EBOLA-RELATED DEATHS Building Citizen Trust in Health Systems

BRENTHURST FOUNDATION SPECIAL REPORT 1/2016

11UNNECESSARY 312 EBOLA-RELATED DEATHS Building Citizen Trust in Health Systems

Helen Epstein

Strengthening Africa’s economic performance 11UNNECESSARY 312 EBOLA-RELATED DEATHS

Contents

Acronymns ��3 Foreword by Olusegun Obasanjo ��4 Foreword by Wilmot James ��5 Foreword by Rosa L DeLauro ��6 Background ��7 What Went Wrong? And What Went Right? ��8 Where Do We Go From Here? ��11 Conclusion ��14 Endnotes ��15 Appendix I: Janusz Paweska ��16 Appendix II: Wilmot James ��20

About the Author

Helen Epstein is visiting Professor of Human Rights and Global Health at Bard College. She is a writer specialising in public health and has advised numerous organisations, including the United States Agency for International Development, the World Bank, Human Rights Watch, and UNICEF. She is the author of The Invisible Cure: Why We Are Losing the Fight Against AIDS in Africa and has contributed articles to many publications, including the New York Review of Books and the New York Times Magazine.

Published in June 2016 by The Brenthurst Foundation

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Abbreviations and Acronyms

A-CDC African Centres for Disease Control and Prevention AFRICOM United States Africa Command AFRO Regional Office for Africa APORA African Partner Outbreak Response Alliance CCCs Community Care Centres CDC Centers for Disease Control and Prevention DART Disaster Assistance Response Team DASD Deputy Assistant Secretary of Defense DoD Department of Defense EML Ebola Mobile Laboratory ETUs Ebola Treatment Units EVD Ebola Viral Disease Gavi Global Alliance for Vaccines and Immunization GHSA Global Health Security Agenda GOARN Global Outbreak Alert and Response Network HSS Health System Strengthening IDA International Development Association IFC International Finance Corporation IHR International Health Regulations IMS Incident Management System MOU Memorandum of Agreement MSF Médecins Sans Frontières NATO North Atlantic Treaty Organization NGOs Non-governmental organisations NICD National Institute for Communicable Diseases NIH National Institutes of Health OIE World Organization for Animal Health OSD Office of the Secretary of Defense PCR Polymerase Chain Reaction PVS Performance of Veterinary Services RCC Regional Collaborating Centers UNICEF United Nations Children’s Emergency Fund USAID United States Agency For International Development WADPI West African Disaster Preparedness Initiative WHO World Health Organization

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Foreword by Olusegun Obasanjo

8 June 2016

uring the Ebola crisis in West Africa I visited the most affected countries – Liberia, Sierra Leone and Guinea – and D witnessed first-hand the devastating impact Ebola had on individuals, families and communities. I met with the African leaders grappling with this crisis as well as the Emergency Response teams combating the outbreak on the ground. The Africans I met in all three countries acted with extraordinary fortitude, compassion and courage, but the scale of the disaster required something more, which is why I became personally involved in mobilising support from the African Union, Africa’s private sector and the international community. The countries most affected by Ebola need our help to recover and rebuild. But if the crisis taught me anything, it was the need for Africa and the rest of the world to urgently find ways to ensure such outbreaks do not happen in the future. But if any unforeseen epidemic outbreak happens, the international community and Africa must be adequately prepared for immediate intervention to prevent the spread of the outbreak. In the case of Ebola, the reaction of the international community was slow, the awareness and cultural practices and the healthcare infrastructure in the communities concerned did not help. In the end, the national and international build-up got to grips with the situation albeit after many lives had been lost and many economies, including those which were just starting to pick-up after many years of civil war, were ravaged. The experiences and lessons learnt must prepare all of us in Africa to be able to cope with any unforeseen natural disaster, epidemic or human disaster. In particular, it is time for Africa’s scientific and health community to step up research and preparation for prevention and cure of the scourge of Ebola and other diseases which affect our continent so profoundly. For that to happen, we in Africa – and especially our governments – need to invest lifelong in our scientists and laboratories, as well as our health professionals. If we can build health systems able to cope with the next unexpected outbreak, we’ll know that Africa has come of age and we are on the way to achieving Goal Number 3 of the Sustainable Development Goals by 2030.

Olusegun Obasanjo Former President of Nigeria Chairman of the Brenthurst Foundation Advisory Board

S T A N D R E W ‘ S H O U S E, 6 S T A N D R E W ‘ S R O A D P A R K T O W N 2 1 9 3 P. O. B O X 6 1 6 3 1 M A R S H A L L T O W N 2 1 0 7

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P R O J E C T A D M I N I S T R A T O R : L E I L A J A C K T E L: +2 7 ( 1 1 ) 2 7 4 2 0 9 6 F A X: + 2 7 ( 1 1 ) 2 7 4 2 0 9 7 E M A I L : j a c k l @ e o s o n . c o . z a

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Foreword by Wilmot James

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Foreword by Rosa L DeLauro

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very year it seems, a new global health crisis In addition to discussing flaws in the response Eemerges. Today, Zika virus sows panic through- to the West African crisis, participants also debated out Latin America and may soon spread north. In three bold international initiatives that will help 2014–5, it was Ebola, which killed 11 312 people avoid future epidemics: Vaccines, Health System in the West African nations of Liberia, Sierra Leone Strengthening to improve health-care delivery in and Guinea in just 18 months. Why aren’t we bet- developing countries and the Global Health Security ter at preventing these epidemics? Why do we lurch Agenda, a vast international partnership among from crisis to crisis and lapse into complacency in nations and international organisations and NGOs between? On 31 March 2016 an international group to prevent and respond to emerging threats. A fourth of public health experts gathered at the Carnegie approach, using diplomatic measures to foster respect Council for Ethics in International Affairs in New for human rights and better governance in order to York for a meeting convened by the Hanna Arendt inspire popular trust in government and foster more Center of Bard College to consider these questions, effective health promotion, was also discussed. by assessing the response to the West African Ebola epidemic.

