at the German Marshall Fund on the International Response to the Ebola Crisis
U.S. Permanent Representative to the United Nations
Good afternoon. On September 18th, six weeks ago today, the United Nations Security Council held its first-ever emergency meeting on a health crisis. A Liberian man named Jackson Naimah spoke to the Council via video link from Liberia. Jackson works for Médecins Sans Frontières, and is a team leader in one of MSF’s Ebola treatment centers in Monrovia. He told the Council that he had lost a niece and a cousin to the virus – both of them nurses infected at work. He said that, as he was speaking to us, sick people were outside the gates of the MSF clinic, begging to be let in and treated. MSF had to turn them away, because they had no more beds. Jackson said, “I feel that the future of my country is hanging in the balance. If the international community does not stand up, we will be wiped out.”
You all are familiar with the statistics of what Ebola has done to Liberia, Guinea, and Sierra Leone. More 10,000 people infected. More than 5,000 people killed, nearly 250 of them health professionals. More than 4,000 children orphaned.
Given these stark facts, I’m especially grateful to you all for coming today. The size of the crowd here is a testament to the growing concern around the world about Ebola.
Having just returned from travelling to Guinea, Sierra Leone, and Liberia, I have two simple messages for you today. First, the international community is not yet doing enough to stem the tide of the epidemic, causing devastating heartbreak to countless families and allowing a global threat to metastasize. Second, based on what I saw this week, the contributions that have been made by the United States and many of the countries represented here today have begun to save lives and offer the first tangible signs that this virus can and will be beaten.
We stand at a historic juncture. We face the greatest public health crisis ever. And we each have the opportunity to work together in support of the brave and determined people of the region to bend the chilling curve of Ebola’s spread and to end the devastation and suffering that it has wrought. To beat this virus and to produce the seismic shift upon which the lives of an entire generation in West Africa depend, we each have to dig deeper, and we each must conquer the fears that this epidemic has generated.
First, the bad news: Everywhere we travelled in the three West African countries affected by Ebola, we saw or heard about alarming gaps in our collective response, and the overwhelming devastation Ebola continues to inflict on the communities who are often just getting back on their feet after years of conflict and repression.
Aid workers in Guinea told us that rural villages just a dozen kilometers away from where the outbreak began have still never heard of Ebola. Outside the capital, even basic supplies like buckets and chlorine are hard to find. Contact tracing teams – the local investigators who track the outbreak’s spread – often lack the money to buy fuel for their motorcycles, and they’re not paid their salaries on time. Burial teams that may have received some protective equipment don’t have enough to go around.
Across the region, in a matter of months, Ebola has reversed years of hard-earned development progress in the affected countries. Since the outbreak began, the number of births in Liberia attended by a medical professional has fallen by roughly 30%, and maternal mortality is rising fast. A new World Bank report concludes that if the response continues apace, the losses to Guinea, Liberia, and Sierra Leone will top some $359 million just by the end of this year and the effects of the isolation the countries are now facing could take years to counteract.
The health profession – never very substantial in the region – has been decimated. Doctors and nurses who didn’t have the proper training to stay safe have been killed in droves by the virus. As the historian Thucydides wrote of the plague in Athens: “They died themselves the most thickly, as they visited the sick the most often.” One victim was Dr. Sheik Umar Khan, age 39, a world-renowned epidemiologist known for reaching into his own pocket to buy medicine and food for his poor patients. He was one of more than 30 health professionals killed by Ebola who worked in the same hospital. Imagine.
A huge number of infections are caused by elaborate burial rituals that become deadly when a deceased person is covered in Ebola. As the epidemic spread these last months, infected bodies have been left to rot in the street for days, because families feared that neighbors would stigmatize them for having a relative die of Ebola, because the burial teams were so overwhelmed by the demand that they could not respond to all the calls to collect the bodies, because team members lacked protective gear required to safely remove remains, or simply because the burial workers didn’t have vehicles or the fuel they needed to power them.
Notwithstanding these grim facts, some in the international community have not yet shouldered their share of the response burden. Some may tell themselves that we have waited too long, the virus has spread too far and too wide in the affected countries, and that it is safer to hang back and hope for the best. Others who read news reports of other countries’ activities, are wrongly reassured by the belief that others – whether NGOs, a handful of wealthy governments, or pharmaceutical companies – will do the job.
