and the announcement that my colleague is going to talk about not only for the ability to improve patient care but also to begin to study the effect of the countries. so, we do hope it would be possible to conduct the trial in

the coming months. we have already begun discussions with all of the developers about how they could do that. we talked about the simple design that could be implemented and start merrily informative. so, once if the capacity is filled in the coming months i think we will be ready to go. the companies are planning to do that. next week i will be in geneva to meet with representatives from the country because critically thereby it is essential and working with them to modify the plan and to have a shared plan. so, ultimately, be products in west africa will depend on multiple parties working together. not only the companies that actually make these products, the health authorities, the regulatory authorities and the u.s. government ability to

establish this kind of infrastructure. this is all extremely challenging that failure is not an option and we do have to find ways to overcome the challenges. failure is just not an option. and i thank you again and the fbi has more than 200 scientific stocks involved in this response and we are committed to doing all we can to respond to the specific epidemic and i will answer your questions at the end. thank you. ' >> thank you to the colleagues at the food and drug administration. the next speaker teachers here at georgetown and the department of health, has a phd from johns hopkins and masters in public health and global health and the school of public health where he

served as a fellow policy prior to georgetown. on the political economy of the health systems in developing countries the community director programs, health systems design, health services delivery and a social science theory. please join me in welcoming. [applause] thank you very much for coming and for inviting me. we have about ten minutes, and in ten minutes i'm going to tell you something about the historical and political

dimensions of the crisis. so it's about how did we get here and where are we going to go, does anybody know what this is? isn't a trick question. you don't get to answer. this is the ebola virus and what do we do about it is the question, just hold onto it for a second. here is another pretty picture. this is the measles virus. some people talk about it is a problem of low vaccine coverage and i'm going to give you a couple of pathogens more as a way of talking about the way that people think about health problems around the world these are the bacteria. this is a quote from the who stop tuberculosis programming bible highlights highlight of this part. it's conceptualized as an access db2 access problem to high-quality diagnosis and patient centered treatment. these are malaria plasmodium.

and i roll back malaria partnership, one thread to malaria is the drug resistance and the solution is to change the policy. here is another malaria aspect. in the global malaria action plan there are two approaches, long-lasting insecticides and indoor residual spraying. okay so these are three diseases and there are four approaches. measles and to promote universal access and malaria drug treatments cut in this case a switch or to kill mosquitoes either with the mets were indoor residual spraying. so here what are the obstacles? here is a quote from one of the

chiefs identifying the very weak health systems. as charles writing in business week and identifying the criminal health systems. here is the voice of america doing a story on the 20th of august noting the three most effective west african countries share we can help your systems. the world world bank in a press release last week identified weaknesses in the health sector and suggested that limiting ebola and its economic impact could be done by investing in the health sector. so, why health systems? and why don't we talk about it with other diseases? it's not that we don't talk about the other disease but we don't focus on it and one reason for that is that we are at the limit of what we can do with ebola. there is no specific treatment or cure or preventative

technologies and there are no vertical solutions. the things that we are good at and global health tend to be things like disaster relief. they tend to be specific interventions. but in ebola we don't have those options so we are left with this remainder of what we say or the dual health systems. that is necessary for all kind of things things that engages the social, behavioral and cultural patterns of usual interventions in health don't go near. these include death rituals. much has been made about that in the west african context where ebola can and has been spread by the handling of the disease patients and includes burial practices, risk factors and also includes the consumptions. general health and sanitary practices also bear on the transmission. preventing and controlling ebola largely relies on the state authority and citizen trust.

ebola and this is not exceptional. health systems have wide benefits. so, here is the mortality roughly 300,000 women per year die if maternal causes. many of those can be prevented with a functioning health system. diseases cost us 800,000 children per year. most of that can be prevented with a functioning health system. childhood pneumonia claims 2 million lives a year and most of that again be saved with a functioning health system. malaria 600,000 a year. hiv-aids 1.6 million per year. we've done lots of things. we've made tremendous progress and narrowed interventions for the statistic diseases. however you've always reach a point you need to have a health system in hiv-aids for instance it is in the continuing care issues where the patients needed decades of treatments now that

we are good at it. it's no longer just one thing that we are worried about even in the programs because the health systems are such a large limiting factor in our ability to promote health. so, why are the west african health systems so weak if they are so useful and one of the fundamental building blocks of the productive and safe society? why don't we have shinning health systems? this is a historical view. west africa the rural health services all day to be control programs that were composed of mobile teams that went from village to village where they found a sign of disease and they did did force to spinal taps and lumbar punctures and then mandatory treatment. they had a single disease focus which was sleeping sickness.

they didn't build any capacities. i would love to tell you that i was the colonial pattern and that we left it in the past, but actually a form of a template for much of what we've done, for better and often for worse. after 1960, the countries themselves try to do better. in the 1960s and 1970s, the world health organization tried to improve systems among many other progress of pursuit but in the 1970s got got the commodity price collapses into the legal crisis hurt both countries and donors. in the 1980s to try to rebalance the economy's that were totally off black but structural adjustment was obligated by the washington institutions. one of the artifacts is that when the country stopped investing in the health systems. since the 1980s, donors have been very little in health systems development, too. the ebola outbreak is one way of talking about the consequences of three days of neglect and

health systems. donors pay for things that easily defined goals and have the links between input and.com that can be somewhat easier to implement. they are weary of ongoing commitments and urgent tasks usually take precedence over others. so, here is a calculus for you. think of how you would conceptualized malaria versus the health systems investments, the annual death toll into the specific needs are clear. it can be measured and estimated. it is diffuse. what intervention. and that is spraying but in the health system is diffuse. there are many possible courses of action. infrastructure, workforce, logistics, funding, popular education. think of the credit claiming opportunities. with a specific disease there is a number of people treated or

burden averted but it's harder to measure the functioning of a health system. in the cost that is easy to specify. but for health systems, it's not. in duration a particular program might end up at the health systems never did. the donors are worried about these things. when it comes to advocacy committee look around the room and say who else is engaged, who is leaving? what happens is that many nations are empty and some kind of lip service or some investments in health systems, but if the answer is to do much more of that ebola is a warning to us. it is a warning for the disease that is often fatal, that is religiously hard to transmit. but as you can see in the troubled states and the nonfunctioning health systems it's gone viral and they mean it in the literal sense. things used to just burn out little epidemics would pop up

here and there and it's so deadly and it killed so fast felt so fast that it wouldn't spread. now it's added into the general population in urban areas. so this is a call for us to take care of some long-lost business to invest in health system in the health workforce and infrastructure and in the system capacity and to embrace the political economy for managing implementation. thank you. [applause] thank you very much for that presentation. >> our next and final speaker in the remaining ten, 11 minutes that we have now is doctor

elizabeth cameron, the director for the accounting biological threats with the national security council staff at the white house. part of this assignment she served in the office of the secretary of defense and the senior adviser and chief of staff for the honorable andy weber. earlier in her career she worked from 2003 to 2010 at the department of state where she did again extensive work in the national scale related to biological, chemical and nuclear weapons production. prior to working in the executive, she was a fellow with the american association for the advancement of science, and at that time she worked for sent to the sender edward kennedy. doctor cameron holds a bachelor's degree in biology from the university of virginia and also a phd in genetics and

