’s done for a wide variety of conditions. And exactly as Jennifer says, it’s an art as well as a science. And it requires sensitivity. It requires trust of the community. And one of the key indicators to determine how effective a response is, what proportion of the new cases arises from contacts who are being followed every day? Because ultimately if that number gets very high, you’ll stop the outbreak. And it’s been persistently low, though getting higher, in DRC, for a variety of reasons. But ultimately if you make sure that you identify each contact, you follow them for twenty-one days, the moment they have fever you isolate them, transmission stops. So it’s the backbone of a response.

One of the most searing memories I have from the 2014 outbreak, the first time I went to West Africa early on in the epidemic I was in Guinea, in a remote rural area. And I was speaking with a middle-aged man who was the contact tracer for the local—the health unit there. And I was talking to him for about thirty minutes about his work. And he was clearly quite good at it. And I said, well, what more could the world do to help you do a better job here? And he said, very respectfully said: I make $4 a day, and I haven’t been paid in four months. I can’t feed my family. And this is at the height of an Ebola outbreak. It just made me furious.

Meanwhile, millions of meetings, and workshops, and good, you know, this about what’s going to do—statements from the U.N. And here’s this period who is actually on the front line who hasn’t been paid his $4 a day in four months. So making sure that people on the front lines get the services they need are really important. And it doubles back the issue of trust. And you might think of it as—think of a building with many rooms, some of which don’t have an alarm or sprinkler system in them. And that’s going to be a risk to the entire building. In the same way, places like North Kivu, or like parts of Pakistan which are deeply hostile to or distrustful of the government, are breeding grounds not just for violence but also for the spread of infectious diseases.

ZBAR: So having experienced that now in Congo, obviously it’s not, to your point, the only geography with these kinds of dynamics. What have we learned or what could we—what would we do differently, given that it’s not the only example?

FRIEDEN: Well, I’ll start and I’m sure others have important inputs here. But if you’re a person in rural Pakistan or North Kivu, and you’ve got no roads, no electricity, there’s corruption in the government, there’s violence, there are no jobs, you don’t have health care, and somebody comes in and says, in the case of polio, take these polio drops, or in the case of DRC do this for Ebola, and you may not have ever seen a case of polio or Ebola respectively, it would be irrational not to be suspicious of that person, and not to be paranoid. So I think we have to address some of the broader issues, even if we can’t make a rapid change in the many challenges that exist. There’s some things that we can do.

We can address the measles outbreak in DRC, which is killing thousands of people. We can—obviously need to address security issues in DRC, which was the trigger for the recent attacks on health workers there. In polio, and I’m also a member of the Independent Monitoring Board for the Polio Eradication Initiative, we’ve looked at this in depth for Pakistan. And every time you go in with a vaccine, you should bring something else. You should also bring clean water, or oral rehydration, or Vitamin A, or malaria bed nets if that’s a malaria issue in that area—not there, but elsewhere. It’s really important that you be able to convey to the people that you’re trying to protect that we care about you, not just about this virus, because they would say very rationally: Why are you really here, right? I haven’t seen polio in years, and you’ve come ten times to vaccinate my kids.

And there’s a wonderful leader who’s now leading the response in DRC, Salam Abdou Gueye, who I met in West Africa during the Ebola outbreak. He worked for CDC previously, WHO now, doing a terrific job there. And he was just coming out of Guinea when I was going in one of the times. And he said to me, I’ll tell you—he’s from the region—I’ll tell you what the people are saying in the community. They’re saying: You people said you’re doctors, you’ve been here for eighteen months, you haven’t treated a patient.

NUZZO: I think another important—oh.

GAVIN: Please go.

