The Ebola Response: Q&A with Laurie Garrett, Council on Foreign Relations

Sep 9, 2014, 11:56 AM

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Almost every day brings reports of new cases of Ebola, the often-fatal virus now impacting multiple countries in West Africa. According to the U.S. Centers for Disease Control and Prevention (CDC), the 2014 Ebola outbreak is the largest Ebola outbreak in history. Spread of the disease to the United States is unlikely—although not impossible—and efforts are underway to find vaccines and cures, including scale-ups of drug development and manufacturing, as well as human trials for vaccines both in the United States and around the world. However, in West Africa the epidemic is impacting lives, economies, health care infrastructure and even security as countries try a variety of methods—including troop control—to get citizens to obey quarantines and other potentially life-saving instructions.

Late last week, NewPublicHealth spoke with Laurie Garrett, senior fellow for global health at the Council on Foreign Relations. Garrett has written extensively on global health issues and was on the ground as a reporter during the Ebola outbreak in Zaire in 1995.

NewPublicHealth: What are your key concerns with respect to the current Ebola outbreak?

Laurie Garrett: My main concern has been about the nature of the international response, which could be characterized as non-response until very recently. And now that the leadership of the international global health community has finally taken the epidemic seriously, it’s too late to easily stop it. We’ve gone through the whole list of all the usual ways that we stop Ebola and every single one of them was initiated far too late with far too few resources and far too few people—and now we’re in uncharted territory. We’re now trying to tackle a problem that has never reached this stage before and we don’t know what to do. The international response is pitiful, disgusting and woeful.

NPH: How do you account for such a poor response?

Garrett: First of all, the World Health Organization (WHO) is a mere shadow of its former self. When I was involved in the Ebola epidemic in 1995 in Kikwit, Zaire, the WHO was recognized worldwide as the leader of everything associated with outbreaks and infection, and it acted aggressively. It didn’t have a huge budget, but it still was able to take the problem very seriously and the resources that were needed were available, and more importantly a very talented leadership team combining the resources of the U.S. Centers for Disease Control and Prevention; WHO; Medicin San Frontiers (Doctors Without Borders); and the University of Kinshasa, Zaire, came together. They respected each other. They were on board together. They worked very closely with the local Red Cross, and they were able to conquer the problem pretty swiftly. 

In contrast, the current outbreak is, first of all, urban. We’ve never seen that before. It’s in at least five countries, three with really rampant spread. Though it seems to involve a familiar strain—the exact same strain as was responsible for the 1976 original epidemic—it’s mutating, and we really don’t know what the mutations signify or what changes may occur with the virus.

And I feel that WHO’s many major budget cuts are impacting the effort, including a 20 percent layoff of its staff, operating with a total annual epidemic and crisis response budget of only $114 million. It’s pathetic. If we don’t radically change everything immediately then we will lose. The virus will win.

NPH: Do you see a ramping up happening?

Garrett: Yes, things are starting, but they’re starting months too late. We don’t even have a designated bank account for deposits from donors. Such basic things have not been accomplished, and we only just got the announcement two days ago that one country, Ghana, is willing to serve as the air bridge for the transport of goods and material and personnel in and out of the epidemic, despite the fact that the outbreak begin last March. And this is an air bridge in principle. In practice, do we have personnel on the ground in Accra, Ghana? Do we have processing of supplies? Do we have warehouse facilities? Do we have a chain of command for decision making? Do we have a system for saying what is needed where in the field, sending that back up and responding at the warehouse level to get supplies, personnel and equipment in in a timely fashion? No. We don’t have any of that. We’re all the way out to September. We don’t have a single one of those pieces in place. It’s appalling.

For 14 years, the WHO struggled to get the nations of the world to agree to the new international health regulations (IHR) which finally passed in 2005 and went into effect in 2010. Among the things in the IHR is the stipulation that the WHO is in charge in a serious epidemic, but it also is a UN agency that never believes it can walk into any situation without the complete cooperation of the local government and that it only serves to support the local government in whatever it’s doing. So now we have three of the weakest governments on planet Earth—three of the poorest countries on planet Earth—two of which went through the bloodiest, most hideous civil wars in modern times, and we’re all waiting for them to take charge? We’re all waiting for them to have the capacity to do something that no country in the world has done: Fight Ebola on a scale that it now exists?

So, we have this contradictory international set up. We don’t have any agreed-upon global government structure outside of the rules of the United Nations. We don’t have any system whereby international responders can pour into a site and do what needs to be done. Everything is done with the careful, tedious permission mechanism country-by-country. No borders get crossed without the permission of the country, and no penalties are applied by anyone—even the Security Council—against governments that refuse to allow border crossings even for medical responders, and that is occurring at this time.

NPH: What recommendations do you have for the global response?      

