>> sure. thank you for having me. it is an honor to be here and i really applaud the efforts of everybody in this audience to put together an academic and government response as quickly as possible. agricultural anthropologist, i would like to start with a story. .. and then finally after two days, they

came to take her way. soon after her husband became symptomatic. the family again called the hotline for days but no one came. the father died and a few days later a burial team came and took away the body. the oakland noted the early signs of able among the children and set to the health care worker, your minister for health care is more for the dead down for the living. this isn't true, right? it happens to be a fact that in the early days of the epidemic the senior leadership at minister of health and social welfare and library worked with the companies in library to set up a phone bank of 24 land lines so the initiate of health could respond to phone calls related to the epidemic. but on friday i was having a conversation with a senior official and he said the problem in liberia right now is that the phones are ringing but nobody is answering the phones. why not? why is there this this juncture

between people calling and people not answering the phone? this is a different story than what we're hearing in the media. in order to understand the story you need to have an understanding of the character of the library health factor and little bit of its history. it's important to understand a library health sector was largely just that in the late 1980s not just as result of the capital withdrawal by the government but as result of political violence. between 1985-1990s there was political violence against the intellectual elite in liberia and many medical professionals fled. soon in the 1990s the civil war broke out an entire library health sector fell into a state of collapse. during the 1990s and well into the early 2000s, most of health care that was provided to the library by police were provided almost entirely by the international community. in 2003 when the civil war came to an end, the liberian population was widely accustomed

to receiving health care from ngos like doctors without borders. between the third of 2003-2005, humanitarian organizations continued to provide health care to the entire liberian population, at the same time and massive repopulation effort -- sorry, resettlement effort was underway from refugee camps in guinea, ghana, sierra leone. the international community at this time was effectively running the entire liberian health sector. things came to ahead and i'm sure this with you because this is one of the most interesting and underrecognized stories of international development and international committed to assistance in the last decade. between 2006-2007, internationally american organizations independently started to make decision to close a the hospitals and leaver shut down clinics, bribery rapidly and without consulting

the health and social welfare. the international response organizations on the ground became very, very afraid to the ministry of health and social welfare became afraid because this was the entire hope sector. as was the entire safety net. a team of international partners including the united states came together in early 2072 devise a plan to manage the transition and health sector from humanitarianism developer. what was put into place was a set of structures to establish a library health sector that would be more robust. okay, so let me give you a little bit of perspective on this. presently the entire budget of the country of library is about $500 million. about $200 million is being spent on health care. of that roughly 80% is being spent by the international community. the liberian matters of social

and -- 50% of that and it is totally going to civil servants ours. so when we're talking about the liberian health sector, and i believe this is also true to a certain extent for sierra leone, we are talking about a health sector that we have built at the international committee with our tax dollars and charitable contributions. these are our health sectors. so what was innovative about the system that was put into place is something called the liberian cool fund. the goal of the pool fund was to sustain an international level of commitment to develop 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 these disparate organizations under the authority and direction of the state. the plan did that very well and one of the things it did very well was it sustained strong leadership at the very top of the system, and it also invested

very heavily in primary health care workers at the bottom of the system. there was a chemist not have medical training that went into nurses and doctors at the bottom level. what was not established was a robust middle, and it's the middle where bio surveillance happens but it's the middle where epidemic response happens. it's the middle where interregional and interstate coordination happens when insurgencies like ebola arise. those resources were not built into place. so during this period i would say that it's fair to say that there are a few canaries in the coal mine. for example, the international committee was working closely with the mayors of health and social welfare. one was a in an advisory capacity but also not exactly in an advisory capacity because of our predominant contributions to the health sector itself.

during this time on an annual basis, when it's safe to say that in a country like liberia, this is true for sierra leone and guinea, epidemics are endemic. on an annual basis cholera, fever, malaria pop up over and over and over, right? 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 nongovernmental organizations that were providing primary health care, right, and as long as the response is relatively quick and it was sort of coordinated, it was deemed to be unacceptable step towards epidemic response. nobody anticipated the fact that an academic -- an epidemic like ebola was going to pop up, but the cause of the epidemic is

that we were depending upon these sorts of pop-ups in order to detect the presence of an epidemic. and when an epidemic like ebola 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 what it was. when it first popped up, it popped up in a rural area but the rural area is nowhere near as remote or rural as the media would have us believe, right? it popped up in a rural village very near a drug road that traveled in guinea and branches off which leads to sierra leone and travels down into the county in the north of liberia and takes you directly on an urbanized road into the liberian capital. it was also recognize the nature of settlement in these

countries. right now in liberia does about 4.3 million people. of that population, approximately 2.1 million people are living in urban areas. and almost all those urban areas are on that road. that road is highly trafficked. it is the central commercial artery that linked together to sierra leone, liberia, guinea and extends off to the northwest. so what we're looking at is a missed opportunity to stop and epidemic traveling along basically one or two roads. why did we miss this epidemic? as it turns out because of the absence of sort of a nation level health structure that could be due bio surveillance, all three of these countries were almost entirely dependent upon the world health organization to do this kind of work. world health organization was doing this would work on a state-by-state basis so when they thought they have a problem

solved in guinea, they cannot shut down operations come are the least forecast the idea they're going to shut down operations and to go to recognize the interregional network and an interregional commerce that was going to spread epidemic and turn into the kind of plague that it is really become am i running out of time speak with no. this is a good transaction -- transition. they have reconstituted efforts from the workers over document governance and take capacity to intervene in these contexts, we -- with always strong international support can you give us some perspective on why are the states getting blamed for failing to effective route respond to the ebola crisis? >> thank you, emily. outside to keep my chair from collapsing. first we need to look at this question about who is doing the

blaming. on the one hand, easy increased numbers of reports of people in various areas of each of these three countries, in some ways a properly blaming their governments for lack of response. also directed at the international community, but if we focus first on this level of looking at, or looking towards their own government, there is an interesting piece in the "washington post" over the weekend about a total shutdown of the health facilities in liberia, for example, every couple of quotes that jumped out to me and i've seen over and over. we blame the government. why hasn't the government seemed to our health care? why are we being forced to dive not just of ebola but of other health care concerns that tradition should be addressed through the health care system and some of the issues that we talked about earlier. so in part, this direction of

blame at the government level or from locals to government, is partly result of 10 years of democratic rule, certainly in liberia and sierra leone, where you have seen some improvements in various aspects of governance and service delivery, but not enough. and where you've seen in recent years in liberia and sierra leone particular book, considerable growth but not significant poverty reduction and so one. so you have what might be called the revolution of rising expectations among an increasing late participatory clinical culture, at least in those two countries. in all three though you have continued context of social tensions left over in the

liberia and sierra leone cases from protracted civil conflict. and more recently in guinea since about 2008, the very unsettled political situation in that country. so there's a sense in general, certainly in liberia and sierra leone, that states should have begun to stand up to some of these challenges after again 10 years of democratic rule and some modicum of economic growth. at the same time, as you look at the political and economic inheritance of these current governments, they are essentially the political equivalent of -- that democratic regimes now in place inherited a broken economy, the social economies, dysfunctional political systems and essentially had to build from scratch out of this try this,

many years of civil war and civil conflict. of course, in liberia and sierra leone we're talking about 500,000 id keys in each country, 50,000 deaths or so in sierra leone, 250,000 in liberia. and there are long-term civil conflicts that took up much of the 1990s while the rest of africa was going through democratic transition, and then in a moment certainly in sierra leone and liberia it was substantially delayed until 2002 and 2003 respectively. guinea of course goes through more recent political upheavals with the death of longtime authoritarian in 2008, and so it has continued politically to struggle with some periodic

