 I didn't even have to try my kindergarten tricks. Excellent. All right, I'd like to welcome you all here to this afternoon's panel. My name is Julie Fisher. I am an associate research professor here in the Department of Health Policy. I'm going to introduce our panel briefly and then turn to them for remarks. So this is a very exciting moment for the global health security agenda, especially for those of us in the private sector. So this is the transition from speculating on what measures will look like to moving toward meaningful action. Unfortunately, the will to move from policy into action is often catalyzed by crisis. I do not need to review the crisis that is going on in West Africa now. It has been discussed this morning and it has been discussed extensively over the past weeks and months. Instead, I will turn to our distinguished panelists and ask them to elucidate the lessons that we are still learning from the ongoing crisis in the response to the Ebola virus outbreak in West Africa. And I'm asking them to reflect on the immediate needs and to discuss what is possible, what it will take to recover and to rebuild, and what it will mean in the context of GHSA to strengthen health systems for the ability to respond effectively and rapidly to future events. So the full biographies are in your packet and were I to detail their illustrious histories, we would still be here much later in the afternoon. So I will very briefly outline and welcome you to look in those packets for details. So first, we are very, very proud to be able to claim Dr. Ron Waldman here in a Department of Global Health at George Washington University, Milken Institute School of Public Health. Sorry, Dean Goldman. Ron has been a pioneer in understanding the epidemiology of refugee health and understanding an evidence-based approach to international response to emergencies. He has applied that knowledge in responding to some of the most profound, complex, humanitarian emergencies of our time and in helping to coordinate responses from both the US government and from international organizations. Dr. Joseph Fair is one of the few people in the world who can be justifiably called a famous virologist. And he has spent the bulk of his career helping to build the capacities for laboratory diagnosis and for understanding emerging infectious diseases in sub-Saharan Africa and beyond. And finally, Dr. Scott Dahl, who has very recently joined the Bill and Melinda Gates Foundation after a long career at the US Centers for Disease Control and Prevention, where he worked on infectious diseases, responding to outbreaks, and establishing global disease surveillance and outbreak response programs, including directing the division of global disease detection and emergency response, and leading the agency's global health security agenda development. So with that, I would like to turn to Dr. Waldman. Thank you, Julie. Thanks for having me. I always think when somebody says that it would take a long time to list your achievements, it just means you're very old. So thank you for that. I have done quite a lot of disaster relief and things in my lifetime. I've done that for the US government from both the CDC and USAID perspectives, and I've worked considerably for WHO. But today, I'm actually here presenting the on-the-ground plans for Save the Children. This is the first time I've worked with a non-governmental organization, and it's quite a steep learning curve for me. So I hope I represent them well. I'm functioning as the team leader for their Ebola response in Liberia. SAVE is active in all three countries and is approaching the problem a little bit differently in all three. And I hope I'll get a chance to explain the reasons for that. We have a team on the ground in Monrovia, and it's moving quickly to implement a particular strategy for response. And I'd like to take the opportunity to outline that strategy, since we're talking about what NGOs might be able to do in response to this outbreak. So I'm going to run through it, and then I'm going to address a few of the constraints that we are facing. And I think I would like to make some general remarks and concluding about the role of NGOs in responding to this type of disaster. So basically, we have six planks to our strategy, if I can refer to them like that. The first has to do with taking care of people affected by infected with the Ebola virus, and that involves providing them with treatment. And in perhaps at least equal or maybe more importantly, making sure that they are isolated and that the opportunities for transmission are reduced to the maximum extent possible. When it comes to dealing with Ebola patients, there's really three levels of care that we envisage. The first has to do with Ebola treatment centers, which were mentioned prominently this morning. These are the hospitals, the kinds of 100-bed units that President Obama has announced the US would be providing. And these exist in small and inadequate number in all three of the countries. They're concentrated primarily in the larger urban areas, almost exclusively in the capital cities in fact, although there are a few on the outside. And as you can imagine, by this time in September, the numbers of cases that are occurring are far, far, far more than there are beds available in these hospitals. So I think many of you have seen in the press and other accounts of people being turned away, actually, from the doors of these hospitals and sent somewhere. Nobody knows exactly where. In order to alleviate the pressure on these large hospitals where infection control is done in the best possible manner that can be done under the circumstances and transmission maximally reduced, in order to relieve the pressure on them, we've come up with a proposal to provide an intermediate level of care much closer to the community itself, rather than 100-bed units with excellent infection control. We're proposing to put up and staff a much larger number of 20-bed facilities close to the community, where infection control would not be quite as airtight. The term that I use to describe them is that they are leaky, but they represent actually the major focus of our strategy. And we think we can help quite a lot to alleviate the pressure on the hospitals. The third level of care, which we're trying to avoid, although there's considerable discussion around this, has to do with providing care in the house itself, in the home, in the household. And the reason that we are somewhat reluctant to propose that and promote it in an aggressive way is that in most of the settings that we're talking about, whole families live in one room so that exposure is likely to be, many people are likely to be at risk should they attempt to care for an ill person in the house. We prefer to be able to diagnose as early as possible and remove the patient from the house to somewhere in close proximity to the community, where they can be cared for by a single family member so that the risk of exposure would be present, but less than it would be without this kind of intervention. The second plank of our strategy has to do with a major effort at behavior change and communications, one of the real sticking points we heard this morning regarding the disease and transmission of the disease is that people have a poor understanding of what it is. And people really, for that reason, are afraid of it, deny it, stigmatize those who are associated with it, and attack those who come to present it. And these are all situations that can be reversed, that can be addressed, that can be reversed. And it takes a coordinated and consistent messaging strategy that gets out to peripheral areas and households, not just once, but repeatedly. And I don't think that enough of this is being done right now, so I think getting out to the village level is something that really needs to be pursued. This was actually the goal of what's been called the lockdown in Sierra Leone that I think has been misinterpreted widely. The goal wasn't to lock people up in their houses so they couldn't get out and spread disease. The idea that the government of Sierra Leone had, and you're all familiar with the strategy that was implemented this weekend, was to go from house to house, explaining to people what the situation was and telling them what to do, should a household member become infected, and so on and so forth. So in that sense, it actually did make considerable sense and had a good rationale behind it. The third plank of our strategy is to deal with the very important problem that I think is being increasingly recognized, but not adequately addressed, and that is that many people are contracting and dying from nonibola disease because of the collapse of the health systems in all three of these countries. The fact of the matter is that these are countries that had fragile health systems to begin with, and people with potentially life-threatening diseases like malaria, like enteric diseases, like pneumonia, particularly children in whom those conditions represent three major causes of mortality, plus women with emergency obstetric complications. These people have no place to go right now, and if they do go someplace, they're likely to become exposed to other people who are visiting those health facilities should they be open with Ebola virus disease. We need to do a lot more starting now to begin the rehabilitation of these health systems that have fallen apart that can be done. We need to do it with extra added layers of infection control, and somehow we have to find the health staff to reopen these facilities, whether they be primary health care facilities all the way up to the hospital level, and to provide appropriate diagnostics and care, because otherwise, except for Ebola virus disease, there's no care taking place basically in these three countries. From our point of view, it's important for a variety of reasons to make sure that people have the necessities of life. We're going to hopefully become involved in a major food distribution program. I'm using food distribution as a kind of slang term, an all-encompassing term. I don't know if that's exactly gonna be the strategy, or if there will be a voucher system developed, or if there'll be tax distribution, but the fact of the matter is, and I was at a symposium at Georgetown University the other day, where it was reported that the economies of these countries is completely tanked. There's no productivity now. The sources of revenue for the government have dried up. Many of them have as major sources of revenue other import duties, and imports are not happening now because of the travel restrictions that have been privately imposed. In addition, indigenous industries, mining, oil production, so on and so forth have all ground to a halt. So the revenues coming to government