Liberias assistant minister of health spoke at the center for strategic and International Studies friday about his countrys response to ebola. He talked about ongoing challenges some of the Lessons Learned and what is currently being done to help eradicate the disease. This is an hour and a half. Good morning, everyone. Im Steve Morrison Senior Vice President here at csis, i direct the globe Health Programs here, and we are joined and honored to have with us tolbert nyenswah. And ill say a few words why were here and how well go about the decision. I want to thank colleagues who helped pull this all together. Katy travis and jesse and so special thanks to them for pulling this together. We were traveling catherine my colleague, and i were traveling in january to liberia and sierra leone, and in the course of that we met this remarkable person tolbert, who is an assistant minister of health, deputy chief medical officer, and most importantly, head of the Incident Management System in liberia, which is the central and most Important Institution driving the response and control of ebola in liberia. Tom frieden when he has visited liberia at various points, has declared that this is the most important person in liberia. Now maybe thats it arguable and in deference to the president and others but one thing that became very clear was that tolbert was indefatigable. He trained as a lawyer and at the university of liberia. He went on to pursue his interests in humanitarian law at Johns Hopkins at emory and elsewhere and then came to Bloomberg School to complete a master in Public Health and then as he will describe, as an a ministerial official, he became at the center of the response directly empowered by the head of state to Carry Forward this and it became terribly important as the crisis worsened in the August September time frame as the mobilization took off in the midfall and up to now and as we entered the new phase. So, we are really honored to have tolbert with us. I learned also in speaking with him, he is a malaria expert. He drafted he was responsible for drafting the First National plan under the president s malaria initiative. The plan for liberia. So, he can speak to many different issues in the course of this. Its a complicated story. We had the chance to go over this when we are together in january and it was the most lucid and cogent and insightful summary of the story and so when they learned that tolbert would be here we asked him if he would come and do a public presentation along these lines. There are plenty of seats up front. I also want to welcome the 75 or so people who were here on line and the audience from cspan so tolbert we are grateful and honored to have you here today. If you could carry us through that then we will do a bit of backandforth and then we will move rapidly to the audience to get comments and questions from all of you. So welcome and we are thrilled to have you here. The floor is yours. Thank you. Thank you Stephen Morrison for the time. It is my pleasure to be here. At this very important situation the center for Strategic International studies and its a pleasure to be in washington d. C. I am honored and privileged to talk to you all and thanks for coming out to hear the story about the Ebola Response in liberia, a horrible story about what we did as a country how we came together as a state and brought a system together very quickly to respond to one of the major threats major global Public Health threats to our existing we as a country were recovering from massive civil conflict 14 years of civil conflict rebuilding our lives as a country, as a people on the extraordinary leadership incredible leadership of backward africas premier president , africas first female african president who democratically led the people of liberia and turned around very quickly and brought the situation after the war years the desperation and the high hopes of our people when we were on the very good trajectory of recovery after the civil conflict rebuilding the Health Care System rebuilding the Education System trying to rebuild some of the very barriers, and reconstruct our infrastructure breaches and then we got some of the steps that the government made to the effort of the president to increase the government overall budgetary support to the Health Care System who got 19 of the budget contributed to the Health System as compared to the 2015 target of 15 contributions to the Health Sector of liberia and 19 before 2015. In africa there was the number one country before the target date. That is the reduction by this year. Liberia met that target in 2012. And we are making progress. And before that gdp growth has reached a. 7 in 2014. 