upheavals in the last few years. we're talking about sort of unsettled political context with the massive rebuilding efforts. and so you've got this odd juxtaposition of rising expectations, at the same time the state capacity is still incredibly limited. 2008 article notes, for example, that war-torn country's experience as they call it development in reverse. and they estimate at the national level the loss of economic growth induced by civil war amounts to a to point to year of the conflict. -- 2.2%. they estimate it takes 14 years under the table -- typical circumstances to reach a counterfactual gdp, a gdp that would have achieved absent the war. so we can see this kind of

scenario unfolding in liberia and sierra leone, tour by these protracted conflicts -- torn. although each of them certainly liberia and sierra leone, sierra leone actually grew on a gdp basis, something like 14% last year. action had a pretty impressive growth rate. liberia also, nine or 10%. consistently averaging five, 6% over the last decade. but from such an incredibly low base, right? we are broadly familiar with the outlines of these conflicts, but these are devastated local economies. so the remark about growth rates near those for example, mozambique after its conflict. mozambique was often held as one of the fastest growing countries in the world, not from such an

incredibly low base that it's taken a generation to begin to rebuild that country. and it is similar here. so we are still looking at among the lowest gdp per capita on the continent and in the world, among the lowest in the human development index, and all these other socioeconomic and political indicators, socioeconomic indicators at least, these countries all fall very, very low our international metrics. so these are areas of great concern that suggest the challenges of rebuilding. and we were just talking about the spread of ebola along these trunk roads and sort of the traveling of ebola from this confluence of the three countries down, particularly

towards monrovia and throughout liberia, but most of the infrastructure of liberia is not that good, right? it is terribly degraded. and so a situation where services are very difficult to deliver care, difficult to deliver reconstruction is very difficult. let me end there, but just the idea of trying to reconstitute the policies from the ground up in only a decade is enormous, the challenges are enormous. and so them to be, for these very fragile political economies to be confronted with such a devastating crisis, that they were, clearly the evidence is clear ill-equipped to handle, is

just, you know, something that raises questions about, the word blame and the idea people blaming the state, blaming the international community. we should not have expected, i think, these states to be able to respond, given that the legacy that we have inherited. the international community response which is something that we're talking about is another thing entirely. and i think a lot of the blame if you will, if we can use that word come is more appropriately leveled at their insurance of being so late to see a muscular response, beginning to see a muscular response by the international community now but it's late in the day but these countries are going to need enormous amount of attention and health that they have not to this point really gotten

politically, beyond simply just the health care needs, but just from a complete development perspective. >> so let's turn from a political economic framework we've been talking about, that structured our understanding of the able epidemic. and dr. habyarimana, which is because a little bit about the social and cultural challenges surrounding the ebola epidemic which is new in west africa? it's been an epidemic that we have observed over the last decade since the '70s, and throughout central africa. but what's new about and west africa is an illness that people have not seen and they don't necessarily fully understand all of the messages coming from every which way. so one reason we're asking dr. habyarimana this is because he was in uganda in 2007 during the

ebola outbreak, and was going to potentially provide us some kind of experience near perspective of the government engagement with the population. >> thank you very much, emily. and thanks to the organizers for inviting me. i'm not an anthropologist but i would like to start with the story that emily has indicated. i left i guess george kennan in december 2007 to go start my sabbatical to do a lot of work, understanding how to improve programs to fight hiv, in some ways a lot of my research has been around hiv. just as we landed, my wife and i had just had a baby, a six-month old boy, the first order of business that is going to attend

a wedding. my wife's brother was getting the. literally the day we arrived. and there was an ebola outbreak about 300 miles west of the capital city. and what was quite surprising, it wasn't fighting for us. all the grandparents and relatives want to hold the baby, and we certainly know enough about how the disease is spread so we were quite concerned about how we would deal with this. we didn't want to upset anybody. but the president that morning had actually made a statement saying people should stop shaking hands. no handshakes. as the way to greet was to wave, and i was very, very surprised that eddie wineland people were running into each other for the first time, you know, typically contact, they hug. people were actually amazing and, in fact, people were quite respectful not to actually ask to hold the baby.

so that in some ways was quite surprising. now, maybe would have been different about uganda was uganda had of course experienced a pretty severe ebola epidemic about seven years before that, that have been quite come in some ways the fatality rate of about 50% in three different regions of the country. so there was some familiarity and, of course, we share a border with the congo and the region, sudan. there have been frequent outbreaks that were quite familiar. and i think there's something about emergencies that make us a little bit easier, a little bit more challenging for both individuals to learn about what it is and what they have to do, as well as the response. i'd lik like to sort of at all o what sharon said earlier, but in some ways it would take about the hiv epidemic when it first

broke in southern africa, it was quite a challenge for, you know, the government didn't help itself by taking particular position much later. but there were people who had doubts about whether this was a real disease. they were tons of conspiracy theories and so did read quite a lot in the press about people thinking that this is not really, you know, what people are saying what it is and how they should respond. in some ways when it first came to the sinai that was kind of my initial sort of stance was this is in some ways it is about learning about a disease, learning both the household level, how individuals deal with it, how different is it, but also the health system in general. we know these health systems are very weak. a lot of the work that i do these in easter eastern and soun africa. these are not in some ways states in the same physical condition that scott talked

about, but they are also very weak. they have lots of problems in sort of deal with sort of basic public health issues. but the star that sharon just give about the hotlines in some ways reminds me of kind of the challenges of the health system at least in the places i'm very familiar with. the brain drain cannot explain the fact that there are people -- this is not a high-tech, you know, you don't require certified years of medical school to do this. this is really about managing health personnel. there's quite a lot of research from many parts of africa, sort of the parts i and for me with messages that this is a big challenge. getting people to actually show up to do the work is quite a challenge. so on any given day, and at least the places i work with, 30-40% of health workers are not what they're supposed to be.

and that's not even including whether they have gloves in the facility or treatment for particular medications. i think all of those things, and i don't know liberia and transceiver and well. i'm assuming things will be a bit worse in those context it i think it makes it really, really hard for the system to respond to something like this when you don't have people in place coming sony 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 only go to the hospital when they are really, really sick after they have spread the disease to lots of different people. in some ways i thought this was about learning and kept households and communities learned about the disease, but the story about 20 for hotlines that are unmanned i think to me suggests there are lots of other

things and a lot is basic management of health care. you don't need a lot of donor dollars and to get people to show up to actually sort of answer the phone. >> and interview paul farmer did recently, he emphasized the need for staff stuff and system but i think that's a pretty good thing to talk about, the things that are at the heart of a living system for providing care for people are suffering, people and their families who are suffering from ebola. i'd 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 that would be treating local health care workers as if they are the frontline of an international response which would mean dividing it with the same kind of care and protections we provide to international staff.