have sunk drastically, and people, obviously many, many people have been put out of work by the collapse of the economy. So food support is really necessary, not only to the treatment centers, not only to villages where there are people infected, but actually for the time being to a large proportion of the population. I think that this is not as recognized as might be. The distribution of food or other kind of livelihood support is also essential to gain people's trust and confidence, which is a very important element in having people actually take ownership of the required interventions by themselves. I really doubt that we're going to be able to bring a halt to this epidemic through imposed measures. I think that it's important for us to promote the local ownership of measures that are required to reduce transmission. Perhaps a little bit particular to save the children is the area of child protection. But there are growing numbers of orphans, there are growing numbers of street children in the major urban areas, and young children who are unable otherwise to fend for themselves, who are amongst the most vulnerable groups affected by the epidemic require clear protection from both. And it was brought to my attention earlier today that the Ministry of Social Welfare in Liberia, where we are primarily located, has been decimated as well as the Ministry of Health by the outbreak. They need hundreds of social workers, they need means of transport to reach these children. I'm just trying to paint the picture where we need to look beyond the health sector because all aspects of society have been affected by this epidemic to this point. When we talk about rehabilitating schools or in the interim providing educational materials, we're doing that in order to avoid a lost generation from developing in these countries. Being out of school for a year is a real tragedy, not only for the individuals who are affected, but for the society and for the country itself. So when we talk about working in the education sector, in the agricultural sector, because the harvest season has been lost, not only interestingly in the three affected countries, but in the surrounding countries as well because of the fear there that groups of farmers and farming in the areas done by groups of farmers, collectives, there's a real fear of contracting the disease. So it's the consequences of this epidemic go far beyond the health sector. And I mentioned it particularly because many of the activities that are required fall in to the traditional realm of development NGOs, many of whom are represented here. So I think we have a reasonably smart and even feasible plan laid out, but there are some serious constraints. And so far, what we've found to be one of the real bottlenecks in this situation, much more so than in others, has been the inability to find qualified personnel. I don't know entirely why this is, we're doing a little survey to see why even within an organization like Save the Children, those people who normally rush to the forefront to respond to emergencies like this are hesitant to do so in this case. So I don't know if it's because the possibilities range everywhere from the fact that medical evacuation procedures haven't been worked out. So people know that they can go, but they're not so sure that they can be taken out. Should they fall ill? They range from that kind of narrow concern all the way to the fact that if you think of what's going on around the world, most people who want to engage in humanitarian assistance and emergencies have been engaged in the past year. It's just a time where so much is going on from last year's typhoon in the Philippines through the situation in the Middle East, through the crisis in the Central African Republic. And even back a few years to the earthquake and collar outbreak in Haiti, there's just been an exhaustion of the humanitarian assistance community. That's another possibility. As I say, I don't have data to explain why it's so difficult, but it really has been to the point where it's unclear to me, and I love the opinion of the others, as to how the 17 100-bed hospitals that have been promised by President Obama are going ultimately to be staffed because I can tell you that from the Save the Children perspective, we're committed to building one 80-bed hospital and staffing one 80-bed hospital in Freetown, and we're having tremendous difficulty coming up with enough appropriately qualified personnel to do so. Secondly, although it shouldn't be the case, money's also an issue, it always is. There is funding, and more funding can be promised, but the question is whether that funding is gonna be put to the appropriate use, and whether it's going to be released quickly enough to make a difference. I have to really say that USAID is often a foreign disaster assistance. From my dealings with them has been doing a really great job. They've really prioritized this, put a very excellent team in the field, they're of course overwhelmed, whatever happens. They can't process proposals fast enough to approve them, put the money out. And I can tell you, it's really interesting for me being now inside an NGO and seeing how they actually operate, Save the Children's very fortunate to have a little bit of leeway. There's like a slush fund that they can draw on and commit their own funds once they become sure enough that funding's gonna come from other sources and that's what we've done. But for smaller NGOs that don't have those means, they have to wait until they get the money and then they can start doing their procurement and that takes weeks to months and then they have to get it out there and everything slows down. It's not as if when someone says, okay, we're really gonna respond to this now, that the next day there's going to be a response. Even for us now trying to get these Ebola care centers, we're planning to have all of our materials in country by the middle of October, although we've been, so it takes about a month, even with the most expert logistics and procurement people in a very experienced agency to do that. I think another problem has been that there's an inadequate understanding of this disease, of its epidemiology and of its potential consequences on the individual, on the society, and on these countries as a whole. And there's a lot of misconceptions that I think need to be clarified that I'm sure will come up during the course of the conversation. So I just wanna end up then by saying that this is, we're speaking about Ebola primarily on this panel because it's such an obvious example of why we need a global health security agenda and why we need it to be so broadly addressed, not only by one country, but by many countries around the world. But I do wanna remind everyone that it simply isn't true that doing anything is better than doing nothing because there are specific things that can be done. We have very clear strategies that ought to be implemented and making sure that everyone involved as more and more people are invited to participate in this broader program or even in the more specific programs. When more and more people become involved, it's really important to have clear, coordinating structures. And the problem with coordination, there was a diplomat at the UN who used the phrase a long time ago that I like quite a lot saying that coordination is the slowest common denominator between actors. And I think that's probably the case and slow is not a good word to use in emergencies. So these coordination mechanisms really need to be thought through and put in place before the event occurs. There was a discussion in the first panel today about how when we have an event like Ebola virus, that's when we all get excited and mobilize then. It's exactly the wrong time for that. It really needs to be done in during the inter-emergency periods and that's the longer pull of the global health security agenda that was, it was said this morning that that would be the most difficult thing to assure is that people keep their eyes on the ball throughout. I think that in regard, one more thought in regard to Ebola is that we just can't deny that the response was very late. The outbreak began in December in the forests of Guinea. By May, MSF had said that their resources were overwhelmed and they called for a much, much larger international response. World Health Organization declared a public health emergency of international concern in August. We're sitting here at the end of September and I'm telling you that a large agency like ours has plans but we haven't really implemented anything yet and probably won't until the middle of next month. So we're very, very late. And we have to be careful because we're late not to feel guilty and to respond to the outbreak as it existed last June because the dynamics of transmission have changed considerably. So whereas the larger hospitals are the way, would have been the way to go at that time I think that at this time they're not gonna be able to handle the load as I mentioned earlier. It's really important that we try to stay ahead of the curve, reduce transmission and lower the number of cases to the point where we can be comfortable instituting more conventional strategies. And that's what our goal basically is. I think if we try to look at, to respond in a manner that would have been appropriate months ago we're just gonna be chasing this epidemic for a much, much longer time than is necessary. On the other hand, I think that we can get ahead of the curve. I agree with the public health authorities who have said that. It's going to take a considerable amount of work, more work than would have been required but it's still very doable but the window is closing very quickly. The time for action really is very narrow and limited. Otherwise we're gonna see the natural evolution of a rather lethal epidemic and I don't think any of us wants to be witness to that kind of event. Thank you, Julie. I'm done now. Thank you. Thank you so much for the invitation to speak today. I'm basically gonna say exactly the same thing Ron did with pictures, all right? Cause, but that highlights how we're facing many of the same challenges in the region where we're experiencing Ebola right now. Do we have a pointer here by chance? It pays down for you if you want to. Oh, just for a pointer, but that's okay. So first of all, I'll give you an idea about the geography we're talking about when we're talking about the outbreak and of course this doesn't include Nigeria and Senegal but what hasn't been widely highlighted amongst these countries and we talk about, you know, country sharing information with each other, what most people don't realize is the three countries that have been primarily affected by the disease are actually part of an economic and political union. It's