Book Launch – Collapse and Resiliency: The Inside Story of Liberia's Unprecedented Ebola Response
J. Stephen Morrison: Good evening, good afternoon, good morning, depending on where you are. I’m J. Stephen Morrison, a senior vice president here at CSIS, the Center for Strategic and International Studies here in Washington, D.C.
We’re thrilled tonight to be able to host the two authors of this tremendous book, “Collapse and Resiliency: The Inside Story of Liberia's Unprecedented Ebola Response,” Dr. Tolbert Nyenswah and Dr. Mardia Stone. My colleague Mvemba Dizolele, director of the Africa Program at CSIS, will introduce them and offer some framing remarks in a moment.
I want to do two things here in just this brief time.
First is to thank my colleagues who’ve made this event possible. Sophia Hirshfield and Carolina Andrada worked really assiduously in order to make this all happen. From our technical team and our communications office, Alex Kisling, Dhanesh Mahtani, Eric Ruditskiy, Qi Yu, and Craig Grunewald all contributed quite a bit to this.
We have today many family members of our two authors and colleagues, and I want to welcome them all here. I think this is a very special occasion. I’m sure you come to this with great pride in being able to see this book come forward and to be part of this event. So a special – a special thanks to you.
A special thanks to Tolbert’s wife, Josephina, and his three children who are with us, Deconte, Nianakam, and Tolbert, Jr. We’re really thrilled that they could be with us today.
Before I turn over to Mvemba, we’re honored today to be joined by Bishop Samuel Jerome Quire, Jr., who is the United Methodist Church of Liberia area bishop. And he’s going to offer a very brief blessing for us.
Bishop, if you could come up here for a moment and do that, please. Thank you for joining us.
Bishop Samuel J. Quire, Jr.: Let us bow in prayer.
Father, we thank you for this day for this is the day that you have made and we are glad that we are part of it. We pray now, Lord, that you will be in our midst, for about nine years ago, Liberia was engulfed with an epidemic called the Ebola virus disease and you made it possible through Tolbert, Mardia, Steve, Ambassador Malac, and others who helped to bring that disease under control, and today we are here to launch that book to remind us about what happened nine years ago.
We thank you for all those who have come, for the two authors, their families who are here, and we pray now that as we go through this process that your presence will be with us. For we pray now in Jesus’ name, amen.
Dr. Morrison: Thank you, Bishop.
Over to my colleague and dear friend Mvemba Dizolele. Thank you, Mvemba.
Mvemba Phezo Dizolele: Thank you, Steve.
Greetings, and welcome again to the Center for Strategic and International Studies. It’s our honor to host Dr. Tolbert Nyenswah and Dr. Mardia Stone for a discussion about this newly published book of theirs, “Collapse and Resiliency: The Inside Story of Liberia’s Unprecedented Ebola Response.”
The string of public health crises – let’s call them epidemics – Marburg fever, avian flu, and so on – has underscored the need for a new policy mindset, one that elevates human security above state security.
Long before the COVID-19 pandemic jolted us into this reality, countries like Liberia, Guinea, Sierra Leone, and Democratic Republic of – Democratic Republic of Congo have long experience and grappled with this self-evident challenge. How does a poor country – by poor I mean not resources but means, such as Liberia, that is recovering from war; or the DRC, that is still grappling with a conflict in its eastern provinces – how do they mobilize resources when such a big surprise, quote/unquote, “hit them?”
We saw this in the case of Liberia where with the leadership at the presidential level with Madam Sirleaf – Johnson Sirleaf, we saw this at the ministerial level, and we saw also what this could bring when communities are starved for resources.
This was the case in communities like West Point where people thought the new center that was opening in their neighborhood was just to serve them. This is kind of what we also struggled with during the Ebola or during the pandemic – the COVID pandemic – on the issue of vaccines. The issue would determine what policy were put in place.
Do the people of Liberia get the first priority in deciding what will be good for them? Was it the case in Guinea and elsewhere?
My name is Mvemba Phezo Dizolele, the director of the Africa Program here. These are some of the issues that we’ll be handling this afternoon. So in “Collapse and Resiliency” our authors, Dr. Nyenswah and Dr. Stone, present an insider’s view of Liberia’s response to the deadly Ebola epidemic.
Particularly, they rely on Dr. Nyenswah’s fascinating journey from his childhood in a rural Liberian village through a refugee camp in Cote d’Ivoire and to leading the country’s response to the deadly outbreak.
Dr. Nyenswah is senior research associate at the Johns Hopkins University Bloomberg School of Public Health, an internationally recognized legal scholar, and a global public health expert. He is formerly the director general and chief executive officer of the National Public Health Institute, deputy minister of health of Liberia, and the assistant minister of health of the Republic of Liberia.
Dr. Mardia Stone is a senior consultant and advisor in the division of global psychiatry at the Boston University School of Medicine, Boston Medical Center. A global public health expert, she’s formerly a World Health Organization consultant in emergency preparedness and an Ebola response team coordinator, senior and technical adviser to the incident manager of Liberia’s national Ebola response and to the director general chief executive officer of the National Public Health Institute of Liberia, who’s sitting right next to me. (Laughter.) She is the author of “Konkai: Living Between Two Worlds.”
Mardia Stone: Thank you.
Tolbert Nyenswah: Thank you.
Mr. Dizolele: I will invite you to make your remarks to frame the discussion for us today. We can go with you, lady.
Dr. Stone: OK. Well, thank you, Mvemba.
You know, actually in 2014 when Tolbert called me I was in Boston at the time and he said, Dr. Stone, you have to come to Liberia to help me – (laughter) – and I’m, like, to help you? Can you pay me? And he said, we’ll get somebody to bring you here. And so I said, fine, I will come to Liberia because I had this desire to be of service and I felt that there’s no way I could have said no. I could not sit in Boston and wait to see what happened in Liberia during the Ebola response.
And so when I arrived in Liberia in August, Tolbert had just been appointed as the incident manager of the Ebola response. So I hit the ground running. We went to every area in the country by road, by plane, to do an assessment of what was actually happening throughout the country and it was then that I realized that there were a group of people descending on Liberia from all over the world, some of whom knew nothing about Ebola, some of whom knew something about Ebola, some of whom had never heard about Ebola, and some of whom had just followed the money trail to get there to set up NGOs in order to take advantage of what was happening in the response.