molecular biology from johns hopkins. please join me in welcoming. [applause] >> thanks to everyone for inviting us here today and for putting together this whole symposium and also for your personal heroism for going to the affected countries and for helping. and i think that is a -- is definitely an untapped resource. people like you that want to help and one of the things we are trying very hard to do is to put in place the mechanisms that people will be able to do that more because there will be the training in place needed to get more people there. so, we have a pretty somber occasion today with the ebola epidemic. we have heard people talk about the possibility that it could

become an endemic and we certainly see the numbers continue to rise in the news reports. today in the modeling coming out from the who and the cdc, certainly it shows what could happen if we do not inject a large pool of international assistance which is something that as many of you probably saw last week president obama is very dedicated to doing. and so i have the pleasure today of talking actually not as much about the immediate response, but the building on what doctor bob bob talked about and what we need to focus on at the same time which is very difficult in the middle of a crisis. but also how do we get ahead of of it not only in west africa but all over the world. on the last slide i think was a reminder that .-full-stop our at the root of the situation, and they are often one of the most difficult things to measure and

find and that is actually one of the reasons why we launched the global health security agenda as not only a substantive agenda about a political one as well. so, i'm going to focus most of my remarks on that, starting in 2011 president obama said we must come together. by this he meant not just other nations but also across the government so bringing together colleagues like my great colleague from across the u.s. government and now colleagues from all over the world from the department of defense, from the foreign affairs, from usaid and other agencies to the public health ministries. this is a mission that cannot be done by one country or one agency alone. it really has to be a group and it has to be synergistic and it has to be organized and all of those things make health systems strengthening of the global health security incredibly difficult but incredibly

important. so, we launched the agenda with 29 other countries and i will talk a little bit more about that in a minute. but we launched in february of this year before the first cases that were reported and we have been speaking about this not just within the u.s. government but with who and colleagues around the world for quite some time. how do you make this issue something that is palatable and as president obama has now said recently about the epidemic this is a national security priority. it's a public health priority but it's a security. is it, what is the proper vision? our vision is pretty ambitious, but i think it's the right vision and that is to obtain the world that is safe and secure from the global health posed by the infectious diseases. so you're not going to end outbreaks but what we would like to do is prevent them from

becoming epidemics. so, we need to put in place the mechanisms that are needed to do that around the world. when we launched the agenda in february on but then secretary sebelius of the health and human services, secretary kerry and the president for homeland security and counterterrorism they also put out the administration's vision for this agenda. and i'm going to read it because it is operational and i will tell you that when we released it and when i was talking about this with people in the february there was a lot of that aspirational. if you look at what is happening now i think it actually reads a little bit differently then it did then. new diseases are inevitable but in the 21st century, we have the tools to greatly reduce the threat posed by the global epidemics. we can put in place a safe, secure, interoperable system to prevent the disease threats,

detect outbreaks in real-time and share information and expertise to respond effectively. this is the vision. if we could do this we wouldn't see what is happening right now in west africa. and this is the vision that we need to get to. so, i don't actually have to answer this question anymore and that's and the slide reflects that it was made many months ago. so why the global health security is no longer a question that needs to be answered as many and that is unfortunate because it can epidemic of this magnitude to get to that point. obviously, we are interconnected. and obviously this is no one nation's responsibility to the international health regulations harsh and back -- hearken back to what we talked about earlier today on the panel briefly. i think it's important that the devastation in life but also the economic consequences of sars in

four months. if you look at the investment flowing into ebola and the need for significantly more investments because the gap is enormous and what we need to do, you look again at what the value of the response on the front end is versus what we will be paying for on the backend and lives lost into the and the economic and peace and security consequences as well. the ihr i'm preaching to the choir for this but they were put in place after the epidemic and in 2005 to really put together the core capacity to the countries would need to be able to effectively prevent, detect and respond to outbreaks before they become epidemics. and the ihr is wonderful because every country that is on the planet that is a member has the responsibility of implementing them, that it's very difficult

to have resources for all of the capacities across the board. and as the doctor mentioned actually synergize them across the pillars in the non- diseased manner and to seek funding to do that is also a difficult challenge. so, they've been successful but in 2012 only 20% of the countries, less than 20% of the countries where able to report that they admit them which means he% of the presented the countries in 2012 were not prepared. and i think that was a huge wake-up call for us and many other countries around the world and it was directly linked to the global health security agenda. so, before i show a slide of what the agenda actually is i will say what it is meant to do. it is meant to basically discuss and identify three basic risk. risks posed by the emerging threats, drug resistance and the intentional creation into the intentional creation of the organisms and the bioterrorism. it's supposed to address the

opportunities. right now we have enormous societal commitment. i think that has grown tremendously since this site was conceived back in february. this is the slightest over from him and it is the best one in the back. we have a lot of models out there for how to build good global health security capacity. one of the challenges of supporting those models and replicating the models in an organized way that is not piecemeal so the countries actually end up with a capability capability at the end of it that is the sustainable and exercisable. and that's been difficult. measurable has been very difficult for the ihr. into s. preventing where possible, detecting rapidly and responding effectively. so the agenda itself is much nicer looking online and very difficult to fit into the slide and be able to read so i made a rather ugly slides that you could actually read the words. but in a sense, it capitalizes on everything that is part of what relates to the infectious

disease. so recognizing that it does look at the chemical and radiological threats into the agenda does not. that's related to the infectious disease threats the agenda doesn't include all of the elements in support of implementing but also importantly the performance of the veterinary services pathway of the world organization for animal health. it also includes areas that have been a huge priority but are not included in the speedy 11 prominently such as countering the antibiotic resistant bacteria and another issue that is of huge importance to the administration in which we also announced a large effort on earlier this month. so, also when we announced the agenda in february, we put forward this plan as a way to not only say exactly what we want to achieve in layman's terms but to elevate this issue with other countries and so if you look at the foreign ministers of the national

security advisers, this threat is currently at the top of the list because there is an epidemic going on but that is usually not the case and if you look passed over the last decade it is very hard to keep this on the front burner. it's hard to feel the economic consequences unless you are actually in the middle of it. we are currently in the middle of that and everyone is feeling the consequences, not the least of which every affected country who is dealing with this untold lives and economic consequences. but keeping this has national security parody since sars has been very difficult so how can we capitalize on that by using language it by using language that the leaders understand and target and effective measures that can actually be devised by the countries to show that they are achieving success and measured externally by others which is another thing that steve levin has not typically included overtime.

so we launched a target for ourselves and published, and these are available online, the 12 targets for our own efforts to improve the capacity in at least 30 countries over the next five years and the targets are not going to go through because they are incredibly long lists but they were put in place with a lot of consultations from experts across the u.s. government into taking this into account scientific literature and implementation studies that have been done over time and we also wanted to choose things that were measurable so i would encourage those of you interested in this to take a look. next step so as mentioned earlier, friday we are bringing together countries at the white house. we have had seven months of work that has gone on since february with an incredible amount of work and leadership around the world. we've had to development

meetings one who stood in finland and one in indonesia that has more than 200 participants and we are bringing the countries to the white house on friday with international organizations, the director generals. we have the united nations and the goal is to highlight the progress that's been made. we have a tremendous number of new commitments and every country invited was asked to bring one for the event. president obama will participate in that event come and the goal is to spur action to prevent this from happening again we will be looking forward in the sustainable mechanism to keep this going over the next several years and without taking away from the leaders who will most certainly be making statements about these in the coming days i would watch this because we are very much interested in how we will take this model forward and