as many people in this audience know, 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 how a clinic every day with insufficient resources, insufficient materials and insufficient support in order to just provide minimal care to people who are breaking their way through. and the getting sick and they are dying. and it was a notorious embarrassment i think to the international community when the senior doctor in sierra leone requested evacuation after he showed signs of symptoms of ebola and he was denied permission and he died. he's not the only one who has been in that situation. we've heard a lot more about controversies about whether or not local health care workers have access to other kinds of experiment of therapies but what we haven't really had a strong discussion about is whether or

not the claim itself to workers as our own and we provide them with the kind of therapeutic support that they might need when they contracted the illness and they most certainly are. so i think that would be one step. >> i just think just repeat as all the things we've 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. what are we, seven months after the first -- even more, eight months after the first cases, and more than two months after we already declared this a crisis, so you know, i think the coordinated international response and many other things were discussing this morning i wants to get the staff and systems goals. >> i concur with scott. ..

in some ways and we have evidence from lots of others. we have the great technologist to deal with malaria and other diseases that we still have a

lot of death and staff and systems in this context. it seems like you know this is an opportunity i think to really sort of focus on the way we advocate resources across and treat them. and you know if there's any silver lining to this dark cloud we may actually focus on putting money into the right places. >> just add to that i think it's also important to recognize that the real frontline of treatment is happening people's homes. so it's disproportionately affecting women who tend to be caretakers as mother or daughter or wife. i can say certainly that is one of my family members is quite ill with symptoms that look like a bowl of my first response will not to be to put on protective gear and there's a lovely article in slate i believe

yesterday about this. there's a lot of human caretaking that is leading to the dissemination of the virus and so the international response needs to rethink its messaging about how to provide care for people who were 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 our messages into the strategies we are proposing that recognize care for their families and loved ones are going to come first almost every time rather than you know people's first response is not, people's first response as family members is not to say i'm going to separate myself and some myself to a therapeutic treatment center where i may never see you again, right? >> can i actually ask a question? so if we can say that a similar

social context exists in uganda how is it a different kind of messaging can be disseminated to families and communities in those contexts years ago they can be disseminated to the library and in the context now? >> i think one big difference between liberia and uganda is where the outbreaks have happened is, uganda is not a highly urbanized society. at least five, 10 or 20 years ago only 10% of the population were in those areas. and i think also you know there is also in some ways be coincidence that this outbreak in liberia sort of happened at the confluence of these two roads and basically traveling

down to the coast and in the same way people are shifting their goods and so on. in uganda i think there has been in some ways and in the -- the, is not that many roads. in some ways the outbreaks in the, don't generate the same level of fatalities. >> but i mean to sharon's point about families and caring for one another which is perfectly understandable, in the ugandan context could the message be delivered to families that you know what you do have to don a protective suit or are we just comparing apples and oranges? >> you know i think the message at least in the crisis that i was experienced directly in, it was simply about transmission. i don't think the message was

trying to direct conditional and having a family member who is ill and what do you do. i think that is actually the very challenging message to deal with and from what i have seen how cases are managed, i think it is very challenging to tell families don't touch somebody, don't help them and don't clean up after them. i think those are really difficult messages and i don't think uganda did anything special. i think we were just lucky that the outbreak happened very far away. >> there are some reports that i have been hearing where some people were coming from the ground up. so in remote areas of liberia where people don't have access to resources in most places don't have access to -- for example people have market bags, like when you go to the

supermarket. there are tons of plastic market bags all over. they are sort of them are mental hazard a lot of the time actually so what family members are doing is they are actually putting market bags over their hands when they are handling their loved ones. i don't know how effective the solution is but it is something that's coming from the ground up and they think that one step that can be taken as turning to local populations to actually try to solve some of these problems themselves in collaboration with international public health messages. >> i thought we could talk about nigeria. it appears that nigeria out cases have been largely contained and their work cases in lagos and potentially elsewhere. can we speak to what happened in nigeria in the context of that?

>> maybe i am 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. the efficiency of legos state governance is fairly well-established. governor fossil and in not very auspicious conditions in lagos has managed to institute an infrastructure that is certainly better by leaps and bounds than that in liberia and sierra leone and guinea. and i think that the nigerians and all of us are actually

fortunate that the outbreak in nigeria started their and apparently has been able to be contained, but you know if you look at nigerian developments and nigerian infrastructure and all the criticism that nigeria gets in the western press and indeed in the african press in this case we seems to have gotten it right and i think it should be applauded. >> you know, it's quite unusual to hear the words efficiency. [laughter] and i think a lot of concerns about this outbreak becoming -- getting out of control with what would happen in liberia. i concur with scott. the legos -- law this government is clearly one of the most efficient but i also think the

timing and the nature and knowing the anticipation and coming after essentially a revelation that there was something really serious going on, i think that was just the right response. there's a big scandal, not scandal the controversy about whether they should really be starting this week where they should be starting at the end of august. and people still think that they should take more precautions but across the entire country they have been able to deal with even in the port where they have had a couple of cases. it is not lagas in terms of management. >> both cases in uganda i believe that nigeria show like ebola response looks like an in

strong states versus weak states. when we think about what a strong state is in the context of how public response to any kind of perceived risk it isn't enough to lead to an understanding of that two political will. liberians and sierra leone have an inordinate amount of political will. they have been extremely vocal in being concerned about this response and really demanding an international response for the crisis. but what you see here is the difference between strong political will and strong political leadership versus strong institutions and 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

support and just above the bottom level. >> i want to put it to some other questions but they're really good questions here so let's take time to talk about them. what specific short-term actions and long-term investments would reduce the gap you identified in the middle where you noted biosurveillance and interregional coordination happens? >> is the question for me? thank you. i think that one of the conversations that has been latent about the liberian health sector and sierra leone and new guinea health sector going back at least a decade has been a question about the issue of sovereignty and self-governance. there were aggressive moves to restore health sovereignty to all of the states as quickly as possible as part of the move to restore general sovereignty to the states as quickly as possible after their post-conflict.

tended. i think one of the steps we may need to do is we may need to start differentiating health sovereignty from political sovereignty. we may need to understand that while political sovereignty is a must and political leadership of the health sector is a must you cannot just hand responsibility to a weak state for the responsibility for an entire health sector to early. and you really shouldn't hand over the operations of the state to a weak states to early because it will have international ramifications. and so if we understand how -- health sovereignty is being different than political sovereignty and if we understand it is being interestedly linked to international biosecurity, we can really rethink how we are

providing support to the redevelopment of the state structures and state institutions. >> said here's another question that builds on on this zoology can jump in. what role can the international community leverage leadership and accountability with state actors who have a noted disconnect with the people. for example and sierra leone were given $10,000 in cash last month to assist with a fuller relief effort in their districts yet this sierra leone and community -- can i just turn that question on its head a little bit? what i would actually like to do is address the ebola epidemic in the best way. one of the stories that has been missed i think in the cultural narratives that are coming out of the ebola epidemic is how

educated these populations all our and mass international short-term responses. in the very recent historical memory of all of these populations there has been mass mobilization's mass vaccination campaigns all within the context of the systems and a lot of this has been done in the context of very powerful reconstruction messaging that place upon things like african solutions for african problems that valorize his local leadership in taking accountability for local populations. and 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 about the risks to their physical health but very little of it has invited the population is up to take leadership in participating in a global response that spaced upon local action and local accountability. i think that there's a lot of opportunity there in a very short-term to kind of change the direction that it's going. >> let's build another question on the one from intra-health international. frontline health workers are essential. we are talking about local and we are talking about ground-level work to an affected the polar response to what kinds of intermediate and long-term investments can be made to train and deploy health workers? as we are intervening in an emergency how can we look at the long game here? so how does their cultural knowledge and asset. usaid unicef hiv and other partners have developed an zero.