NUZZO: Yeah. I was just going to say, I think another important sort of day-to-day benefit that we should think about trying to build now is to strengthen these health centers. As I mentioned, a lot of the transmission has been happening at health centers. So people are bringing their children in, for example, for treatment for something else, and in the process are being exposed to Ebola. Health care workers are becoming sick. This is a sign of sort of a weakness in the broader health system that is—should be there to serve the day-to-day needs of the population. Strengthening those health centers such that they can deliver care in a safe and effective manner is both good for controlling Ebola, as well as good for day-to-day health—meeting the day-to-day health needs of the community and, in my opinion, can do a lot in terms of lessening some of the suspicion when we have to have standalone programs.

ZBAR: Wow, it’s amazing. It’s almost like a—in some ways today the hospital system in the U.S. being one of the least-safe places to be from a microbial resistance perspective. But go ahead.

GAVIN: No, that’s such a great point, about health centers, but also a reminder that, you know, the sort of governance deficiencies in Congo have these very, very real and dire consequences. And that these big governance questions, they trickle down pretty quickly. The minister of health in the DRC was fired and arrested over the course of this last year, largely around corruption-related charges related to Ebola budgets. But the overall budget of the DRC is woefully inadequate and much of it gets siphoned off.

So for me, one of the big, well, what do we have to do to get better at this, is—and it’s not terribly popular in Washington right now—but is to acknowledge that spaces that are ungoverned or very poorly governed—this idea that we can just sort of let them churn in chaos and it doesn’t affect us, our interests, or our security—it just doesn’t work. It’s not real. It’s a—it’s a fantasy. And that requires a lot of very hard, very long-term sort of multilateral slog to try and get better at helping places where governance is just failing people.

FRIEDEN: Michelle, can I ask you a question? DRC is almost the poster child country for the resource curse. Are there—

ZBAR: You should explain what that is for everybody.

FRIEDEN: Probably Michelle would be better at explaining what it is and what it comes from. But basically countries which have large natural or other valuable resources, the energy is spent in who captures the state to extract the dollars and governance tends to be much worse than poorer countries that don’t have those resources. But what can be done in places like that, either structurally or otherwise, to make a difference on the political scene?

GAVIN: Right. Well, that’s teeing me up very nicely because I used to serve in Botswana, right, which is a diamond rich state, and one of the—you know, Botswana and Norway are sort of the other examples, where resources have been used to very good effect to sort of further the overall development of the population. And it really all comes back to governance. All roads sort of lead back to establishing some kind of accountability and relationship of trust, and investment in people. And these are—these are things that cannot be disregarded. And there’s no workaround. And they’re very, very hard to do.

ZBAR: One more question just before we open it up to members for questions. One the therapy side, you mentioned this briefly, there’s been a significant amount of progress. We have two therapies at least now that are available, the REGN-EB3 and monoclonal antibody 114. Those have shown dramatic improvements in patients who were infected. Are we done there? Do we have what we need? What else do we need?

FRIEDEN: Well, we still have a more than 60 percent case fatality rate. So we’re not done yet. Again, drugs don’t work unless you can get them into people promptly. And so that comes back to the issue of both competent public health services and the level of trust and safety in the environment. And the issue of how can you operate in a place with insecurity is very, very important. On one hand, it means we need to do more and more in strengthening local capacity because the international move in is going to be more risky, it’s going to be slower, it’s not going to be as effective. On the other hand, we need to start looking around the world at what are these other places like the places without an alarm system or sprinkler system? And what are somethings that can be done, whether it’s providing water and sanitation, or roads, or jobs, that will mitigate some of this risk?

The treatment is really exciting. It’s effective. But, you know, so is rehydration—giving people oral rehydration. And so the—we want to provide the best possible prevention and care everywhere we are. And that will have, as the vaccine has, knock-on positive impact because if people find that if you go into the center and you come out alive, they’re more likely to go in earlier and therefore spread less and have an incentive to identify more contacts. So again, these are important new tools, but it just shows how the political context can overwhelm technology, particularly in disease like Ebola where control of Ebola—just to—just to make clear—is really hard. It’s very straightforward, except you have to pretty much do everything perfectly. You can’t miss a single contact. You can’t miss days of contact follow up. You can’t have a single lapse in infection control or a single unsafe burial, or you’ll have another chain of transmission.