most important for this group how the non- governmental and academic sector and the young leaders of the united states and the planet can take part. the epidemic has garnered a tremendous amount of interest in the academic leaders community. and i think that is another thing that georgetown has taken a leadership role and we are looking forward to how that can be capitalized on to build this agenda and also provide great assets to the immediate response. just in closing i would say that the last thing it is difficult to book a spoof on the short-term immediate response which is overwhelming at paramount while also looking at what we need to do for the future. i think it is critically important and i would like to close by using a quote from our president from last week where he talked about the immediate response but if you read what he said which was on the slide and if you read a little bit further in that speech, the president

himself is focused on the future and i think that we have to be because the message here is that we can do this. we have the tools for the national security threat and many other threats are less tractable than this one that we have to be able to mobilize together and organize in a systematic way to do it. [applause] thank you very much doctor cameron. we have just about four minutes left for questions, some of which you have submitted it to me now. i think doctor cameron is going to have to return to her place of work, however i was wondering if you wouldn't mind just joining me out here for a few minutes and one or two questions

go ahead and transition to the panel. again, in the interest of time i was wondering if you'd be willing to expand a little bit on what you have already mentioned but in more detail with being a catalyst for helping to bring new vaccines, medications, devices that are safe and effective to the market particularly now in this context of ebola in west africa and the international community responds. if you are going to geneva perhaps you have been there not that long ago. in terms of clinical trials for the vaccines or treatments where

the drugs were antibodies can you just in general terms without referring to anything proprietary of course talk about is there a precedent for this type of international response during the public health emergency and if not how do you see looking with international partners and regulatory and otherwise for a response to ebola in west africa. >> is it on in the back >> there is precedence for this scale that would have to respond has been somewhat different of course because of the unique characteristics of this outbreak and also because of where we are today at the fda. five years ago, the president

launched the initiative that provided additional resources to be able to more effectively engage to the resources and added to the scientific it to the scientific program specifically to address these types of issues. so come as a result for example in the area of diagnostics we have a long-standing collaboration in the department of defense, and we have been engaged with them and getting ready the diagnostics for passages such as ebola that are very difficult to validate in the absence of disease because usually these are the foundations of the requirement of the actual disease. because we were -- we had readied all of this work we were able to in a matter of days authorized the use of the test for emergency use and this diagnostic test correctly used not only overseas but also in

the response network to end a patient's come back from affected countries and there would be a suspicion that has been authorized for use of the emergency that is being used. as a comic that is just one example that it's not just the emergency response, but there's a lot of activity that happens even before the emergency. and the same thing with the developers for the products. in addition to the regulatory review, an expert in the review and helping them to ready the applications we have incentives that we can make use out of to speed the development as well as some financial incentive. so we have designated one of the companies, one of the products for the drug designation that provides economic incentives for them and the additional resources for clinical testing as well as if they get the credit approved or have it

extended over the perco of exclusivity for the companies to engage in the therapeutics. so come it is a multifaceted response. and again, we will look at every possible way to engage with the developers to speed up development and to the development and to facilitate access to the products for the emergency. >> we have about two more minutes. one question that we have for doctor bump to expand on what you already talked about. you mentioned in the past and there is a there is a focus on this sleeping sickness and now there is a focus on one disease, ebola. but can you comment on how the response to the ebola epidemic is going on now in terms of health care systems and how it might be approached in a more optimal manner in terms of not

only responding to the ebola crisis that we have right now, but england forward in terms of trying to strengthen the health care system across the countries impacted by ebola and i hope that this will lead into the next two panels in the morning as well. >> that is a great question and it's one that is hard to operationalize. it's easy to imagine what a single intervention should look like and it is easy to feel the heat and a crisis. so, in this case to make a clinical example, this is like someone in the midst of a heart attack thinking about how they should really exercise. welcome of those are going to kill you even if you get over this, so even though it is challenging to conceptualize what it is going to look like the obstacles here certainly begin with trying to put out this fire. the ebola is deadly. in this case a 50% mortality.

so, we really need to step up as we are stepping up to me to think about what are the underlining systems. as, where is the old workforce? are or the supplied come they supplied, or the numerous enough? then we have to ask where do they get health information. what is their interface with the government to actually trust the government? the underpinning includes the technical and the moral as well as the political. so, we have the most promising and most attractive approaches in the first world usually just think about the second goal trade so we need to do that and that is the basis of our response but then many to think about what are the political systems into the decision-making process that we can use to set the priorities to manage implementation, and then what are the moral things like what are the that are the choices, what are the trade-offs of one disease versus another those are not things that should be done in washington. they should be done by the people. thanks.

>> thank you all so much for joining us this morning. we are thrilled to have such a great turnout. this is the first panel of the ebola symposium this morning. this one is giving you some sort of historical, social, cultural and political economic context for the reasons behind the devastating ebola crisis in west africa. we had a little bit different perspective this morning. we have a political scientist from a health economist and political anthropologist. so let me first introduce the panelists and then we will begin. first, welcome to the assistant professor of anthropology and african studies at the university of florida. he studied the last sector of west sector of the african humanitarian response for the last decade. she's the author of the recently published book entitled

searching for normal in the wake of the life. -- liberian war. doctor scott taylor in the school of foreign service and the director of african studies program, doctor taylor research focuses on the political economy with particular emphasis on the business state relations, private sector development, governance and political and economic reform. finally we have doctor james who joins us from the school of public policy here at georgetown university. the research interests are in development economics and political economies with particular interest in the constraints to health as well as health policy. he also brings insider knowledge to the panel as he was in uganda during the ebola outbreak in 2007. before we begin the discussion among the panelists, i'm going to pose a question to each of the panelists to give some

context into their particular perspective beginning with doctor who,. you've been studying the health sector and west african humanitarian response for over a decade. this means conducting use of fieldwork in the region including the region of guinea. the first epicenter of the outbreak. and then in the affected regions of liberia. can you provide a context for what it is about the situation in liberia specifically that has made this crisis gets so bad so quickly? >> thank you for having me. it is an honor to be here and i applaud the efforts of everybody in this audience to put together an academic and governmental response as quickly as possible. as a cultural anthropologist i would like to start off with a story. and this is coming from a friend of liberia that was released in late july, 2014.

during the visit to a family of orphans, three little boys come a health care worker was chased away by the orphans on goal. but before she was chased up a was just a victim of the uncle explained to the health care worker but their mother had contracted ebola from there and who had died. another showed signs of ebola, the family called a widely advertised hotline at the ministry of health for several days. if no one came to take her to the treatment units. they called and called. finally after a few days of burial they came to take her away. soon after, the father becomes a dramatic. a few days later they came and took away the body. the uncle noted the early signs among the children and said to the health care worker the minister for health care is more for the dead and for the living.

it happens to be a fact in the early days of the epidemic for the social worker in liberia worked with the token indications companies in liberia to set up a phone bank of 24 land mines so they could respond to phone calls related to the epidemic. but on friday i was having a conversation with the officials of the social welfare and they said the problem is that the phones are ringing but nobody is answering the phones. why not? why is there a disjuncture between people calling and people not answering the phone. this is a different kind of story than that we are hearing in the media. and in order to understand the story, and you need to have an understanding of the character and a little bit of its history. it's important to understand that the liberian health factor was in the 1980s not just as a result of the capital withdrawal

by the government, but also as a result of the political violence. in 1985 and 1990 was the concern of the vertical violence against the intellectual elite in liberia. as the 1990s the civil war broke out into the entire liberian health sector fell into a state of collapse. during the 1990s and well into the early 2000's most of the health care that was divided the population was provided almost entirely by the international community. and in 2003 when the civil war came to an civil war came to an end, the liberian population was widely accustomed to slowly receiving health care from the ngos like doctors without borders. between the period of 2003 and 2005 from humanitarian organizations continue to provide healthcare to the entire population at the same time that the settlement effort was underway from the refugee camps in guinea, sierra leone.