Background

Since Ebola was first identified in 1976, there have the US Centers for Disease Control and Prevention been 25 known outbreaks, but the West African epi- (CDC) mobilised 200 doctors, epidemiologists and demic killed more than ten times as many people other experts to try to control the epidemic, the larg- as all previous ones combined. On 6 August 2014, est deployment in the agency’s history. They set up a the World Health Organization declared the West call center where the public could phone in reports of African Ebola Epidemic a Global Health Emergency suspected cases and organised logistics that reduced and the international community responded at the response time so that ambulances arrived within once. By then cases were doubling rapidly and some hours instead of days. The CDC also set up mobile experts were estimating that there could be over a labs that reduced the time between case identifica- million cases by the end of the year if nothing was tion and diagnosis from days to hours. South Africa’s done. The crisis had come to be seen not only as National Institute for Communicable Diseases set a health issue, but also as a matter of global secu- up a similar system in Sierra Leone. rity, calling for military involvement. The Pentagon Most Ebola cases are acquired through exposure established a Disaster Response Team to plan inter- to bodily fluids via physical contact with sick or dead ventions. In September, US Secretary of State John victims. The most vulnerable people were health Kerry, Defense Secretary Chuck Hagel and National workers and relatives caring for the sick or carrying Security Advisor Susan Rice joined representatives out traditional funeral rituals that involve wash- from 55 other countries at the UN Security Council ing the dead body. With no vaccine or treatment to plan the way forward. They resolved that the US – as yet – the only preventative weapon we have would take primary responsibility for the response in against Ebola is behavioural change. Even before Liberia, and Britain and France world concentrate the WHO’s (World Health Organization) declara- resources in their former colonies, Sierra Leone and tion, local government health departments in the Guinea, respectively. Cuba sent doctors; Japan, South three countries had been issuing clear warnings to Korea and China contributed millions of dollars to the general public, urging people to report suspected the response as well, along with the EU, Australia Ebola cases to the authorities and to avoid close con- and other countries, and philanthropists such as Bill tact with them. But for months people ignored these Gates, Mark Zuckerberg and Paul Allen. warnings and behaviour didn’t change. In Liberia in In Liberia, the US military built treatment centers particular, many nurses continued to offer care on where Ebola patients received basic nursing care and a private basis in the communities where they lived.

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Since they had no protective gear, hundreds acquired contributed to widespread refusal to comply with the infection and died. In Sierra Leone, teams from behavioural change message issues by local health Médecins Sans Frontières (MSF) were stoned when workers. Such behavioural changes were slower they arrived to investigate outbreaks in communities. to occur in Sierra Leone and Guinea, which may Gradually, the massive international response explain why, although Liberia’s epidemic was much and deployment helped restore people’s faith in the more severe early on, it subsided more rapidly than public health system. This was especially true in in the other two countries. Liberia, where popular mistrust of the government

What Went Wrong? And What Went Right?

Blame for the severity of the epidemic has been cast and international actors had allowed to spiral out of far and wide.1 Wilmot James, South African MP control. and Shadow Health Minister noted that the WHO In Liberia, Mahoney explained, the government at inexplicably declared a ‘health threat of international first attempted to impose an involuntary quarantine concern’ very late in the day and that the three most in an urban slum where officials believed, errone- severely affected countries, Liberia, Sierra Leone and ously, that cases were concentrated. International Guinea may have had economic interests in resist- public health officials had warned that quarantine ing such a declaration. Local health systems were would not staunch the epidemic even under the best in a dreadful state and emergency response health of circumstances because the virus had already spread professionals and workers were thin on the ground. throughout the country and in any case, quarantines Local financial systems could not process aid, philan- are very difficult to maintain, but this advice was thropic and private donations rapidly, sometimes not ignored. Soldiers were deployed at the entrances to at all, and local communities were suspicious of their the slum and the population, already disgruntled by governments’ intentions and responded to health the slow pace of development in the country and warnings too late. what they saw as a pattern of corruption, rioted. The quarantine was rapidly lifted and the Liberian Health Ministry with help from the CDC and other Blame for the severity of the epidemic partners changed course. An Incident Management has been cast far and wide System (IMS) was set up to focus efforts on five tasks: (1) safe transport, isolation, and treatment of patients with suspected disease followed by labora- The challenges were enormous even after help tory testing and contact tracing; (2) ensuring safe arrived. The Conference was fortunate to hear burials; (3) promoting infection control throughout from two men who had been in the vanguard of the health care system; (4) providing clear and effec- the response in Liberia and Sierra Leone. Frank tive communication to affected communities and Mahoney, a CDC infectious disease epidemiologist the general population; and (5) strengthening the has been battling emerging infectious diseases since national incident management structure to support he joined the agency in 1992 and was team leader the response. for the Ebola response in Nigeria and Liberia. Janusz At first, patients were isolated within existing Paweska, Head of the Special Pathogens Unit of healthcare facilities but nosocomial (clinic or hospi- South Africa’s National Institute for Communicable tal acquired infection) transmission and fear among Diseases (NICD) is a pioneer in viral diagnostics, healthcare workers led many of those facilities to detection and discovery. He set up a remarkable close and the IMS team eschewed attempting to mobile Ebola diagnostic lab in Sierra Leone in 2014. treat patients in Liberian health facilities. The early Mahoney and Paweska both conveyed the challenges symptoms of Ebola resemble malaria and other dis- of fighting an epidemic that communities, nations eases common in this part of Africa and local health

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facilities were at first unable to properly identify and people might succumb to the disease. There was no refer Ebola patients because health workers hadn’t one-size-fits-all strategy to deal with such a crisis. been trained to do so, and they lacked the protective The virus was spreading in both dense urban and PPE suits to keep them safe. In some areas, up to remote rural areas, and operational challenges were 20 per cent of Ebola cases were health workers them- numerous. selves, and this along with fear of the disease led to The isolation measures – ETUs and CCCs – as reduced healthcare provision, avoidance of presenta- well as simple behavioural change initiated by com- tion to local facilities, and a further reduction in the munities themselves, finally helped to interrupt capacity to provide isolation and care. Ebola transmission in Liberia. The most important MSF, CDC and WHO had all dealt with previous features of the response, according to Mahoney, were Ebola outbreaks and based on their experience, they that it was government led, flexible, involved a strong urged the government and international partners strategic working group of government and develop- to build dedicated Ebola Treatment Units (ETUs) ment partners, including WHO, CDC, UNICEF, – most in large towns and cities – to safely isolate and MSF and other NGOs, as well as US government care for patients. The ETUs were tent camps staffed agencies that included DART, USAID, DoD, NIH with doctors and nurses in protective gear where and the CDC. The greatest obstacles to rapid pro- patients could receive basic nursing care. However, gress were Liberia’s weak disease surveillance systems training adequate numbers of staff, providing suffi- which relied on inappropriate reporting forms and cient personal protective equipment and finding and inefficient data management, a weak system of con- building suitable facilities was slower than hoped. To tact tracing and late recognition and response to the reduce transmission in the meantime, Community needs of survivors. Care Centers (CCCs) where patients could be kept near their families were also constructed in villages The isolation measures as well as experiencing outbreaks. simple behavioural change initiated There was no one-size-fits-all by communities themselves, finally strategy to deal with such a crisis helped to interrupt Ebola transmission

The IMS strategy team also strengthened the Meanwhile, in Sierra Leone, Paweska was setting dedicated ambulance service to transport suspected up a system to rapidly diagnose Ebola in suspected patients to ETUs. Early on, it was clear that isolation patients. He and his team arrived in late August, of patients at home was impractical and potentially when many patients were being stranded for days in dangerous, particularly in cities and towns because Ebola Holding Centers – similar to Liberia’s ETUs Ebola patients produce increasingly copious amounts – without knowing if they had Ebola or something of highly infectious diarrhoea and vomit as the dis- else. Slow diagnosis was contributing to overcrowd- ease progresses. Even the sweat of a sick person or ing of facilities and fear of seeking treatment, which corpse can transmit Ebola to a caregiver. Many rela- contributed to further spread of the virus. tives, neighbours, faith-based healers, and others had Paweska’s mobile Ebola molecular diagnostic been exposed to Ebola while transporting patients lab in Sierra Leone was a part of the WHO–Global and dead bodies via taxis, motorcycles, or on foot. Outbreak Alert and Response Network (GOARN). The greatest challenge was prevention. By early Testing could be done on the spot, obviating the August, suspect and probable Ebola cases were dou- need for shipping specimens to regional centres or bling every two weeks in Liberia. Back at the CDC even other countries, and greatly simplifying patient headquarters, statisticians were predicting that if the management. Staff worked with national laboratory virus’ swift spread continued, more than a million