ZBAR: Thank you. At this time we would like to invite members to join our conversation with their questions. Just a reminder that this meeting is on the record. Please wait for the microphone and speak directly into it. Please stand, state your name and affiliation, and we ask that you limit yourself, please, to one question and keep it concise, so as many people as possible can speak. Please, at the front table.

Q: Thank you very much. My name is Joanna Weschler. I work for Security Council Report, a small nonprofit organization.

And I wanted to ask our panelists whether or not social media have played a role in creating the Ebola crisis in the DRC? And the reason I’m asking is that Beni, the place Michelle Gavin described as being where the Ebola workers are targeted, was also very recently a place where U.N. peacekeepers had been targeted in a very violent way, with the property being trashed, burned. And it was really quite a serious crisis for peacekeeping. And someone who had just came back—come back from that place, from the scene, used the phrase, “weaponization of communications,” referring to use of social media to spread false information, to spread incentive to attack, and also to use false U.N. identity. And I’m curious whether any of that has also happened in the context of Ebola in the DRC. Because, as we know, everybody in East Africa, they don’t have much, but they usually have cellphones.

GAVIN: So I’ll start just by saying I’ve seen reports like that as well. And there is no question that sort of disinformation and manipulation—this kind of social media manipulation of populations is a trend throughout Africa, and the rest of the world. And so—but I don’t—I think that it is particularly effective when the ground is ripe, right? And in the case of Congo and the peacekeepers, it’s very much like the example you gave of the—you know, the doctors have been here for eighteen months I haven’t seen them treat a patient.

They are the peacekeepers, and yet people are living in terrible insecurity, in part because the government chose to launch an offensive against one of the armed groups, the ADF, right? The ADF then responded with attacks on civilians. Everyone’s wondering, what are these peacekeepers here for if they’re not providing me security? And so the conditions are quite ripe to mobilize people. So whether there’s a—someone kind of orchestrating this or not, I think the fundamental questions of service delivery and trust remain. And it would not be as easy to get that done on social media without those conditions.

ZBAR: Jennifer? Did you want?

NUZZO: Yeah. The only thing I would add to that is I too have heard reports, you know, of rumors being spread. People don’t believe that Ebola’s actually an actual thing. I think in any environment you’re going to have some degree of that. And having a plan for how to respond to that is important. That said, what I have heard is that from the response side that that hasn’t necessarily hindered vaccination uptake, for instance, when they go in post-response. So I think it’s really important to, you know, acknowledge that this will be something that has to be addressed because, you know, as was said, you know, if you have actual resources to offer people who become sick, a treatment for instance that could help cure them, that there is a sense that the team has something to offer, as well as you can see tangible benefits in the community. And I’m absolutely confident that the communication challenges can be overcome. And, you know, I don’t want to give the impression that the media is always going to be complicating, because in almost any environment it’s going to be possibly one of our best communication tools.

FRIEDEN: And actually, in many of these communities there’s a lack of access to basic cellular service. So there’s—there isn’t the same kind of viral spread of misinformation. But we’ve seen for almost every outbreak that the viral spread of misinformation can be very, very fast.

ZBAR: Great. We have a question at the very front here.

Q: Thank you. Craig Charney from Charney Research.

I’m wondering if you’re following the right public health model in response to Ebola. Wouldn’t it make more sense, rather than waiting for clinics full of nurses and doctors to die, simply to routinely vaccinate all nurses and doctors in West and Central Africa against Ebola?

FRIEDEN: That’s what’s being done.

Q: Yeah—

FRIEDEN: That’s the goal. The challenge is there’s a shortage of vaccine.