NGOs are already giving their all to this response. Of the dozens of NGO representatives I met on my trip, every single one was drawing upon his or her expertise to help with the Ebola response, from the education program officer now providing psychological treatment for children orphaned by the virus; to the media trainers who used to work on other things now collaborating with local radio stations to share Ebola survivor stories to try to deal with the stigma. Were it not for the efforts of these organizations, the outbreak would be much, much worse. But they are maxed out. They cannot fill all the remaining gaps without more support.
Of course, certain governments have a greater capacity to contribute than others, and that capacity brings with it a greater responsibility. President Obama fully understands this. Under his leadership, the United States has already provided more than $360 million to fight the outbreak in West Africa, and announced our intention to devote more than $1 billion to the whole-of-government Ebola response effort. We have deployed more than 250 civilian, medical, healthcare, and disaster response experts from multiple U.S. government departments and agencies. We’re committed to sending as many as 3,200 U.S. military forces to the region, more than 1,000 of whom are already on the ground.
I was privileged to meet with some of these service members this week and I can tell you that they are already hard at work. These forces are supporting the U.S. effort to construct and support up to 17 Ebola Treatment Units, establish a regional training hub where we will train up to 500 local health care workers and providers each week, and they’re providing crucial airlift and logistic support to other responders. I also visited the U.S.-built hospital for foreign and Liberian healthcare workers and responders which will be operational early next month and staffed by the U.S. Public Health Service, whose officers are already on the ground training in other ETUs around Monrovia.
Six days ago, European Union members announced a campaign to rally 1 billion euros in support to pay for the Ebola response, including the construction of facilities to care for patients. Countries have already pledged some 600 million euros in support, a promising sign of the commitment of EU member states. EU members have also come together to offer critical medical, air, evacuation support to international health care workers who contract Ebola, a vital assurance to those working on the frontlines to end the outbreak that they will not be left behind. Other countries have stepped up in ways large and small. Having slayed the Ebola demon in its own country, the Nigerian government recently announced it would send some 600 health care workers to the affected countries. Cuba, a country of just 11 million people, has already sent over 250 health care workers, and 200 more are on the way.
This is a crisis that is so vast, with needs so great, with potential consequences so dire, that no country can afford to stand on the sidelines. A few are doing a lot. But a lot are doing very little, or nothing at all. It is well past time to join what is a historic, groundbreaking, lifesaving mission – a noble mission.
We need more doctors and more nurses. More beds and more treatment facilities. More personal protective equipment. More burial teams and more ambulances. More cell phones. More SIM cards. More motorbikes and trucks and helicopters. More plastic gloves, more bleach and more thermometers. And the list goes on and on.
And even if we are able to build a bed for every infected person, and even if we can eventually ensure every one of those individuals gets the quality care needed to have a fighting chance of survival, that still will not be enough. We need to move beyond treating the sick to preventing new infections – in the affected countries, in neighboring countries, and in nations around the world. We have been playing defense with Ebola. Now we also need to go on offense. To do that, we need more contact tracing teams, who can reach more communities with greater speed. We need more accurate, real-time data collection, which can be shared across borders; not only for tracking the virus’ spread, but also to anticipate and preempt its next moves. And we need more effective public awareness campaigns, hyper-targeted to the most marginalized populations, which are often the most vulnerable.
Every single one of these gaps must be filled. The longer we wait to fill them, the longer the virus will replicate and the more that it will kill. In addition to gaps, we have other concerns. There is a risk we will fall back on business-as-usual and process-heavy solutions, which locate decision-making in far-away capitals, rather than empowering people on the ground to adapt their tactics to what is happening day-to-day.
Too often, we have seen, the international community provides resources that cannot easily be re-purposed rather than providing resources that are flexible, and which governments and humanitarian groups can adapt to the evolving crisis on the ground. We tend to plot out static, long-term plans to respond to the outbreak, and then stick to them, rather than developing fluid structures that can move with the virus, a virus whose movement is difficult to predict.
There is a risk, too, that we will spend billions of dollars vanquishing the virus but leave behind little more than broken healthcare systems, fragile infrastructures, and the memory of a remarkable anti-Ebola surge that then receded. Instead, we must ensure that at every opportunity we help create and deepen local capacity through partnership with governments, with teachers, with local institutions and local NGOs. So my first point is that we need to do much, much more.
My second message, however, is one of profound hope. I did not go to Guinea, Sierra Leone, and Liberia expecting to find much cause for hope at this point. But today, the affected countries are, in fact, in a very different place than they were six weeks ago. I came away more convinced than ever that if we rally the right response, together, we can stop Ebola.