And so when we decided to write this book we decided that we would tell the story. The reason it’s called the inside story is because it is the inside story. I don’t think that there’s anybody else who could have told this story better than Tolbert, with me assisting him, because we talk about the politics of government, we talk about the unpreparedness of the government, we talk about the social constructs of the country, and we talked about the rituals that actually people practice every day that was normal for them, the nuances of the culture, and we put it in the perspective that, you know, nobody really knew about Ebola.
All we knew is that 90 percent of the people will die and these people felt that they were going to be traumatized, and they didn’t trust the government. They didn’t trust the government because they felt that the government wasn’t handling the response adequately.
And so we had to decide what would be the method of approach, and in advising Tolbert as his advisor one of the things that we decided to do was to make the government see the Ebola response from a different perspective, to see the response as a government responsibility, as a government problem, and not wait for the development community or the international community to come and take possession and literally lead the response.
And because the government took a while to get to that point, and actually I can say this – that they arrived at that point after Tolbert became the incident manager because before everything was haphazardly done. And once the Ebola response took shape then you had people like the former ambassador, Ambassador Malac, who is sitting in the audience today, who literally ran this campaign with the U.S. government to save Liberia.
And so we thank you for being here today, Ambassador, and we thank all of the people who contributed to bringing Ebola out of Liberia. The story we tell includes all the Liberians who participated in the response. Everybody who had a role to play in the response is acknowledged in this book and we want to say thank you to Steve and CSIS and to you, Mvemba, for hosting this launch. We’re honored to be here, and thank you for your generosity.
Mr. Dizolele: Thank you. You’re welcome.
Dr. Stone: Thank you. (Applause.)
Mr. Dizolele: Sir?
Dr. Nyenswah: Sir, thank you. Greetings, everyone. Today is special. Good afternoon. Good evening. Good morning. I know there are people online in Europe, China, Africa that are listening later this evening.
Before I move on with my remarks, I will, first of all, beg your indulgence or actually, please, if you – if you can, to stand for a moment of silence. The reason we need a moment of silence is that 192 health-care workers – including some of the best medical doctors, internists, surgeons – who did not know about Ebola at the time and the weak infection prevention control system died from Ebola in Liberia. And if you put the number to the region, Guinea and Sierra Leone is even more than that. And 300-plus health-care workers in the country got infected in a tiny population at the time of just over 3 million people. Now it’s about 5 million people. To lose that number of health-care workers was something to me I see very, very hard and really hard. So, in their memory and the other 4,800 Liberians that died from Ebola and got infected, I will ask you to please stand for a moment of silence.
(A moment of silence is observed.)
Thank you. You have your seats.
And in “Born in Such a Time,” which is chapter two of the book, you will find out that if you flip these sheets I dedicated this book to my father, the late Reverend Willan K. Moses Nyenswah, who was a Methodist pastor and his great – (inaudible) – bishop is here. Served the United Methodist Church in Liberia for a very long time and gave birth to a child in a village called Panama in the southeastern part of the country. May his soul rest in peace. And my mother, who is in Monrovia now, and we had great conversation about this meeting today. To them, I salute them.
And, Steve, thank you very much for introducing my family. My wife is sitting right there. This time, we are not separated. We are in one single room. And my kids, Deconte, Nianakam, J.R. – Tolbert, Jr. – are talking about Ebola.
That fearful moment when I was called by the president of Liberia, Her Excellency President Ellen Johnson Sirleaf, that you are called to action, I remember August 11 walking home, and in our hiding place – that how they call it in Liberia – our bedroom, when I – when I look at my darling wife, I say: I have something to tell you, that I was chosen by the president to lead the Ebola virus disease response.
The first thing was she was quiet for a while and said: But why you? Because we listed in in Monrovia, people are in the streets dying. Hospitals closed down. The entire Liberia was on the edge – fear, agitation, frustration. Liberians were leaving the world – Liberia and going out as refugees. And the first thing she said was: I think this is our end. Because families were dying in their numbers, wipe away.
But then I remember very well, as the story is told in the book, my father will have family meeting. I’m a fit person. We pray every morning as a group, kids coming up, and, I don’t know, something he would tell me: You will be a leader one day. You will lead a community, you will lead a society, you will lead a nation, and you will lead a world. So I’m preparing you for that. So that thinking came to mind the next day when I went to the Ministry of Health to take the helm of authority. And so, Madam and the kids, thank you. We are – we are alive to tell the story today.
And President Ellen Johnson Sirleaf, the reason she’s a hero for me is that two great lessons are learned. There are so many other lessons in the book, but I learned a lesson that to lead effectively you must have a support cast, like Mardia sitting here. And the support cast for me were the Liberian(s) that rise up – Liberian technicians, medical doctors, epidemiologists – to support me as the chosen person to organize the Incident Management System. That supporting cast was incredible, and we did what we could do with the support of our international partners.
Another thing is I learned that leadership comes from within. It was Tolbert who was leading the Incident Management System, but the responsibility to lead come from outside. And that’s what President Sirleaf did. If she didn’t choose me to lead, my skills would have been demonstrated as an incident manager, and she stood by me. All of the test of time as a president I had direct contact with her, and I describe that in the book very clearly.
That helped me because Liberia is divided, Madam Ambassador knows, in a hierarchical system. I was assistant minister. If you describe the tier of bureaucratic leadership and all of that in Liberia, an assistant minister reports to a deputy minister, deputy minister reports to the minister, the minister reports to the president. So to have chosen a young assistant minister and charged him with the responsibility when 2,000 people are already dead, schools closed down, the Liberian people was calling the government to resign because they couldn’t do the job, and so I’m grateful to Madam Sirleaf for that and the community of people that we worked with.
CSIS – thanks, Steve. Thanks, my brother. Steve went to Monrovia when everybody was leaving the country, when border were closed. The international world cut off West Africa. The three most affected country were labeled as people who carry Ebola. Those responders from international organizations like the CDC led by the USG, the Chinese, African CDC, and others. And Steve arrived when I was chairing my incident operational meeting. In the morning – 8:00 a.m. in the morning I would start my operational meeting, which would end at least by 8:45, 9:00 a.m. in the morning. Then I start the main incident management meeting about 9:00 a.m. to about 10:00 before going to a brief the president or international responders.