2014 i became it became a very difficult year in liberia and the entire region. The entire west african sub region and my description of that is that ebola was not just something in liberia and the region but we were really dealing with the disease that had serious implications on the entire world. It shows how interconnected we are as a people because the fact that ebola can cross the border they didnt need a passport to enter the United States. Ebola needed no passport to enter European Countries and we saw that so those of us in west africa that are on the frontlines of fighting this disease are sacrificing for the rest of the world. This is the kind of feelings that we got as people, as a country and we came together to fight this disease. And so under the leadership of the president when the disease struck in guinea in december of 2013 very close to the liberian border the proximity of the border we knew very well that liberia wasnt safe especially in the most populated at the center of the disease. We were aware that it was a terrible situation. By march precisely march 22 ebola struck and we had a case of the disease and imagine the entire region guinea liberia and sierra leone, there was no in liberia so we needed to take the specimen across the border to have it tested and know whether or not we were dealing with the virus and disease. Before that liberia was also battling with lots of fever and the signs and symptoms of ebola related to some of the common diseases that we were seeing in our Health System like fever headaches bleeding from the orifices, from your eyes, your nose and your ears those were signs so we could not really distinguish whether or not it was ebola or fever. So the first case, our minister of health and announce that the Ebola Outbreak was in liberia and we notified an organization that we had a strange disease in the region. It was the first time the ebola has left since the history of ebola since 1976 ebola in the east african area. We have no knowledge in west africa of such disease. This was the first time so the Health System was not equipped to deal with the issue of isolation testing of people with the disease and all that so we had to deal with the situation and to do that we are organized as a government and the minister of health and created a National Coordinated unit meeting every day strategizing how to deal with the situation. People were being infected so we had the first wave of the outbreak in march and april. The first wave of the outbreak had only six confirmed cases with six confirmed deaths so was a 100 fatality rate in the first wave. We dealt with the situation the first wave and went at least 60 days without a new case of the disease but in guinea and sierra leone got hit in may. Guinea and sierra leone were still reporting the virus so we could not declare the virus has a country because liberia and guinea sierra leone we have intermarriages and crossborder issues, farming. You can walk across the border and 100 crossborder points so we could not declare we were out of the woods as a country. Then we had a second wave of the outbreak in may. It became the epicenter close to the guinea border and we had a number of cases, all of the 50 counties for the first time the capital city of monrovia got hit with the disease. We have a case of a 14yearold girl that traveled from sierra leone leon and settle down with her family in monrovia. Monrovia 1. 5 Million People and people started getting infected from the disease. We have three counties who had become the epicenter. By the time we got to july and june morobe have got infected and by june, july and august the situation was on out of control. We were reporting 60 to 70 confirmed cases. August was terrible. Disparity, frustration. The government had to put in place a system to deal with the situation. So my role from the very beginning of the outbreak i was cheering the social mobilization component of the outbreak so my job was to go to all the Radio Stations in liberia. I would go to the Radio Station and announce that we have a number of cases in the country and we had a number of deaths so i was giving a report on a daily basis and explaining to the liberian population what ebola was the signs and symptoms of ebola, how you can prevent yourself from the disease. The disease had no cure and no vaccine so was the Public Information campaign. I was talking to the press cnn cnn, cnbc. At the time to Country Offices usaid, these organizations were focused on Development Work so the initiative of this to give that support to look at this as a threat to humanity we did not receive that International Support until march april, may june, july so we were calling to attention that this was a Global Health problem that needed the International Community support. So by august the World Health Organization director announced that ebola in the region was to be elevated to phase three of disease pandemic as a global Public Health problem and my very good tom franey the head of the center for Disease Control center in liberia in august sent in some very strong epidemiologists and the rest of the cdc liberia and then we sat down and established the Incident Management System in which the president of liberia asked me to leave. I chaired it and put in place and incident Management Structure with key areas. The structures did exist before the meeting was established. Whether you had to make it strong combined with international experts. So with that the ims system was because if you look at the center for Disease Control there was an incident management to support that so its like a replica of the cdc Incident Management System that i chair in liberia with five areas. Number one, in august, september the outbreak was very big. 100 confirmed cases with people dying in the streets. No treatment bags to put people. There was fear, desperation and agitation in the community and so we had to put in place a Case Management team responsible for building the ebola treatment units. We have put in place social mobilization in a designated area to be put in a Laboratory System in another strategic area area. The epidemiologists and Psychosocial Support. Those areas were set up and what we did as the commanderinchief under the president it was like