antero.org to connect health workers to national communities. so how can we think about long-term -- how can we think about taking advantage of community level intervention and community level knowledge and i think she is saying mitigating the epidemic immediately but also thinking long-term of building health systems, health networks that stay beyond ebola. >> so let me see if i can take a crack at this. so i think in some ways dealing with the immediate epidemic is clearly the urgent issue but the training, to go back to the 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 this one about how we allocate our resources between -- the hospitals and capital cities and other urban areas versus really good public health facilities and these rural communities. 10 years ago the world bank did a study of seven countries including two in africa at the time, looking at absenteeism of health workers but also looking at sort of what exists in these health facilities. a random sample of the facility and on and off visits to see what was in those spaces.

one of the strong correlations between people working and providing services was essentially the quality of the facilities or the structural factors. is there water in my facility? is my facility well-stocked? those facilities tend to have people working and so stocking up these facilities is really a logistical challenge and a governance issue that when you send a bunch of gloves to the facility that they actually get there and they don't end up in a market in monrovia or freetown. i disagree a little bit with sharon when she says we have political health sovereignty. i actually think some of these things and clearly the big things that we have to play an

important role but some of these things like getting stuff were supposed to be in making sure people are doing what they are supposed to be doing is fundamentally a local accountability problem that in some ways parliamentarians and the people should be leading the charge. and so i think the first step has to be trying to build a health facility very close to these communities and giving the frontline workers in these places the tools and the training. clearly dealing with a bullet is different than dealing with so people need the confidence to engage. if you are turning people away because he was a health worker are scared, that's certainly not going to help dealing with

future threats. >> in order to leverage the knowledge and participation of the community, trust is going to be essential and partnering with international actors or national actors or regional actors. the reestablishment and indeed in some ways the establishment of trust between communities and various authorities structures and the problem is in this context where services are not being provided or declining and people are dying what you have is distressed levels actually rising. so in order to engage the community's comment seems to me the very first thing that needs to be done is to try to establish trust, reestablish trust within the community and

that's going to be exceedingly difficult. >> i'm going to have to pose one very specific question to dr. abramowitz and that i'm going to give each panelist in on time to give some concluding, so we have a little bit of extra time. first, there are a lot of questions that are past that make me understand the people are wondering what does it mean to have a health response and what is the health system and who are these different people? i was wondering if professor abramowitz could speak a little bit to the liberian situation of who is who on the ground and how can we work together? >> sure. if i can add one other narrative that came out of somebody working working in liberian ministry of health last week. he wrote a note to a colleague of mine that i was talking to this weekend and he said just this past friday a man who had contracted ebola search for hospital and he had traveled to

every treatment center in monrovia. they teach one he was turned away for lack of a bed. he then use public transportation to go to the ministry of health and social welfare and the ministry of health and social welfare had no assistance in no assistance and he waited for three hours for someone to help him until he was told that no one could find a bed for him and there was nowhere for him to go. finally he left and the health worker who is writing the message went on to note either he went back home to seek care from his family or he went off to face it will let alone to prevent the spread of infection to his loved ones that nobody knows where he went. he just walked out the door. people are asking questions about who the health workers are. the answer is very -- fairly straightforward. the true primary line of health care is the health care that happens with him. as a professional health care sector which is the nurses and the doctors who are providing clinical treatment either in primary care facilities many of

which are overwhelmed and shut down or in treatment centers. then what else is there? the answer is we are asking health care workers to be more responsive than the question is what why? if you have people who are coming to you seeking some sort of support and there are no beds and they are being turned away the national ministry of health and social welfare and nobody has anything to offer them. they are allowed to stay there until they finally leave. what exactly is it that we are asking of these people to do? their response is as valid and as good as they can possibly give. there are no beds. the united states last week said 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 exactly? is emmylou will be providing supportive services to people in local communities? we also announced we were

sending 16 or 17 therapeutic treatment facilities for each county in liberia and i suppose that means there's going to be supportive treatment provided there. i don't want to overthink the case that this is in some ways just the problem of human resources. i believe many people on the ground are both willing and eager to obtain treatment in many people are willing and eager to provide treatment. >> what is the treatment look like? both of the community in the state level and urban arra are areas. can you provide a description of what it looks like? >> it's largely supportive treatment. it's largely rehydration and the treatment of opportunistic infections of people can allow the immune system to develop in a response to fight off illness. for example they have set up camps in several arra areas and they are kind of makeshift

clinics that are containing cases and caring for people. >> that's right and the kind of care they are providing our supportive care. so essentially rehydration and trading of opportunistic infections. >> who is running the clinic? >> ngos pretty much. >> local ngos? >> that's a complex question. it's a large area and there are a lot of people involved. >> these are just questions coming from the audience. >> i also want to add that in the absence of additional areas local populations are seeking solutions themselves. i just heard last week reports that there is an emerging black market and survivors blood that people are distributing to

others so that also raises some public health issues as well. it's important to be mindful of the local solution to the local problems that people are generating and anticipating other issues that may arise. >> let me just briefly most of my research falls probably into what people would describe i think not quite accurately as the africa rising narrative but nonetheless it's mainly focusing on the advances that africa has made an political and economic development over the last 10 or 15 years and what's wrong with it is advised into general, that all of africa's rising when we

certainly know that that's not true. my fear about the ebola narrative is that is now becoming the metanarrative for all of africa if you will at least see this in everything from the trivial relations of safaris in kenya to the closing of borders to the south african response and even researcher colleagues have canceled trips to southern africa because they are afraid of ebola. you know i think this borders on hysteria actually and that kind of response is negative certainly for the larger africa rising narrative and it's also not realistic. the danger as we talk about this very important debilitating crisis particularly in these

countries that we 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 frankly when my researcher colleagues were avoiding 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 the disease in some ways in which we can combat it but not to lose sight of the fact that this is an painfully, 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 is not just in africa problem. that becomes a dominating narrative for africa but rather it's a global problem that needs a global response and a

realistic view about what's happening in the rest of the continent. >> i want to address two issues if i me and point the direction to two places in the same time. one thing we want to keep our eye on well this whole crisis is unfolding, think we need to be mindful of their risk for destabilization. these populations have shown extraordinary resilience under strain late difficult circumstances. that kind of resilience is not undoable and i think where we are starting to see a real risk of breaking down population resilience is an in the area of food security. as a result of the ebola crisis people, families are hoarding food and people who sell food are hoarding food. they are starting to be some price-gouging taking place. the car stuck the sack of rice in areas that haven't been affected by the ebola virus has

doubled. and areas under quarantine are going to require ongoing food supply for a long period of time. you may not see a large-scale violent response to ebola that you post it in a response to hunger. ..

it will pay i would say compounding dividends containing the crisis and hopefully regain it to ss. >> well, i would like to build up on the communications. some of the other work here and one of the things we realize this public health messaging could be kind of boring, the simple imperative, trade safely, speed kills. in some ways it makes sense to sort of think carefully about how people have these messages and what the responses. if we get that right, that is much, much cheaper than another

vaccine. but the other thing i would like to add-on is in some ways what jesse was talking about this morning, which is we don't invest in health because it's hard to figure out what the benefits are. the costs are large. in some ways the costs are quite large. managing and providing incentives and materials is not really easy given the history of these systems. but in some ways, you know, if there's any good thing that can come out of this really, really tragic crisis, i hope it is that we will not just simply, you know, it takes the president's position that we are going to go when and provide some immediate relief for the crisis in liberia, build more hospitals and provide training. that is great. we need that right now. what we need for the future is to increase the effectiveness of every dollar we spend in the health system is to really

strike those substances. it doesn't matter how good the technology we generate maybe if we can't reach, the people that had these problems. so in some ways, hopefully this may be a call to action, to make the boring, but high long-term return investment in the health system. >> well, thank you offers same throughout this panel. >> thank you. it was certainly inspiring. but also sobering to hear directly from president johnson's early about her challenges and her plans. i think it was exciting. so thank you to see bradley in particular for organizing that segment. so, let me just try a little orientation for the final segment of two-day symposium.