Steve arrived in my office, a little office like this. Show up. Where are you coming from? I’m from Washington. You’re from Washington? Yes. But people are leaving, Steve. Tolbert, I came to appreciate and understand what’s going on. I gave him a couple of minutes’ briefing. I was not in a nice tie like this, white shirt, and sitting down. I was in a T-shirt and briefed Steve.
Later on, Steve sent me an invitation and I spoke right on the podium in 2015 to narrate the story on what was going on in West Africa. Thank you, sir.
Dr. Morrison: You’re most welcome.
Dr. Nyenswah: To the Johns Hopkins University Press – Robin Coleman is not here. When we start – he’s here?
Dr. Stone: He’s right here.
Dr. Nyenswah: Robin? Great. Welcome.
We started this journey. I got to know Robin when I was doing my MPH at Johns Hopkins, 2011-2012. Graduated in May. Robin had an interview with me. President Sirleaf has appointed me as assistant minister. Being in the press, he had an interview with me. Tolbert, I hear your story. You’re going to be appointed as a big man in Liberia. And so he interviewed me and we kept in contact since then. So when the issue of the book was brought up, Dr. Stone and myself we had a discussion, I kept in connection with Robin.
And I will assert to be a leader you must have the support cast, people around you. You can do everything you can do, but they can give you the support to excel to where you want to go. Today we have a book because of the work of Robin and his team from the Johns Hopkins Press. Thank you. (Applause.)
I will give you three essential element, very important, before we go into the nuances in depth with the discussion: the context; the response itself; and then, lastly, the lessons we learned as people and the recovery and resilient process that is beneficial for global health today.
Liberia was recovering from a civil war. Two hundred and fifty thousand people lost their life from 1989 to 2003. The health-care system was broken. Infrastructure were looted. Liberian turned refugees around the world. President Ellen Johnson Sirleaf elected in 2006 trying to rebuild a country. Health-care system in shamble. Health-care workers flee the country, turn into refugees.
Then Ebola struck. It devastated already infrastructure that were not in existence. Then we put in a response. The response was a replica of the United States Center for Disease Control Incident Management System. It was my first time practicing an Incident Management System. When Dr. Kevin De Cock, who was then the CDC lead, arrived in Liberia – and there was a debate between CDC and WHO which response system we should use, but we used the Incident Management System, put command-and-control leadership structure. We put in place case managers, contact tracing, psychosocial support, Ebola treatment units, managing of the dead bodies, social mobilization, deal with survivors – about 3,000 survivors from Ebola in the country. That’s how we mounted an adequate response that was determined to be successful. And the reason it was successful? Liberia was the hardest-hit country amongst the three, but we got to zero before Guinea and Sierra Leone.
And I flew to Guinea and Sierra Leone to also help with their response. And those lessons we learned with recovery, capacity building are all imprinted in here and documented well.
So, Steve, I look forward to the conversation. Thank you.
Dr. Morrison: Thank you very much. (Applause.)
There’s a couple things that jump out in this book that I want to try and hear a little more from you and Mvemba will have some similar thoughts. One is the turning moment in August – July-August of ’14. I’ll say a few words about what it looked like from here but I’d like you to give us a little bit more of a feel of that existential threat and that moment of decision.
Another thing that I’d like to hear more about is your effort to assert Liberian ownership over what was happening. Control of science, control of the research, a partnership – real partnership – and, of course, coordination of the response when you had all of these forces coming into play including 2,800 U.S. military, a USAID DART team, Deborah Malac, and others coming in in a profound, you know, response and you’re there to make sure this is a Liberian response.
You talk a lot in your book about traditional societies, about the challenge in terms of transmission from unsafe burial practices. The decision to go to cremation was very controversial. I’d like to hear a little more about that.
Back to the moment of crisis, here in Washington, you know, there had been a slow burn in ’14 around this, right. There was a slow recognition. There was a team sent out in March-April. That team came back. Did not really sound the alarm. The outbreak sort of declined for a period of time, then came back in June. MSF started to sound the alarm in June. People weren’t paying all that much attention. Then we hit July and August and all hell started to break loose.
I remember Tom Frieden went out for a trip – a visit to the region but particularly Liberia. Came back in August. Went to the White House briefing. They put out a projection that upwards of 1.5 million people might die in West Africa if this were uncontrolled.
President Obama – there was a big – up to that crisis point I think it’s fair to say the White House did not really take this all that seriously and suddenly it turned around, and the key moment, it seems to me – and I’d love to hear your – you saw this – was your defense minister showing up in Washington, D.C., around Labor Day carrying a letter from the Madam President Johnson Sirleaf saying, we are at an existential crisis here and we need a – we’re making a request for a military and civilian mobilization from the United States to break the paralysis and support our efforts here. And, of course, President Obama delivered his famous speech at CDC on September 16th declaring that there would be 2,800 troops deployed and that this would be a priority.
Tell us a little more about that moment. You were appointed August 11th, I believe –
Dr. Nyenswah: Yeah.
Dr. Morrison: – by the president. Prior to that it had been a very fragmented response, triple response in all these different areas, and so this was a moment of real revised thinking and shortly thereafter the WHO had just declared the global emergency and then we had what happened here in Washington.
But say a few words. Mardia, do you want to say a bit and then Tolbert?
Dr. Stone: Well, before August I was in Monrovia with my team from Boston, and there was talk of Ebola but in Monrovia everybody thought that, well, Ebola isn’t coming to Monrovia. It’s all the way in Lofa close to the Guinea border. So nobody took it seriously.
And when Ebola finally reached Monrovia I think that the ministry was totally unprepared because they were expecting this epidemic to be in rural Lofa County. But what happened was between June and July, you know, the amount of people who got infected – there was a traveler coming from Lofa who actually took a taxi from Lofa County to Monrovia and they had a transit point in – near the airport in Firestone and there is where this person was determined to have been infected and taken out of the taxi.