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counterparts, the WHO country office, and the it was the only unit with the capacity to diagnose the international response team. huge number of suspect cases coming in. The great- By March 2015 Paweska’s NICD group had est challenges included electrical outages, and other deployed eight teams to operate the Emergency infrastructure problems that caused equipment to Medical Lab in Freetown-Lakka. Each team com- malfunction. Particularly vulnerable were the PCR prised three to five members, rotating in every four diagnostic machines, which overheated due to high to seven weeks. The teams intensively trained Sierra ambient temperature and problems with the power Leonean scientists and technical personnel in facility supply. Dysfunctional air-conditioning units made operational logistics, biosafety and diagnostic proce- work in the biocontainment chamber, glove box and dures which allowed for successful handover of the other lab areas highly uncomfortable, especially for Lab to the Sierra Leonean Ministry of Health and those wearing full BSL3 lab gowns. This posed the Sanitation on 24 March 2015. By 29 February 2016 threat of human errors and safety risks. Other poten- the Lab had tested 9 161 clinical specimens of which tial risks to laboratory staff included unsafe packaging 26 per cent were positive for Ebola. and inappropriate primary containers for blood and The Lab was set up in the Western Urban Area of buccal swabs from suspected Ebola patients. The lab Sierra Leone, an early Ebola hotspot, and for weeks had to be closed several times for technical reasons.

Ebola Statistics as on 11 May 2016

Deaths Cases Case Fatality Italy 0 1 Deaths Cases Rate (%) Mali 6 8 Guinea 2 536 3 804 66.67 Nigeria 8 20 Liberia 4 806 10 666 45.06 Spain 0 1 Sierra Leone 3 955 14 122 28.01 UK 0 1 Total 11 297 28 592 39.51 USA 1 4 Total 15 35

HEALTH CARE WORKERS S 1 122 L ■ C 10 666 ■ D L 06 0 852 2 6 Diagnosed USA 1 1 U 0 1 S 0 492 20 Deaths N 6 1 I 0 58% 2 62 Case Fatality Rate T 11 12

0 000 10 000 1 000 20 000 2 000 0 000 Source WHO

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Where Do We Go From Here?

Ebola Vaccines The Global Health Security Agenda As the University of Minnesota vaccine expert With those thoughts in mind, the Conference par- Michael Osterholm informed the conference, the ticipants discussed two important new epidemic global community has redoubled efforts to develop preparedness strategies now being advanced by an Ebola vaccine in the past two years. Such a vac- high level development partners, one top-down, cine had been in the works for over a decade before and the other bottom up. Andy Weber, former the West African epidemic, but lack of funding and Deputy Coordinator for Ebola Response at the a general assumption that Ebola outbreaks were US State Department, Theresa Whelan, Principal invariably small and easily contained, meant progress Deputy Assistant Secretary of Defense for Stability had stalled. Since then, numerous clinical trials have Operations and Low Intensity Conflict and Wilmot been initiated or completed, and a phase 3 trial has James, MP, discussed the Global Health Security demonstrated clinical efficacy for Merck’s candidate Agenda (GHSA), while Kristina Talbert-Slagle, Ebola vaccine known as rVSV-ZEBOV. Lecturer in the Yale School of Public Health, discussed Health System Strengthening (HSS). James, Whelan and Weber convincingly argued Dealing with future epidemic that dealing with future epidemic crises will require crises will require an alert, an alert, capable and adaptable disease control and prevention system much like America’s CDC or the capable and adaptable disease national infectious disease monitoring and response control and prevention system systems of other developed countries. In February 2014, President Barack Obama established the GHSA that aims to prevent avoidable epidemics – whether The Global Alliance for Vaccines and naturally occurring or caused by intentional or acci- Immunization (Gavi) has agreed to stockpile dental release of microorganisms – detect threats 300 000 doses of pre-licensed rVSV-ZEBOV and early, and respond rapidly. Merck has submitted an application to the World The GHSA is a collaboration of more than 50 Health Organization for it to be used in emergencies nations and international organisations to reduce and plans to apply for full licensure soon. Johnson & biological threats worldwide. In the US, it is led Johnson and GlaxoSmithKline also have promising by the Department of Defense (DoD). The DoD Ebola candidate vaccines in clinical trials. has long had myriad public health and humanitar- These vaccines alone won’t eliminate the Ebola ian assistance programmes, including various labs threat, let alone the threat of other epidemics. More and bio-surveillance programmes, but through the data is needed on the safety and efficacy of these vac- Global Health Security Agenda, the DoD’s efforts cines; the regulatory processes in African countries are becoming more coordinated. In Liberia, the needs to be expedited, and African public health DoD was able to respond quickly, providing engi- leaders must plan for how the vaccines will be used. neering support, medical training and lab assistance. All of these activities, along with the refinement of It also built ten additional ETUs, as well as a mobile the vaccine itself need to be prioritised, and it is medical facility specifically to treat healthcare work- hoped the international community won’t drop the ers. The Department’s logistics hub in Senegal helped ball just because Ebola no longer seems as scary as the Liberian government, other US agencies and the it did in 2014. Most importantly, a greater empha- international donor community to mobilise their sis on epidemic preparedness in Africa in general is own resources. Among the DoD’s most important needed. contributions was building the confidence of the Liberian government which was struggling to recruit health workers, many of whom were frightened of contracting the disease.

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Now that the epidemic has subsided, the DoD tend to have higher budgets, the former sees their is working to strengthen national bio-surveillance new role as an opportunity, whereas some in the and disaster management in West Africa and beyond health community see the encroachment of secu- through its Cooperative Biological Engagement rity organisations on their turf as a threat. No doubt Program, or CBEP. The DoD’s Chemical and some balance will emerge, but this is new territory Biological Defense Program is also working with the for both disciplines and professions. Diplomats National Institute of Health and the CDC on Ebola must recognise that infectious disease outbreaks are vaccine and therapeutics trials in West Africa. And increasingly seen as security issues that call for more the Africa Command’s (AFRICOM) African Partner than humanitarian charity. At the same time, we Outbreak Response Alliance programme, or APORA, must be concerned about military support, neces- is training military medical leaders in 11 West sary and welcome though it was in West Africa. As African nations in leadership, transparent communi- the US learned when it attempted to use soldiers to cation, defining military roles, identifying regional deliver food aid in Somalia in the early 1990s, retool- capabilities and addressing gaps. AFRICOM’s West ing armies for humanitarian purposes carries grave African Disaster Preparedness Initiative (WADPI) risks if troops are seen to be taking sides in local con- recently trained approximately 800 African military flicts. Human rights are also too easily suspended in health workers in the development of Ebola pre- settings where they never had much force in the first paredness and response plans; chemical, biological, place. radiological, and nuclear incident prevention and The GHSA also envisions a network of African management; hazardous materials decontamination Centres for Disease Control and Prevention and crisis communication. Plans are in the works for (A-CDC) Regional Collaborating Centers (RCC) more such courses across the African continent. with one in northern, eastern, western, central and The involvement of the US Department of southern Africa. These will be fully-fledged public Defense in beating Ebola in West Africa marked a health institutes designed to deliver technical support change in the discourse on health and security. In to the continental A-CDC. At the moment, Africa’s security circles there is talk of the Pentagon’s increas- regional economic communities are in the process of ing involvement in health, and in the increasing nominating one national public health institute per involvement of health organisations like the CDC in region. With technical input from their partners, the the security domain. Because defence establishments AU requested the regional economic communities