called the Mano River Union adding to that quote Du Bois and you'll notice I put in my talk a combination of socioeconomics along with a legendary contagion and the reason I talk about socioeconomics is we can't deny that this tropical disease just like many tropical diseases disproportionately affects the poor and they are always the most at risk. Sierra Leone for example, if you look at the Human Development Index for last year for Sierra Leone it ranked 177 out of 197 countries surveyed. So to say that the public health infrastructure was fragile already is an understatement. And so looking historically at where we've seen Ebola outbreaks, of course we've seen them mostly in the Congo Basin and Central Africa. What all of those outbreaks really shared in common is that they did happen in quite rural and remote areas. There were roads to them but these are not good roads. These are terrible roads on a normal day. It was really hard to get inside and outside of those areas. And then when you look at where it occurred in Guinea it occurred right at the nexus of a tri-state region. And what I wanna emphasize with that tri-state region again going back to the union idea these are purely colonial borders. The languages, the tribes, et cetera they all cross all three of those borders and that's why you have such fluid movement of people across those borders. They're going to see their family. For example, the very first two cases that were reported in Sierra Leone were actually not Sierra Leone cases. They were two people that got Ebola in Guinea. The bodies were repatriated to Sierra Leone. We tested the bodies in Sierra Leone and they were indeed positive. And that was the first kind of border control we did was banning the transportation of bodies across borders. So why is this different? I've already said that the first two points but I can't under-emphasize that more than a decade of civil conflict has led to almost a complete lack of trust in government. And we're only 11 years out from that. So you imagine building an entire healthcare system basically from scratch along with that public health going into it. 11 years is not a very long time to develop a system. And so the fragility can't be under-emphasized. Very early on, and this was very popular we had a lot of denial and scattering. And when I talk about scattering that really is a result of that civil conflict. Run and flee was the mentality that was developed over a 10-year period because that was the only way to stay alive. And so now that has been transposed to Ebola. And was this a unique spillover event? Was Ebola there before? Like my colleague said earlier, the taxa was there. When you look at the rainforested regions, yes, it's the same across the Central African Basin. Back in 2008, we were looking at patients that were admitted to the Lassa fever award in Kenamas here early on. These were patients that were admitted for suspected hemorrhagic fever. So they were there for a reason in a hemorrhagic fever ward, but they were negative for Lassa fever. So we decided to go through and look for other common denominators that might exist. And just for the fun of it, we did throw Ebola in there. And what we found is around 8.2% of the patients that we tested had IgM specific antibodies for Ebola Zaire. So meaning they presented to a hemorrhagic fever ward with hemorrhagic fever symptoms, and they have IgM meaning they were recently exposed. So why didn't that turn into an outbreak? That was probably 18 cases at most, but it wasn't an outbreak. They weren't clustered. There was no epidemiological linkages between them. So were they individual events? That's what we have to presume at this point, but it points to evidence that the virus already existed in nature there. So how did it get this bat? When we look at early on in the outbreak, all of the international attention, the MSF, the WHO, everything, there were, I don't know how many exactly, but there were a lot of people in Guinea. Everybody was focusing on Guinea. And we weren't really taking into account that tri-state region and the flow of people. You had a team of maybe 10 in Liberia and a team of maybe 10 in Sierra Leone covering those entire countries, trying to make them prepared, trying to heighten sensitization, trying to help people look at the borders. We didn't want to close the borders because there are 10 times more unofficial borders than there are official borders. So when you close the official borders, what happens, everybody starts going to the unofficial borders. Again, with that run-and-flee mentality, or they just want to be with their family who happened to be on the other side of the border. Essentially, the international community was all packed up when the first reported cases were in Sierra Leone. I'm heavily biased towards Sierra Leone, by the way, because I'm just coming back there. And as Rod said, coordination and communication have been one of the most significant barriers to success. And I mean that on every level within the country, the international communities, the feds with the NGOs, et cetera. Now that's starting to happen better now, but you really have to ask, after 40 years of knowing about Ebola, why is every outbreak ad hoc? We don't have standard PPE that we use for Ebola. We don't have standard diagnostics that we use for Ebola. There are certain things that we do, just standard epidemiology, et cetera. But we really are approaching each one of these outbreaks of, oh, there's an outbreak. What do you have? What do you have? What do you have, et cetera? Whereas in the meantime, between outbreaks, we could be doing all that work and know before it happens. So now just to narrow in on Kenema, which is the current kind of epicenter of the disease. And you'll see Kenema highlighted there. Eastern District of Sierra Leone. The road from Kenema to Liberia, even though it's a very short distance, takes about four hours. You can see it's almost triple the distance, but from the border, from Liberia to Monrovia, it only takes about four hours because their roads are much, much better. But focusing on Kenema. Kenema is the third largest city in Sierra Leone. It's a major transit point and through fare for Sierra Leone and Liberia. Most people haven't seen this highlighted, but it's also home to the Sierra Leone's People's Party. So if you're looking at Sierra Leone, much like the U.S., it is a two-party system. If you're calling the Republicans in Democrat equivalents, there's a Democrat in office. The Republican strongholds happen to be the current epicenters of the virus, right? So Kenema, Kailahoon, that's where the opposition lives. And so we'd be remiss to think that this is not being used as political fodder too. Of course you're letting us all die because we're not going to vote for you. So you've just left us alone. So again, feeding into these conspiracy theories that their government has abandoned them. The Kenema Government Hospital until this event was the third largest, just like the city, it was the third largest healthcare facility in Sierra Leone seeing hundreds and hundreds of patients per day. Now it's all but closed. Ebola is the only thing that you will see inside the Kenema Government Hospital. And what was really unique to Kenema and to Sierra Leone and Liberia is really, this is the first time we've ever had an outbreak of hemorrhagic fever in an area that is already hyper-endemic for a hemorrhagic fever. So we have lots of fever which presents eight to 10 cases per week just as the Kenema sites during the dry season, which we just started about two weeks ago. So now complicating the Ebola outbreak is we have patients simultaneously presenting with hemorrhagic fever and it might be LASA. So we are testing for LASA, but as Ron said, we're already over capacity with our Ebola beds. So right now they're all being mixed together, which is a really bad thing because you can actually survive LASA. There's a treatment for LASA. We have no idea what, if there are co-infections and what the result of those co-infections would be, but obviously it wouldn't be good. And interestingly, it's a culture that is very, a community rather that is familiar with hemorrhagic fever. You see LASA fever signs everywhere in Northwestern Liberia and Eastern Sierra Leone. And it's because they've lived with LASA fever for almost 50 years, so they know about it. They know what hemorrhagic fever is. There's very simple to understand public health messaging. It's spread by rodents, keep a cat in your house, cover your food and water, clean your house. If they find a rat, pick it up with gloves, et cetera. So and the one I found more humorous, this is a taxi on the bottom left saying, if you rob me, I'll give you LASA fever. So that's how well-known hemorrhagic fever is in the area. And when you're looking at Kenema again, and again the episode, it's made a lot of news. This is the LASA award in Kenema. Now that picture on the top left, my top left, was about 10 years ago, but that award hasn't really changed since then. And you look at the bed on the bottom left and kind of the hallways, you really wouldn't want to be sick in this award. But it was unique in the sense that it was a dedicated award just for hemorrhagic fever, because that is what they saw the most of in that area. Facing many of the similar circumstances that were presented earlier, top right, that's the morgue. You can imagine the average temperature in the dry season about 38 degrees. There are rats, it's extremely hot, there's no security. Bottom left, you're looking at the canteen. So if your family, if you have a family member inside with hemorrhagic fever, the hospital doesn't have the food or the money to feed you. Your family has to come there and cook your food and they give it to you. So if you're a patient without a family member or family members to do that, then you're gonna starve inside the ward. They wouldn't let you starve, but you're not going to be well fed. And this is the laboratory that we set up in Kenema almost 10 years ago now, and so that's currently serving as the laboratory for the Ebola diagnostics. And so something we wanna talk about here, we had a dedicated LASA fever team, and this was a team of about 22 people, and that comprised everything from epidemiologists, mammologists, doctors, and nurses. Overall, about 35 rather than, but 20 or so clinical team. In this picture alone, we've lost five of those individuals to Ebola. Most people are familiar with Dr. Khan in the middle. So Dr. Khan was the only infectious disease doctor in Sierra Leone, 39 years old, had just finished his infectious disease fellowship in Ghana and returned about six months earlier and was glowing. So excited about his research career and tackling LASA fever back in his home country. The nurses to his