But in the meantime all the other people who were in this vehicle with him continued to Monrovia and we believe that that is how Ebola hit Monrovia because when people arrived in Monrovia nobody knew whether they had been exposed or not. They went into different locations within the city and the next thing you knew everybody started showing up infected with Ebola and that’s how it got out of hand.
But, for me, I had come back to Boston with my group from Boston and at that time they were at Mass General Hospital. And I’m sleeping one morning and Tolbert calls me. He had just been appointed as the incident manager. This is August 11th. And he said, Dr. Stone, you’ve got to come and help me, and I’m – help you do what? I mean, I’m not an Ebola expert. He said, but I need you to help me. You’re the only person I can trust to help and guide me through this process. I really need you to come.
And I had previously worked with Tolbert during his tenure at the malaria control in Monrovia and that’s how we got to know each other. And so I said, well, if somebody is calling me and telling me that if you don’t come to help me I don’t know what’s going to happen I have to go. And my friends and colleagues in Boston said, you cannot go to Liberia. Ebola is dangerous. You’re going to get infected. I said, I’m not getting infected and I’m going to Monrovia.
So I think within, like, five days I landed in Monrovia and Tolbert picked me up and there we just started working, coming up with some strategy, because at the time the Liberians themselves realized that they had to save themselves. You didn’t have this influx of international pooling into the country at that time. So they figure, well, if we don’t have ourselves, we’re all going to die of Ebola. And arriving in Monrovia at that time it was like, OK, I need to protect myself. But I also have to be of service. And so I did. I mean, we traveled all over the country by car into the most horrific places, the most treacherous roads, trying to do an assessment of what was happening. You know, what the health system was in the different counties.
And because the infrastructure had been – had collapsed, people were – health workers had decided that they were not coming to work because they didn’t have the security, they didn’t have the equipment. They didn’t have the protective equipment to work. And so you had this craziness going on. And then every – and then they all went on strike, demanding that the government should give them hazard pay if they were expected to go to work. And so Tolbert would be so distressed. And he would be almost in tears. And my role, coming in as his advisor and technical assistant, was to keep him focused and to keep him in communication with all of the experts from the CDC.
Kevin De Cock, who happened to be a friend of mine. I met him in Monrovia, and I’m like, what are you doing here? (Laughter.) He had come in with the CDC as the team lead. You know, so you had all of these people who came to help. But getting through to the Liberians themselves that this disease is deadly was a challenge, because they were accusing the government of bringing in something to kill off people. You know, but there were all of these different misconceptions about what Ebola was and what it would – was intended to be done by having Ebola in the country.
But the important thing that we decided was that you’ve got to have the messaging, the public health messaging, to turn the people – the orientation of the people, to get them thinking, prevention, protection, and to understand, educate them on what Ebola was, and how they could really protect themselves and stay safe, and stay alive. And so that, for us, was the big challenge in the beginning.
Dr. Morrison: Thank you. Tolbert, the violent confrontation in West Point was part of the story, right? There was – as the shock unfolded in Monrovia, as you point out, people didn’t think it was happening and then the flame was lit, and then you had this escalating confrontation that became very violent. How did that play into the decision to try to get it right, to reset? How did that happen?
Dr. Nyenswah: So to corroborate a story that Dr. Stone just narrated, three different responses were taking place in Monrovia alone. In the Liberian Constitution it is enshrined that when there is insurrection or crisis – so Ebola was seeing, like, insurrection. So the president, who was the commander-in-chief, President Sirleaf, she chaired a crisis management team because it’s war. That’s how the early days of the Ebola crisis was. So she had organized this big team that she herself was chairing. I believe the ambassador was going to those meetings. And the speaker of the house of representatives was going to the meetings, traditional leaders, religious leader. Big conference room of incident managers. It wasn’t incident management at the time, but national response team.
Then there was another crisis management group meeting in our General Services Agency of Monrovia with the logistic team. And then we in health had a technical response meeting in the Ministry of Health, chaired by the minister of health. And these three groups were not talking to each other.
Dr. Morrison: Yes. (Laughter.)
Dr. Nyenswah: So no one knew what kind of command was being given and who’s to execute what command. We, in the Ministry of Health, thinking we’re doing our best. And our traditional partners, you know, USAID have been in Liberia for long, WHO have been there, and I think one of the – MSF after the war remained. They were supporting the Ministry of Health. But then things broke loose. No capacity. People were dying more, as you described, with Tom Frieden going out.
And Dr. Frieden arrived in Monrovia, literally you see dead bodies in the street. My wife, my kids, we had to escape our house for two weeks because someone has taken a corpse, dead body, in front of our gate. My telephone was the 24/7 line that people were calling to deal with the situation. And people in the neighborhood knew that I was the incident manager. So I needed to take ambulances to pick up dead bodies in the streets. So they threatened me with Ebola, corpses, and all of that.
But when Dr. Frieden arrived, between – I think it was in August. And he came to the Ministry of Health. Dr. Wilhelmina has just put me in charge. But let me go back a little bit. Before being the incident manager, I was responsible for psychosocial support and dealing with the media. So I was going from one radio station explaining the epidemiology of Ebola, telling the public what to do. And why, we knew was the case fatality rate of Ebola was 90 percent. It kills people. You get it. You don’t survive. That’s the message we’re giving the people. So I was put in charge. Minister Wilhelmina when the first day introduced me to the team that this is now your new incident manager president, President Sirleaf has asked her – sorry – asked him to put me in charge of the response.
After we have just left a very, very intense, chaotic, health care workers meeting at the Monrovia city hall – were you with us?
Dr. Stone: Mmm hmm.
Dr. Nyenswah: So I went – I wasn’t sitting on the podium. Junior minister sitting with health care workers. But I was taking notes on what was going on. The health-care workers had gone on strike because of no pay. They were frustrated with the minister, and they didn’t want to see the minister. So President Sirleaf was chairing the meeting herself, frustrated. That evening, she went to the Ministry of Health. I walked down the steps while going out, going home. The president just walked by me. Security forces went back upstairs, went upstairs to the minister’s office.