The Six Building Blocks of a Health System

• Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources. • A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive). • A well-functioninghealth information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status. • A well-functioning health system ensures equitable access to essential medical products, vaccines and technolo- gies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use. • A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient. • Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system-design and accountability.

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to nominate one national public health institute per depend on donor largesse. They also require political region to do the job. commitment from national leaders and the commu- The African Union has since signed a nities they govern. Memorandum of Agreement (MOU) with the US The neglect of health systems, especially in Africa, government to establish the A-CDC which will has partly resulted from the retreat from the public focus on surveillance, emergency preparedness and sector that followed the end of the Cold War. Only response and strengthening International Health when disaster strikes does the international com- Regulations which govern reporting, transport, munity recognise how important a well-functioning trade and communications in the event of a health public sector is. In Liberia, the Health Ministry did emergency. warn locals early on about the dangers of Ebola, and urged people to report suspected cases. But many people, perceiving the government of neglecting their Health systems don’t only depend needs and engaging in corruption, did not heed this on donor largesse. They also advice. A well-functioning health system that met local citizens’ needs before the crisis hit would have require political commitment inspired greater trust, and effected faster behaviour from national leaders and the change in response to warnings. A robust health system would have also meant that local nurses would communities they govern have been adequately paid, and would not have needed to moonlight to earn extra money, which is how many became infected. A robust health care Some diplomats have expressed concerns about system would have meant that hospitals and clinics the capacity of the AU to deliver programmes. Few would have been adequately staffed and equipped to AU members pay their dues on time and some don’t handle the early cases when they were few in number do so at all and thus it is not surprising that the AU before the epidemic spiralled out of control. is a slow-moving bureaucracy. High-level leadership Unfortunately, in the battle between the affected has sometimes seemed aloof from the affairs of the countries’ health care systems and Ebola, the virus Union. Still, the AU is the one body with the cred- won. In Liberia, for example, nurses, doctors and ibility to get African governments to work together, other health personnel were approximately 30 times as they must in order to deal with diseases that know more likely to be infected with Ebola than the gen- and respect no national boundaries. eral population. The country’s health system, already unstaffed, lost hundreds of workers, with grave con- Health Systems Strengthening sequences for the future, even though Ebola itself has Kristina Talbert-Slagle concluded with pleas for been all but eradicated.2 This Ebola-related shock strengthening local health care systems in develop- to the health care system is predicted to result in a ing countries. Since 2000, donor governments have 111 per cent increase in maternal mortality to 1 347 spent billions on programmes to control malaria, deaths per 100 000 live births – the second highest HIV, tuberculosis and other diseases, but relatively in the world, after Afghanistan.3 The aftershocks of little on supporting the health care systems – the doc- Ebola are also projected to increase infant mortality tors and other personnel, the supply chains for drugs by 20 per cent (from 54 to 64 per 1 000 live births), and supplies, the infrastructure and equipment, the and under-five mortality by 28 per cent (from 71 to information systems and the governance structure 91 per 1 000 live births).4 – that perform the daily work of keeping populations Talbert-Slagle described the characteristics of a healthy. For years, public health experts have decried strong, resilient health care system that could deal the concentration of resources on a small set of killer with crises like Ebola.5 Such a system would have a diseases, sometimes to the detriment of the health strategic health information system and surveillance systems that would make programmes to fight those networks that monitor the status of the system and diseases sustainable. But health systems don’t only impending health threats. It would address a broad

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range of health challenges, enhancing public trust in change. When health crises did occur, such adapt- normal times so that new threats could be recognised ability would enable lessons to be learned quickly, and addressed more rapidly, in cooperation with the so that short-term performance is improved. Too population. often the humanitarian response to health emergen- A resilient health system would be capable of cies has a short half-life, leaving little benefit for the containing novel health threats while delivering larger health system post-crisis. The ability to adapt core health services, so as not to propagate instabil- depends upon strong and flexible leadership, a good ity throughout the system. This will require excess data system and the capacity to use it, as well as capacity that could be mobilised quickly in times responsive bureaucracies.6 of crisis. This in turn will require long-term invest- In Liberia, this will mean hiring and training ments in infrastructure and health worker training, thousands of new, properly remunerated health as well as capability for emergency measures like iso- workers to be deployed around the country, convert- lation units. ing Ebola Treatment Units and Community Care Truly resilient health systems would also bring Centres into health facilities and improving the together diverse actors, ideas, and groups to share nation’s health infrastructure generally, including information and coordinate activities under the systems for maintenance, transportation and referral guidance of a designated focal point that would also and construction of new health facilities. Liberia will handle the crucial and delicate task of communica- also need a National Public Health Institute, an tion with the public. improved surveillance and response system and pub- Such a system would be constantly adapting lic health laboratories. to long-term epidemiological and demographic

Conclusion

The Global Health Security Agenda is already find- and Liberia all have recent histories of bitter civil con- ing support from the US government and African flict, and allegations of high level corruption appear partners. Health System Strengthening, a more almost daily in the press. This has reawakened popu- complex set of tasks seen as benefitting mainly local lar suspicion concerning the integrity of the leaders African women and children, has, until recently, of these countries and fuelled the spread of rumours been a harder sell. Thankfully, the Gates Foundation, through the social networks upon which most peo- WHO and the World Bank have recently taken up ple typically reply for news and information. It was the challenge.7 this particular political mood that some maintain Important as these initiatives are, even more work contributed to the particular catastrophic situation is needed at the higher level of governance, democ- in West Africa by delaying behaviour change. If so, racy and human rights in Africa. We still don’t know the implications of this reality are subtle. It doesn’t what made the West African Ebola epidemic dif- mean that all countries with unpopular governments ferent from the previous 24 Ebola epidemics, all of are vulnerable to outbreaks of Ebola. Indeed, it is which occurred in African countries lacking a net- very unlikely that if Ebola were to break out again in work of CDC Global Health Security institutes, and West Africa that people would respond as they did many of which had even worse health care systems in 2013. But it does mean that in addition to apply- than Liberia’s, Sierra Leone’s or Guinea’s in 2013. ing global measures such as a more robust emergency However, some experts have pointed to particularly preparedness system for Africa and improved health poor relations between the governments of the three systems, more care must be taken to understand the countries and their people.8 While popular discon- particular political climate of each country, and if tent with national leaders exists in many African possible, implement programmes to foster democ- countries, including those that have been better able racy, human rights, impartial justice and intolerance to cope with Ebola in the past, Guinea, Sierra Leone of corruption and inspire greater trust in government.