Q: Right. What I was going to say is, this is going to require a significant investment. We’ve made significant investments for diseases like AIDS, TB, and the like. Likewise, isn’t it worth considering making Ebola one of the routine childhood vaccinations that children get in those regions as well? Again, yes, it would involve a significant investment. But, on the other hand, maybe instead of trying to rush from room to room in the building to see if there’s a sprinkler system, maybe you should just try to fireproof the building.

FRIEDEN: Right. So the vaccine is not a panacea. The vaccine doesn’t cover all of the strains of Ebola. And the duration of immunity isn’t well delineated. So at present, it probably wouldn’t be appropriate to put in the childhood vaccination schedule. Health care workers, absolutely, in areas that have Ebola, just as health care workers should get Hepatitis B vaccine to protect themselves against Hepatitis B. They should certainly get the Ebola vaccine.

There has been a shortage of the Merck vaccine. The J&J vaccine has just begun to be used. It’s a two-dose vaccine. And we think definitely this is one of a series of things that should be done to protect health care workers. Half of the health care facilities in most of these areas don’t have running water. So even to tell people, wash your hands—but absolutely there’s a need to protect health care workers as a—as a key priority here.

ZBAR: Great. We have a question right here on the other side of the room.

GAVIN: I think she—

ZBAR: Oh, sorry, Jenny, were you going to add to that? Go ahead.

NUZZO: Yeah, the only thing I was going to add to that was, just to flag that in some instances there have been refusals of the vaccine among health care workers. And to kind of paint the picture for what we’re talking about, is that in many of these health clinics, you know, the term health care worker is possibly not what you would interpret here in the United States. It’s not always doctors and nurses. Sometimes, you know, individuals with much less training. And so, you know, communication about the vaccine benefits, and willingness to take the vaccine in the absence of an ongoing outbreak are all things that we’d have to consider as well.

Q: Hi. Bruce Knotts. Unitarian Universalists United Nations Office. And I’m a retired FSO. And also teach at the School of Social Work at NYU.

And we looked at the Ebola crisis from a social worker perspective and looked at the psychosocial disruption that happens. And there was a lot of credit given to the international community for dealing with the medical emergency, but not much for dealing with the psychosocial fallout that happened afterwards. If you could comment on that.

FRIEDEN: So the impact on survivors has been enormous. And continued stigma is huge. The fact that it—there were some episodes of sexual transmission many months after recovery didn’t make that any simpler. Some of us had hoped that all Ebola survivors would be offered a potential role in the response—a paid role in the response. But you see just one more of the areas where you have huge challenges in poor communities—you have one more thing layering onto that. And the goal really is to try to strengthen communities in a broader way so that you have more resilience to deal with not just Ebola but other things as well.

One of the areas that a lot of work has gone on is the anthropological understanding of some of the practices. And I think there has been some progress in a recognition of, for example, safe and dignified burial being a flashpoint with communities. And several of the episodes of violence in the 2014-2016 epidemic were related to inadvertent lapses in cultural sensitivity on the part of responses, often from the same countries. Urban responders going into a rural area and not wearing the right clothing, or not being—acting in a way that was felt respectful. So I think there’s been some, though not sufficient, progress understanding that a sociological and anthropological understanding of the community is an integral part of the response.

NUZZO: I agree with that.

ZBAR: Let’s go back to—sorry, go ahead, please.

NUZZO: I was saying that I agree with that. One of the saddest stories that I heard after the West Africa epidemic was one of the health care workers who had been featured on Time magazine, you know, the persons of the year one of the years they selected the Ebola health care workers. And one of the women who was a health care worker in West Africa who survived having been infected with the virus later died following childbirth because she hemorrhaged, and she went to a health facility, and they knew that she had been previously infected with Ebola, and they were afraid to treat her because they were worried that they might become infected. You know, the epidemic was over, but nonetheless that stigma still followed.