this panel is entitled where do we go from here? and accordingly, we have brought together some panelists to help us not only take stock of what we have heard already, but to take a bit more of a forward focus on what are the implications of what we have heard this morning, particularly what are the implications we look ahead to what can be done? so i'm really excited about the group we have here. let me briefly introduced the panelists going across from my left. first is suzanne kim. she is the deputy director of the o'neill institute for global health law at georgetown university. susan holds a jd mph and mba degrees to prove it. in 2001 she served as special consultant to the state department regarding global funds to fight malaria.

susan has worked on a variety of health issues including implementation of the international health regulations come pandemic response and infectious disease control. and so, we are looking to susan bringing a legal perspective here in the discussion. next to susan, we have heard from her radle, but a sandwich professor of the donald mchenry chair and global human development at your 10 university school for an service. steve has held senior positions in the u.s. government including senior advisor for development of secretary of state hillary clinton, chief economy for international development and deputy assistant secretary of treasury. steve as you could tell from the early presentations advised the governor of liberia among many other governments on economic development issues. and then, last but surely not

least is dr. ron waldman, professor of global health at the george washington university. ron has had an exceptional and distinguished career in public health including service at the centers for disease control and prevention, usaid and the world health organization and united nations. his resume is very long and very distinguished, but includes an extraordinary list of initiatives including smallpox eradication campaign, developing a newscenter for forced migration and health, endemic preparedness for the new government and lead roles in response to the indonesian tsunami in tahiti earthquake. with respect to the current crisis, he is the team leader for save the children ebola response. one thing i would say is i've had the deep fortune of actually working with all three of these panelists in different parts of my career. susan with the o'neill

institute, steve estate and ron at hhs. i think we are meant for a terrific panel today. we will follow the same format as the earlier panel. we will do some general questions and then i will post to the panelists on specific questions that have been developed by the students here. so, but they just say -- i am just going to ask everybody to ask a general question to reach a view to kick this off. let me start with susan kim. susan, you have heard this morning much discussion has been about roles and responsibilities of governmental institution, both global and domestic. the issue of law comes to bear here too because those are the instruments we use to decide who does what, where and when. so i guess i would love for you to reflect on what you have heard them what you know about the ebola tragedy from the legal heirs, particularly i suppose with respect to the implementation of the

international health regulations. kick us off. thank you. >> thank you very much for having me. i think as john mentioned, i will sort of be speaking within the context of the international health regulations or the ihr. dr. cameron actually spoke about them earlier this morning and really what the ihr is this a legal global framework to respond to detect monitor and respond to disease outbreak. and really prevent the spread of the international spread of disease. there's an international treaty of the world health organization and they've been around a while. since around 1969. as dr. cameron mentioned this morning, they were revised in 2005 to more effectively respond to disease is that transcends national borders. so sars was a catalyst, but also hav and ironically things like ebola. so, at its core, it is a fairly

complicated instrument, but at its core, what it really is as it establishes a mechanism for capacities at the domestic and international level. countries themselves are responsible for implementing the difference -- different elements of the ihr, which includes sort of monitoring and surveillance local disease outbreaks. one specific criteria and satisfied in terms of severity, the ability to transcend international borders, novelty, then a reporting mechanism back to the who about whether they need to find a more international system. sort of this to be at the global what you have heard referred to as something of a public health emergency of international concern. but essentially is a type of sword of global amber alert for public health emergencies. basically it is a way to effectively signaled the global

community that this is an emergency. it will transcend or has the potential to transcend international borders and people should pay attention and start to mobilize. in terms of resources, whether it be financial, medical and human. and i think sort of additional action can be taken when a sub? is implemented in these include temporary recommendations that restrict travel and trade. the declarations obviously of the sic has multi-implications. these can be severe because i think you have heard from president surly, with the dissension across borders, this has to be an economic implication. the who doesn't tend to declare a sic. since 2005, he only declares them three times. in 2009, it was each one man one. earlier this year was polio and in august it was the bola.

so specific to the current outbreak, one of the questions is whether a sic was declared too late. it's hard to assess overall, but the answer is probably yes. they are declared on august 13th. i think from some of the remarks made earlier today, you can probably see this sort of ebola had taken a foothold in the countries and started to reverse borders around may or june and sort of as i mentioned, as a type of sort of emergent the alert system, the declaration sends a clear message that sort of the world needs to mobilize them because they have done that late, you have heard it very difficult consequences of this timeline. >> thank you. let me turn if i could to dr. waltman because i think susan laid out the architecture for the legal responsibilities

about how the international community should respond. dr. waldman, give me your experiences working internationally unwelcome or sense of where we are now, but particularly what lessons do we draw from this experience in terms of going forward, in terms of health systems refers on much about, but also the international response. >> thanks, john. is this microphone on? thanks, john. i would like to address the problem in two parts. one is what we can do about this horrible outbreak now and then where we can go from here. i want to start by saying that in regard to dr. kim statement, every time she used the word probably too late i would take up a point. i don't think it's really an issue that the world did respond to lay. we allowed the outbreak could spread and we allowed the number of cases to grow to a point

where it's very, very difficult to contain. the outbreak probably began as long ago s. december and the first cases were reported in the fourth of any. doctors without borders announced in june that their resources have been overwhelmed and they could no longer even try to contain the outbreak from spreading in the world health organization founded in august the u.s. government announced its first major foray last week. so we have responded to that. there is no point at this time to point their fingers. that could be part of the case study as the president suggested. but at this point, for all kinds of reasons ranging from the humanitarian, two very, very, very practical, political, social and economic consequences

that are yet to be seen, we need to do as much as we can. so let me just say i think many of you if you are following this outbreak may be thought an article in the "washington post" this morning reports on a newly evolving strategy that may or may not be able to have an impact on the situation. let me just go over very briefly at the planks of the strategy that post of the partners now agree on. number one is the management of cases of ebola virus disease. basically this revolves around getting people off the streets and isolating them for the duration of their illness. we do not want to allow people to have any opportunity whatsoever to transmit the virus to others. it is a highly infectious disease. fortunately, it is not spread through the air by the respiratory route your one has

to come in contact with surfaces contaminated by the body fluids of a sick person or with a fluids themselves. but still, when people are exposed, when they develop illness after an incubation period that can vary from a few days to weeks, the proportion of people who come down with this disease, who died, is scary. it is well over 50%. as a result in the worst-case scenario that might've been mentioned earlier this morning that are going to be released by the cbc this week, the cdc is saying without their intervention as president surly said, the number of cases is estimated to surpass 500,000, which means we are very likely to see between 300,000 were a hundred thousand deaths over these three countries. it is just phenomenal. they are numbers that are so big for infectious disease outbreak that it's hard to get a grip on

