 Good morning, everyone. I'm Steve Morrison, Senior Vice President here at CSIS, Director of the Global Health Programs here. And we're joined and very honored today to have with us Tolbert Neonswa. And I'll say a few words about him in just a moment and why we're here and how we're going to go about this conversation this morning. I also want to thank colleagues who helped pull this all together, Sahil Angelo, Katie Peck, Travis Hopkins has been very helpful, and Jesse Swanson. And so special thanks to them for pulling this together. We were traveling. Catherine Strifle, my colleagues, Catherine and I, were traveling in January to Liberia and Sierra Leone. And in the course of that, we met this remarkable person, Tolbert Neonswa, who is an assistant and minister of health, deputy chief, medical officer, and most importantly, head of the incident management system in Liberia, which is the central and most important institution driving the response and control of Ebola in Liberia. Tom Frieden, when he has visited Liberia at various points, has declared that this is the most important person in Liberia. Now maybe that is arguable in deference to the president and others. But one thing that became very clear was that Tolbert was indefatigable. He's a leader. He brings he trained as a lawyer at the University of Liberia. He went on to pursue his interests in humanitarian law at Johns Hopkins, at Emory, and elsewhere, and then in 2012 and 13 came to the Bloomberg School to complete a Master's of Public Health there at that institution. And then, as he will describe, as a ministerial official, he became at the center of the response, directly empowered by the head of state to really carry forward this. And it became terribly important as the crisis worsened in the August-September timeframe as the mobilization took off in the mid-fall and up to now, and as we've entered this new phase. So we are really honored to have Tolbert with us. I learned also in speaking with him that he's a malaria expert. He was responsible drafting the first national plan under the president's malaria initiative, the plan for Liberia. So he can speak to many different issues in the course of this. What we've asked Tolbert to do is to speak for 15 or 20 minutes and take us through the story of the outbreak and the response and the different phases. Tell us a bit about the way the government organized itself, his own role. Tell us a bit about the US entry and the entry of others. Tell us a bit about where we are now in this current phase of attempting to get to zero in Monrovia and elsewhere within Liberia. It's a complicated story. We had the chance to go over this when we were together in January. And it was the most lucid and cogent and insightful summary of the story. And so when we learned that Tolbert would be here in this period, we asked him if he would come and do a public presentation along these lines. There's plenty of seats up front. I also want to welcome the 75 or so people who are here online and the audience from C-SPAN. So Tolbert, we're very grateful and honored to have you here today. If you could carry us through that, then we'll do a bit of back and forth. And then we will move rapidly to the audience to get comments and questions from all of you. So welcome. We're thrilled to have you here. The floor is yours. Thank you. Thank you, Steven, Morrison, for the time. It is my pleasure to be here at this very, very important institution, the Center for Strategic and International Studies. And it's a pleasure to be in Washington, DC. I'm honored and privileged to talk to you all. And thanks for coming out to hear the story about the Ebola Responding Liberia horrible story about what we did as a country, how we came together as a state, and pulled up system together very quickly to respond to one of the major global public health threats to our existing as many kinds. As a country, it was like recovering from massive civil conflict, 14 years of civil conflict, rebuilding our lives as a country, as a people, under the extraordinary leadership, incredible leadership of Africa's female president, first African female president, President Elling John Sincerely, of democratically led by the people of Liberia, turned around very quickly and brought the situation after the war years, the desperation, high hope of our people. We were on the trajectory, very good trajectory of recovery after the civil conflict, rebuilding the health care system, rebuilding the education system, trying to rebuild some of the very barrows, reconstruct our infrastructure, bridges and road. And then we got some of the important steps that the government made through the effort of the president for us to even increase the government overall budgetary support to the health care system. We've gone 19% of the budget contributed to the health system as compared to the 2015 target of 15%, the Abuja target for 15% contribution to the health sector, Liberia has gone 19% even before 2015. In Africa, there was the number one country that met MDG-4 before the target dates. That's the under five mortality reduction, MDG-4 by two tiers by this year, but Liberia met that target in 2012, reduction under five mortality. And we were making progress with also maternal mortality reduction, health system strengthening. And before the GDP growth has reached 8.7% before the Ebola crisis in 2014. And so 2014 have become a very, very difficult year in Liberia and the entire region, the entire West African sub region. And my description of that is that Ebola was not just something only intended for Liberia and the region, but we were really and really dealing with a disease that had serious implications on the entire world. It shows how interconnected we are as a people because the fact that Ebola can cross the border, it didn't know passport to enter the United States. Ebola needed no passport to enter European countries, and we saw that. And so those of us in West Africa that are in the front line of fighting this disease are sacrificing for the rest of the