GAVIN: Yeah. it’s hard to overstate too the layers of trauma, right, in eastern Congo in particular. So unless I’m mistaken, I think UNICEF is supposed to taking the lead there on sort of psychosocial support in the context of the Ebola epidemic. But there are layers and layers, right? There’s the insecurity of these militia attacks. There’s sometimes where state security forces have fired on people at funerals. There’s—who are upset about the burial practices. So many elements to it. So this idea of a holistic community resilience makes a lot of sense to me.

ZBAR: Let’s go to the middle table on this side. And please keep your questions brief. Thank you.

Q: Hello. Thank you. My name is Monwar. I work for Permanent Mission of Bangladesh to the U.N.

So seeing two expats, one from the political side and one from the health side, I was actually encouraged to ask this question. Because traditionally health has been discussed in the WHO in Geneva. But recently for last one or one and a half years, we have seen that this is drawing increased attention at the U.N. level. So I was just thinking, because health, including Ebola, emerging and new infections, bioterrorism are the complex emergencies which needs rapid response actually has two aspects. One is the political aspect, that includes governance, policies, and security issues. And another is the social aspect, that includes actually a kind of more investment to the health institutions or services, capacity building, and also the social safety. So I was wondering, I mean, the—you two expats, how you see these two converge at the global level? I mean, there is political efforts to, you know, forget consensus on how to deal with this kind of emergencies, but what is your suggestion or opinion to see more effective? Thank you.

GAVIN: Well, I do think things have been getting better, right, and not just in the last two years. But I think the first Security Council meeting on the health issue was convened by Richard Holbrooke, actually, in the early 2000s, around HIV. So I think people are getting more comfortable talking to each other. And they’re, you know, to my mind, because most of my work’s been in the U.S. government, there’s getting the U.S. government in this integrated place, right? And there—I know there have been calls to sort of reestablish a directorate for some of these global health issues at the National Security Council, which it used to exist and then I think under some of the reforms under the tenure of John Bolton was removed from the flow chart, and those responsibilities kind of some here, some there, divided up. That can be challenging.

But then there’s really the issue of multilateral cooperation and leadership. And that’s an incredibly important issue. If you look at the response in West Africa, there is no—I don’t think anyone would dispute that the U.S. played an incredibly important leadership role. It certainly was largely the people of West Africa themselves who fought in the trenches and ultimately were victorious. But there’s a need for multilateral leadership, which isn’t, you know, particularly a strong suit in the U.S. right now.

FRIEDEN: I would say there are—there’s two different kind of diverging areas. One, most health decisions ultimately are political decisions. And having good political leadership can make an enormous difference. I would point to, in the noncommunicable diseases, Uruguay and Chile have the best tobacco and nutrition policies in the world. Why? Because the president of Uruguay was an oncologist and the president of Chile was a pediatrician. So the—

ZBAR: Are you announcing your candidacy?

FRIEDEN: No. (Laughter.) The point being that even nonphysicians, who would like to see—really get that health is important and give it priority. On the other hand, we want to make sure that the health expertise is insulated from politics, so that we have reporting of diseases accurately, that we follow what is technically necessary in terms of getting the work done. So it’s an interesting balance. You’d like commitment, but not meddling. You’d like commitment, but not endless meeting stating commitment. (Laughter.)

ZBAR: Great. Dr. Allen Hyman, the front table.

Q: Thank you, Brett. I’m from Columbia University’s medical school.

So one of the areas of good news, as far as I understand, is Liberia. And I think the WHO has declared Liberia to be free of Ebola. And I imagine there must be some political decisions that the leadership made there that enabled them to make this claim. Could you elaborate on that?