them. one area of intervention are the hospitals called the bola treatment centers. steve mentioned that president obama has pledged to liberia 17100 hospitals. whether or not that is the best strategy, what proportion of the overall strategy does hospitals need to play is up in the air. i will come back to it. we've been pushing a save the children, very hard to have been an intermediate layer of care closer to the community with a little bit less strict isolation procedures so we know that what we are proposing in terms of facilities will be part of the problem of transmission, but we hoped they would be a bigger part of the solution of getting people out of their homes, off the streets and in places where transmission can be restricted to an absolute minimum. but president surly is so right

on. she stole my thunder i am sorry to say. this won't work unless the communities are convinced to take ownership of the situation and of the problem. for all of the reasons that the president mentioned, this is proving to be extremely difficult to do. but there are many people who are keeping their ill family members home, become the next those themselves. if they are family members or village neighbors should die, they are conducting burials and a very unsafe manner. burials are a super spreading event for people, because of the traditional burial rights, put themselves in particular exposure. crowds come, detach the dead audie and they need to be careful to supervise. so the community action, it

tends that behavior change are really the only thing that will bring about relatively rapid end to the academic if that is even feasible at this time. president surly also emphasize the fact that many people in liberia are dying of non-ebola disease because there are no health facilities that are functioning. so, things like malaria, pneumonia, complications of pregnancy. people are dying because they have no place to go. if there are facilities that are functioning, then mixed in with all of those people with those conditions are also people with early symptoms of ebola virus disease because the symptoms are not scraped. early symptoms of a person with ebola are characterized by or a cough or fever or the symptoms of the most common potentially

fatal diseases. so this is a real disaster and a difficult problem to overcome. triaged needs to be done. ebola patients need to be separated from non-ebola patients. but our sciences and fast enough to allow us to do that very quickly. there is no rapid test for the detection of ebola virus. there is only taking blood, sending it from a peripheral area to a laboratory, wherever it may be, doing a test that takes four to six hours to complete. getting results back. in the meantime, often mixing of the ebola and non-ebola patient has occurred. and facilities, where they functioning, would be super spreading sites or amplifying types of the outbreak. so we are really looking at the major challenges. two other quick things. one has to do with the protection of children. there's a growing number of orphans. there's a growing number of children in the streets. they don't know what to do,

where to go. they are very vulnerable and may need to be cared for and protected. it is very difficult to convince people to foster, to take in children whose relatives had ebola and the children may be exposed. finally, and this will tie in some with what steve is going to say. there are real hardships in people's inability to pursue their livelihood. there is no money coming into household. and without money, there is no purchasing power, even for the basic things like food that people need. so food distribution is becoming a growing issue, growing area of concern. of course food, water and basic things need to be provided at the hospitals and ebola care centers, but even now within the villages and communities, people are having difficulty. as you might know, there is a lock day for three days in sierra leone. the biggest complaint i have heard in the population was

their inability to serve enough food to carry them through those days. people live from hand to mouth and don't have large reserves and food stock needs to be some fermented either by the distribution of food to south, or by other systems, whether they are voucher systems or cash transfers. so i just wanted to say, what are the constraints. when i figure out what to do, but there are severe constraints there's not enough money in this response yet. the response is okay, big, getting bigger. the world health organization committee u.n. has called for over a billion dollars in funding. that is not yet available and i know from what is coming to the ngos so far that there really isn't that much money and if you concentrate on the high level facilities, the 100 bed treatment centers that president obama promised, the budgets for those right now that are being submitted to the government call

for more than a million, $1.5 million a month for their operating costs. so whatever money has been pledged is going to be exhausted all too rapidly. secondly, human resources. this is by far the biggest constraint that all of the responders are facing. there are no people available for this response. if you ask that may not want to go there because the threat would be able to get out, should they get in is a dangerous situation. but local staff also was very reluctant to sign-up to work on mass. in any event, the numbers of health personnel and support personnel required are really high when we are talking about the need for isolation, for water and sanitation, for disinfection, for burial purposes. these are good jobs to have. they are not nice and people don't want to brush up and

volunteer. the final constraint, we don't know very much about what is going on. these are uncharted waters. there have been ebola outbreaks in the past, but the response has been pastor. we have been able to contain them early on. here, we have never dealt with anything like this. even proposals like the ones i mentioned of the intermediate level close to community care, we have no idea if that would be part of the solution or part of the problem. every action taken needs to be carefully evaluated in real-time so we can see the impact it is having and we can see whether or not we want to pursue that line of work. so i guess i am coming across as not being quite as optimistic as president surly and by nature and fairly cynical to begin with, so that's not a good team. [laughter] but the outbreak, the director of the cdc, the director general

of the who come at the u.n. special representative for ebola virus, we've heard all these people say the situation is out of control. it is out of control. it is going to take a gargantuan effort just to bring it back, just to bring it back to a situation that can be controlled and that is that we are shooting for now. not even bringing an end to it in the immediate future, but rather just getting a handle on what is going on come the reducing trans mission to the point where there is no more growth of the outbreak only slow growth of the outbreaks of some of our more traditional means of containment can be more effect is. >> thank you. that's a sobering -- steve, let's turn to you. i think ron's message is clear. as he said, it's been reiterated by global health leaders. the epidemic is out of control

and the control measures that we are bringing them putting in place are being put into place by various partners are really an uncharted space right now. people are going to have to learn. we don't know what works in this context. so with that, it would be terrific if you could build on the conversation is started with the president, but also, where do you see the economic impact here for the three countries, for the region, more broadly for the continent and also, how do we think about the kind of investment needed to sustain economies while public-health measures are brought to bear, which will undoubtedly take a sustainable amount of time. >> thank you, john. first point i want to make is this is an epidemic of poverty. strictly a disease of poverty. anybody can get it, but it's an epidemic of poverty, just as low incomes and lack of food and

lack of water are all manifestations of poverty as is the literacy and many other manifestations of poverty. the weakness is and lack of capacity to respond to public health crisis is just as strong an indication of poverty. through that unfortunately there is a self reinforcing negative cycle that we are beginning to see here. as the disease worsens, that undermines capacity and undermines finances and economic ability and political systems and legal systems, which in turn further weekend the entire economic and social system, which are cutting incomes and leading to more poverty.

so, it is a horrible crisis because for the last nine years, since the elections of 2005, liberia has been in more of a positive reinforcing cycle that improvements in economic and political systems are leading to higher incomes, less poverty, increases in school enrollments, strengthening of democracy, which in turn are reinforcing each other or had been reinforcing each other. the positive steps in one area were reinforcing positive steps in another. i spend so much progress since the end of the conflict in 2003 and the elections of 2005 in liberia, also in sierra leone, a little bit less because the political system just began to change more recently in 2008. but we are seeing a reversal from a positive reinforcing echo back to a negative worsening

cycle. and if this is an epidemic of poverty, one of the things that has really made me frankly quite angry as to blame the victim syndrome that has been about for the last several months. the problem is that these people are stupid in terms of their cultural practices or the government doesn't have the competence of capacity or you know, they make dumb mistakes and we can all see these as the state senate to things more seriously and were able to treat people that this would end. and it's really quite sad that once again we see the blame the victim kind of situation. this was not anyone's fault. this is an act of nature. deeply unfortunate that it came into a region of the world that was very fragile in terms of its very promising recovery and was

overwhelmed very quickly. scott taylor said it, dr. bob said earlier, who would've expected -- who could've expected they would've had the systems in place to respond. there is, as several people have said and ron just said, they're a bit less sincere for the future of the international system and its inability to respond because this isn't the last ebola crisis. it's not going to be the last public-health crisis and this is what makes those enormous weaknesses in the global ability to respond to emerging diseases. i am not an expert on not another soul comment on that. or is a huge lesson going forward. ..