world. And this is the kind of feelings that we got as people, as a country, we came together to fight this disease. And so under the leadership of the president, when the disease struck in Guinea in December 2013, very close to the Liberian border, in Guiguedo and we were the proximity of the border, the poorer nation of the border, we knew very well that Liberia wasn't safe, especially in the north, our local county, the most populated, had become an epicenter of the disease. We knew very well that we were in a terrible situation. And so by March, precisely March 22, Ebola struck, local county, we had a case of the disease, and imagine the entire region, the Manor River Union, Guinea, Liberia, and Sierra Leone, there was no viral hemorrhage lab in Liberia. So we needed to take the specimen across the border to have it tested and know whether or not we were dealing with Ebola virus disease. And before that, Liberia was also battling with endemic contrails of LASA fever. And the signage symptoms of Ebola are related to some of the common diseases that we were seeing in our health system, like LASA fever, also, fever, headaches, vomiting, bleeding from all of the orifice of hemorrhage from your nose, from your ears, from your eyes. Those were signage symptoms of LASA fever. So we could not really distinguish from whether or not it was Ebola or LASA fever. So the first case was diagnosed. Our Minister of Health, Dr. Walter Gweningali, pronounced to the world that Ebola outbreak was in Liberia. We notified the World Health Organization that we had a strange disease in the region. It was the first time that Ebola has left since the history of Ebola, since 1976. Ebola had been in the East African area. We had no knowledge in West Africa of such disease. And this was the first time. So the health system was not that equipped to the extent to deal with the issue of isolation, testing of people with the disease, and all that. So we had to deal with the situation. And to do that, we had organized as a government in the Ministry of Health, created the National Coordination Unit. We were meeting every day, strategizing how to deal with the situation, yet people were getting infected. So we had the first wave of the outbreak between March and April. The first wave of the outbreak had only six confirmed cases with six confirmed deaths. So it was 100% case fatality rate of the first wave. We went, we dealt with the situation, curved the first wave, and gone at least 60 days without a new case of the disease. But then Guinean, and then Sierra Leone got hit in May. Guinean and Sierra Leone were still reporting the virus. So we could not declare the virus over as a country because Liberian, Guinean, Sierra Leonean, we have intermarriages. We have cross-border issues, farming. You can walk across the border and no visa, poor about close to 100 border crossing points on official and official. So we could not declare that we were out of the hood as a country. Then we had a second wave of the outbreak in May. That's the major, major and terrible part. Lofa County again became the epicenter close to the Guinean border. We have a number of cases, all of the 15 counties for the first time. The capital city of Monrovia got hit with the disease. We had a case, a 14-year-old girl that traveled from Cala, Guinean, Sierra Leone, and settled down with her family in Monrovia. Monrovia has 2,000 of the country's population, 1.5 million people. And people started getting infected from the disease. We had three counties got infection, had become the epicenter. By the time we got to July, June, Monrovia got infected in June by June, July, August. The situation had gotten under control. We were reporting, like, 60 to 70 confirmed cases per day. In August, it was terrible. Panic, fear, despair, frustration, the government had to put in place a system to deal with the situation. So my road from the very beginning of the outbreak, I was chairing one of the thematic group, the social mobilization component of the outbreak. So my job was to go to all of the radio station in Liberia after putting in place the mechanism. I would go to the radio station and announce that we have the number of cases in the country. We had the number of deaths. So I was given the daily situation report that we call the CETREP report on a daily basis and explaining to the neighboring population what Ebola was, the sign and symptoms of Ebola, how you can prevent yourself from the disease. The disease have no cure, no vaccine. So it's just the public information campaign. I was talking to international press, the BBC, CNN, also calling on the attention of the world. At the time, the World Health Organization, country offices, our development partners, the USAID, these organizations were focused on development work. So the emergency initiative of this to give that emergency support to look at this as a threat to humanity had not come. We did not receive that international support by March, April, May, June, July. And so we were calling the war retention that this was a global public health problem that needed the international community support. So by August, the World Health Organization director General did announce, Margaret Chen, that Ebola in the region should be elevated to fix three of disease, pandemic, as a global international public health problem. Then my very, very good friend, Tom Freening, who I must congratulate here, the head of the Center for Disease Control, Visitor Library in August, sent in some very strong epidemiologists like Kevin DeCorte and the rest of the CDC folk visited Liberia. And then we sat down and established the incident management system in August, which the president of Liberia asked me to lead. And so I chaired the incident management system, put in place what we call the incident management structure with key, key T-mounted areas. Those structure did exist even before the incident management system. The coordination meeting was established, but then you had to make it strong with combined with international partners