the international community at the time was effectively running the entire liberian health sector. it's one of the most interesting underrecognized stories of the humanitarian assistance that has happened in the last decade. between the period of 2006 and 2007 and international humanitarian organizations independently stood to make decisions to close down hospitals and leave or shut down clinics in the chain commission very rapidly without consulting the health and social welfare. the international response organization became very, very afraid and the social of the social welfare became very afraid because this was the entire health sector. this was the entire safety net. and a team of international partners including the united states came together in early 2007 to advise the plan to

manage the transition of the health sector for the humanitarianism to develop it. and what was put into place is the set of structures to establish the liberian health sectors that would be more robust. let me give you more perspective on this. it's about the dollars. about $200 million is being spent on healthcare. of that, roughly 80% is being spent by the international community. the liberian minister of social welfare is covering 15 to 20% of that and it is entirely going to the civil servant salaries. so, when we are talking about the liberian health sector and i believe that this is also true to a certain extent we are also talking about a health sector that we have built in the international community with our tax dollars into charitable contributions. these are our health sectors.

the goal was to sustain an international level of commitment to developing the liberian health sector while giving the minister of health and social welfare the ability to set a strategic priority and to bring all of the disparate organizations under the authority and the direction of the state. the plan to do very well and one of the things they did very well is it sustained the strong leadership at the very top of the system and also invested very heavily on primary health workers. there is a tremendous amount of training that went into the nurses and doctors at the bottom level. it's the middle where the surveillance happens. it's the middle where the epidemic response happens.

it's the middle where the interstate coordination happens when emergency arises so during this period i would say it's fair to say that there are few canaries in the coal mine. for example the international community was working closely with the ministry of health and social welfare and one with one with a say in the advisory capacity but also not exactly in the advisory capacity in the predominant contradictions to the health sector itself during this time on an annual basis when it's safe to say in a country like liberia is it true for sierra leone and guinea as well, the epidemics are in the neck.

under the systems that were put into place, it was deemed to be not ideal but acceptable for local pop-ups of epidemics to be identified by the voluntary nongovernment organizations of primary health care. the response was relatively quick and it was sort of coordinated and it was to be an acceptable step towards the epidemic response. nobody anticipated the fact that an academic was going to pop up, but the cause of the epidemic is that we were depending on the sort of pop-ups in order to detect the presence of the epidemic and when the epidemic popped up, it wasn't recognized for what it was until it was a bit too late and it also really wasn't recognized for where it was. and when it first popped up, it

is in a rural area but the area is nowhere near as remote or rural as the area would believe. it's popped up in the village near the trunk road traveled independent branches that lead to sierra leone and then travels down to the county that is north of liberia and it takes you directly on an urbanized road into the capital. it was also his recognized the nature of the settlement in the countries. right now in liberia there are about 4.3 million people approximately 2.1 million people are living in urban areas and almost all of those urban areas are on the road. that road is highly trafficked and it is the central commercial artery that linked together to sierra leone, and even extends

off into the northwest. it is a missed opportunity to stop an epidemic traveling along basically one or two roads. as it turns out because of the absence of the health structure that could do the bio surveillance, all three of the countries were entirely dependent on the world health organization to do this kind of work. and the world health organization is doing this kind of work work on a state-by-state basis, so they thought they had the problem solved they kind of shut down the operations or at least forecasted the idea that they were going to shut down the operation and failed to recognize the interregional networks and commerce that was going to spread the f. at the neck and turn it into the plague that it has become. am i running out out of time? >> this is a good transition

actually. liberia and sierra leone ostensibly have been under the international community for more than a decade with regard to the health sector. while they have reconstituted after the civil war. so if we are talking about the governance and government and the state capacity to intervene in the context, with the already strong international support can you give a perspective on why are the states getting blamed for failure to effectively respond to the crisis? >> i'm trying to keep my chair from collapsing. first we need to look at the question about who is doing the blaming. on the one hand, you see the increased numbers of the reports of people in various areas in each of the three countries. and in some ways appropriately blaming the government for the lack of response and also directed at things in the international community.

but if we focus first on the level of looking at their own, looking toward their own government and seeing if there is an interesting piece in the "washington post" is just over the weekend about the total shuts down of the health facilities in liberia for example for example and there were a couple of quotes that jumped out to me we blame the government. why hasn't the government looked at healthcare and not just at the ebola but other healthcare concerns that traditionally should be addressed in the healthcare system and the issues that we talked about earlier. so this direction of blame at the government level from locals to government is partly a result of ten years of democratic rule in liberia and sierra leone

where you have seen some improvements in various aspects, but not enough. and you've seen in the recent years in liberia and sierra leone considerable growth, but not significant poverty reduction and so on so you might have the revolution of the rising expectation among the increasing participatory chair at least in those two countries. in all three, you have the continued context of the leftover leftover indian liberia and sierra leone and in the cases from approach wreck civil conflicts. and more recently since about 2008, the very unsettled political situation in that country. so there is a sense in general in liberia and sierra leone that they should stand up to some of

the challenges after the democratic rule and a modicum of economic growth. at the same time as you look at the political and economic inheritance of the current governments, there are democratic regimes now in place inherited and broken economies into the dysfunctional economies which function of political systems and essentially built from scratch out of this many years of civil war and conflict and we are talking about 500,000 in each country, 50,000 deaths or so in sierra leone, 250,000 in liberia and there are

long-term civil conflicts that have much of the 1990s while the rest of africa was going through a democratic transition and then in moments certainly in sierra leone and liberia it was substantially delayed until 2002 and 2003 respectively. ginny of course goes through the more recent political upheavals with the authoritarian of 2008 and so it has continued politically to struggle with periodic peoples in the last several years. as we are talking about the unsettled context of the massive rebuilding efforts and so, you've got this odd juxtaposition of the rising expectations and at the same time the state capacity is still incredibly limited.

so, the 2008 article notes for example that war-torn country's experience as they call it development in readers and they estimate that at the national level the loss of economic growth induced by the civil war amasses 2.2% for each year of the conflict. but moreover, the cost could keep accumulating so they estimate that it takes 14 years under the typical circumstances to reach the counterfactual gdp that they would have achieved absent the war. so we can see this kind of scenario unfolding in liberia and sierra leone by these protracted conflicts that although result and each of them certainly liberia and sierra leone that grew on a gdp basis that said something like 14%

last year and it actually has a pretty impressive growth rate. liberia also has 110% and consistently averaging five or 6% over the last decade. we are broadly familiar with the outlines of the conflicts and the acumen but these are the state of political economies so that the remarkable growth rate shop near those examples. mozambique was also held as one of the fastest growing countries in the world but from an incredibly low base that it's taken a generation to begin to rebuild that. we are looking at the list of gdp per capita on the continent and in the world among the lowest in the human development

index and all these other socioeconomic political indicators these countries will fall very low on the international metrics. so these are the areas of great concern that suggested the challenges of rebuilding and we were just talking about these trunk roads and to sort of do traveling of ebola from the countries down particularly towards liberia does most of the infrastructure of liberia is not that good. so the situation where the service is a very difficult to deliver some of the reconstruction is very

difficult. so let me just end they are just the idea of trying to reconstitute the policies from the ground up and only a decade is enormous. the challenges are enormous about it and so than to be -- for these very fragile economies to be confronted with such a devastating crisis, the evidence is clear that it is ill-equipped to handle it raises questions and people blaming the state and the community. we should not have expected i think the states to be able to

respond given that the legacy that they have inherited, the international community response which is something that we are talking about is another thing entirely. and i think a lot of the blame if you will is more appropriately leveled there in terms of being so late to see the response in the international community now. it's late in the day. but these countries are going to need it. but at this point they haven't really gotten the healthcare needs but from the complete development what is structured on the development and could you speak to us about the social and cultural challenges surrounding

the epidemic which is new in west africa. it's been an epidemic that we have observed over the last decade and throughout africa but what's new about it is that it's an illness it is an illness people haven't seen and they don't necessarily fully understand all of the messages coming from every which way. ..