In Guinea, we saw the power of religious leaders coming together to use their pulpits not only to share religious doctrine, but also to share public health information. Under Grand Imam Camara’s leadership, the Imams of Guinea have clearly communicated that a safe burial can be consistent with a religious burial. In our meeting with the Grand Imam in Conakry’s Grand Mosque, he unequivocally told us that “religion cannot stop science.” The Grand Imam has asked the leaders of the 12,000 mosques across the country to amplify these messages and to encourage their congregations to cooperate with local and foreign health workers.
In Sierra Leone, we saw first-hand how a surge of international aid and coordinated leadership can produce dramatic results in just a matter of days. A week before we visited, President Koroma had set a goal to retrieve victims’ bodies and give them a dignified burial in Freetown within 24 hours of their being reported. This is a crucial way to help slow Ebola’s spread, because traditional burial rituals have been a major cause of new infections.
On Tuesday, we visited Freetown’s new Ebola response call center. A robust public information campaign had spread the word among the city’s residents to call “117” when a person was suspected of having Ebola, or when a sick person had died. The message was getting through. On the wall of the call center was a map of Freetown. Sierra Leonean volunteers were using red pins to mark the locations where bodies had been reported. When a team retrieved and buried a body, the red pin was replaced with a blue one. A week earlier, the Sierra Leoneans told us, only 30% of bodies were being collected and buried safely within 24 hours. By the time we visited – in no small part due to the infusion of British military and civilian experts and other international partners – 98% of reported bodies were being buried within 24 hours. On the map, we saw a single red pin surrounded by a sea of blue pins. Swiftly modeling this in all of Sierra Leone’s 12 districts is critical.
In Liberia, the U.S. military forces deployed by President Obama are on the ground, working side-by-side with a team of some 50 experts from the Centers for Disease Control who have been deployed since March. USAID, the U.S. Public Health Service Commissioned Corps, and the Liberian government are part of this collective effort and their impact has been striking. We flew to Bong County, where we visited a remote U.S. Navy Ebola testing lab. Before the lab was up and running just two weeks ago, Liberians in the area waited at least five days for Ebola test results to come back from labs in Monrovia, and samples were often lost in transit. While people waited to hear results, they were often quarantined with other Ebola patients, increasing the risk that those who did not have the virus, who were waiting to get a test result back, would contract it while waiting. Now the results take three to five hours, freeing up beds and allowing those infected to be swiftly isolated so they do not pass along the infection and so they can begin treatment earlier, which can dramatically, of course, increase the rate of survival.
Armed with the knowledge of how to stop the spread of the virus, many Liberian communities are leading grassroots prevention efforts. One community in Montserrado County created a local committee to go house-to-house, separating infected individuals into buffered zones. Now people who have been exposed to the virus and are at risk of infection are isolated until 21 days pass. Their system draws on knowledge of older generations in the community, who had been taught a similar approach for containing smallpox decades earlier. As President Johnson Sirleaf said to me of the community-based response: “If communities work, it works.”
I mentioned Jackson Naimah and his powerful presentation at the UN Security Council in September. Well, I caught up with Jackson during my stop in Liberia and heard how the MSF clinic where he works no longer has to turn people away, because they now have enough beds. I asked him what kept him up at night and to my surprise, he told me that he was worried about how his society would deal with the lasting damage caused by Ebola after the epidemic had been brought to an end. A month ago, it wasn’t clear how we could bend the curve at all. And now, notwithstanding the very, very steep mountain yet to be climbed, some are able to imagine what their societies will look like after we not only bend the curve, but end the curve.
We know exactly what must be done to bring this outbreak under control. We just have to marshal the will to do it. And for anyone who doubts whether we can do it, consider the following:
There were more than 20 outbreaks of Ebola before this one – all of which began in underdeveloped countries. We contained every single one of them.
Nigeria and Senegal both registered cases during the current outbreak, with Nigeria identifying more than 20 cases in two distinct regions. Both countries were able to track down and contain those infected with the virus, and both have since been declared Ebola-free.
Individual towns and districts in the affected countries have also shown they can contain the virus. Leaders in the Télimélé district, in the northwest of Guinea, started preparing for Ebola shortly after the outbreak started. When the first cases surfaced there in May, the response was immediate. Community leaders, including local religious leaders and griots, disseminated a clear message that the only way a person could survive Ebola was to seek medical treatment immediately. Trusted local health workers fanned out to local communities to raise awareness about the virus and to instruct how to prevent infections. Médecins Sans Frontières set up an isolation wing in a local health center to treat the sick. And a 14-person contact tracing team traversed the district on motorbikes, tracking down some 250 people who had interacted with the infected people. Twenty-six infected individuals were tracked down, 16 of whom survived. The 62% survival rate in Télimélé’s outbreak was more than double the average in the rest of Guinea, because the community recognized Ebola early and knew how to respond. No new cases have been reported in the district since that first outbreak.