and experts. So with that, the IMS incident management system was the tool because if you look at the Center for Disease Control, if there's an incident, they have the incident management system to support that. So it's like a replica of the CDC's incident management system that I chaired in Liberia with about five, five thematic areas. Number one, in August, September, the outbreak was very big, 100 confirmed cases per day, people dying in the streets, no treatment bags to put people. There was fear, desperation, and agitation in the community. And so we had to put in place a case management team that's responsible building Ebola treatment units. We put in place social mobilization with community engagement as another thematic area. We put in place laboratory system as another thematic area, epidemiology and surveillance with contact tracing as part of it, and then sacrosocial support. So those thematic areas were set up and what we did as the commander in chief, the president, under the mandate of the president, it was like, look, this is a Liberian problem. We face in the situation, we have to find solution for this. And so the intervention had to be led by Liberians. And so I'm in charge as the commander in chief of this country, and the incident manager with the thematic area was led by Liberians. So I chaired the incident management system. All of the thematic areas were chaired by Liberian. But what we did was, with our international partners, we incorporated them. And so each thematic area is chaired by a Liberian, but co-chaired by an organization like CDC will co-chair the Epi-surveillance Team, WHO will co-chair the case management team, social mobilization will be chaired, co-chaired by UNICEF, sacrosocial support logistic will be co-chaired by the Waffle Program. And so we organized this multinational response to deal with the outbreak. But before we have all of these sophistication, the Liberian people themselves took charge of the disease and then the social mobilization component, the community engagement component and the ownership. People change their behaviors over time. By September, we started seeing the CELF banding. This in August, this exponential projection that 1.4 million people were going to die. If nothing was done, CDC came up with the report that 20,000 people, the WHO said by 20,000 people were died on the weekly basis. So the Liberian people got the message and said, look, we have to change our behavior. So simple messages were thrown out there. Number one, the disease has no cure. The disease has no vaccine. The disease had a very high case fatality rate of close to 25 to 90%. And so, but it is preventable. So what you need to do is if somebody is sick, make sure that you don't touch sick people. Make sure that you don't bury it dead. You call the health team. Make sure that you wash hand 24 hours with soap and water, chlorine. And so everywhere you went in Monrovia or everywhere you go right now, there are hand washing corners to shops, to homes and market places, supermarkets. Everywhere there's hand washing corners, people washing their hands, no touching of their bodies. So the behavior changed alone. Play a very, very critical role. In combination with the huge, huge international support. The international community came very late, but came very big. And we are very much grateful when I told you we met in the office that under the leadership of President Obama and the people of the United States of America, we saw when President Obama announced on the request of my president, President Ellen Johnson-Salev and President Obama announced that this was a serious problem and the world needed to come. We started seeing the Chinese, the Europeans, the Americans, and the entire world came to the aid. By August, September, we started to construct about 29 Ebola treatment units under the help of the U.S. government who were working with the U.S. military, the Department of Defense, 101st Airborne Division, General Dara William, Major General Dara William, and us were working together, then Dara's left, and then Voliski, Major General Voliski. We had a trip, we flew on the U.S. helicopter on the field so many times to go and construct ETUs, go and visit the labs. The country that did not have laboratory system, we had about nine Ebola labs that were installed. We have community care centers, about 15 of them were constructed. Community care center is where you move people from the community, put them there and get to that point where they have place to be until you prevent secondary infection. We train contact tracers because for you to get ahead of the disease, as we did, every effective person in the contacts must be traced for 21 days. That's very, very much important. So it's easier to break the back of the disease, break the chain of transmission if all of your contacts are on the contact list. If the person is infected and they are on the contact list, you can monitor them, remove them, put them in an ETU, the Ebola treatment unit, and monitor them. So we started seeing the trend of the disease come down between September, October and November. And today the exponential projections and increase of number of people that were going to die from Ebola. We didn't have that number of persons. We had about 3,000 confirmed deaths, over 3,000. We have healthcare workers. The human story to this, this disease is associated with affection, caring for your loved ones. So the most affected people were close family members and healthcare workers. Because healthcare workers are those that give care to patients. So most of them got infected. We had 300 healthcare workers that got infection and 179 of them died from the virus. And so this has really really struck our human resource development package as a country in the healthcare sector. And I remember as a person in October I had to lead a team myself to bury about 34 human beings died from Ebola. We were looking for a place to bury those people that were resisting the community because the community people rejected