FRIEDEN: So the West Africa outbreak was ended after tremendous effort on the part of many people with leadership from the countries. Uganda has been able to resist, essentially, the importation of Ebola on multiple events, and the spread of Ebola. It really comes down to, can a country find the threat quickly, respond rapidly, and prevent it wherever possible? And that is the combination of a political commitment to health and transparency, and core competence in what governments can so. Resolve to Save Lives, the initiative I lead now, we are working with about forty countries around the world to help them step up preparedness. Go from red to yellow, yellow to green, in terms of a range of capacities that will keep them safer, keep the countries around them safer, and keep the world safer.

ZBAR: Do we have a question in the back? Over here.

Q: Hi, there. My name’s Elizabeth Radin. I’m an international affairs fellow here at the Council. And my fellowship is supporting the—to work with the International Rescue Committee primarily on learning from past global health responses for addressing future health and humanitarian emergencies.

So on that theme of lessons learned, I think we’ve heard a range and a breadth of insights from the experience in West Africa and the experience in DRC. If there were to be an Ebola outbreak tomorrow in a low-resource, conflict-affected area—say, South Sudan or Afghanistan—what would be your topline critical strategy to respond better next time, and put those—that range of lessons into quick action?

FRIEDEN: Do you want to start, or shall I start? I guess the first thing is before an event we need to strengthen the local capacity. And that means epidemiology, surveillance, laboratory, and response capacity. These are the core components of being able to find a problem when it first emerges and then respond rapidly. So we need to strengthen, essentially, the public health safety net in especially the places that may be difficult to get to for an international response. The local response is always going to be quicker, cheaper, more effective. And so strengthening that local response is crucial. And then the ability to flex in very rapidly is also quite important. And that means U.S., U.N., WHO, other responsive agencies.

It’s encouraging, for example, to see World Health Organization African Regional Office much more competent than it was in the past, with very good leadership from Dr. Moeti. She’s got excellent staff there, some of the world’s leading experts in there. So strengthening the local and regional expertise is crucially important. And then going in from the outset with as much understanding of the political, sociological context as possible is important. But I also think we have to recognize that there are some contexts where it’s going to be extremely difficult, even with the best of efforts.

NUZZO: And I would just add, you know, the example from the prior question about talking about Uganda and its swift response to an imported case. Shortly before that case occurred, they conducted a local exercise that involved health facilities. And that particular health facility, that saw that case, was involved in that exercise . And they identified a number of sort of shortcomings in their protocols that were fixed. And fortunately it was fortunately timed because then they, unfortunately, saw a case. I think those sorts of preparedness activities, in addition to the core public health resources that Tom mentioned, but also to make sure we involve in the health facilities and the health workers at those facilities, are really critical.

But we also need to really think about—when we talk about these outbreaks, as we will increasingly be, that occur in insecure environment, what our—what are our, you know, international plans and protocols for mounting, you know, a multi-country response? You know, it’s—if we compare what’s happened in the DRC versus in 2014, the international presence is much smaller. The number of countries involved are fewer, because many of them have simply decided that the situation in DRC is too insecure for them to risk sending their staff. It’s an understandable calculus that they go through, however we can’t just simply kind of throw our hands up when deadly outbreaks occur in insecure environments because these environments, you know, create situations that encourage the development and spread of diseases like this. And we need real effective policies that can enable health workers to come in, and public health responders and security to come in, and to try to support the local response if the resources there are insufficient.

ZBAR: OK. Let’s see if we can squeeze a few more questions in before we wrap up. Right in the front here.

Q: Thank you very much. I think somebody talked about Patrice Lumumba and so forth. My education on African politics began when I was a teenager, witnessing the exit of Belgians from Congo, when they were thrown out in the ’60s.

And my question is regarding the commendable performance you mentioned on outbreak and surveillance with respect to DRC. I was stunned to hear. And of course, in the 2014-16 period, Nigeria was very fast to act on contact follow up and prevention, including with the one doctor who came, I believe, from Liberia or a person from Liberia that went to Port Harcourt. Two hundred people were contacted. And I was there personally during that period. And I saw the controls put in place.