to the set of circumstances like this one when one of the things they need is cash in figuring out how to do

that. usaid is providing $5 million in cash and they were twisted and pretzels to figure out how they were going to provide $5 million in cash. the imf is actually going to step up in the next two weeks or so and provide around $50 million cash to the liberian government and seller smaller amounts so the organizations is going to be one of the first to step up. but i do worry about the longer-term impact on the economy and the impact on investment going forward because i think it's going to be to attract investors going forward and this is having a huge impact on individual people. people are out of jobs, not being able to work on the construction sites and retail shops as taxi drivers a lot of them have lost their jobs. so, anger is rising both in

terms of the disease and are able to provide for their families. anger is on the rise. in the fragile democracies quite promising democracies and they have begun to deliver the goods and i worry that among many of the casualties one of them will be the lack of the loss of faith in the ability of democracies to provide the goods. already we are seeing the warlords and associates of the former warlords saying i should be in power and with elections coming up in a couple of years, we will have to see how that takes shape but i do belief that there are much bigger implications here, economic and

political systems and people's belief in those economic and political systems not to mention their belief in the world order and international systems in their ability to respond. he outlined the steps going forward and it doesn't have to end in catastrophe. we are running out of time but there is still some time. the key will be for not just the people in liberia to begin but for the international community to provide the cash, the other experts that can help turn this around and begin to make those investments in agriculture for the u.s. through the u.s. future program to get farmers back to work through trade to take sure that there are trade concessions that outside investors will be somewhat more open to investing in these countries going forward

to investing in infrastructure, roads and power systems that will have a long-term benefit that will get people back to work quickly. there has to be another prong to this effort which, so far, isn't really happening in order to get people back to work to be able to care for their families and get these economic systems going in a more positive correction. >> if it is okay i would like to follow-up with follow up with you on the last point because it does seem to me that we have seen the global public health committee responding but what you are laying out as an economic agenda for these three countries of the region and again the imf is to be credited with the initial steps it's taken but it seems to me the president also laid out a broad agenda around trade.

who could take that lead the lead and do we have a global architecture that is for all of the panels. >> we have an insufficient global architecture on these issues. it's going to have to be slightly different in each country because the major bilateral actor is different in each country and in liberia and the united states into sierra leone it's the united kingdom and in new guinea if the french government so that isn't going to change and the reality is that the united states is going to focus premier league on liberia. we might not like that and we might hope that there is a regional response. all three of those governments have to step up and then several key international organizations as i mentioned. who would have guessed darth vader himself to the age-old nemesis. that is over but they still have this reputation but far from the

out of date image of the strong conditionality they are going to be the ones that will step up as part of existing programs and commitments that have already been made and that the government are all in compliance with. you will see it is going to be october 3 at will be on page 26 of the newspapers at the board will approve i think it is going to be about $48 million for liberia and other amounts. the world bank is going to step up. they've made many commitments so far. they sound like encouraging commitments as far as i can talk there is less happening on the ground and the bank has to step up on the power and roads as well as some of the cash to supplement. bilaterally the u.s. response so

far is certainly good. it is a step up but if you look at what the president said in a press release last week, there is nothing on the economic side. what they are saying is that will come. but there has to be similar but have to support farmers getting back to work in infrastructure investments, i hope the corporation is flexible in sierra leone and its partner countries to move forward on infrastructure investments. we are going to need the commerce to step up on trade and think about the kind of things that we can do to encourage trade and remove terrorists and open up the doors, so it's going to take efforts from a number of

factors and there isn't an overall coordinator to do it. it's a different different pieces that have to fit together in a puzzle to make this work and get the economic response we need as quickly as possible. >> as we turn to the public health response it seems to me if that is the case on the global architecture i would like to go back to where we started. i think that you laid out and i would agree i think that people are -- there are people working in all of these organizations incredibly hard to respond that it's a question whether we as a global community have the instruments and the infrastructure to respond and it seems in this case we have responded slowly and effectively but i guess the question i would

ask you in your analysis is this a situation where the legal instrument or sound but in this case we didn't use them to their full potential or are you beginning to see the lessons emerge in which responses like this will be conducted? >> overall i think it is a legally sound instrument and it's the sort of execution limitation of it and i think as many people you limited to it's difficult to think about what is the process and execution of how do you address a heart attack when you are in the midst of a heart attack and has mentioned this morning in the assessment of whether the countries have actually implemented the capacities that was around 20%.

the 2013 is more positive but for those of you that do surveys, take that with what you will. also, part of that is the institute was engaged for example in terms of the resource allocation and in a training course for the folks on the implementation and these were primarily for the middle and lower income countries what exactly are the core capacity requirements and how do you implement the treaty that because of but because of the course concerns really i think what we found in doing the course very few countries had a sort of dual layer at all and the ministry of health explained to them what are the requirements and how do you implement that and it doesn't have to be a lawyer. anyone in the ministry of health that can actually explain what are we required to do. so when you think about do these

countries have effective -- is it an effective mechanism yes if it is implemented correctly. has it been implemented correctly? no. with something for example the concern has been declared three times. the first was each one and -- h1n1. each one we got a little lucky because it could have been diffuse and spread but it didn't have sort of morbidity and mortality. moore could have happened and one of the questions is what would happen with a disease outbreak that would have significant mortality and i think that you see the consequences of that now. >> even if we have legal instruments that describe the responsibility it still requires

the institutions and the capacity to do so and i know we focused a lot on the countries and i want to be called present of steve's cautioned that this is not about blaming the victim. given your experience in global public health responses, what lessons do you see that we can begin to think about in terms of the international system including the who, what do we need to be thinking about because obviously we need to be thinking about how do we avoid being in this situation again? >> i think that they were underfunded in this particular area and it may or may not be true. the start of the macro level we are seeing a shift in the global health priorities as the countries are growing economically. they are going through something called the epidemiological transition which means the disease profile in many low and

middle income countries are starting to shift from one that is dominated by infectious diseases to one that has to put a greater priority on the disease that occur when people live longer. on the cardiovascular diseases, cancer, mental disorders and so on and so forth into that means the money is shifting from one area to another. so there has been some decline in attention to infectious disease control at the global level, certainly in the wealthier countries like our own you don't have to read far into the newspapers to learn about the epidemic's occurring in this country. but on the global scene as well parts of who like the global

outbreak alert and the areas concerned with emerging pandemic threats they don't have the same funding now as when we had the eminent threat. because of the threat in fact there have been a lot of preparedness activities in a lot of countries in a lot of parts of the world. the u.s. was engaged as were other parts of the system and at that time it was in the late 2000 there was a whole society approach adopted to the control of these emerging pandemic threats. interestingly the one part of the world where there was the least activity taking place within the part of the world this is occurring now. it just wasn't seen to be very vulnerable area for the emergence of the pathogens. we had a high risk map for the

countries and we thought that west africa there were some threats there but it really wasn't on the map. it didn't reach the level of the area of high concern so in addition to the fact that these are poor countries with very fragile health systems and little attention in the light and light being shone on them because of the lack of an epidemic history like this, just all of the circumstances coming together that resulted in this late response. if i had responded appropriately in june when the doctors without borders could no longer deal with it we are responding now that people have a tendency to hold themselves so we are responding when we know that we

should have responded in june and we are responding to the problem as it existed in june. doing then what we should have done now and we need to be responding now to the situation as it will exist in october and november. we need to get ahead of the curve. every day we spend chasing the virus is going to be another day that we fall behind ultimately. so there are some fairly drastic slow since being proposed and i don't know the lookout of the of them but they have to do with restricting people's rights of movement. and i hope it doesn't come to that but for the control of disease like this, who knows what can happen. i think -- i tell my students they ought to go and watch the

movie contagion which is a picture of what might come although i hasten to add and i want to repeat there is no threat. i want to build on what steve said actually. there's extremely little or no threat for the elitist countries of the world they have systems that can deal with it. we will know when the first cases arrived in the united states and our public health service will be able to contain it very rapidly and very effectively and that is a situation with most countries. it is an epidemic. but on many levels to continue to do our best to bring this under control now if we get it back to the point where more conservative, more traditional measures of containment can be put into the fact and reverse the tide. >> do you want to comment?