and just as we landed my wife and i had a 6-month-old boy and the first order of business was to attend a wedding. my wife's brother was getting married. literally the day we arrived and there was an ebola outbreak about 200 miles west of the capital city. and what was quite surprising and what was frightening for us and all the grandparents and relatives want to hold the baby and we don't know enough about

how the disease is spread. we are quite concerned about how we would deal with this. we didn't want to upset anybody. the president that morning made a statement saying people should stop shaking hands. no handshakes. the way to greet was to wave and i was very surprised at a wedding where people were running into each other for the first time. they hug and people were actually amazing. in fact quite respectful not to ask to hold the baby. so, that in some ways was quite surprising. now maybe what may have been different about uganda is uganda had of course experienced a

pretty severe ebola epidemic about seven years before that that had been quite devastating. so in some ways the totality rate was 50% in three different regions of the country. so there were some familiarity and of course we share up border with the, and the region in sudan there have been frequent outbreaks that were in some ways quite familiar. i think they're something about a new disease that makes it a little bit easier, little bit more challenging for both individuals to learn about what it is and what they have to do as well as the response. you know i would like to sort of add a little bit to what sharon said earlier. in some ways if you think about the hiv epidemic when it first broke in southern africa, it was quite a challenge for the government didn't help itself by taking a particular position

much later. but there were people who certainly had doubts about whether this was a real disease. there were tons of conspiracy theories and we have certainly read quite a lot of the press of people thinking this is not really what people are saying it is and how they should respond. in some ways when i first came to this panel that was my initial sort of stance was that this is in some ways about learning about a disease, learning both from the household level how individuals deal with it and how different it is but also the health system in general. we know these health systems are very weak. a lot of the work i do is in eastern and southern africa. in some ways the state is in the same difficult condition that scott talked about but they are also very weak. they have lots of problems in dealing with basic public health issues. but the story that sharon just

gave about the hotlines in some ways reminds me of the challenges of the health system at least in the places that i'm very familiar with. the brain drain cannot explain the fact that there are people on the spotlights. this is not a high-tech -- it doesn't require five years of medical school to do this. this is about managing health personnel and there is quite a little research from many parts of iraq and certainly parts we are familiar with that suggest that this is a big challenge. getting people to actually show up to do their work is quite a challenge. on any given day and at least the places i work with, 30 to 40% of health workers are not way there are supposed to be. that's not even including whether they have gloves in the facility or treatment for particular medications.

i don't know liberia and syria very well but i'm assuming things will be a bit worse in that context. i think it makes it really hard for the system to respond to something like this when you don't have people in place. it certainly doesn't help households who don't trust that they will get the care they need if they can't get the response on the phone and it makes it very hard. people will only go to the hospital when they are really really sick after they have likely spread the disease to lots of different people. i thought this was about learning about households and communities learning about a disease but the story about 20 for hotlines that i'm in suggest to me there are lots of other things and a lot of them have to do with the basic matter of health care. you don't need a lot of donor dollars to get people to show up to answer the phone. >> interview paul farmer did

recently, he emphasized the need for staff systems i think that's a pretty good thing to talk about, the things that are are really the hardest elevating systems and providing care for people who are suffering, people and their families are suffering from ebola. i would like to open this question to all of you to discuss what type of state international relationship needs to be in place to respond to this crisis and how do we get staffing systems in place? >> i can start with one proposition and i would treating local health care workers as they are the frontline of an international response which would mean providing them with the same kind of care protections that we provide to international staff. as many people in this audience no health care workers are among the most affected by the ebola virus. their mortality rate is much higher than many others.

they are heroically and valiantly showing up at clinics every day with insufficient resources and insufficient materials and insufficient support in order to just provide minimal care to people who are braving their way through. they are getting sick and they are dying. it was a notorious embarrassment to the international community when a senior doctor in sierra leone requested evacuation after he showed signs of symptoms of the bowl and he was denied permission and he died. he was not the only one who's been in that situation. we have heard a lot more about controversies about whether or not local health care workers have access to see map and other experimental therapies but what we really haven't had a strong discussion about is whether or not we claim these health care workers has as their own and we provide them with the kind of therapeutic support that they might need when they contract the illness and they most certainly are. i think that would be one step.

>> just to repeat all the things we have been talking about this morning about these countries simply can't do this without an enormous international response. we are starting to see it now. seven months or even more, eight months after the first cases and more than two months after after we already declared it as a crisis. selecting the coordinated an international response in the things we are discussing this morning are to get to that staff and systems goal. >> i concur with scott but let me see if i can suggest what to staff and systems main? from males have a lot of these health systems deal biased towards treatment rather than prevention so dr. bond talked

about this earlier this morning and i think one of the challenges in trying to meet the global health security goals and objectives is that we have to invest in some ways in prevention. it doesn't help, we can generate the best technologies vaccines and other things are these crazies but if we can't get them to the people who need them then in some ways and we have a lot of evidence. we have the great technologies that deal with malaria in the great technologies that deal with their own diseases but we still have a lot of have a lot of deaths depth in the systems in this context. this is an opportunity to really focus on the way we allocate resources across prevention and treatment.

and if there's any silver lining is we might have to focus on them put money in a lot of cases. >> to add to that i think it's important to recognize that the real frontline of treatment is happening in people's homes. the virus is disproportionately affecting women who tend to be caretakers. as a mother, a daughter, a wife i can say certainly that one of my family members is quite ill with symptoms that look like ebola my first response will not be to put on protective gear and to say spam bad. there's a lovely article in slate from i believe yesterday about this. there is a lot of human caretaking that is leading to the dissemination of the virus. the international response, it needs to rethink its messaging about how to provide care for people who are showing symptoms

of the virus to recognize the fact that these people live in the context of social worlds in which people are willing to live for each other and die for each other. adaptations need to be made to her messages and strategies we are proposing they recognize people relations for care for their families and loved ones are going to come first almost every time. people's first response is family members is not to say i'm going to separate myself and send myself to a therapeutic treatment center where i may never see you again. >> and i actually asked the question? if we can say a similar social contexts exist in uganda and central africa how is it a different kind of messaging can be disseminated to families and communities in those contacts years ago thing can be disseminated through liberians?