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Such changes will not occur overnight, but the defending human rights, especially in those coun- international donors can help accelerate progress by tries that rely on them for foreign aid. standing with those fighting against corruption and

Endnotes

1 See Final Report of the Ebola Interim Assessment to help countries close gaps in primary health care Panel (WHO, July 2015); and WHO Secretariat 26 September 2015. Response to the Report of the Ebola Interim 8 Karin Landgren Shares the Lessons She Learned from Assessment Panel (WHO, August 2015). Ebola. School of Public Policy Central European 2 Liberia Health Workforce Program Proposal. University. 1 February 2016. https://spp.ceu.edu/ 3 According to the World Health Organization. article/2016-02-01/karin-landgren-shares-lesson 4 Evans, David K et al. Health-care worker mortality s-she-learned-ebola; The Ebola Lessons Reader. and the legacy of the Ebola epidemic. The Lancet International Rescue Committee. March 2016; Global Health. Volume 3, No. 8, e439–e440, August Helen Epstein. Ebola: An Epidemic of Rumors. The 2015. New York Review of Books. 18 December 2014. 5 Margaret E Kruk, Michael Myers, S Tornorlah http://www.nybooks.com/articles/2014/12/18/ Varpilah, Bernice T Dahn. What is a Resilient Health ebola-liberia-epidemic-rumors/; Sara Jerving, ‘Why System? Lessons from Ebola. Lancet 2015; 385: Liberians Thought Ebola Was a Government Scam to 1910–12. Attract Western Aid,’ The Nation, 16 September 2014; 6 Investment Plan for Building a Resilient Health Susan Shepler, ‘The Ebola Virus and the Vampire State,’ System in Liberia 2015 to 2021. Ministry of Health, Mats Utas blog, 21 July 2014; and Terrence McCoy, Government of Liberia, Version 15 April 2015. ‘The Major Liberian Newspaper Churning Out Ebola 7 Bill & Melinda Gates Foundation, World Bank Conspiracy After Conspiracy,’The Washington Post, Group, WHO News Release: New partnership 17 October 2014.

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Appendix I: Janusz Paweska

Timeline on the rise, decline and impact of similar illness followed by rapid death. The same Ebola Viral Disease in West Africa was true for several midwives, traditional healers, It would have been difficult for the geographical and staff at a hospital in the city of Gueckedou who point of origin of the Ebola Viral Disease (EVD) treated them. During the following week, members in West Africa to have occurred in a more com- of the boy’s extended family, who attended funerals plex terrain. The disease broke out in impoverished or took care of ill relatives, also fell sick and died. By post-conflict countries with weak health systems, on then, the virus had spread to four sub-districts via a virgin soil with no previous experience of Ebola. additional transmission chains. The outbreak began spreading in a small village in The first alert was raised on 24 January, when the Guinea on 26 December 2013, but was not identi- head of the Meliandou health post informed district fied as Ebola for several months. Initial misdiagnosis health officials of five cases of severe diarrhoea with a as more common disease conditions and delayed rapidly fatal outcome. That alert prompted an inves- identification catalysed the rapid spread of the EVD tigation the next day in Meliandou by a small team epidemic. From the original epicentre in south- of local health officials. The reported symptoms, east Guinea, Ebola spread rapidly to neighbouring including diarrhoea, vomiting, and severe dehydra- countries. The epidemic was further fuelled by poor tion, appeared similar to those of cholera, one of the management of cases, ineffective outbreak responses area’s many endemic infectious diseases. However, no and weak healthcare systems in countries with inad- firm conclusions could be reached. A second larger equate healthcare personnel, under-resourced health team, including staff from MSF went to Meliandou facilities, unsafe burial ceremonies and poor infec- on 27 January. Microscopic examination of patient tion control. samples supported the conclusion that the unknown Retrospective studies directed by WHO and disease was likely cholera. Following the team’s visit, Guinean health officials identified the index case in other deaths occurred, but were neither reported nor West Africa’s Ebola epidemic as an 18-month-old investigated. boy who lived in Meliandou, Guinea. The boy devel- On 1 February the virus was carried into the oped an illness characterized by fever, black stools, capital, Conakry, by an infected member of the boy’s and vomiting on 26 December 2013 and died two extended family. He died four days later at a hospital days later. The exact source of his infection has not where, as doctors had no reason to suspect Ebola, been identified, but likely involved contact with wild no measures were taken to protect staff and other animals. The remote and sparsely populated village of patients. As the month progressed, cases spread to Meliandou is located in Gueckedou District, known the prefectures of Macenta, Baladou, Nzerekore, and as the Forest Region. Much of the surrounding forest Farako as well as to several villages and cities along area has, however, been destroyed by foreign mining the routes to these destinations. The Guinea Ministry and timber operations. Some evidence suggests that of Health issued its first alert of the unidentified dis- the resulting forest loss, estimated at more than 80 ease on 13 March 2014. On that same day, staff at per cent, brought potentially infected wild animals, WHO’s Regional Office for Africa (AFRO) formally and the bat species thought to be the virus’ natural opened an Emergency Management System event reservoir, into closer contact with human settlements. for a disease suspected to be Lassa fever. A major Prior to symptom onset, the child was seen playing investigation, involving staff from the Ministry of in his backyard near a hollow tree heavily infested Health, WHO AFRO, and MSF, took place from with an insectivorous bat species, Mops condylurus. In 14 to 25 March, involving site visits to Kissidougou, 1996 this bat species was shown to be susceptible to Macenta, Gueckedou City and Nzerekore. That the Ebola Zaire virus experimental infection without investigation found previously unknown epide- showing any clinical symptoms. miological links between outbreaks and identified By the second week of January 2014, several mem- Gueckedou City as the epicentre of transmission for bers of the boy’s immediate family had developed a a disease that still had no known cause.