>> basically in the midst of an emergency committee intervening authority has the ability to enact what could be fairly extraordinary and coercive measures at the individual level. this is sort of i think we send the legal framework of those that are domestic and global levels that are permissible and it really depends on the balancing. and i think for those of you familiar with the public law it is the notion of the restraint, so the state has the power and the duty to react but they must also do so with restraint. and these are outlined with an international human rights instruments which is the seer accused principal pie and really i think not just with ebola but any that can enhance upon the race it is whether they are more

legal, directed towards the legitimate objectives from a strictly necessary, strictly necessary to achieve the objectives based on the scientific evidence, but limited duration, and i think that it would be the least intrusive and restrictive measure to achieve the overall objective. i think one of the questions folks have now and the health experts are sort of more knowledgeable of this about whether the notion of regional quarantine is appropriate or sort of individual quarantine enough and i think even if it is sort of completely possible to store someone in isolation and quarantine is it not the least restrictive and sort of intrusion intrusive measure to prevent the case it might not be lawful to do so. >> just going through some of the questions that we've got here but let me -- before we start to these in a phrase which i do think is an epidemic of

poverty, i really do like that and we saw some action last week in the un security council which is something it doesn't typically do in this kind of case that you can argue that that is just the resolution. but it is likely that future epidemics will -- it is plausible that the future epidemics are going to happen in the poor countries with few resources and the global community and international community needs to be mobilized politically to respond if you are going to hope to be ahead of of this or at least in sync with the crisis as it emerges.

it's particularly helpful to the people in poverty but it is also something that we need to do globally. and i just bb that because the larger argument is going to be necessary and whatever we do. >> the trick or part of the trick is to try to stop some of the fear mongering but at the same time continue to be serious about the potential impact on the epidemic not just in west africa but more broadly especially as this begins to spread. the fear mongering i think some people do it with the intention of we've got to wake people up to realize how challenging the situation is because it reminds me a little bit about, you know, i think some of the proclamations about the threats to the national security were overdone in the years after 9/11 and frankly as a mechanism to get people to act on the various issues i think it can be overdone.

the trick is to get the balance where we are not just scaremongering but we are getting that message out in the clear ways about the threats not just in the immediate public health threats but again to the international systems and the views on democracy and the international economic order that have already been taking a hit since the 2008 financial crisis in the invasion of iraq and the rc in the democratic recessions in a number of countries and in the beginnings of the questions of the effectiveness of democracy and the prime ministers of hungary calling for the liberal democracy for example. and i worry that this speed into the narrative so part of what we have to do is get that america's output can convince people of the seriousness of this issue without fear mongering. but i do think that for all of

the pessimism and the challenges , these are matters of choice. as much as this is a natural disaster that comes out of nowhere that we can't completely stop, there's a collective choice in the international community to make over the coming weeks and months. you used the phrase political will but we have in our collective power the ability to begin to a place to do this under control if not stop it in the months to come can we get to the place where this is at least under control and stabilizing if not -- yes we've done it with hiv and it's not over. with the number of deaths in no

area and after escalating for decades have fallen very sharply because of international decisions to fight it and fight it harder. finally people ramped up and made the choices and the resources to the people. we did in it in polio is almost eradicated but not there yet. and this is in many ways similar to those. i render in the early '90s i'd been thinking a lot about the early days of when people were finally recognizing the severity of hiv. and it took international communities way too long to step up, but when we didn't have a big impact and the question for me now is whether we will collectively make that choice. and a lot of this .-full-stop united states not only bilaterally but because of the leadership of the united nations and the world bank and the imf and other places that people still look to the united states.

i worry because there are retired generals saying this is a bad use of u.s. troops. obama is putting them in harms way and all that stuff who still don't recognize the bigger issues that are at stake so there is a lot of work to be done at the good news is that this is the choice and we do have the brains and the resources and the people to bring it under control and i hope that we make those choices. we are beginning to nudge in that direction. we need to move much aggressively. if we do that we can bring this under. we collectively can bring this thing under control i think. >> i'm going to go to the questions now and one that talks about what we've been focusing on in the three countries must immediately impacted, but that this question asks really if we are in a situation where this spread to surrounding countries where we have the next tier out

of synagogue. can you describe do you think we will see more of what we've seen in the three countries as impacted or other more dynamic than here if we see this spreading dramatically in a nearby country? spinnaker think it is obviously speculative. i'm a little bit surprised and i do not fully understand why the disease hasn't spread to other countries. one case in senegal. in the two sites we don't know what is going on with them in nigeria. maybe it has spread to other countries. it hasn't yet reached the point of visibility although i know

that there are people looking on the alert at least in probably the other neighboring countries as well. i know that usaid is conducting regional preparedness workshops now in those countries as we speak taking lessons from the pandemic could hurt this plan that has been developed for influenza. i don't think that we entirely understand the dynamics of this epidemic or how it's spread. we've heard the terms exponential growth and accelerated growth. it's really hard to model the spread of the outbreak even when we observe it up close because not even every county in the countries has afforded the cases. so the way that it moves is not really clear. it seems to move somehow in spurts that will reach a particular area and affect a lot

of people in that area and then we won't see it again and then it will occur in another area and that is what happened in that contributed to that response that although we knew that virus was easily spreading in the forest of guinea there was a period when it became acquiescent and they didn't react because it appeared to be on the wane and very few of the cases would be imported into that there was an explosion and so it isn't clear what the dynamics are. i can't really answer that question except to say that if it does start affecting other countries and there is a chain of transmission established that is parallel to the ones we are seeing now than all of the things that steve said about the economic consequences and the potential political consequences goes into effect with other countries as well

>> the next question gets to the issue of the medical countermeasures and the question really is what do you all belief or is there inappropriate economic investment or emerging measure of the treatment and the vaccines but also looking down the road and i know that you have given some thought to this issue of how do we create the right conditions for making therapy available when science allows them. to the great extent in the measurement of the united states and other countries. >> i think that's absolutely the investment in these types of things should be done, but i think as the doctor can attest to and others, when there are

things framed on the global context, that requires as you pointed out in the political will not just investment, it's not even just about the money or where it is going to come from in terms of if these things are done, how do you figure out the appropriate allocation and it really requires people i think to think about it before hand. so absolutely i think that there is a place to think about making future investments in the medical countermeasures, but folks need to give serious consideration to what the framework will look like. ..