that Ebola people should not be buried in your community. So we had the government had to purchase a piece of property that from 12 o'clock in the afternoon up to 2 a.m. in the morning, we were on the field trying to bury these people through a military deployed because there was agitation, the government had to deploy the military to help me protect the team and myself on the field. We saw stories where the mother died from the virus and the little kids will go to suck the mother's breasts with those things. This did happen. We saw stories where relatives will look on their brothers and sisters and they are placed in body bags and cremated burning because of we had to make sure that people are safe and dignified barrier. So the combination of all of these got us to where we are today in Liberia. We have 14 of our 15 counties that are freed of Ebola. For the past 21 days, some have gone 42 days, some have gone 60 days, some have gone 90 days. Some counties have gone more than 95 days without a single Ebola case. And this morning I read a report it's also that way that 14 counties are still free from the Ebola virus disease. We have transmission still taking place in Moserado on a weekly basis, sometimes three cases or two cases. But what is important is one single case of Ebola is an outbreak. So the fact that Monrovia is still reported one or two cases, we are not of the root yet. And the fact also that gaining several new are still reporting huge number of cases. We hope the three countries can get to zero at the same time and then we can celebrate and say, okay, Ebola is over. After Ebola is the rebuilding of the healthcare system. Why Ebola from the first place is because of a weak healthcare system. It's because of inadequate resources to support the healthcare system. And so we need to build a healthcare system not only pre Ebola, but more than what existed before Ebola. Then we can build a resilient healthcare system that we can stop not only Ebola, but other epidemics in the future. And so this is the role that we play. Now we are into phase two of the Ebola outbreak and phase two have four strategies. Number one strategy for phase two is to continue the community engagement, social mobilization campaign. Number two strategy for phase two is the rapid isolation treatment of Ebola that is the right strategy. What we do, if there's a hotspot, we remove the cases and put them in an ETU and give them care and put that hotspot on a control. Number four is real time contact tracing and epi surveillance. That is making sure that every single case, the case the contacts are 100% on the contact list, making sure that getting all of the contacts to treatment early and cut the secondary infection. And number four in phase two to get us to zero is the cross-border initiative with Guinea, Liberia and Sevelio, where we can have synergies in our interventions and have the disease under control. But my thing to the international work and the great help we got from our international partners under the leadership of the United States government, is the major tragedy that will happen in Guinea, Liberia and Sevelio is for our international partners. But this time this thing is over. To jump on the airplane and move to the capitals in Geneva, in Washington, in New York, and leave those robbery health system and don't help us to build it. That would be the worst mistake that we would make. Ebola, as I said earlier, is not the only West African problem. It could have the same catastrophic effect on other part of the world. And so we should take that very, very seriously. As I listened to the news headlines, the CNN, the BBC and all of the new headlines, what you hear about now is, I say, what you hear about these days is the Syrian war, terrorizing. And we're not hearing about Ebola, as we were hearing about Ebola August, September, October and November. And that has also an effect because it drives where the international support should go. So we should maintain our focus in the region and ensure that the great help that we got from the international world to get into zero in these countries should be maintained so that we help to help the national governments through budgetary support, make sure there are healthcare systems, make sure that the agriculture sector, like our government, major priority, port energy and roads, major priorities of Madam President, Elegance, and Sally. That's the hardware component of it, but the software component, it is agriculture, education, healthcare and better living for the people of Liberia. Thank you. Thank you very much. This week, we had discussed earlier this week, the President, President Obama, spoke publicly, I believe it was Wednesday afternoon, to announce that the U.S. response was entering a new phase, that our military would be phasing down to a residual force, residual presence of about 100 troops that had been at its peak at 2,800, I believe there's a number, but reaffirming a couple of things very, very strongly by the President directly, and the messages were that this was succeeding and we were in this new phase, the two were in, that we were in on the long haul, but shifting to a predominantly and overwhelmingly civilian agency, non-governmental partnerships with your government in moving ahead, and obviously taking a region wide approach. It's interesting to remind everyone here, the U.S. response was driven by the tapping into the disaster assistance accounts, of which by the time we got to the end of the year, we had expended somewhere in the order of $900 million, or made that commitment. Actually how much was expended by the end of the year is another question, but a massive commitment. On the military side, there was an initial reprogramming of up to $750 million. The accounting on those expenditures is still not completed, but you see the vastness of the response, and it was predominantly focused upon Liberia, and then in December, Congress came forward and made a emergency appropriations of 5.4 billion, of which 3.7 is outside our borders, and