right, the two gentlemen have passed and the lady has survived. Afana, she did get infected and survived, and then looking to his right, the gentleman second to his right has also passed. Now, not quite the same experience, but the gentleman on the far left was the WHO representative who has also moved on since this outbreak started. So the confounding issues, as I said, we had a fully dedicated staff to treating LASA fever. Typically occurs in the dry season, which we're already starting. Just in Kenema alone, 40 of the healthcare workers have been infected and that includes everything from doctors to nurses to lab techs where those lab infections or was it someone treating someone on the side doing malaria smears, which is often a common way to make extra money on the side because a government salary is not that much in Sierra Leone. So if you can do business such as giving malaria smears for someone on the side, that's what you'll do. So several of the lab technicians, that's how we suspect they became infected and even cleaners. Probably the worst paid guys in the whole building. Of course they got it and of course they passed. As I said, LASA is already starting to appear we're co-admitting those with Ebola and healthcare workers are gonna have to be recruited or completely retrained to enter the system. Again, because right now you've read abandon ship, right? When you watched all of those colleagues die that I just pointed out, every other nurse and doctor at that facility said, he was the best, he was an infectious disease doctor. He was trained in this and he's seen it for eight years and he's dead. The nurse matron died 30 years operating with LASA fever, she's dead. So everyone saw that and they said, well, if they're dying from this there's no way I'm gonna handle this because I've never even dealt with LASA. So where are we today? We're largely past the denial phase of the outbreak. Most everyone does believe it's real now. In the earlier days they didn't believe it was real because one, they thought their government was just using it as an excuse to get money. That was a very popular one. The other in Sierra Leone in particular was the political divide. Either you've introduced something to us to make us sick because an election is coming up in just two years or that this doesn't exist at all and you're just trying to make it economic hardship for us. And you really almost have two halves of the population. Half believe that science is the solution. They've heard about the experimental antibodies treatments. They've heard about the vaccines. And I have to caution, the introduction of those ideas have now led to this mass belief that that's gonna be the solution to the outbreak. The solution to the outbreak, you can build treatment centers for the next 12 months. You're never going to have enough beds unless we stop the transmission of the virus from person to person, which is exactly what Ron was talking about with our house to house survey. It was actually called a house to house survey, not a lockdown, but unfortunately CNN picked up on lockdown and that's how they portrayed it. But with our house to house survey, that was to educate everyone on what is Ebola and then to also talk to them about kind of the realities with experimental antibodies and vaccines. This is not something you can put your faith in that it's gonna save your life. We have to think as public health professionals and that's what we're conveying to the public that our primary focus is saving those that are not infected while concurrently helping to treat those that have been infected and hopefully improving their outcome. And then you have really half of the population that believe traditional healing is the answer. Now, traditional healing can mean a lot of things. It can mean drinking an herbal cocktail or it can mean bloodletting or a number of other things. Primarily what we've seen in the transmission cycle is through the bloodletting and it's really both of these populations because you have the people believing in the science, they wanna come to Freetown. They don't wanna stay in Kenema because Kenema's out in the country, that's the epicenter. They wanna come to Freetown where the hospitals are better. What they're not realizing is all the hospitals in Freetown are closed. As Ron was saying, we have no idea probably. I don't know if we ever will know how many people have died of non Ebola related causes. Normative infections, I can tell you horror stories just from the early days of the infection. A woman in birth traveling around Freetown, she had complications, she was bleeding. Five different hospitals would not admit her. She literally drove around in an ambulance for seven hours until she died in the back of the ambulance. Every hospital said no. And so you've seen a complete breakdown in an already fragile and public health infrastructure. So what are our most pressing challenges today? Incomplete contract tracing. As we said, the international community was all but packed up back in around March. We thought the outbreak was over. Two or three contacts were missed. That two or three contacts is all it took to result in the largest outbreak of Ebola in history. There, as we've already said, insufficient number of beds for infected individuals. There's really no system of triage. Now that's improving, but typically all the patients are lumped together. Suspected with probable with confirmed. So suspected, you have no idea if you have Ebola. So you're putting that person in a room that you know does have Ebola and that's a recipe for disaster. Now again, that's improving as facilities improve. There's an insufficient number of ambulances and burial vehicles. The ambulance on the top right is kind of the typical state that you'll find a lot of ambulances in. So why don't we ship ambulances from the US? They don't work in that environment. The acronym for Ford in West Africa is found on the road dead. So we have to order these ambulances and you think, well, okay, let's order 300 ambulances. Well, as Ron mentioned, there's about eight global disasters going on right now. The first time we called for ambulances, they said, well, there's a three month wait because each of these ambulances has to be converted into an ambulance. Then it has to be shipped. Then you have to get it out of the dock, et cetera. So even if we had ordered them six months ago, they would just now be arriving. So we've ordered used ambulances, et cetera. Those are things that usually are not done, but we have ordered used vehicles in this case just because we have to have more transport. Same thing with burial vehicles, pickup trucks. Now the complicating factor here right now is that you have both of those things being used for both of those tasks. And so you can imagine a confirmed Ebola patient that just passed. You just took that patient to be buried outside the ambulance and now you're picking up the woman that's giving birth. And so again, a recipe for disaster. An irregular supply of PPE and other needed tools. When I say irregular, PPE has been one of the most misused terms or I guess misunderstood terms in this whole outbreak. Huge donations coming in from the US and everywhere else, either from the Sierra Leonean, Liberian diaspora, from church groups, et cetera. But this is not PPE made for Ebola in probably half the cases. So it's received, everybody says, oh, I have PPE. And PPE means something different to everyone. But those irregular supplies of PPE and not really knowing how to use them safely have led to probably a lot of infections. So this is really gonna have a lasting impact. And we need to think both in the short-term immediate response to the outbreak, but we also need to think medium and long-term. And so the economies of the Menon River Union were already weak. If you look at the economy, or the GDPs rather of Liberia, it's approximately $2 billion per year. Sierra Leone's approximately $5 billion. Now you look at the cases that were exported to Nigeria and Senegal. Comparatively, Nigeria has $550 billion in GDP per year. It has a CDC, it has aggressive epidemiology response systems. So they contained it. They investigated it very quickly. The communication was very good. And so far they haven't had any further trouble with that. Same with Senegal, to a lesser extent. Public distrust in the government has increased dramatically since this occurred. Ellen Johnson's early picture on the top right, along with my colleague from Kenya earlier. When we were getting ready to wrap up in Liberia, and she was telling us we had done such a great job. Now I feel kind of bad that she was saying that since Liberia has turned out so bad. Public distrust in the governments, we don't know if that will ever be regained in either of these countries because it's been a major setback. And arguably this population has not undergone trauma such as this since the conflicts that they experienced ending in 2003. So how do we stop this from happening again? We really have to reinforce the basics in epidemiology and in surveillance. There's a lot of focus on push-button surveillance systems, but if there's either not a trained person on the other end or a button to push or power to power the button on the other end, it really doesn't do much. So it's these trust-based relationships and investing in people. If you look at the DRC outbreak currently, the leader of that outbreak, and one of our panelists was talking about it this morning, they have psychologists, they have a mobile lab, they get going. Someone invested in that guy 35 years ago, Jean-Jacques Mouillier, anybody that works in Ebola knows him and he's one of the greatest guys in the world, but somebody invested in him about 30 years ago and made him an Ebola expert on his first outbreak, he is still there. He is the guy that's orchestrating all of those teams. When you watch the old 70s Ebola movie, he's a young man in that film talking about Ebola, et cetera, but it is that investment in people that is lasting. Developing affordable diagnostics, and I emphasize that work in low-resourced settings because there's varying levels, and we've talked about it this morning, so I won't go into it, but there's point of care, there's PCR, and they all really work in slightly different settings. It's not that you want one or just the other, but what we want to do is make the most impact and that's really gonna be at the bedside, but not ignoring that you do need reference labs in each of these places. We wanna discourage the donor mentality in this response and take the time to actually work hand in hand with our colleagues in the MRU, not only to conduct surveillance and response, but to really sustain them over time. And interestingly, again, I go back to LASA fever. So Sierra Leone and Liberia had