There is one grave threat that endangers our ability to build on the momentum of the last few weeks to actually stop the spread of this deadly disease. That grave threat is fear. Ebola has no greater friend than fear. The virus thrives on it.
We see fear in the affected countries. It is a fear that drove the residents of the West Point neighborhood of Monrovia to overrun a building housing Ebola victims. Members of the community had set aside space to move men and women with Ebola out of their homes, to protect their loved ones. But fearing the possibility that gathering the sick together in one space would make the virus more likely to spread, a mob drove out the patients and ransacked the facility.
It is fear that leads community members to stigmatize survivors of the virus, or the relatives of those who have died, or even the health professionals and other people aiding in the response. A 24-year-old survivor in Guinea told me she had lived three lives: her life before Ebola; her life in the hell of her infection; and her life since recovering. She said the stigma she has suffered since beating Ebola has made her current life the hardest. The stigma had so affected her that she said she was amazed by President Obama’s embrace of Nina Pham, the Texas nurse who was just cured of Ebola. When I went to give this young woman survivor a hug goodbye, though, she demurred and offered a fist bump. She did not seem yet to fully trust that she was cured or to recognize that she had done nothing wrong – only the virus had.
It is fear that has caused some of those who develop a fever or other symptoms not to come forward to seek help, putting themselves and the people around them at greater risk. Fear that going to seek care will make them sicker, or that seeking help will alienate them from their communities.
We also see fear in countries like my own, whose active participation is critically important to bringing this outbreak under control. All over the world, governments and our fellow citizens are afraid that if we send doctors or nurses or soldiers or engineers or other volunteers to the affected countries, we will put our own communities at risk.
The fear is understandable. Many of our countries, like those most affected, are dealing with Ebola for the first time, and it is a dangerous and terrifying virus.
Leaders have a responsibility to listen to the fears coming from the public, and to try to understand them. And we also have a profound responsibility to enact public policies that keep our own citizens safe. And as President Obama has repeatedly said, the best way to keep Americans safe – or citizens of any of our countries – is to stop the outbreak at its source.
When isolated incidents happen, they grab headlines, and the facts and the science tend to recede into the background. Two days before I left New York for Guinea, an American doctor named Craig Spencer – who had recently returned to New York after a tour helping those sickened from Ebola in Guinea – came down with the virus. My five-year-old son Declan begged me not to travel to what he called the place where there is “bola.” It took the calming words of my mother, a physician, to reassure my little boy that the virus is not airborne and that the protocols to stay safe are extremely reliable, as the presence of many, many thousands of visitors to West Africa who have not contracted the virus attests.
We cannot eradicate fear altogether. But we can educate ourselves and our communities about when fears are legitimate, and when they are unfounded or counterproductive. Local community and religious leaders can help provide a bridge of trust between humanitarian workers and the villages they come to help. Public campaigns can inform communities that Ebola survivors pose no risk to their neighbors – as President Obama has done with his hug of Nurse Pham. Leaders can send a clear and consistent message to their citizens that the best way to beat Ebola is to seek medical help immediately, as Islamic clerics in Guinea have been doing in their sermons.
We have to bring the same empirical approach and measured judgment to evaluating risk in our own communities and countries. So while statistics on infections in West Africa are frightening, we must educate our own societies about the breaches in safety measures that gave rise to these infections, as well as to the vast differences between the capacity and preparedness of our health systems and those in West Africa.
In the United States, we are doing that by reminding the public that only two people so far have contracted Ebola on our soil: two nurses who treated a patient who contracted it in West Africa. And today, both of those nurses are disease-free. Of the seven Americans treated for Ebola so far, all were detected early and have survived. So has the nurse who was infected treating a patient in Spain.
Prior to the outbreak, Liberia had approximately 50 doctors for the entire country of 4.3 million people. That’s around one doctor for every 100,000 people. Sierra Leone had two doctors for every 100,000 people. The United Kingdom, by contrast, has 279 doctors per 100,000 people. France has 318. Germany: 380. The hospital where the American doctor infected with Ebola is being treated in New York has 1,200 physicians on staff – more than 24 times the number of doctors in all of pre-Ebola Liberia.