So I’d like to ask you if there are themes that emerge from successful efforts in places with difficulty, like in eastern Congo and DRC, as well as in other places where, you say, well, these things that worked. Are there common themes or are they just pieces of luck?

FRIEDEN: No, it’s very clear. It’s a strong public health network. What happened in Lagos was a man came from Liberia, died. And the initial response was not optimal. And that was really the moment of just terror. There were—Ebola could have spread all over Nigeria, all over Africa for months or years. And we then redeployed the Polio Eradication Initiative infrastructure to address Ebola. And it was that re-deployable infrastructure that took excellent proactive action, stopped the outbreak in Lagos, stopped it, as you mentioned, in Port Harcourt after. So I think that is one of the core lessons from the past few years, that we need to strengthen public health systems, not for—not only for individual diseases but being able to deploy them for the next threat.

GAVIN: If I could—this is going to be very quick—but just to say, you know, relative to the capacities in Congo after ten Ebola outbreaks, right, at the capacities in Uganda. And the critically important point that’s been made, that we can’t just give up. I do think it’s really important to remember that for all the problems there’s extraordinary human capacity out there, right, on the ground. Brilliant scientists, incredibly dedicated doctors and nurses. And some of these health workers who, yes, don’t have as much training, but are willing to deal with very difficult conditions and take a lot of risks to try and help each other. And I think it’s important that we acknowledge them. And it’s not as if there’s no one there to believe in. They’re extraordinarily heroic people, and very capable and competent people on the ground who when organized and resourced can get a lot done.

ZBAR: I think we have time for one more question. How about right in the front there? Yes.

Q: Thank you. My name is Neal (sp). I’m with the New York City Health Department.

And I was wondering about whether we’re going far enough upstream in preventing these outbreaks and epidemics. You all brought up a lot of good examples of how once there’s a spillover event, such as, like, Ebola virus from a natural reservoir, like a bat, into the human population, there’s ways to respond. But what are the ways that we can be going further upstream to prevent that spillover event in the first place from occurring from a bat or a rodent into the human population? Should we be talking more about environmental conservation in public health?

GAVIN: Well, I am all for talking about, you know, realities of climate change and the fact that it’s going to inevitably lead to more and more migration, right, that’s going to have all kinds of unintended consequences. So it all has to be in the conversation.

FRIEDEN: I think there’s a lot of good things that need to be done to conserve the environment. How much impact they’ll have on these somewhat unpredictable spillover events isn’t entirely clear. But that doesn’t mean they shouldn’t be done. I think we still don’t know a lot about the ecology of Ebola. We have pretty good ideas of what might be driving it. But if you look at some of the forest areas and protein sources for communities, it’s a lot easier to say don’t eat bushmeat than it is actually say—make that a practice, where there may be a real shortage of nutrition in some places.

ZBAR: Terrific. Well, I know right in the front you had—maybe we can squeeze one more in, if you want to ask your question briefly. Sorry, just in the last minute here.

Q: Yeah. Hi. I’m Joan Kaufman from the Schwarzman Scholars program.

 I know the Chinese jumped in for the West Africa epidemic, and then following that—with a considerable contribution—and then following that worked together with CDC to set up the Africa Union CDC. Has that new organization played any role in the current outbreak? Is that positive? Is that a good development? How’s that working?

FRIEDEN: We work closely with the Africa CDC at Resolve to Save Lives. And it has been an important new resource for the continent. They’ve been responding to this and a number of other outbreaks. They’ve been strengthening laboratory services in the region as well. As a part of the African Union, some of the administrative flexibility isn’t what they or I think everyone else would like, but it’s a great new resource for the continent.

Q: (Off mic.)

FRIEDEN: Yes, yes.

ZBAR: Great. Well, with that I’d like to thank you all for participating, and from Stockholm as well. (Applause.) Thank you. Thank you for your past, and current, and future contributions to the fight against Ebola.

FRIEDEN: Thank you.

(END)