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On 21 March, the Institut Pasteur in Lyon, Filovirus outbreaks are commonly associated France, a WHO Collaborating Centre, confirmed with limited surveillance and resource-constrained that the causative agent was a filovirus, narrowing health system, both partially as a result of impover- the diagnosis down to either Ebola virus disease or ished conditions (prevention, detection, diagnosis, Marburg haemorrhagic fever. The next day the lab- bio-surveillance, response and research activities). oratory confirmed that the causative agent was the Control of the EVD epidemic in West Africa Zaire species, the most lethal virus in the Ebola fam- would have been impossible without a large-scale ily. That same day the government alerted WHO to international response. Rapid laboratory confir- what was described as a ‘rapidly evolving’ outbreak of mation of EVD cases was essential in bringing the Ebola virus disease. outbreak under control and minimising its further WHO publicly announced the outbreak on geographic spread. its website on 23 March. Forty-nine cases and 29 Countries with weak health systems cannot deaths were officially reported. The fear that Ebola withstand a sudden emergence of deadly pathogens. virus would become embedded in impoverished, Under the weight of the EVD epidemic, health sys- congested, urban areas soon became a dramatic real- tems in Guinea, Liberia and Sierra Leone collapsed. ity. EVD cases were confirmed in Conakry by late People stopped receiving or seeking health care for May, in Monrovia by mid-June and in Freetown by other more common disease conditions that cause late July. In the ensuing months, Ebola also spread more deaths annually than EVD. The severity of to Senegal, Mali, the USA and the UK, but in con- EVD compounded by fear from both within and trast to Guinea, Liberia and Sierra Leone, it was outside the affected countries, caused schools, uni- controlled. In the three most affected West African versities, markets, businesses, airline and shipping countries the outbreak was out of control, cases were routes, and borders to close, further deepening the rising faster than the ability to contain them and setback to struggling economies. What began as a interventions were urgently needed to stop the out- health crisis snowballed into a humanitarian, social, break at source and reduce risks of further spreading. economic and security crisis. The Ebola crisis under- Eventually on 8 August 2014, the WHO scored a point often made by the World Health declared the Ebola outbreak in West Africa as a Organization: ‘fair and inclusive health systems are Public Health Emergency of International Concern, the bedrock of social stability, resilience and eco- and on 19 September 2014 the UN Security Council nomic health’. declared Ebola outbreaks in West Africa as a Threat The unprecedented outbreak of EVD in West to Peace and Security. Eventually a massive deploy- Africa from 2013 to 2016 has highlighted the need ment of resources and international donations began for improved rapid diagnostic assays. Timely labo- to flow to avert an EVD disaster. ratory testing of suspected viral hemorrhagic fever Thousands of health care and relief workers, cases is critical for patient management, reducing laboratorians and other professionals from countries the risk of infection, and for limiting virus spread. around the world descended on the towns and cities Provision of rapid and more widely accessible diag- in Guinea, Liberia and Sierra Leone in a struggle to nostic capacity in West African countries affected by contain the EVD epidemic over two years. While the the EVD epidemic was one of the priorities to com- Ebola crisis spurred an unprecedented international bat the Ebola crisis. A bottleneck in rapid testing for response, the many failures in the Ebola responses Ebola virus infection left patients stranded in Ebola and lessons learned (underfunded national health holding centres for days and thus contributed in rais- systems, delays in international response, inefficient ing fears of seeking treatment. Rapid and accurate resource mobilisation, ill-defined responsibilities, laboratory confirmation of EVD suspected cases was insufficient coordination) prompted a need for trans- paramount in the control of the EVD epidemic and formation of the existing worldwide health systems, minimising its further geographic spread. including the building of robust national health sys- In response to the public health emergency tems and the empowerment of the WHO. caused by the EVD outbreak in West Africa many countries deployed mobile laboratory facilities to aid

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rapid Ebola diagnosis on the scene of the outbreak back in school, farmers back planting in their fields, hotspots. The NICD established an Ebola Mobile businesses back up and running, and investors back Laboratory (EML) diagnostic capacity in Freetown into the countries. in the second half of August 2014 as a part of the One of the top priorities of the World Bank WHO–GOARN to the Ebola epidemic in West Group support is to build a strong and well-trained Africa. The Western Urban Area of Sierra Leone, health workforce in the three countries, and build where the NICD teams worked, remained an EVD resilient health systems that can deliver essential, epidemic hotspot for months. For weeks during the quality care in even the most remote areas; improve EVD crisis in the capital of Sierra Leone, the NICD disease surveillance; and quickly detect, treat and EML was the only Ebola diagnostic capacity able to contain future outbreaks. respond to the overwhelming and increasing demand The primary cost of the EVD epidemic is in human for EVD diagnosis. lives and suffering – but the crisis has also wiped out From the beginning of the EML operation in hard-earned development gains in the affected coun- Freetown, NICD teams undertook the training tries, and will worsen already entrenched poverty. of Sierra Leonean scientists and technical person- On 17 April 2015, the World Bank Group issued nel in operational logistics of the facility, biosafety an economic update showing the Ebola crisis con- and diagnostic procedures. This effort culminated tinues to cripple the economies of Guinea, Liberia in the successful handover of the EML to the Sierra and Sierra Leone, even as transmission rates show Leonean Ministry of Health and Sanitation on significant signs of slowing. The World Bank Group 24 March 2015.The EML is still operational and now estimated that these three countries would lose at plays an important role in the WHO recommended least US$2.2 billion in forgone economic growth in enhanced surveillance of Ebola cases post-Ebola out- 2015 as a result of the epidemic. break. As of 31 May 2016 the NICD-established Recent studies have found that the socio- EML tested more than 10 000 clinical specimens economic impacts of Ebola in Liberia and Sierra (blood and buccal swabs) from suspected EVD cases. Leone have included job losses, smaller harvests and Although WHO terminated the Public Health food insecurity, though the use of public services Emergency of International Concern for the Ebola appears to be improving. outbreak on 29 March 2016, the affected countries To ensure that the world is better prepared and must remain vigilant and focused on getting to and responds much more quickly to future disease out- sustaining zero Ebola cases in Guinea, Liberia and breaks, the World Bank Group, WHO, and other Sierra Leone, especially with flare-ups of the disease. partners, developed a plan for a new Pandemic There must be a focus on helping these three coun- Emergency Facility that would enable resources to tries recover and rebuild their economies and health flow quickly when outbreaks occur. systems. The World Bank Group also has established an Ebola Recovery and Reconstruction Trust Fund to Further facts about Ebola in West Africa address the urgent and growing economic and social The World Bank ascribed losses of over US$2.2 bil- impact of the crisis in the region. lion to Guinea, Liberia and Sierra Leone for 2015 As of 1 December 2015 the World Bank Group to the EVD outbreak. Whilst billions were spent by has mobilised US$1.62 billion in financing for Ebola countries around the globe to keep the EVD out- response and recovery efforts to support the coun- break at bay, another US$1.62 billion are being tries hardest hit by Ebola. This includes US$260 invested by the World Bank for recovery efforts in million for Guinea, US$385 million for Liberia and the wake of the outbreak. US$318 million for Sierra Leone. The World Bank Group worked closely with The US$1.62 billion total also includes US$1.17 the affected countries, the UN, WHO, bilateral, billion from IDA, the World Bank Group’s fund for civil society and private sector partners to support the poorest countries and at least US$450 million response and recovery. This includes restoring basic from the IFC, a member of the World Bank Group, health services, helping countries get all children