>> i think one big difference between liberia and uganda is where the outbreaks have happened. uganda is not a highly organized society. at least five, 10 or 20 years ago there was only 10% of the population in urban areas. i think also there is also in some ways the lack of a coincidence that this outbreak in liberia happened at the confluence of these roads and it's just basically trampling down to the coast. in some ways the, there are not that many roads.

they don't generate the same level of fatalities simply because it's not an issue. >> to sharon's point about families which is perfectly understandable. in the ugandan context that the message be delivered to families that you do have to don the protective suit the protective suit horror which is comparing apples and oranges? >> i think the message at least in the crisis that i was, that i experienced i think it was simply about transmission. don't think the message was trying to direct conditional on having a family member who is ill and what do you do. i think that is a very challenging message to deal with and certainly from what i have seen of how cases have managed, i think it is very -- to tell

somebody don't touch someone, don't help them, don't clean up after them. i think that's a very typical message and i don't think uganda did anything special. i think we were just lucky that the outbreak happened very far away. >> here are some reports have been hearing where some of these answers were actually coming from the ground up. in remote areas of liberia where people don't have access to resources, most places don't have access to latex clothes for example. people have market bags, when you go to the supermarket. there are tons of plastic market bags all over. they are sort of an environmental hazard a lot of the time actually. so what family members are doing is they are putting market bags over their hands when they are handling their loved ones. i don't know how effective the solution is the something that's coming from the ground up in one

step that can be taken is turning to local populations to solve some of these problems themselves in collaboration with international public health messages. >> i thought we could pivot for a a minute to talk about nigeria. it appears the nigerian cases have been largely contained and there were cases in largo's and potentially elsewhere. could you guys speak to kind of what happened in nigeria and how that's different? >> i mean maybe i'm reverting to my discipline but i think much of what happened in nigeria thus far can be credited to an effective political response and the fact that the first infection occurred in legos rather than the other way around

after the escape of this one quarantined patients, of course there was a small outbreak there. the efficiency of legos state governance is fairly well-established. governor facella and not very auspicious conditions in legos has managed to institute an infrastructure that is certainly better by leaps and bounds than that in liberia and sierra leone and new guinea. i think that nigerians in all of us are actually fortunate to the extent that the outbreak in nigeria started there and apparently has been able to be contained. but if you look at nigerian development, nigerian infrastructure and all the criticism that nigeria gets in

the western press and indeed in the african press in this case they seem to have gotten it right. >> is quite unusual to hear the words efficiency. and i think a lot of the concerns about this outbreak becoming, getting out of control with what happened in nigeria. i concur with scott. the legos government in some ways is amongst the federal states in nigeria is clearly one of the most efficient. but i also think the timing and the nature in knowing who the index patient was and coming after essentially at least a revelation that there was something really serious going on, i think that produced the right response.

schools are only just starting. there's a big scandal, not a scandal but controversy about whether they should really be starting this week were the end of august. and people still think that they should take far more precautions. across the entire country they have been able to deal with, even import harbor where they have had a couple of cases they seem to be able to get it under control. port harbor is under legos management capacity. >> both the cases of uganda and nigeria show what a polar response looks like in strong states versus weak states. when we think about what a strong state is in the context of health sector response or public response to any perceived risk of asthma not to believe

that understanding to political will. liberians have an inordinate amount of political and what we will hear from the president very soon. they have been extremely vocal in being concerned about this response had really demanding an international response to the crisis. but what you see here is the difference between strong political will and strong political leadership versus strong institutions. it takes again that middle level of the health sector and security sector collaboration and response in order for there to be a robust epidemic response that goes below the top-level voice of support and above just that bottom level health response. >> i want want to pivot to some other questions because there are some really good questions here so let's have some time to talk about them. what specific short-term actions and long-term investments would reduce the gap identified in the middle where you noted

surveillance in interregional coronation happens. >> this is a question for me? thank you. i think that one of the conversations that has been latent about the liberian health sector in the sierra leon and guinean is a question about sovereignty. there were aggressive moves to restore health sovereignty as quickly as possible as part of the room -- after their post-conflict. today. i think one of the steps we may need to do is we may need to start differentiating health sovereignty from political sovereignty. they may need to understand that while political sovereignty is a must in the political leadership of the health sector is a must

you cannot just hand responsibility to a weak state or the responsibility for its entire health sector too early. and you really shouldn't hand over the operations of the state to a weak state too early because it will have international ramifications. if we understand health sovereignty is being something fundamentally different and we understand it's being intrinsically linked to international biosecurity, we can really rethink how we are providing support to the redevelopment of the state structures and state institutions. >> here's another question that builds on the cello they can jump into what will her into

what role or waste in the international committee leverage leadership and accountability with state actors who have a disconnect with the people? they say for example and sierra leone -- forget than $17,000 cash to do with a bullet in their communities get the sierra leone community -- let's leave it there. i'm not sure what the rest says. sorry. >> and i turn that question i've had a little bit and when i would like to do is how can we leverage local response in way that helps to address the ebola epidemic in its most robust way. one of the stories that has been missed i think in the cultural narratives coming out of the ebola epidemic is how educated these populations all our en masse international short-term responses. in the very recent historical memory of all of these populations there has been

masted mobilizations, mass political registration drives, mass vaccination campaigns all within the context of weak systems. a lot of this has been done in the context of powerful conflict reconstruction messaging that plays upon things like african solutions for african problems that valorize his local leadership in taking accountability for local populations. i think this is a real missed opportunity right now in terms of the public health messaging response to ebola. most of the current messaging campaign has been predicated on terrorizing the population and the rest of their physical health but very little that has divided the population itself to take a leadership and participating in a global response that's based upon local actions and local accountability. i think there's a lot of opportunity there in a very

short-term to kind of change the direction it's going. >> let's build another question. this comes from someone from health international. she says health essentials ar are -- to an effective ebola response to what types of intermediate and long-term investments can be made to train health workers as we are intervening in an emergency. how can we look at the long game here? how does the cultural knowledge present an act says? unicef and hae have developed a hero to connect health workers to national communities for a better response. how can we think about long-term implementation and think about taking advantage of community level interventions, community

level knowledge and i think she's saying mitigating epidemic immediately but also thinking long-term of building health systems, health networks that stay beyond ebola? >> let me see if i can take a crack at this. so i think that in some ways dealing with the immediate epidemic is clearly an issue but the training, if you go back to this staff and systems is i think the way to build the long-term capacity to deal with future issues. so i think the first question and i think the first issue that must be dealt with is one about how we allocate resources

between new hospitals in capital cities and other urban areas versus really good public health facilities in these rural communities. 10 years ago the world bank did a study of seven countries including two in africa ethiopia and uganda at the time looking at the absenteeism of health workers but also in general looking at what existed in these health facilities. it was a random sampling of the 70s, about 100 in this country and on and off visits to simply what goes on at those places. one of the strong correlations between people working in providing services was essentially the quality of the facility they dealt with so structural factors.