It was – the meeting was just five minutes. I was still standing up. She left, and I received a phone call. Tolbert, at the behest of the president, see me tomorrow. Yes, sir. Walk upstairs. The minister calls me, the president has just left here and says I should put you in charge of the response. What, me? (Laughter.) I said, OK, Minister. Thank you. I will only need a note that the president have asked you to put a charge on your response. And he did that, to his credit. The next morning, he introduced me to this big group of people as incident manager. I could barely pass to go and sit in my seat as incident manager. So I chaired my first meeting.
That day, everybody went home. I went home. Took some notes. And then start to reinvigorate the entire Incident Management System, with the support of Dr. Kevin De Cock from the CDC. They were working under the leadership of Ambassador Deborah Malac. And then brought in some Liberians, appointed a deputy incident manager, two of them – two full deputy incident manager; appointed thematic heads for case management, contact tracing, psychosocial support; and form a small team. So we collapsed all of the other people that were meeting in Monrovia, that chaotic situation, and brought in a command-and-control system with the Incident Management System approach.
Kevin are giving me some notes. They appointed air RADS to work with me on the Incident Management System from the CDC. And the CDC colleagues now are rotating. WHO was also in the room. But this was one other thing. You brought in West Point. Crucial time. Since they were described as a military stuff, to describe West Point, it’s one of the biggest slum community right on the outskirts of Monrovia. A densely populated slum. We constructed or remodeled a school building. And it was – it was set aside for West Point to use. Because we knew that West Point would have been a spot that will produce more Ebola cases because of the conjunction, knowing that the transmission of the disease is by touching, close population, close that people.
So, West Bank got the school building and started off putting sick people into West Point. But what happened was there was this state representative who was using ambulance. He had about two or three ambulances and taking Ebola cases from everywhere you could find them in the street, and took them to West Point, and dumped them in the school building. That was used – the entire city ambulances started trooping into West Point. That got the people agitated. And the president issued an order, that’s some of the lessons and mistakes we learned, and deployed the military to quarantine West Point. When West Point was quarantined, the community got frustrated. We barricaded the West Point community and people came in the street. There was a gunfire and a little boy got killed in that situation. That’s what fueled the West Point situation. And everything went out of control.
But at this time, another mistake – we’ll come to the lessons and successes. Liberia was on fire. Guinea was on fire. Sierra Leone was on fire. The question I was asking myself as international – as incident manager was, this is not the first time Ebola happening. Since 1976. Why was big power like the U.S., global power like the U.S., what was happening to WHO? The major voice in the room was MSF.
Dr. Stone: Belgium.
Dr. Nyenswah: MSF Belgium. Calling the word that – MSF is Doctor Without Borders – calling the world’s attention that there would have been catastrophic if nothing happens. And I was talking to the BBC, talking to the CNN of the world, calling the world to Liberia. It took six months before the World Health Organization would declare public health emergency of international concern. But let me tell you something, if I get the days right, the ambassador sitting there declare her own emergency actually on the 7th. On the 8th, President Sirleaf declared a state of emergency, closed the borders, closed schools, send the government home, before WHO declare public health emergency of international concern. I think that was a mistake.
The word should never – in a reflection piece we said that – never. And I’m happy that we learn a lesson. COVID we declared it sooner than the time. Ebola in DRC was declared as public health emergency. Mpox, formerly monkey pox, was declared a public health emergency. So that’s the signs behind what happened. We can go on and on and talk about history. But Dr. Frieden, I want to end on this note, on this – on this part of it. When he went to Liberia, he sat with me one-on-one and said, Tolbert, our first priority is to remove the dead bodies from the street. We will give the support – the U.S. will give the support to the International Federation of the Red Cross, working with the Liberian Red Cross, with trained dead body management teams, and remove those dead bodies from the place, start to build Ebola treatment units. Went across the country, as Dr. Stone said.
And all of these internationals, from China, from Cuba, from the EU, African Union was great to give the support. And we never had place to build Ebola treatment units. I remember the president and the ambassador, my counterpart at the time – you know, the CDC rotates. It was Jake Tappero – Jordan, sorry. Jordan Tappero was the head of the of the CDC at a time. He called me up. Tolbert, the ambassador and the president are coming out. We need to go and find Ebola treatment units, where to build them. I say, OK, Jordan, I’m available. I think, Dr. Stone, you went with us that day. The Ambassador was in a convoy, the president was in the convoy. We went to the stadium, this football stadium was identified as one of the sites. We went to the Unity Conference Centers, where we have conferences; was identified. We went to the international airport. It was all over the place, president and ambassador in the convoy, moving, finding space to build Ebola treatment unit.
Dr. Morrison: That’s great. You know, we – looking back, it’s kind of astonishing to recall that the U.S. government chose to deploy up to 3,000 troops to Liberia to break a public health emergency in partnership. I mean, that was unimaginable, and also would have been unimaginable to have Joanne Liu, the then-president of MSF, communicate to the White House her support for military intervention in these circumstances. That’s how extreme it seemed.
Mr. Dizolele: Thank you, Steve. Thank you, both, Doctors, for your presentation here. Makes me think of the plague, you know, to hear what you talk about, people dumping bodies in front of other people’s houses, on the street. On one level, it’s a story of people giving up. On another level, it’s a story of a lot of resiliency. So kind of, they go together. So I think for those of us watching from – I’m Congolese. I was not there when Ebola started, but I’ve read – I’ve gone back to the declassified cables. And it’s interesting, the Congolese government, Mobutu at the time, was very forthcoming with the new disease. They held press conferences. He talked about it to the population. He put military airplanes at the disposal of the doctors. When I read the declassified cables, Zaire decided there was an emergency. They’re going to announce it to the population. The CDC – the embassy and the CDC in Kinshasa, and the CDC in Atlanta, we’re fighting, trying to decide what do they tell the world?
Dr. Nyenswah: Similar thing. (Laughter.)
Mr. Dizolele: So it was very interesting. It is clear what’s happening, yet the Americans are fighting among themselves, like, what do we announce to the world? So a question is, it was obvious in the case of Nigeria that there was a breakdown in public trust. Serious public trust breakdown. You described that a little bit, Dr. Stone. How you, as a technical team, do you work? How do you work with other agencies to rebuild this trust in the system in Liberia, so that people actually can believe what you’re saying? So they don’t believe it’s something made in the lab in Atlanta, as people had said about AIDS and HIV, that this was fabricated somewhere as part of the U.S. CIA NBC program, right?