Garrett: Inside Liberia, Sierra Leone and Guinea right now—and probably Nigeria—each of these countries has its own internal issues to deal with, many of which stem from the legacy of the civil war and the distrust that still is pervasive across all the different cultural, religious and ethnic groups inside the countries. No outside force can come in and solve that problem. That’s up to them. What outsiders can do is assist with the technology of communication. So, for example, if the president of Liberia wanted to be able to give rapid notification to all the people of Liberia on a daily or even multiple-times-a-day basis about the movements of the virus and where it might be—where cases might be appearing and so on—she might turn to outsiders to develop an appropriate cell phone app for distribution of that message. But the content of message—the cultural flavor of that message—is up to Liberians. Outsiders cannot make that determination.

Right now, there’s so much not done that you almost have to do everything at once. Within the next week we should have sorted out the following:

One, there should be an international acceptable, transparent and accountable central bank repository with a central control over the flow of financial resources dedicated to this epidemic. It is logical that it should be based at the World Bank. Representatives of all affected countries, as well as the largest donors, should sit on the board that oversees that account, and it should be an account that can accept not only government donations, but also private-sector donations so that corporations that do business in these countries can make donations. How that money gets meted out should be determined by a board to which everyone is a representative that oversees the decision process—not a day-by-day meeting to decide spending, but an oversight on the accountability and making sure that no country feels like some other country is getting too much money and they’re not getting enough. 

The second thing that should be in place immediately is a command and control structure. Included in that is centralization of information regarding human resources. One estimate put out last week is that we need 11,000 health care workers on the ground right now. Eleven thousand? Where the heck are these people going to come from and how do we manage the fatigue and exhaustion issues and rotate people out of danger for two-week R&Rs and then back in, the way MSF is doing? And who screens the volunteers? I’m sure there’re a lot of people out there that would raise their hand and say “I want to be a hero, send me to the epidemic.” But are they the type of people you really want to put on the ground? Do they know what they’re doing, or would they be more trouble than they’re worth? We don’t need to have any more infected health care workers and we need to be sure that people know the procedures and follow them and that they understand what the chain of command is and follow it.

You can’t recruit from 200 countries around the world for skilled personnel to get to where they’re needed in a hurry unless you have a centralized control and command structure of some sort. We need a staging area. Not just saying that Accra will allow planes to land and come and go from the epidemic. That’s great, but where are the warehouses and who is going to be overseeing the warehouses?

The scale of what we need right now is commensurate with the scale of the response in 2005 when the great tsunami overwhelmed Aceh, Indonesia and Southern Thailand, Malaysia and Sri Lanka. That involved almost the entire Pacific fleet of the U.S. Navy just to move supplies, and we don’t see anything akin to that now.

NPH: Who is taking the lead now?

Garrett: On August 12, U.N. Secretary General Ban Ki-moon appointed David Nabarro a special coordinator for the entire U.N. Ebola response. Nabarro played the same role in 2005 regarding H5N1 bird flu and the possibility of a giant pandemic coming of super deadly influenza. He knows how to do it. He knows all the players. He knows what the different problems are and foibles and weaknesses of the various agencies within the UN family.

The problem is that this is bigger than the UN family, and what we don’t have is any kind of coordinating mechanism and ability to kick butt that extends beyond the boundaries of what classically is considered under control of the United Nations. And Nabarro, he’s not a miracle worker. If, for example, MSF put out a call saying they wanted military medical response, then the single greatest rapid response force for medical disasters on the planet today is the U.S. Army and Marines, because we’ve now been fighting on multi-fronts in combats since 2001, and we have battle-hearty, danger-experienced medical teams in mobile units that can drop into a location and within less than 10 hours be treating patients. MSF wants them on the ground. But those are U.S. military personnel. Does Liberia want uniformed U.S. military personnel on its soil? Does Sierra Leone, does Guinea, does Nigeria? These sorts of things are very tough decisions. They have political layers that are very difficult to sort through on a rapid basis or even to anticipate repercussions down the line.

[Editor’s Note: On Sunday, the White House announced that the Pentagon will send a 25-bed field hospital to Liberia to help provide medical care for health worker. According to a Pentagon spokesman, the hospital will be set up by the U.S. military and then turned over to the Liberian government to operate. There are no current plans for the U.S. military to provide medical treatment.]

We have a kind of hodgepodge, ad hoc committee approach to solving these things. It’s not ideal. What we are now seeing, what the world is now witnessing, is the frailties of globalization—a system that was developed for globalized trade and economics, but has never functioned well for globalized governance in a crisis.

>>Bonus Links: FRONTLINE will air a documentary this evening—called “Ebola Outbreak”—filmed in Sierra Leone, one of the West African countries currently grappling with the epidemic. Read more from PBS about Ebola, then check local listings for the documentary air time and station.  

This commentary originally appeared on the RWJF New Public Health blog.