These numbers not only tell us why we are much more prepared to prevent outbreaks in the United States, the United Kingdom, France, Germany, Belgium, and so many other countries. They also underscore why it is so important that the volunteer health care workers brave and altruistic enough to serve in West Africa be encouraged to go and be shown respect upon return.
But instead of knocking down the obstacles standing in the way of their service, some are choosing to put them up. These kinds of restrictions could dissuade hundreds, if not thousands, of skilled volunteers from helping stop Ebola’s spread – which is in the national interest of every one of our countries. And they place an additional burden on people who, at significant risk to themselves, volunteer to help sick people in countries that are not their own, far away from their own families and loved ones. These volunteers are heroes to the people they help and they are heroes to our own countries. They should be treated like heroes when they return.
After this trip, I understand the fear on a personal level, as well. Meeting with Ebola survivors or health professionals who had treated patients, I’d sometimes hear that little voice in the back of my head asking: What if the science is wrong? We all hear those voices of fear in our heads. That is what makes us human. The challenge, especially for leaders, is not to let them rule us. Like all of our fears, we must confront them. And when science warrants it, when the facts warrant it, we must overcome them. The science is right and the risks can be managed. As the late, great, UN diplomat and humanitarian Sergio Vieira de Mello used to say, “Fear is a bad advisor.”
In moments of fear, we must force ourselves to think of the men, women, and children on the front lines of this conflict – whether they are the volunteers from our countries, or the countless Guineans, Sierra Leoneans, and Liberians fighting for their lives, their families and their future – our shared future. As a young man from Sierra Leone told me, when I asked why he had volunteered to work in an Ebola treatment unit, he said, “If we leave our brothers and sisters to die, who knows, it might be us next. It is a point of duty.”
That duty is a duty we all share. We must ask ourselves: twenty years from now, when we look back on this historic crossroads, will we want to say we left this fight to the people of the affected countries? Will we want to say we did not act because we thought others would win the fight without our help? Will we want to admit that fear held us back? If we will not want to give these answers when we are asked in twenty years – and make no mistake, we will all be asked – we have to do more.
We talk a great deal about the numbers with respect to the crisis: numbers of new infections, numbers of deaths, numbers of bodies collected. Let me close by telling you about what lies behind the numbers.
One family, six members: a father, a mother, an uncle, and three children. The father, Alexander James, was a health promotion officer with MSF in Liberia. His job was to travel around the country, teaching communities how to avoid infection, and what to do if they got sick.
First, on September 21st, Alexander’s wife became infected and died. They had been together for 23 years. He said, “She was the only one who understood me very well. I felt like I’d lost my whole memory.” Days later, Alexander’s brother, who had taken care of his wife, became infected and died, too. Then Alexander’s two younger daughters both died. Alexander said, “I was breaking in my mind.”
Out of six, there were only two: Alexander and his sixteen-year-old son, Kollie. Then Kollie became sick as well. Alexander brought him to a clinic. They were separated by a fence. Alexander went to speak to his son. They could not touch. I cannot tell you how many times I was told in my trip what an inhumane virus Ebola is; how, in cultures known for their warmth, it preys on the simplest acts of affection. An embrace. Holding hands. The wiping of tears from a child’s face. Ebola punishes us when we cannot repress these impulses. So, father Alexander was forced to speak across a fence to his son Kollie.
Alexander said, “Son, you’re the only hope I got. You have to take courage.”
His son responded, “Papa, I understand. I will do it. I will not die. I am going to survive and I will make you proud.”
From the other side of the fence, Kollie was given treatment and fought for his life, while his father waited. And then, slowly, he began to recover. As the days passed, he gained strength. And eventually, a test came back showing that he was Ebola free. He was allowed to walk out of the clinic and hug his father.
Kollie was the 1,000th person to be cured in an MSF clinic. A family of six, reduced to two and almost to one.
In The Plague, Albert Camus wrote, “It could be said that once the faintest stirring of hope became possible, the dominion of plague was ended.”
We have so many reasons to have hope in our capacity to curb Ebola’s devastating spread. We find hope in every survivor, like Kollie, who has fought the virus and won. We find hope in every volunteer in West Africa who, out of a sense of duty, is working to serve his or her country and community. We find hope in the brave doctors and nurses from our own countries, who – driven by a sense of common humanity and common security – leave behind their loved ones to help people from other nations in their time of greatest need. And we find hope in every person who survives, every family that is untouched by the disease, every community that successfully eliminates Ebola. We cannot let our fears stand in the way of these hopes.