So how do you rebuild that? But also, how do you reclaim – Steve alluded to this a little bit – how do you claim reclaim this management? In the words of the Congolese at the time in ’76, that said: We got this. It’s a disease. We’re going to communicate to our people. So what happened in your case?
Dr. Stone: Well, I’m glad you mentioned the Congo situation, because the epidemiologist who actually identified the Ebola virus came to Liberia with a team of five people.
Mr. Dizolele: Dr. Muyembe?
Dr. Stone: Yeah, Dr. Muyembe. And I believe that was the turning point in the response strategy, because he – the WHO rep sent for him. They came to Monrovia. And we had all of this big meeting. And they actually said, you know, you can contain Ebola yourselves. You don’t need a whole – you need some of the expertise and the resources coming from the outside, but in terms of containing it within the country, the Liberians can do that, if you know how. And so what he did with his team was to sit with the WHO and the rest of the Liberian team and tell us the strategy on how they were able to combat small epidemics, you know, of Ebola, because they had multiple epidemics of Ebola. And they never had more than 50 or 100 people at one time.
And once he came – once a Congolese team came to Liberia and we had this big meeting, that changed the approach to the response, because then community involvement became essential. The messaging became essential. The public health messages, as Tolbert said earlier, was that Ebola kills everybody, you know, practically. Ninety percent of people will die. And so the messages had to be changed to tell people that if you learn how to take care of yourselves, prevent Ebola – handwashing strategies, no touching, no kissing, no hugging, no shaking hands, all of those things that were –
Dr. Nyenswah: Yeah. Then for the other one, that – no eating something. (Laughter.) Certain things.
Mr. Dizolele: You think something wild from the – from the bush.
Dr. Stone: No eating something in Liberia means no having sex. (Laughter.)
And so – and so all of that came – you know, all of those conversations were being held. And those messages were literally being designed graphically for the population that couldn’t read or write, so you had all of these graphic pictures being disseminated all over the country. And so once the messages were changed and people in households – whole households died – you had in one household seven people, 10 people who die because they were all infected, and then people started hiding the sick and burying the dead. So we had to combat all of these. We had to confront them and say you cannot do this.
So how do you – how do you embrace the cultural nuances and still instill public health prevention into these people? And that was one of the challenges.
And once social mobilization and community engagement became centerpieces for the response, the people began to respond more positively. And I think that was a turning point in – that was another turning point in the Ebola response. And that’s how, after – by December, you had fewer and fewer and fewer cases of Ebola in Liberia.
Dr. Nyenswah: So if you look at the science first, before I go to the communication piece, we publish a paper, what turns around the Ebola epidemics. And we catalog the reproductive numbers and time series of what happened in the response. One of the major evidence we capture was community engagement and what the community people did themselves. Before the international euphoria arrived and the support by September and October, you see the epidemiologic curve have already bent because of that community cohesiveness, support, and community mobilization.
And we did multiple communication channels by mass media; talking to people, interpersonal communication; smaller groups getting together. Handwashing was promoted. UNICEF play an incredible role, as Sheldon Yett – I understand he was supposed to be here – who was the head of UNICEF, worked very hard with the community of people. The chiefs, the herders, the traditional people came together.
Today, there are people who believe – who still believe that Ebola was manufactured somewhere and taken to Liberia; that is it not a zoonotic disease that caused that. And there are people who will live with that forever, the conspiracy theorists or, you know.
But one of the strategy was for community engagement I had to literally lead a journalist and the press to Ebola treatment units where people were dying and who was getting infected. There were communities that were mobilized themselves and would carry out social mobilization, a community mobilization team there to talk to people and educate them about the disease. Then the community started cascading and doing support for that. Health-care workers were dying. When colleagues saw a difference, they started practicing now the IPC – that’s the infection prevention and control – practices.
And so community engagement got real bottom-top approach. Every county had their community engagement groups coming together. We would go to the press. I was briefing the press every day at a specific hour that I had to do go the Ministry of Information. They organized a press briefing session that I would do to raise communication, community engagement support. And there were groups all over Liberia that were training the community to disseminate messages.
But when people fear for themselves, it can change behavior. And one of the major difficult part in any outbreak response is behavior change.
Dr. Morrison: Yes.
Mr. Dizolele: And part of – one thing that you mentioned in the book is health-care workers – EMTs, nurses – refusing to deliver babies.
Dr. Stone: Well, yes. And for me as a gynecologist-obstetrician, that was concerning because where would the pregnant women go? You know, they couldn’t go to – they couldn’t go to the hospital because they were turned away, and the reason is because the health-care workers were afraid of being contaminated with the blood. You know, labor and delivery is a very bloody event. And so they were saying that if we bring in all of these pregnant women and have them labor and deliver, the risk of getting Ebola is much, much greater, and so they refused to have them. People had to –
Dr. Nyenswah: Turn away.
Dr. Stone: Literally, some people were delivering on the streets. Some people were delivering at home. And there’s one situation where this woman was pregnant and it seemed like she had a breech presentation, and so they were doing a home delivery. And in this home delivery, because the baby wasn’t coming, people put the compression on the uterus, on the fundus of the uterus, and literally forcing this baby to come out. And she ended up with a ruptured uterus, which was a fatal event.
But you know, these kinds of things were happening, and so people became more concerned with creating situations, creating a facility where people who didn’t have Ebola could get care, because most of the people who had chronic diseases like hypertension, diabetes, heart disease couldn’t get care because all of the facilities had shut down. And so if you had a chronic disease, you literally were at risk for dying because you couldn’t get the care you needed. And in the case of the pregnant women, it was a(n) ongoing situation for a very long time in the beginning of the response.
Dr. Morrison: May I? We’re getting towards the end of our hour, and I want to ask Josephine Nyenswah to speak and say a few words about how she saw this and experienced this. And I’d ask – like to ask –
Dr. Nyenswah: Krimisha (ph).
Dr. Morrison: Pardon me?