look this is a liberian problem problem. We are in a situation where we have to find a solution for this. The intervention had to be led by liberians so i am in charge is the commanderinchief of the country and the Incident Manager was led live by liberians. All of the areas were liberian but what we did was with our International Partners each area is chaired by liberian and cochaired by an organization like the cdc and w. H. O. Cochaired the Management Team and social mobilization would be cochaired by unicef Psychosocial Support would be cochaired by the program so we organized this multinational response to deal with the outbreak. Before we had all of the sophistication of the liberian people themselves took charge of the disease and the social mobilization component committed an engagement component and ownership and people change their behaviors over time. By september we started seeing this exponential rejection and 1. 4 people were going to die in and cdc came up with what they report that w. H. O. Said about 20,000 people would die on a weekly basis so the liberian people got the message and said we have to change our behavior. Simple messages were sent out. Number one the disease has no cure. The disease has no vaccine. The disease had a very high case fatality rate of close to 25 to 90 but it is preventable. So what we need to do is if somebody is sick make sure that you dont test sick people, make sure that you dont bury the dead. You call the health team. Ensure that you wash your hands 24 hours with soap and water so everywhere you went in monrovia and everywhere you were right now there were handwashing corners in shops phones and marketplaces supermarkets. Everywhere there were handwashing corners people washing their hands in a touching a dead body so the behavior change a loan played a very Critical Role in combination with the huge huge International Support. The International Community came very late and we are very much grateful and when i told you in our office under the leadership of president obama the people of the United States of america we saw when president obama announced their request of my president and president obama announced that this was a serious problem and we started seeing the chinese the europeans, the americans in the entire world come to the aid and by september and august we started to construct the ebola treatment units with the help of the u. S. Government working with the military, the department of defense and the first airborne division. Major general williams and i were working together. Major general wolinsky we had a trip. We flew on the u. S. Helicopter in the field to construct btus and visit the labs to the country that did not have a Laboratory System we had ebola labs that were installed and we had community centers, and the Community Care centers where you move people from the community and put them there where they get to the point where they have a place to be with the secondary infection. We trained Contact People because for you to get ahead of the disease as we did every infected person and contact must be traced for 21 days. That is very important so its easier but the trainer trends the chain of transmission if all of these contacts are on the contact list and they are on the contact list you can monitor and remove them and put them in that ebola treatment unit and monitor them. We started seeing the trend of the disease come down between october september october november and today the exponential projections and the increase in the number of people that were going to die from ebola, we didnt have that number present. We had about 3000 confirmed deaths over 3000. We had Health Care Workers. This disease is associated with infection affection, caring for your loved ones. The most infected people were close family members and Health Care Workers but Health Care Workers gave care to patients so most of them got infected. We had 300 Health Care Workers that got the infection and 179 of them died from the virus. This has really struck their Human Resource development in the Health Care Sector and i remember in october i had to lead a team myself to bury that died from ebola. We were looking for a place to bury those people. The community rejected people with ebola. People could not be buried in the community so we had to purchase a piece of property from 12 00 in the afternoon after 2 00 a. M. In the morning trying to bury these people. There was agitation and the government had to deploy military to protect the team. We saw stories where a mother died from the virus and the little kids would go to the mothers. We saw stories where relatives would look on their brothers and sisters and they were placed in body bags and cremated, burned because of we had to make sure that people had safe and dignified burials. The combination of this got us where we are today in liberia. We have 14 or 15 counties that are free of ebola for the past 21 days. Some have gone 42 days and some have gone in 60 days and some have gone 90 days. Some communities have gone more than 95 days without a single ebola case. This morning i read a report that 14 counties are still free from ebola virus disease. We have transmission taking place on a weekly basis sometimes three cases or two cases but what is important is one single case of ebola is an outbreak. So the fact that monrovia is reporting one or two cases we are not out of the woods yet and in fact also
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