existing LASA fever programs. However, there was no lab in Liberia to diagnose LASA, so we had one contiguous LASA network between Sierra Leone and Liberia. On the Liberian side, we just had epidemiologists, and what they would do is take a sample, call us when they had a suspected sample, we drive to the border, they're on the other side of the border, they hand us the samples, we take it back to the lab, we test, we call them, and we tell them it's LASA fever. Back in May, we set up the diagnostics in Monrovia to do LASA fever, and analyzing the samples that were coming in, we found yellow fever, we found West Nile, we found LASA fever, we found everything that you would want, you would think you would find when you start looking for it. And so just my last kind of point on this, and this is something that I feel strongly about. You've had so many people in the room this morning talk about how do I volunteer or how do I help. Something that we had before that we don't have anymore was the public health service ready reserves or the like. What we need is to get away from that ad hoc response to everything. So why is MSF so successful in what they do? It's ironic that people distance them so much from military organizations because they run just like a military organization. Logistics, supplies, everybody has the same training, everybody has the same tools, and you do not go to the field unless you have that training and those tools. So are there any silver linings out of this? Really, we hope to emerge with a stronger healthcare system in the region geared towards surveillance for hemorrhagic fevers and other tropical infectious diseases that we'd normally see there. We've had a huge struggle in finding trained individuals that are able to actually respond to this outbreak. After this outbreak, though, that you can imagine, there's gonna be hundreds of people that are actually trained to respond to Ebola. So hopefully we won't be in that situation again anytime soon because this outbreak is gonna be the next six to eight months. And then finally, just because you have two, you now have an endemic hemorrhagic fever with a hyperendemic hemorrhagic fever, hopefully someday that these sites could be used to train responders on how to deal with hemorrhagic fevers because really the interaction with patients that have hemorrhagic fever is no different amongst the syndrome. So the syndrome is the deal, not the virus. So I'll just recommend a book about how NGOs can fit into this. I won't go into it, but a very good book to read if you wanna figure out how we can do this all together. Thank you very much. Yes, please, yes, you're on. Wow, so it's hard to know what I have to add, so I'll be brief. I actually met Ron Waldman in 1994 in the GOMA refugee crisis. You may remember, GOMA occurred after the Rwandan crisis when about a million people who feared for their lives in retribution from the genocide crossed the border into what was then Zaire and set up north of the town of GOMA where they were met with cholera first and then Shigella dysenteryi. And there was massive death. Ron led the CDC team that was sent in response to the UN request for help. And when we got there, there were literally hundreds of thousands of people in fields north of GOMA. And when I say fields, you look across the field and you just saw masses of people. There were a few little shreds of blue plastic tenting that UNHCR had given, but mostly it was just people, no facilities, no latrines. And so cholera swept through there. And in a short period of time, you had tens of thousands of deaths. I focused on the unaccompanied children centers and these were centers set up to handle the children whose parents had either died or abandoned hope and they were gathered in these little centers and we would go around in the morning and find little bodies stacked outside the centers like cordwood. So it was chaotic and the response was chaotic. I'm picturing this huge room where the central meetings were held and Ron and the other UNHCR leaders would say, right, all of you all who wanna do surveillance go over here and three-quarters of the room would go over there and the ones doing water and sanitation over there and then everyone would bumble over that way and the people educating on nutrition go back there and there's another 40, 50 people back there. There was one little group in the back or probably like two guys from, I think it was the Army Corps of Engineers and one German guy from a German firm that I cannot remember and the Germans said, okay, we're the water pumpers and they didn't do anything else and they did it really, really well and I went to their camp one afternoon, it was lunchtime and it was fantastic. I mean, none of us were, we were sleeping on concrete, none of us had eaten and they had these tables spread out, they had this hot food cooked. I don't think they had German beer but they had like fresh bread and the pumping was continued, they divided into three teams so that the pumping continued all the time and they basically pumped the water out of Lake Kivu and they chlorinated it so it was safe and they put it into trucks and they made lunch and they didn't do anything else and the other organizations would get the trucks and drive the trucks out and educate the population on how to use the water and so forth and these guys didn't do anything else but it was the one area of the response that we never had to think about. I mean, from the beginning to the end, the water was pumped out of the lake well and efficiently and it never went wrong. They had generators, nothing ever broke down and that part of it always worked and I've thought about that in the subsequent 20 years of doing emergency response at CDC and now the first couple of weeks at the Gates Foundation about the German water pumpers. So when I joined the foundation about all of three weeks ago, they weren't involved in Ebola or emergency response to any great or public extent and then about two weeks ago as you've heard was the announcement that they'd committed $50 million at least to the Ebola response and there's been a great scramble to figure out how the foundation can contribute and I thought you might wonder why and so I've thought a little bit about a foundation whose primary purpose is not Ebola or even emergency response and yet it became increasingly clear, especially in the last month or two, month or so, that Ebola is the most important health event in West Africa today. Ebola is the most important health event in West Africa today and it will be a watershed in public health for African leaders will forever view public health in a different way just like leaders in Asia have always viewed public health in a different way after SARS and so there really was no way to proceed with health programs as usual in the face of an epidemic that was threatening to tear the fabric of public health apart in West Africa. Also the foundation, it has some assets for one thing, it has funding, a lot of funding and it can be used fast and flexibly and was given really quickly to the organizations on the front lines like WHO and CDC and UNICEF that needed quick funds with no strings attached to use it for what you need it for. Also, and I've learned this in a few weeks, the foundation has some of the most talented public health staff in the world and they have a special ability to take technological solutions from the concept phase to actual delivery in the field incredibly fast and they have some experience with emergency response, the dedication to the polio response in Nigeria meant that they've had some experience with emergency operation center. So a little bit about that with help from the Gates Foundation, CDC and others, Nigeria had set up six polio emergency operation centers and when the first Ebola patient went to Nigeria in Lagos it was possible to build on that infrastructure to establish an emergency operation center that could do what was needed to detect and contain the spread of that importation and it worked. Thanks to the local leadership, the resources that I mentioned, an NGO called eHealth was also critical, the imported case was detected, the contacts were listed and traced, the sick people were isolated safely and the interruption of transmission occurred and this is what needs to happen in dozens of other African countries in the coming weeks to months if a transmission of Ebola is going to be interrupted. So just a couple of specifics about emergency operation centers. Peter Zheziatarsky who runs the EOC at CDC likes to talk about stuff, staff and systems and people tend to focus on the stuff first, the physical infrastructure of an emergency operation center, the space for meetings, the infrastructure for displaying information, the ability to take data from the field and consolidate it and present it to public health leaders for decisions and to communicate with other emergency operation centers in the area are critical. But staff are also critical, well-trained and well-drilled staff and at the center of that an incident manager who should be in charge of the entire operation and should report to the highest relevant authority in this case for Ebola in West Africa, it's generally gonna be the president or prime minister and also who's authorized to run all other aspects of the national Ebola response, so that's critical. And then third systems, this is the protocols that allow for the data to be consolidated quickly and moved into presentations and for a contact tracing to happen really fast. That stuff has to be rehearsed, it has to be put in place and then rehearsed and the best way to rehearse that is by doing that for regular public health events over and over and over again so the staff are ready to go and the protocols are working. So I think I'll stop there and I'll leave you with three messages. First, if you're from an NGO, pick an area to focus on and do that well. Remember the German water pumpers. Figure out what your special area of expertise is and then do it really, do it better than what anyone else can do and do it better than what anyone has even envisioned so that it could be done and you'll make a huge contribution. Second, if you're from a foundation, get into the global health security agenda. Like the Gates Foundation that wasn't involved at the beginning, Ebola has shown once again that an epidemic disease can disrupt all kinds of public health infrastructure and that it's worth investing in the response to it. And third, for those of you who are from governments, in the area of respond, I would argue that the single most important thing you can do is get an emergency operation center stood up, make sure you have an incident manager who's appropriately empowered and make sure that you exercise it using regular responses to public