Dr. Nyenswah: And Krimisha (ph).
Dr. Morrison: And I’d like to ask Ambassador Malac to say a word, too. If both of you, with a microphone, could just stand up and say a few words. Josephine, thank you so much for being with us.
Josephine Nyenswah: Thank you.
I was a little afraid when he came home that day to tell me about the appointment and worrying about us as a family. But I gave him hope because I knew how tense the country was and how much people were on the street, and most especially, one of our neighbors died. And actually, you just need to get it, as the head, as you were appointed.
But one of the situations that had me panicking as a model to our kids was when the – when he led the group, he went to do a burial with, I think, over 500 persons in a truck. And so my – (inaudible) – and he stood – they stay there up to 3:00 or 4:00, the morning hours, because the community refused for them to do the burial. And when I kept calling and calling and calling, he was, like, Josephine, why am I so afraid? We had to call police to come over because the community deny us. (Laughs.) And finally, he got home.
And I just had that thought. I told one of the boys living with us to bring water in a bucket with some chlorine, and I chlorinated our water. And I was, like, hell, you’re not entering this house today, Nyenswah. (Laughter.) He said, why? I said, no, you’re taking off the clothes, you’re washing. (Laughs.) You are turning the front lights off. He’s going to take shower right here. And from that day he wanted – every day I ensured that he – (laughs) – he took off his clothes and have a shower out there with chlorinated water before he go home.
But I’m so grateful today that we are here to discuss Ebola, too. It was terrible as a family and we’re so worried about him being the lead, but we are grateful that at least he brought Ebola to an end for our country. We are a proud people. Thank you so much for this unique occasion.
Dr. Morrison: Thank you. (Applause.)
Deborah, why don’t you come over here. I should have done the same with Josephine. I apologize. Why don’t you come here so that you are on camera.
Ambassador Deborah R. Malac: Oh. I’m not sure that’s a good thing, but – (laughter).
First, thank you, Steve. It’s wonderful to see Tolbert and Mardia again. Reliving – as I read your book, reliving some of those very dark times and I think some of the very positive times. And you have talked about some of that today, about how we were able to, you know, supporting the Liberian government, supporting President Sirleaf’s leadership to really work together. And that was our approach, was to keep the Liberians in the lead and let you make – you know, make the decisions and us support you as we needed to do. It was – it was a difficult fight, but it was something that I never doubted that we would eventually overcome.
And it is – you know, we talked a little bit, Tolbert, about leadership, making the point about what is important. I think in these crisis situations leaders emerge, people who you may not assume are the person that you want to be in charge – an assistant minister – or it could have been anyone. To see the number of Liberians who came both from within Liberia or came home to help was really heartening, and to see the capacity and the ability there.
But the one point I would make is – and I hope that this is the lesson we take from the book, which we still haven’t learned completely, which is investing in building capacity in every single country; that global health, that disease-response capacity is absolutely fundamental. And we all need to be part of it. It doesn’t need to be funded solely by the U.S. or by any one entity. But if we ignore it, we ignore it at our peril, as we learned firsthand during the fight against Ebola.
So I congratulate you on your book. I enjoyed reading it. I learned a lot about Tolbert’s past that I didn’t know at the time. (Laughter.)
Dr. Nyenswah: Thank you, Ambassador.
Ambassador Malac: So thank you. And thank you for your leadership, again, on all of this. And thank you, Steve.
Dr. Nyenswah: Thank you.
Dr. Morrison: Thank you. (Applause.)
So there’s many topics we could go into depth, but I think we’re getting to the end of the hour, and we want to have a break and a reception and sign some books. So I’d like to ask our – my three fellow speakers to sort of offer a closing note around, you know, what gives you the greatest optimism and hope coming out of this experience, which was such a profound experience. Why don’t we hear from Mardia and Tolbert, and then Mvemba gets the last word?
Dr. Stone: First, I’d like to thank all of you who are here today to celebrate with us the launch of this book. And my friend Louisa (sp) and her husband, Matthew, came all the way from San Diego to support me. So thank you. (Applause, laughs.)
And my siblings are here. My older brother Todd and my brother David, my cousin Wachen and William, who gave us – Tolbert and I spent several months meeting at their house in Baltimore to work together on this book, and they are here today to celebrate with us. So I want to say thank you.
And for me, participating in the Ebola response in Liberia was, for me, my career high. I had had many highs and many lows, but that, for me, was a big, pivotal moment because I got to see firsthand how to deal with this massive epidemic of global proportions. And I got to work with someone who, even though I was a technical assistant and advisor, he listened. So it made my work easier. It made – and we had to literally stick together in order to fulfill the task that we had at hand.
And so the Ebola response opened my eyes in so many ways. I saw the politics of government, the politics of international health. I saw the politics of intellectual properties and all of the fussing and stuff that goes on behind it. (Laughter.) And so I’m grateful that I had the opportunity, and I’m really grateful that I took the time to allow myself to go without fear.
And so I thank Tolbert for literally having the confidence in my capability to call me on the phone when he was declared the incident manager for the Republic of Liberia. And so I am just – I am just excited. I’m elated. I thank Robin. (Laughter.)
Dr. Nyenswah: Who you haven’t seen before. (Laughs.)
Dr. Stone: I mean, we’ve gone through a lot of iterations before we arrive at this point. (Laughs.) So thank you for your patience, and I’m just grateful for everybody, all of my friends. Anne Hawkins, I hadn’t seen for quite a while. I mean, for all these people who have come here to support us today. And to you, to C(S)IS, and to you, Mvemba, thank you for this delightful event.
And one person I forget, Sophia. Where is she? All the way over there. She sort of coordinated us in getting this thing to happen.
Dr. Nyenswah: Yes. Sophia, great job. (Laughs.)
Dr. Stone: So we are – we are blessed to have your support and your generosity in hosting this event. And also to the Gates Foundation.
Dr. Morrison: Thank you. Thank you. That’s so gracious of you, Mardia.
Dr. Stone: Thank you.
Dr. Morrison: Tolbert, I don’t know if you can top that, but give it a try. (Laughter.)
Dr. Nyenswah: So I said something in the book that Ebola was a blessing in disguise.