is there watered my facility, is my facility well stocked? those facilities tend to have people working and so stocking up these facilities is a logistical challenge. it's a governance issue when you send a bunch of gloves to some facility that they get there and they don't end up in the market in monrovia. i disagree with sharon when you have to separate political and health sovereignty. it's clearly the big things where the international committee has to play an important role. some of these things like getting stuff were supposed to be and making sure people are doing what they are supposed be doing is fundamentally a local accountability problem that in some ways parliamentarians are

the people's representatives and should be leading the charge. so i think the first step has to be trying to build health facilities very close to these communities and giving the frontline workers in these places the tools and the training. clearly dealing with ebola is very different from health care. people need the training so they have the confidence to engage and to treat patients. if you are turning people away because he was a health worker are scared, that's certainly not going to help the true threats. >> in order to leverage the knowledge and participation of the communities trust is going to be essential in partnering whether the partnerships are international actors or national

or regional actors. and indeed the establishment of trust between communities and various authority structures is going to be central. the problem is in this context where services are not being provided or declining and people are dying, what you have is just trust levels are actually rising. so in order to engage the communities it seems to me the first thing that needs to be done is to try to establish, reestablish trust with this community. that's going to be exceedingly difficult. >> i'm going to pose one very specific question to doctor of rama waits and that i'm going to give each panelist at time to give concluding thoughts. we have a little bit of extra time so i'm going to take

advantage of it. first there are a lot of questions that make me understand that people are wondering what does it mean to have the health response and who are these different people? i was wondering if professor a promo blitz could speak to the liberian situation of who is who on the ground and how does it work together? >> sure. if i can add one narrative that just came out of somebody who's working at the liberian ministry of health last week and he wrote a note to a colleague of mine that i was talking to this weekend. he said just this past friday a man to contract with ebola had search for hospital bed and he traveled to every treatment center in morobe. in each one he was turned away for lack of a bed. he then used public transportation to go to the ministry of health and social where -- welfare. he begged for assistance and he waited three hours for somebody to try to help him until he was

told that no one could find a bed for him and there was nowhere for them to go. finally he left and a health worker who is writing worker who was writing the message went on to note that either he went back home to seek the care of his family or went off to face a bola alone so as to prevent the spread of the infection to his loved ones. nobody knows where he went three to swap out. we are asking questions about who the health workers are in the is fairly straightforward. the chu primary line of health care which is to the health care that happens in the home. physicians assistants and nurses and doctors providing clinical treatment either in primary care care facilities many of which are overwhelmed or shut down and then what else is there? the answer is when we are asking health care workers to somehow be more responsive the question is in what way? if you have people who are coming to you seeking some sort of support and there is no beds

and they are being turned away and they come to the national ministry of health and social work welfare and no one has anything to offer them. they are allowed to stand there until they find relief, what exactly is it that we are asking these people to do? their response is about as good as a combat boot -- possibly get. they are at capacity and there are no more bids. the united states announced last week we are going to be going in and training 500 health care workers a week to provide services. what does that mean exactly? does that mean willfully be providing local support services? we also announce we will be building 16 or 17 therapeutic treatment facilities for each county in liberia. i suppose that means there will be supportive treatment provided there. i don't want to overstate the case that this is in some ways

just a problem of human resources. i believe many people on the ground are both willing and eager to obtain treatment and many people are willing and eager to provide treatment. >> what is the treatment look like? both at the community and state level and urban and rural areas. can you provide a description? >> it's largely supportive treatment. largely rehydration and the treatment of opportunistic infections that people can allow their immune systems to develop some sort of antibody response to fight off the elements. >> for example they have set up camp in several rural areas and they are kind of makeshift clinics that are containing cases and caring for these people. >> that's. >> that's right and the kinds of care they are providing our supportive care. essentially rehydration and the treatment of opportunistic

infections. >> apart from msf and humanitarian responses who is running the clinic's? >> ngos. >> local ngos? >> that's a complex question. it's a large area and a lot of people are involved in the response. someone else on the panel me know. >> these are questions coming from the audience. >> i also want to add that in the absence of additional answers local populations are seeking solutions for themselves. i heard last week reports that there is an emerging black market in survivors of blood that people are distributing it to others. that also raises some public health issues as well. it's important to be mindful of the local solutions to local problems that people are

generating in order to anticipate other issues that may arise. >> would you expect to take some time to give some concluding comments? >> let me just say quickly most of my research follows probably into what people would describe i think not quite accurately as the africa rising narrative but nonetheless it's mainly focused on the advances that africa has made in political and economic development over the last 15 years. in a 1 cents africa rising narrative what's wrong with it is it's always been to general. this has all of africa is rising and we certainly know that's not true. my fear about the ebola narrative is that is now becoming a metanarrative for all of africa if you will. we see this in everything from the trivial cancellations of safaris in kenya to the closing

of borders to the south african response to even researcher colleagues who have canceled trips to southern africa because they are afraid of ebola. you know i think that this is -- borders on hysteria actually. that kind of first bonds is negative certainly for this large a -- larger african rising narrative but it's also unrealistic. as we talk about this very important disease and this debilitating crisis particularly in these countries we should not lose sight of the fact that this is not all of africa that we are talking about. i'm preaching to the choir somewhat with this audience but i was shocked to find one of my researcher colleagues who was supporting zambia because of ebola.

i think that just shows the value of forums like this to share information that come to grips with the scope of this disease in some ways in which we can combat it. but not to lose sight of the fact that, and thankfully so, this is largely a disease of a particular region at the moment that is hopefully going to be contained or will be contained and that the response, this is not simply an africa problem that becomes the dominant narrative for africa but rather it's a global problem and need school to responses and to bear in mind this realistic view about what's happening in the rest of the continent. so thanks. >> i want to address two issues if i may or point your directions into place at the same time. the first thing, i think one thing we want to keep our eye on what this whole crisis is

unfolding unfolding is unfolding is the think we need to be mindful of destabilization. these populations have shown extraordinary resilience in extreme circumstances up to the present of that kind of resilience is not undoable. i think where we are starting to see a real risk of breaking down population resilience is in the area food security. as a result of the ebola crisis people, families are hoarding food. people who sell food or hoarding food. there are starting to be price-gouging that's taking place. the costs have doubled and areas that are under quarantine will require ongoing food supply for a long period of time. you may not see by large-scale violent response to a bolo or to

the response to that but you will see a response to hunger. i think that is where social breakdown stands the risk of happening so we need to be very aware of that. i also want to highlight the fact that i have been, i'm very hopeful that integrating a socio- cultural aspect into public health and medical responses could have a really powerful effects on containing the epidemic outbreak. thus far there has not been a significant outreach to political scientist economists are anthropologists in order to really understand the local factors underlying people's responses to the public health and medical aspects. that needs to be taken up much more loudly and much more quickly and at the highest level the highest levels as soon as possible in order for there to be a robust integration of socio- culture factors into the response.

it will pay i would say compounding dividends in terms of containing the crisis and hopefully bringing it to its end. >> i would like to build up on charles comment on communication. some of the other work that i am involved in one of the things we have realized this public health messaging tends to be boring. the simple imperatives like drive safely, speed kills and in some ways i can make sense of this and think carefully about how people approach these kinds of messages and what the response is. if we get that right that's much much cheaper than vaccines. the other thing i would like to add on is in some ways what jesse was talking about earlier this morning. in some ways become the best of health systems because it's hard to figure out what the benefits are.

the costs are large. the costs are quite large. in some ways if there's any good thing that can come out of this tragic crisis i hope it is that we will not just simply take the president's position that we are going to go in and provide immediate relief for the crisis in liberia, build more hospitals and provide training. that's great and we need that right now but what we need for the future is in some ways to increase the effectiveness of every dollar we spend and health systems to really strengthen those health systems. it doesn't matter how good the technology we generate maybe if we can't reach the people who have these problems. in some ways hopefully this may

be the call to action to make a boring but high long-term return investment in health systems. >> thank you all and thank you all all for stinkers panel. >> good morning everybody. i'm the director of the ebola program here at georgetown and a longtime economic adviser to president sir leaf and others in the government of liberia. i think we are ready to go. i know we have a connection. there we are. good afternoon madam president. thank you very much for taking the time to be with us here this morning in georgetown. we have a crowd of a couple other people here that are very appreciative of you taking the time to join us today. first i just want to thank you for taking the time to be with us this morning.