health outbreaks so that you're ready when Ebola comes to your country. So, thanks. Well done, well done. We have a few moments for questions while our microphoneists enter the room. I'd like to start off very briefly with one question, which is you've all addressed the need for strengthening systems going forward and the lessons we learned from this. Can you talk very briefly about the, I like the paradigm stuff, staff and systems. You've talked about capacities at the national level, what will have to be built or rebuilt. A little bit about what we do at the global level to prepare with stuff, staff and systems. We've gotten slowly off base for this response. Is there anything that we could put together at the international or global level that would help accelerate that response in the future? I'll just give one quick thought in that standardization because I think Joseph, you talked about the challenge of lack of communication between the different countries and the different areas of the response and that's a lesson that we shouldn't have to relearn. If we put in collectively a standard approach to emergency operation centers, for example, so that there's a similar footprint in each place as that will greatly facilitate the exchange of information. People communicating with each other will know what an incident manager is and who's doing what in each country. So to the extent possible, if these, and here we're focusing on response, if these response mechanisms can be standardized, it will facilitate communication in the event of a big global outbreak like this one. I just add to that training and connecting individuals, individuals that usually go through some kind of significant training together usually stay in touch and that is that information and communication flow that is so valuable across borders. And then secondly, I would say the pre-positioning of at least critical supplies for events such as this and it doesn't have to just be people but emergency response supplies that are standardized, for example, and that was done to a certain extent prior to this outbreak, for example, with PPE in Brazzaville, but when you try to get into Brazzaville on a normal day, it's not that easy in traveling within Africa, it's not so easy itself. So pre-positioning them in countries that are stable, economically viable and that are willing to serve as regional leaders, I think is also an advantage, could be an advantage. I feel a little bit sad by the question because it's one that has been asked after every emergency. We should have learned these lessons already and I just ask myself why haven't we and why are we asking ourselves these questions? Still, why aren't the three attributes that Scott mentioned, why aren't they in place already? I don't have an answer for that and I don't know if we'll have an answer for that after this outbreak either. I don't know what those factors are that impede progress. I hope that the Global Health Security Agenda will be a solution to that problem of lessons identified but never learned. I hope that this time it'll stick. Thank you. Ali Rashid from Interpol. It's more of a comment actually than a question. I simply wanted to highlight the fact that obviously the public health sector is being basically hammered or overwhelmed by the outbreak but it's not the only sector that has been affected. Low enforcement, the security aspect of the outbreak and the implications. We used to traditionally think of low enforcement exclusively when it comes to the deliberate release, whether it be by security, securing the agents from falling into the wrong hands or responding to a deliberate release by bringing the perpetrators to justice. Even in Interpol, most of the training and efforts of being deploying within the international low enforcement community were focused on the deliberate. With the Ebola outbreak, we're realizing that addressing the issue and supporting low enforcement community authorities in the response and obviously the prevention as well is crucial. We're having a lot of requests coming from African countries through our official channels asking us what kind of support can we provide to them because the low enforcement entities and authorities on the ground are also overwhelmed securing their population and keeping public safety and security in an acceptable level, I would say. Coordination, exchange of information is crucial as well especially when it comes to the border's control issue. We are thinking of using our international communication secured network to helping these countries communicate among each others from, again, a public low enforcement perspective. But all of that is not feasible to be implemented efficiently if the interagency approach is not being addressed and gladly enough within the global health and security agenda, we have one of the packages, the action packages, focusing on this multi-sectorial response and addressing explicitly the low enforcement component from a macro scale, meaning establishing these frameworks, legal frameworks, establishing these MOUs, cooperation agreements, not only on the national level but also regional and global scales. So we can actually address not only the deliberate release of agents but situations as the one we're facing with the bull outbreak in West Africa in a comprehensive manner, addressing all relevant sectors at the same time. Thank you. What I'd like to do now is I collect a couple of questions. We have hands up here, I'm here. Three questions, we're to collect three questions and that's all we have time to collect. Ask our speakers to address them together and then we're going to cede to our next panel. Hello, hi, thank you very much. Chris Long from the University of Sussex. I was wondering what the panel's thoughts were on the characterization of the outbreak as a kind of unique and unprecedented urban outbreak and the implications of this for prevention and preparedness. Let's get to it again with the microphone over here, please. Let's go to just one hand and then. Yeah, David Brennan with the results. So just wondering if you have anything to say about the expansion of the quarantine and travel restrictions that Sierra Leone announced earlier today. It sounds like there are now a million people under quarantine and people are worried about starvation in those areas because of inability to travel. And second question, if there's time, if you had five minutes with President Obama later today, what would you tell him about this? What more does the United States need to do? One more question here and then we're clearly we can answer all of those in five minutes. Thank you for three great presentations. I really liked them and you told it as it was and as it is. And I think Ron, you were alluding to the fall of governments, being something which we all dread. And I know that the president of Sierra Leone has a sort of easy armistice with his tribal chiefs and the other people in government until something goes really wrong. So my question is, and we've talked about it, the urgency, you mentioned slowness, why haven't we learned? I think at this point is, from your point of view, Ron, and your insights, how long do you think we've got before these governments fall and we are in an even worse situation? Back to war. Any other questions? Mark Smolensky from Skull Global Threats Fund. Mine is more of a comment to try to help us who are out there that fall into your category, Scott, of foundations. It's really easy for a foundation to just give a check and say, good luck with Ebola. We're sort of in a different situation as a foundation because we have lots of proposals of people on the ground coming to us to use technology for contact tracing and so forth. And that's much more engaging for us because we scrutinize all the money we give year in and year out. So then to see something like Ebola where everybody's dumping in money, my request is, could we, and we've done this for every humanitarian crisis, can we get some sort of feedback to the donors who are giving money to pots of money to know that that money really mattered in the end because we've seen humanitarian crises where there's lack of accountability for money. There's, you know, a lack of understanding about where does the money go and how is it distributed? So like, there are lots of people out there who really wanna help with Ebola, but there's also people who don't just wanna write a check. They actually wanna do something with the money that's meaningful. And I don't hear a lot of conversations about how to do that particular coordination. You have enough challenges with all the people on the ground and I'm not saying you need to do this now, but we talked about after action reports, after every crisis, if we don't figure out the cost of this Ebola outbreak, which is really in my opinion, an example of other outbreaks we are going to see in other parts of the world. And you know, when we have a respiratory outbreak, again, it'll be a lot different than Ebola. And so we need to really learn everything about Ebola and I just also put out a plea to please help articulate how the money is spent because that will be important for donors for the next one. Okay, so what I'd like to invite is each of our panelists, I'm sorry, we don't have time for any questions. Each of our panelists to go one at a time and respond to the most appropriate question in one to two minutes, please. Ron, starting with you. Yes. I'm just gonna forget about how many months it's gonna be until things that fall apart, but there certainly is the potential there, not only in Sierra Leone, but in the other two countries as well. I was at a conference at Georgetown a couple of days ago. Some people are here who were there as well and Steve Radelet was speaking and he felt that for these fledgling democracies that if they couldn't bring this under control very quickly, that people would begin to question the effectiveness of democratic government in many countries. And in Liberia, for example, the warlords are beginning to make statements and saying, well, yes, they had acceded to a democratic election, but that maybe they had made a mistake and that they should actually take back the power in order to bring this under control. So I think that it's a very real question. It would be really entirely speculative on my part to say and how many days or weeks or months these governments could fall. But I do think that the point has to be made even a public health event like this, it has real ramifications on all aspects of the social and economic and political structures in these countries. And that's, I just wanted to tie that in with the question from Interpol because and with my previous comment, because we have been doing this for a little while and Scott knows well that when we were