Dr. Morrison: Mmm hmm.
Dr. Nyenswah: And the reason is that, with what we went through and how we did it, we built some capacity and resiliency. And this is why, when the title of the book – “Collapse and Resiliency” – was intentionally after we discussed with our acquisition manager.
Immediately after Ebola, global health security was introduced to Liberia, the global health security agenda. And I led the establishment of the first National Public Health Institute of Liberia through the effort of CDC, WHO, the ambassador of the USG, and other partners. And the National Public Health Institute, we took also component of some units within the Ministry of Health, did some state tours. We went to Italy, Thailand. We took Europe, Asia, and the United States. I was at the CDC and met with Dr. Frieden and his team. And then we signed our first cooperative agreement – co-op – with the U.S. CDC and pumped some money into establishing the Public Health Institute.
That built capacity for three epidemiologists. It was the first time Liberia had three epidemiologists. We trained, before I left Liberia in 2019, about 300 to 400-plus of them, disease detectives and intelligence, in all 73 health districts in Liberia. So I can sit here, and if you talk about mpox in Maryland or you talk about Lassa fever or you talk about any disease, I can sit here and call the three epidemiologists that we gave you a detailed description of that disease. We built laboratory capacity in Liberia that we can test for over 16 different pathogens and store them in Liberia.
We also put together a monetary valuation system and built IDSR. IDSR is integrated disease surveillance system in a country, across the entire country.
So that capacity building have paid off. When COVID struck, Liberia was one of the country with few – very few deaths, and people knew exactly what to do.
And some of those lessons, I brought them with me to the United States. When I got here, when COVID struck, one of the things that the United States was struggling was contact tracing.
Dr. Morrison: Yes.
Dr. Nyenswah: Contact tracing, I remember the journalists were calling it “contract tracing.” (Laughter.) I said, no, it’s contact tracing – (laughter) – and not contract.
So, at Hopkins, my colleagues and myself in the Department of International Health, we developed a contact tracing course – and I spell that out in the book – that trained 1.3 million people. All U.S. 50 states’ health departments used that contact tracing course to certificate people before they employed them in the United States as some of the lessons learned from Ebola that we brought here to a high – very high-income country. And so – and as I said about that – (applause) – thank you. Thank you. Thank you.
And one thing I learned to close on, Steve, thank you very much for the support. As I said in my TC statement when I started, effective leadership, there should be a support cast. And you are some of the people, and you, and Robin, and all of you in the room here.
And with all the geopolitical tension – Ambassador, I will close on this note. With all of the geopolitical tension with China, United States, one – two critical meetings that happened, the inside story – the inside story, right?
Dr. Morrison: Yes.
Dr. Nyenswah: My friend who was the head of China CDC, George Gao, has sent Chinese to Liberia. The United States have just sent CDC folks to Liberia. We met in one conference room. Let me tell you something: The geopolitical tension was eased. We were discussing disease and epidemiology. The Chinese and the American were working very closely together to do that.
And then the U.S. military was deployed. I’m very excited with the generals that I work with. I learned a term from a general, General –
Dr. Morrison: Volesky.
Dr. Nyenswah: Gary Volesky and Darryl Williams. When they went to Liberia, the Liberian population thought the United States are sending military to overthrow the president. (Laughter.) That was the discussion. I saw the ambassador explain to the president: We didn’t come here to overthrow you, Madam President. (Laughter.) And we worked with the generals. I remember Darryl telling me that we are here to support the civilian authority, and so they did everything. I flew in the Black Hawk with the general, went across Liberia to build Ebola treatment units.
So I’m excited. And thanks, all of you, for coming. You have busy schedules. Thanksgiving is right in the corners.
I want to thank my friend Sam Johnson for coming from all the way Delaware with his daughter. Alicia, please stand. Sorry. I hope I didn’t embarrass you. And then Mr Jackson – (inaudible). My brother Thomas, Reverend Thomas Nyenswah.
And all of you in the room, thank you. It was very terrific. We appreciate your time. It’s a privilege. I hope I’m invited in this conference room again. (Laughter, applause.)
Mr. Dizolele: Well, thank you to our friends who joined us today to attend this, but particularly to the two doctors – the two good doctors. (Laughter.)
I think it warms my heart to see the long road that Liberia has traveled on this. Stories of pandemics, and the pandemics tend to cast Africa through a certain light, and it’s typically not a good light. So groups like ours, CSIS, we work hard to breach that narrative. It is obvious – we saw this with the Ebola – the COVID-19 pandemics, where a lot of the knowledge that the Global South has garnered over the years was actually ignored by the greater North, right? The entire protocol, the decision-making of what – how the world should behave during the pandemic was made in the North when, in fact, there were many doctors like yourselves and across Africa who had knowledge. They were not consulted.
So I think as we’re going through the next round of whatever crisis is going to befall us, I think this is something Steve, myself, and other analysts really want to push, that there is knowledge in the South. I’m much more comfortable with a Ugandan doctor, a Liberian doctor when I get sick then I would be with a Norwegian doctor. So when I come back, I always bring my malaria medicine, partly because I’m afraid if I go to Georgetown I will become a case study. (Laughter, applause.) They’ll bring all the students, come and look at me, and trying to decide what it is, and then three days later they will send my blood to Louisiana. By the time the result come back, I may be dead. (Laughter.)
So, anyway, I want to say thank you on this note. Steve, thank you for assisting the Africa Program.
Dr. Morrison: Thank you.
Mr. Dizolele: Back to you.
Dr. Stone: And may I just say one thing? For all of you in this room, this book is the only one of its kind, the inside story. There’s nobody else who can tell this story. So if you are so inclined and you get the book, you’ll really know what happened in Liberia. There’s no other Ebola book like it. And that’s just my pitch. (Laughter, applause.)
Dr. Morrison: Thanks to all of the staff who made this happen. Thanks to everyone who’s here for – online and in person. Apologies for our delays. We’re very pleased that you stuck with us. We’re now going to adjourn. And those of us who are here, please join us for a reception and a book-signing exercise and a chance to have a glass of wine and some hors d’oeuvres and relax and spend a little more time together. Thank you.
Dr. Nyenswah: Thank you. (Applause.)