>> good afternoon steve. i'm very happy to be here. >> we know that your time is very short. >> good morning. i say good afternoon and i corrected myself because i know it's morning for you. >> that's all right. we know you're time is very short and we just wanted to ask you a couple of questions on how the status of the current situation where you see things going. first kenny just give give us an update on the current status of the epidemic and the outlines of your strategy in the weeks ahead to begin or to continue to battle the epidemic? >> steve the epidemic continues to be a serious situation. 13 of 15 political subdivisions are now called response counti counties. we have over 1500 people dead,

85 of whom are professional oral regular health care workers. we have four major ebola to me in its serving the country where all marsh work is being done to be able to build more on the ground. we still have lots of people in the communities that based upon conditions are still in denial or still using methods of care whether it's going to the church are going to the mosque or believing in some extraordinary magical way of beating the disease. we still have people again based upon our culture of extended family that are not ready to

turn their loved ones and even when they see signs of the disease. we are starting to build more e.t. use. we are starting to get a bit more robust in our community work to enable them to take ownership to understand awareness among them. their predictions are recently came out from cdc that are very horrendous and scary to all of us. if nothing is done at this point in time we do believe we have our structures in place and now we have our strategy. our strategy is to make sure we have the ability to get the -- where they can get early treatment and we have been successful steve.

they have been treated and walked away up to get them at an early stage. those efforts are another way and we are very glad with the robust response. that's going to make a major difference in our efforts. the cdc wants all the nations to put in place in terms of facilities, resources, treatment, awareness that is epidemic and decline as fast as it accelerates. that is their objective to get there. >> thank you. you mention they ramped up u.s. efforts. last week president obama announced a major new effort that would involve 3000 u.s. troops, several hundred beds in field hospitals.

i believe 17 field hospitals with a hundred beds each supplies 500 health care workers a week. can you tell us more about your response to that ramped up effort, it is sufficient and would you believe you will begin to see the impact on the ground? >> we first of all have expressed extreme gratitude to president obama in the united states for this effort. it's major. we are to have perceived brigadier general williams who is heading a team. he's here and he's been around to do an assessment of the centers. he has participated in structures and strategies. we have brigadier general rodriguez coming in from germany on friday was going to begin discussing with general williams and others how they can accelerate the effort but these

things do take time. building e.t. is going to take several days. even the hospital that was promised we have done the initial assessment that is going to take time to get that done. this epidemic moves so fast that is where building the facilities to accommodate them people have died. dying by the hundreds every day. it's a question of when can we get this acceleration? i believe given another couple of weeks we will see this major effort begins to show results. >> thank you madam president. he also mentions some of the difficulties communicating directly to the citizens of liberia around the seriousness of the epidemic, the accuracy of the claims of what ebola is and does not, some of the difficulties around cultural practices, around aerial and

other things. what's your strategy to begin to address that and to get the communication out and the education necessary for people to better understand the epidemic? >> we have got to get right into the communities at the grassroots level and we have got to use a military residence, people who can speak the dialect, people who know the culture, people who live with them a man whom they trust completely. this is an unknown enemy. anybody coming from outside even if you are with best intention trying to teach them they act suspicious because they don't know. getting good at the community level with the young people in community and the preachers and community, the teachers and community. that's the only way we can break

through the denial and the fear. >> beyond or in addition to the direct impact on people affected by ebola itself, what's the situation with the rest of the health care system and people who are looking for care and treatment on blue area, tuberculosis and other kinds of ongoing health problems? >> we have the a health care system that is in stress. it was not a perfect one anyway given the fact that we have lots of infrastructure problems, getting people to hospitals and clinics. it's a difficult one given the conditions but now with 85 health workers having died because they didn't know how to protect themselves many of them

have walked off the job and refuse to go back. as a result most of our health facilities are not -- [inaudible] what this means is lots of people who don't have ebola are dying and so the numbers include many that are not ebola victims but who died because they could not access the health center because those stores are closed or it's nonfunctional. what this means is we run the risk and some reversals of the gains we have made in the health care system. we have been doing great. we have made the best progress of countries. we are doing well and the malaria declined. the chances of all of those being workers is very high if we

can quickly get those facilities functioning again. i must say that this has received attention of partners. the uss well and so far we are treating ebola. we want to make sure that we get our health centers functioning again for regular health care and i do believe as a result of this is a positive thing. >> have you stopped in terms of growth and probably contractin

contracting -- i know they shine again in iron ore mine has closed its operations along with the palm oil plantation work is stopped in restaurants and hotels are closing down. construction activity is way down. what is your sense of the economic impact and where is it the most severe? how do you see that rebounding in the future? >> the economic impact is severe. the operations as you pointed out of concessions, contracts on our infrastructure. all of those have stopped or slowed. we know that there's going to be a price increase as a result of shipping costs and who's coming

to library and going out out. there will be loss of jobs because of the close of business and hotels and entertainment centers is going to decline because general economic activity is result of so many people with high purchasing power having left the country. we know that put this all will mean it is per-capita income will also fall. but let me say that we are working hard on medikids to address this decline. we believe there's a potential to stimulate the other sectors of economy the economy that have not been very high in production such as our fishing business but areas that we are looking at. also we are going to get some help from the world bank and from the african bank to be able

to hold these activities. there are many people that are coming into the country. there'll be some restoration of purchasing power through the thousands that are coming as health care workers or technical assistance or even a u.s. military and people that come out in a small way. someone of that gap exists because of this decline so we are looking at this. i'm glad that the secretary of africa sending a team to work with us on this and what measures we can take to stimulate those other sectors that have the potential to make up for some of the slow. some of them we are still tracking. maybe i'm not the at the same level but they have started to operate and if we can show a decline in ebola within the next month or so we expect it to return but there will be a

long-lasting effects that will reduce the growth rate and we will see some income -- [inaudible] [inaudible] >> you know weeks and months of what more can the international community do in terms of the direct impact on the bowl bowl itself and health systems for bradley in the economic recovery, what further steps would you like to see the international community take? >> as an immediate step up pressure on airlines in the shipping companies to stop ostracizing us so that we can reduce the cost and we can have free movement of goods and services that people return to the country for her. once that happens we will have a very positive effect on concession workers and contractors who feared they

would not be able to get out if there were elements or they had to leave for whatever reason. that's an immediate thing that can be done. in the longer, in the medium and longer term the framework, to question of identifying those areas where we can expand production to be able to get the potential that has not been tapped. so is that partnership that will lead into working together. economic reconstruction and recovery. >> very good. last question for you madam president. the applet has a number of students, undergraduates, graduate students, faculty and other people from around georgetown and from our community more broadly. to speaking directly to them, what can they do? what would you like to see us do as a small community here in

washington d.c.? >> it could be a good case stu study. >> always be academic. always be academic. >> you know see where we are. see where we are today and look at some of the measures we are taking. begin to monitor e-mail and evaluate their progress and look at whether our assumptions and projections have worked and can they stand up to those two years later? you have seen where our projections were right or wrong based upon the results that you would come up with. i think it would be a good one and because i have confidence, but me tell you i am optimistic steve. i know that the growth rate has been projected and declined

sharply. i will not accept that. i say we'll find potential areas that will make up that gap. let me say to them that we will overcome a bowl and the economy will bounce back. challenge me. >> madam president all of us want to thank you for your optimism and your tireless efforts in this time and for your courageous leadership in the past but particularly in this present time. it's an inspiration to all of us and we just want to thank you once again for taking the time to be with us this morning. thank you very much. [applause] >> it was certainly inspiring but also sobering to hear it directly from president johnson sir leaf about her challenges and their plans.