faced with the threat of H5N1 influenza, which we still are, there was a lot of activity done under the guise of pandemic preparedness and many, many simulations were held in many, many places, both at country level, regional level, national level and international level within the United Nations. And those simulations brought together elements from the whole of society, including law enforcement. So every sector that could have been touched and affected and every sector that had a role to play in pandemic control was brought in to do simulations. I don't know what happened with it all kind of fell apart when the H1N1 influenza pandemic actually occurred because of all of the money immediately went from preparedness to response and never came back to preparedness after that in the way that it should have. But I think that the problem is that the knowledge and the experience and the practice that's so important resides in individuals rather than institutions. It doesn't get to be part and parcel of the institutional operation. So there's still a lot of people around, many of them are in this room, who were involved in important ways in pandemic preparedness and the leader of the UN, a pandemic preparedness program at that time was David Nabarro who's been drawn on to lead the UN response to Ebola now. I think it would be great if there were other people who could be called upon to do it as well. But I am afraid that we have difficulty transferring the knowledge that we gain from individuals to institutions. Just to quickly agree that governments will be held accountable, I think that's right. We remember after SARS, the mayor of Beijing was fired and so was the minister of health. In a big event like this, there will be accountability and that's not going to be lost on African leaders any more than it was on Asian leaders. But to address Mark's question about foundations and being flooded with proposals and so forth, I can just say very recently, the Gates Foundation has taken a position that a proposal should be prioritized in country by the EOCs. And in a way that is reinforcing of the leadership and authority that I was just speaking about for the Emergency Operations Center to prioritize what needs to be done on the ground and to ask them to prioritize and to have. So if you're from another foundation, I would encourage you to consider that as a way to reinforce the authority of the Emergency Operations Center in country. And I couldn't agree more that having done that, we also ought to be committing to evaluating what we fund and figuring out what works and what doesn't for the next time. I can touch briefly on the quarantine issue and that'll feed into maybe the urbanization of the outbreak question. So thoughts on the quarantine of the nation. It was definitely not an easy decision to make on behalf of President Caroma. However, looking that or seeing that hundreds of thousands of people travel from the Eastern districts every day into Freetown for commerce, et cetera. He was weighing the risk of the many versus the few. And so the problem there is just like in any other government, I always say that you don't believe in conspiracy series if you've ever worked for a government. So it's because no one talks to each other and it's kind of the same thing in these nascent governments. These governments, if you look at just even nine months ago, it was no big deal for drugs to come into the airport and they sit three weeks in the airport because immigrations and customs needs a memo that has to go to the tax office, that has to go to about five other different agencies and it takes two to six weeks if you're lucky to get the drugs out. Now you're forcing them and that's where you come into this emergency management mentality that has not existed before. They have to talk to each other. I can tell you personally, I sit up until about three o'clock in the morning trying to get body bags out of the airport. And we had 15 bodies stacked up outside of a treatment center. So you can imagine how a patient lying in that treatment center is seeing the patient that was just lying next to them before looking just outside at 10 to 15 bodies lying there in the rain. And so really forcing those different sectors of government to work together has never been done before in this region. And so now, I think we're making progress on that front and that leads us to kind of the urbanization issue. And I think what Sierra Leone is trying to do with the quarantine of approximately one third of the country is to prevent Monrovia. When Dr. Frieden arrived in Sierra Leone, he was very frank with the Ministry of Health. He said, you have three weeks to four weeks before you are Monrovia if you do not act right now. And so, as Scott was saying, there were political ramifications to everything that happened. The Ministry of Health was sacked the very next day. We lost the WHO representative the next week. And so they're just essentially trying to present vast urbanization. It already is in Freetown. It's being spread in Freetown, but they're trying to rent the further importation of the disease from outside of Freetown. I'd like to ask you to help me thank our panelists. And now I'd like to invite everyone to remain where you are because we're going to turn this over immediately to Ambassador Bonnie Jenkins, the special envoy and coordinator for the threat reduction program to the US Department of State to introduce our next guest. Good afternoon, everyone. I see everyone's still wide awake. That's really great. I think we've had some very excellent panels today. And it's really, really my honor to introduce our speaker, not only because of the wonderful things that she's done, but also because her government, Finland, has been so helpful and so instrumental in the GHSA effort that the US government is leading and working closely with our partners, increasingly with our partners as we go forward in this five-year effort. And so I just wanna always thank Finland for everything you've been doing and continue to do to help move this effort forward. It's my honor to introduce Minister Susanna Hovenin, the Minister of Health and Social Services of Finland. Just a little short background. In 1999, she was elected to parliament as the only woman from the Central Finland Electoral District. During her first term in parliament, she served on three committees and was elected to the working committee of her parliamentary group. In 2008, she began serving on the board of directors for the Social Democratic Party and continues in that role today. She's currently a fourth term MP and one of the most longstanding political figures from Central Finland. The minister has, she served as the Minister of Transport and Communication from 2005 to 2007, and she took up her current post as the Minister of Health and Social Services in 2013. So please help me welcome Minister Hovenin. Your Excellencies, members of the Civil Society, future leaders in global health security, ladies and gentlemen. This is a big challenge after these panelists for me to be presenting here, but I do my best. The conference today has focused on the need to accelerate international action towards global health security. We have heard alarming updates on the current Ebola outbreak in West Africa. The UN General Assembly has been discussing the outbreak and decided to set up the United Nations mission for Ebola emergency response. Tomorrow, a large group of countries will be meeting together with international organizations in the White House to make five years' commitments towards a world safe and secure from infectious disease threats. As swift approvals of the UN Security Council and General Assembly resolutions show, the international community places the Ebola response high on the agenda. This outbreak demands rapid action. The UN system and the most affected countries need all available support to deal with the outbreak. Finland calls for strong international coordination and the strengthening of the WHO's leading role in the humanitarian health response. We must work in a unified and coherent manner in order to make the most of our collective resources. It has taken us months to step up our game and to the calls from WHO, MSF, and the Red Cross and others. The situation is nearly out of control. Despite the efforts on the ground to control the epidemic. Civil society has played a significant role in the response, which we are very grateful. As we have heard today, we still have a chance to turn the situation around. We must seize the moment and act accordingly. The Ebola epidemic must be overcome as fast as possible. We all, big and small, can show our commitment to solve the crisis by accelerating immediate action. Finland has actually doubled our humanitarian assistance to WHO and the Finnish Red Cross. Hopefully the others will do the same. In the long run, we must place more emphasis on the implementation of IHR or over the globe. Global health security is in our hands. Public health threats are best prevented by strengthening primary healthcare so that we can prevent, detect, and respond in all countries before outbreaks occur. So far, only 65 countries have declared to have implemented to the IHR core capacities. Our disaster is handled that does not always depend on the level of development. A severe epidemic can have the power to cripple a whole society. In its assessment of the global response to the pandemic H1N1, the International Health Regulations Review Committee came to the conclusions in 2011 that, quote, the world is ill-prepared to respond to severe influenza pandemic or to any similarly global sustained and threatening public health emergency. Beyond implementation of core public health capacities called for in the IHR, global preparedness can be advanced through research, reliance on the multi-sectoral approach, strengthened healthcare delivery systems, economic development in low and middle income countries, and improved health status, unquote. Developing and maintaining IHR core capacities is crucial for the control of communicable diseases of global concern today. The health threats are best tackled by meeting the core capacities within each country before the outbreaks occur. Under the global health security agenda, Finland commits to a five-year long biosafety and biosecurity capacity-building project in Tanzania. Finland has continuously stressed the importance of building up sustainable primary healthcare and related infrastructure. We believe it should be included on the post-2015 agenda. Health for all is a concept that was initiated actually over 30 years ago, but it is still highly relevant. In today's world, however, the health sector cannot operate alone. We need cross-sectoral collaboration in order to respond to the challenges we are faced with. Health