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to enable trade, investment and employment in (which only had about 50 to start) and an 8 per cent Guinea, Liberia and Sierra Leone. reduction in nurses and midwives. In Sierra Leone, it According to the new World Bank report means a 5 per cent reduction in doctors and a 7 per Healthcare Worker Mortality and the Legacy of cent reduction in nurses and midwives. In Guinea, the Ebola Epidemic published in The Lancet Global the reduction is smaller, 2 per cent for doctors and Health, the outbreak of Ebola in West Africa could 1 per cent for nurses. leave a legacy significantly beyond the deaths and At the outset of the epidemic, WHO ranked disability caused directly by the disease itself. ‘The Liberia, Sierra Leone, and Guinea as 2nd, 5th and loss of health workers to Ebola could increase mater- 28th from the bottom, respectively, among 193 nal deaths up to rates last seen in these countries countries in terms of doctors per 1 000 people. 15–20 years ago’. The loss of health workers due to ‘Ebola has weakened already very fragile health the Ebola epidemic in West Africa may result in an systems in these countries’, says David Evans, Senior additional 4 022 deaths of women each year across Economist at the World Bank Group and co-author Guinea, Liberia and Sierra Leone as a result of com- of the report. ‘Ebola’s devastating impact should plications in pregnancy and childbirth. Maternal be the catalyst to strengthen the health systems far mortality could increase by 38 per cent in Guinea, beyond their pre-Ebola levels.’ 74 per cent in Sierra Leone, and 111 per cent in The report suggests that to save these lives, 240 Liberia. doctors, nurses and midwives would need to be hired Since the Ebola epidemic hit Guinea, Liberia and immediately across the three countries. This is a small Sierra Leone, health workers have died at a higher fraction of the 43 565 doctors, nurses and midwives rate than any other population group, exacerbating that would need to be deployed in Guinea, Liberia skill shortages in countries that had very few trained and Sierra Leone to achieve sufficient access to essen- health personnel to begin with. Even once the coun- tial health services as implied by the Millennium tries reach zero Ebola cases, this will negatively affect Development Goals. the health of their populations. ‘These countries require urgent investment in As of May 2015, 0.11 per cent of Liberia’s entire health systems starting with a substantial increase in general population had died due to Ebola, as com- the number of trained health workers,’ says Dr. Tim pared with 8.07 per cent of its health workers, Evans, Senior Director of Health, Nutrition and defined in the study as doctors, nurses and midwives. Population at the World Bank Group. ‘This is to In Sierra Leone, the loss was 0.06 per cent of the ensure that Guinea, Liberia and Sierra Leone are not general population compared with 6.85 per cent of only equipped to deal with future deadly epidemics the health workers, while 0.02 per cent of Guinea’s but that every day, mothers have access to the quality overall population had died compared with 1.45 per health care they need that will save their lives and cent of all health workers. prepare them for a more promising future.’ According to the report this translates into a 10 per cent reduction of doctors in Liberia

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Appendix II: Wilmot James

Global Health Security Agenda while advancing global bio-surveillance, and The Global Health Security Agenda is an effort by frameworks to advance safe and responsible nations, international organisations, and civil society conduct; to accelerate progress towards a world safe and secure -- Reducing the number and magnitude of from infectious disease threats. It aims to promote infectious disease outbreaks; and global health security as an international priority, -- Establish effective programmes for vaccina- and to spur progress toward full implementation of tion against epidemic-prone diseases and the WHO International Health Regulations 2005 nosocomial infection control. (IHR), the World Organization for Animal Health (OIE) Performance of Veterinary Services (PVS) Detect Threats Early: including detecting, character- pathway, and other relevant global health security ising, and transparently reporting emerging biological frameworks. threats early through real-time bio-surveillance, by: The GHSA seeks to: • Launching, strengthening and linking global networks for real-time bio-surveillance: Prevent Avoidable Epidemics: including naturally -- Promoting the establishment of monitoring occurring outbreaks and international or accidental systems that can predict and identify infec- releases by: tious disease threats; • Preventing the emergence and spread of antimi- -- Interoperable, networked information- crobial drug resistant organisms and emerging sharing platforms and bioinformatics zoonotic diseases and strengthening international systems; and regulatory frameworks governing food safety: -- Networks that link to regional disease detec- -- Reduce the individual and institutional fac- tion hubs. tors that enable antimicrobial resistance and • Strengthening the global norm of rapid, transpar- the emergence of zoonotic disease threats; ent reporting and sample sharing in the event of -- Increase surveillance and early detection of health emergencies of international concern: antimicrobial resistance microorganisms and -- Strengthen capabilities for accurate and novel zoonotic diseases; transparent reporting to the WHO, OIE, -- Measurably enhance antimicrobial and FAO during emergencies, with rapid stewardship; sample and reagent sharing between coun- -- Strengthen supply chains; tries and international organisations. -- Promote safe practices in livestock produc- • Developing and deploying novel diagnosis and tion and the marketing of animals; and strengthening laboratory systems: -- Promote the appropriate and responsible use -- Strengthen country and regional capacity at of antibiotics in all settings, including devel- the point-of-care and point-of-need; oping strategies to improve food safety. -- Enable accurate and timely collection and • Promoting national biosafety and biosecurity analysis of information; and systems: -- Laboratory systems capable of safely and -- Promote the development of specific multi- accurately detecting all major dangerous sectoral approaches in countries and regions pathogens with minimal bio-risk. for managing biological materials to sup- • Training and deploying an effective bio surveil- port diagnostic, research and bio surveillance lance workforce: activities, including identifying, securing, -- Build capacity for a trained and functioning safely monitoring and storing dangerous bio-surveillance workforce, with trained dis- pathogens in a minimal number of facilities ease detectives and laboratory scientists.

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Respond Rapidly and Effectively to Biological the capacity to plan for and deploy non- threats of international concern by: medical countermeasures. • Developing an interconnected global network -- Strengthen policies and operational frame- of Emergency Operations Centres and multi- works to share public and animal health and sectoral response to biological incidents: medical personnel and countermeasures with -- Promote establishment of Emergency partners. Operations Centres; -- Trained, functioning, multi-sectoral rapid In order to encourage progress toward these goals, response teams, with access to a real-time the Atlanta-based CDC developed Action Packages information system, and capacity to attribute to facilitate regional and global collaboration toward the source of an outbreak. specific GHSA objectives and targets. Following the • Improving global access to medical and non- May 2014 GHSA Commitment Development meet- medical countermeasures during health ing in Helsinki, countries identified discrete GHSA emergencies: Action Packages, which were discussed further at the -- Strengthen capacity to produce or procure August 2014 Global Infectious Diseases Meeting in personal protective equipment, medications, Jakarta. vaccines, and technical expertise, as well as

GHSA Action Packages

All countries that support the GHSA are welcome to participate in one or more of the Action Packages listed below and are asked to consider specific commitments across these areas on a national, regional, or global basis:

1. Antimicrobial Resistance 2. Zoonotic Disease 3. Biosafety and Biosecurity 4. Immunisation 5. National Laboratory Systems 6. Real-Time Surveillance 7. Reporting 8. Workforce Development 9. Emergency Operations 10. Linking Public Health with Law and Multisectoral Rapid Response 11. Medical Countermeasures and Personnel Deployment

https://www.cdc.gov/globalhealth/security/actionpackages/default.htm

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Participants in the conference his medical degree from the University of Texas Medical School in Houston and completed a resi- Learning from the West African Ebola dency in family medicine at Baylor University in the Epidemic: The Role of Governance in Texas Medical Center. He joined the CDC in 1989 Preventing Epidemics as an epidemic intelligence surveillance officer and completed a preventive medicine residency in 1992. Thursday, 31 March 2016 He has worked on a variety of domestic and interna- Carnegie Council for Ethics in International Affairs, tional assignments throughout his career, with a focus New York City on emerging infectious diseases, outbreak response, and immunisation. He was the CDC team-lead for Roger Berkowitz: Associate professor of political Ebola response in Nigeria and Liberia. studies and human rights at Bard College; Academic Director, Hannah Arendt Center for Politics and the Michael Osterholm: Internationally recognised Humanities. Author of The Gift of Science: Leibniz expert in infectious disease epidemiology. He is a and the Modern Legal Tradition; co-editor of Thinking member of the National Academy of Medicine. in Dark Times: Hannah Arendt on Ethics and Politics. Osterholm led investigations into infectious disease outbreaks during his 15 years as state epidemiolo- Helen Epstein: Visiting Professor of Human Rights gist at the Minnesota Department of Health. He and Global Health at Bard College. She is a writer is the Director of the Center for Infectious Disease specialising in public health and has advised numer- Research and Policy. He served as a special advisor ous organisations, including the United States to former Secretary of Health and Human Services Agency for International Development, the World Tommy Thompson on issues related to public health Bank, Human Rights Watch, and UNICEF. She is preparedness. the author of The Invisible Cure: Why We Are Losing the Fight Against AIDS in Africa and has contributed Janusz Paweska: Head of the special pathogens articles to many publications, including the New York unit of the National Institute for Communicable Review of Books and the New York Times Magazine. Diseases (South Africa). His field of interest is viral diagnostics with a focus on development of novel Wilmot James: Member of Parliament of South techniques for rapid pathogen detection and discov- Africa and the official opposition’s Shadow Minister ery, epidemiology and ecology of arboviruses, and of Health. He spent most of his professional life at viral hemorrhagic fevers and virus-host interactions. universities in South Africa, the US, and the UK. Paweska has been a part of international research The author and editor of 17 books, James says expeditions and international outbreak response his greatest honor was to coedit the late Nelson missions for Ebola, Marburg disease, and Rift Valley Mandela’s presidential speeches published as a book fever. He led the discovery of a new Old World titled, From Freedom to the Future, and given to arenavirus that he named Lujo virus. Mr. Mandela on his 85th birthday. James is non- residential senior fellow at the HAC at Bard College Amy Savage: Visiting Assistant Professor of Biology and Honorary Professor at the University of Cape at Bard College and the Director of the Citizen Town’s Medical School. He spent 12 years as a trus- Science Program, a core curricular academic expe- tee of the Ford Foundation and entered public life in rience intended to develop and elevate scientific 2009. James received a Ph.D. from the University of literacy of the College’s first-year class. Savage is a Wisconsin-Madison. molecular parasitologist specialising in zoonotic and vector-borne infections of medical and veteri- Frank Mahoney: Infectious disease epidemiologist nary importance. Savage received her B.S. from the seconded by the CDC and Prevention to the Health University of Connecticut, M.S. from the University Department at the International Federation of the of Florida, and Ph.D. from Yale University in the Red Cross and Red Crescent Societies. He received epidemiology of microbial disease.

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Kristina Talbert-Slagle, Ph.D.: Senior scien- to the Ebola crisis. President Barack Obama empha- tific officer of the Yale Global Health Leadership sised the need for a whole-of-government response Institute and a lecturer in the Yale School of Public that utilised global resources and talent to stop the Health. Her research focuses on exploring paral- epidemic. Weber worked with partners from across lels and intersections among complex molecular, the US government and around the world to bring individual, community, and population systems, the epidemic under control. with a focus on global health security. She is inter- ested in better understanding how viruses like HIV Theresa Whelan: Principal Deputy Assistant and Ebola exploit fragility in national systems and Secretary of Defense for Special Operations/Low how to anticipate and protect against similar infec- Intensity Conflict in the Office of the Secretary of tious disease outbreaks worldwide. Talbert-Slagle Defense (OSD). She has over 28 years of experience has recently engaged with colleagues at Yale and in as a career civil servant in the defense intelligence, Liberia to support efforts to strengthen health man- defense policy, and national intelligence communi- agement in Liberia post-Ebola. She teaches courses at ties, 22 of which have been focused on African issues. Yale University on the biology and social context of Her prior leadership positions include those of HIV/AIDS, health systems strengthening in Liberia national intelligence officer for Africa on the National post-Ebola, and methods of global health research. Intelligence Council, Deputy Assistant Secretary of Talbert-Slagle received her B.S. and B.A. degrees Defense (DASD) for Homeland Defense Domains from the University of Kentucky and her Ph.D. and Defense Support to Civil Authorities, DASD for from Yale University in the epidemiology of micro- Defense Continuity and Crisis Management, and bial disease. DASD for African Affairs. Other positions in OSD included those of Principal Director for African Andrew C. Weber: Former Deputy Coordinator Affairs, NATO Team Chief on the Balkans Task for Ebola Response at the US Department of State. Force, and Countries Director for Southern Africa In this role, Weber helped lead diplomatic outreach and West Africa. to ensure a speedy, effective, and truly global response

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Building public trust in effective organizations is essential for fighting health crises such as Ebola. By bringing together social scientists, political leaders, and infectious disease specialists, we will investigate how educational, governance, and healthcare resources can be better deployed HOW TO GET INVOLVED WITH THE against future outbreaks. HANNAH ARENDT CENTER THE HANNAH ARENDT CENTER PRESENTS

Donate annandaleonline.org/arendtmember Facebook facebook.com/HannahArendtCenter Website bard.edu/hannaharendtcenter Twitter @Arendt_Center “Learning From the West African Blog hannaharendtcenter.org Instagram @hannaharendtcenteratbard Learning from Ebola Epidemic” is grounded in the Global Health Security Agenda, The conference is sponsored by the Honorable Wilmot James, South African MP, and the the West African following organizations: which was established in 2014 Ebola Epidemic: to advance a world safe from The Role of Governance in Preventing Epidemics infectious disease by preventing future epidemics, detecting Carnegie Council for Ethics in International Affairs threats early, and responding to New York City March 31, 2016 outbreaks rapidly and effectively. Image: ©artshock/Shutterstock

HOW TO GET INVOLVED WITH THE HANNAH ARENDT CENTER THE HANNAH ARENDT CENTER PRESENTS

Donate annandaleonline.org/arendtmember Facebook facebook.com/HannahArendtCenter Website bard.edu/hannaharendtcenter Twitter @Arendt_Center Blog hannaharendtcenter.org Instagram @hannaharendtcenteratbard Learning from

The conference is sponsored by the Honorable Wilmot James, South African MP, and the the West African following organizations: Ebola Epidemic: The Role of Governance in Preventing Epidemics

Carnegie Council for Ethics in International Affairs New York City

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