in all policies was a concept introduced by Finland in 2006, introducing a systematic method of work in this respect. The World Health Assembly confirmed this approach through a resolution this May. We see global health security as a manifestation of this concept. The health sector needs to work together with agriculture, environment, development, defence and other sectors to sustain health security. The health in all policies approach could be also utilized for promoting health security. This approach has particular relevance in tackling the root causes of ill health, promoting well-being and ensuring equal access to health services for all. From our national perspective, health security in Finland relies on a number of solid foundations. Firstly, we rely on existing public health structures and processes which operate not only in times of crisis or emergencies, but are part of the day-to-day operations of the health and social welfare systems at all levels of government, from the local to the national level. Secondly, it is crucial to maintain cooperation and coordination between different sectors of government and society as a whole. Across such diverse areas as food safety, animal health, environmental health, defence, foreign affairs, transportation, border service and civil protection. And finally, Finland is and has for long been an avid promoter of the principle that health should be integrated in all impact assessment. As an example of the intersectoral cooperation and coordination in health security, the National Communicable Disease Surveillance System is built as a network which utilizes the day-to-day operation of the entire health sector, both public and private, and throughout all levels of care. The health sector has a close cooperation with other sectors through their agencies, such as food safety authority and defence forces. In conclusion, the international health regulation is a remarkable international milestone in the improvement of global health security. The achievement of full compliance with IHR obligations globally will be the most important step in the prevention of national and international spread of communicable diseases. However, the full implementation of the IHR relies on the continuous political, economical and legislative commitment of all member states. In that respect, we welcome the initiative of the government of the United States to invite countries to join forces in the global health security agenda. It brings together with major international organizations and other actors, such as non-governmental organizations, philanthropic foundations and development banks. Finland is fully committed to the global health security agenda, and we really hope that we will have the opportunity to cooperate with many of you in this very important endeavour. Thank you very much. Thank you. Thank you for those remarks. I really appreciate that. Well, we are at the end of today's meetings, and my job really is to thank everyone for everything that's happened today. First of all, thank you to George Washington University and everyone here who arranged and hosted this event. And I also want to thank the GHSA NGO, the steering group that planned this event. There was a lot of work that they went into, that they engaged in to make this happen. So I want to thank them for all of their hard work on this meeting. I would also like to thank on behalf of the NGOs, steering group, all the panelists who took part and gave us their very important thoughts on GHSA and the role of NGOs. Of course, I want to thank Minister Hovenin for once again making some comments. It's been a great honor for me to work both within the government and with NGOs on GHSA. And it's really an opportunity for me to be reminded of just how much hard work and how much is really going on outside the government. There's so much that I feel like I have information overload after some of these conversations, and I realize how much is going on. And really, I'm not sure we even know how much is going on or if we even know what everybody's doing. So similar to what happens in the government where it took us a few months to really get a handle on who's doing what, who's doing the same things, how can we make sure that we're fulfilling the gaps and not stepping on each other's toes. I think we finally figured that out through a number of meetings which has really led to a really strong multi-sexual response. Within the government. But I think something similar needs to be done with NGOs in terms of figuring out who's doing what, who's where in the world, who's on the ground, who's doing work that's similar to things the government's doing, what foundations are doing what in which countries and who are they working with. It's very interesting, as some of the meetings that we have, I noticed like in the US, some folks in the government don't know who's in their country doing what. It's just, this is a lot going on. That's a good thing. I think it's good that there's a lot going on and we want that to continue because everyone who's working in this area is already part of GHSA. You're already doing the work, you're already engaged. So it's not a question of getting engaged in GHSA. You're already doing it. It's more a matter of who's doing what and looking at the action packages which you will get to see and to see how what you're doing may fit into what some of the governments are planning to do on an international scale. So I think following this meeting that may be some of the things that the NGOs can actually engage in is to determine for themselves who's doing what and while I didn't know this government was going to do this action package in this particular country where I am engaged, and while I didn't know this other foundation is doing this and so I think a lot of that really would be important. It would help us and it would also help yourselves. As you've heard, we will have the meeting tomorrow at the White House with 44 countries represented by a number of ministers. This has been, I think, a really good effort. It's had a lot of side benefits in terms of working with other countries, with countries working within their own domestic structures. We had the great meeting in Finland and then we had another very good meeting in Indonesia and the White House meeting is following up on those two very good meetings. It's really good work in progress, what we're doing internationally on GHSA and having countries from different regions and people within each country talking to each other about the different parts that prevent the tech response, which is really good information exchange, a really good understanding of what everyone's doing. As you heard from Laura Holgate this morning, we're going to have quite a few folks there from the US and from internationally, our secretaries of defense, state, HHS will be there. As well as a number of other important individuals and can't emphasize enough how important the multi-sexual effort has been and how within the government we have all of those departments, including USAID, USDA, FBI, all of the agencies and departments that play a role in this are represented. CDC, of course, are all part of this. But we recognize from the very beginning the important role that NGOs play. Even before we had our launch in February 13th, we had an outreach meeting with NGOs on the 6th. So even before our launch, we had an opportunity to speak to NGOs to hear about what they're doing and to just give them an idea of what the government is trying to do in GHSA. And so I think from the very beginning, and some of you were at that meeting, it was an opportunity to engage NGOs early on. And, you know, whenever we have our meetings at the White House, there's always a question, okay, what are the, a lot of it was a meeting about how the NGOs doing with the meeting and now the question will be, okay, now what? You know, how the NGOs engage. So those questions will continue to come and so I hope that those of you here can find Samantha's force. We heard about a number of ways in which you are already engaged, whether it's being a link between the government and activities on the ground, whether it's the work you're actually doing on the ground, whether it's the foundations who are funding the work, whether it's the academic institutions who are promoting an understanding of what's going on in the GHSA space, whether it's think tanks who are writing about some of these things. All of you are playing a different role based on what your expertise is and what you're doing, but they're all an important part of this global health security agenda. As I said, you will see action packages and I would just ask that you look at those, look at the measurements, the targets that are in the action packages, see if some of those are things you're already doing. And one of the roles of NGOs, of course, is to ask the government questions and to ask us how we don't question some of the things we're doing, because it helps us to have a better product in the end. You heard about the next generation, which is an effort, of course, to help sustainability in the most important way, which is to engage our young people in this effort so that they understand the importance of global health security agenda, the understanding importance of how do you deal with any bolder type thing in the future? How could you prevent it? How do you detect? How do you respond? And so, I mean, what we're hearing is good, but we have to make sure that those who come behind us also understand the importance of this and are engaged continuously in that effort. Before you leave, I would like everyone to take an opportunity, if you can, to see the posters upstairs. We have some very good posters from a number of you here in the room, and you can visually see what's going on, what NGOs are doing, what government is doing in this space. So if you have some time, I would just ask you to do that. And then at 430, there's going to be another next generation session here in the auditorium, a breakout session. For those of you in the next generation who want to take part in this, please do. I'm not saying that if you're not in the next generation, you can't listen. And you can figure out for yourselves who those are. But there is going to be a session of 430 here, and for those of you who are not in the next generation, please encourage your colleagues to be a part of this effort. So once again, I just want to thank everyone who's here, whether you're an organizer in this effort, whether you came as a panelist, for whatever reason you're here. Thank you for what you're doing in the GHSA space. And we're just getting started. It's a five-year effort. We're just getting started, so there's going to be a lot more coming. So we hope that you are as excited as we are. Thanks.