arguably 60 or 70% of those funds are going into West Africa in this phase, and there is a focus on building capacity, building health security capacity, helping in the recovery strategies. So at least for the next two year period, there is from the US standpoint, there's ample resources. Spending those really smartly and wisely in support of good-costed plans is going to be one of the challenges, I think, that we face in this period, but we are in, I think, a fortunate position here. There's always in these emergencies the danger of a cliff, of the emergency fades, the threat fades, and the interest fades, and there's not that commitment over the transition period and into the longer term, and so having you here and reminding us of this is very important. I think some of the pathways have been laid down in terms of the appropriations and the way that those are oriented. If you could say a few words in reflection specifically about the military engagement and what was the significance in your mind of having the commitment on September 16th by the president up to 3,000, and then having the deployment that followed soon thereafter, if you could say a few words about that. I thank you. I think my reaction to that is, I think the military made their goal, I think the media goal, they were able to partner very well. The US military were able to partner very well with our armed forces of Liberia, gave them capacity building that partnership to build more than 17 Ebola treatment units in all of our counties. And the military did also help with the laboratory testing that got us very fast turning around time of testing the Ebola virus disease in less than four hours. The results are available. That capacity was built and logistic capacity also moving around with logistics during the peak of the outbreak. And so I think the military met that goal. So scaling them down for April, I think it's a very good timing of time, but we have to, and what I do also know is that even if there were need in case, which we don't pray for, to have more cases, there was an opportunity to get that kind of support back. But I think they met the requirement, they met the goal. We work together very closely to get Ebola treatment unit built, get logistics out there, make sure that the laboratory system was strengthening build capacity for our Liberia military guys to do their job. So you feel confident that today you have through the incident with the oversight of the incident management system, you have access to sufficient ambulances and laboratories, you have the isolation and containment, you have the case investigation and contact tracing teams and the data coordination that that infrastructure is in place. It needs to be sustained and strengthened. And as you say, within Liberia itself, the biggest immediate challenge is in Montserrado County and Monrovia proper, right? Right, that's correct. The capacity is there. Our response has reached the optimum that we can respond effectively at any time. We can, every county has a well-built isolation unit with the U.S. General and myself was in the last ECU, second to the last ECU was in Zaza. We visited there. Every county is having its own Ebola treatment unit. That's the case management components out of it. So if there were any resurgence or increase in the number of cases in any given county, you have at least 50 to 100 beds isolation unit available. We were able to better pre-position our labs at a rigid level. There were nine labs that were taken to Liberia, about four of them have been placed into regions so that we can have our testing capacity. It does not affect the contact tracers because the contact tracers, community health volunteers, some of them are active case finders moving to house to house, looking for the contacts, social mobilization also continue. The only thing is that how we leverage the resources that weren't in there with Ebola respond to build our normal health care system is what we need to do now with right now. The planning processes are going on with building a resilient health care system with costing a detailed plan with effectual prevention and control, looking at our health care facilities and how you leverage the resources and support the health care system. One, but in a short, medium to long term raising the kind of resources. Yesterday I was at a broadband trying to talk to our colleagues there to have some resources that we can raise for our health care system. Liberia has a pool fund that we are also looking up to finding additional resources in there to support our clinics and health centers. Human resource for health is a critical challenge. We lost a lot of our health workers that are to be about the confident in the health care system have to be built so that people can have the confidence to utilize the health care services. And by doing that, you have to train more physicians, you have to train more physician assistants, you have to train nurses, maids, wives. Even the last month, we still have not got to the level yet where somebody can work less than one hour to get to a health care facility. With those kind of systems, you need your community health workers to reach the last month to provide services for preventable diseases, improve your immunization system, improve your human resource for health capacity, strengthening infrastructure, supply chain, and all of these services need to be. But how do you leverage now these resources for Ebola to get the health care system supported? And the United Nations has also been very, very much helpful in the system with World Health Organization, WHO. And for the first time, the United Nations established the United Nations Mission on Ebola response for the first time for the UN Security Council to approve establishing a separate mission for Ebola. We think that was very, very much useful. This multi-national partnership was critical in the response. Can you say a word about two issues? And then I'd like to open to the floor. First is the regional context. There's a lot of diplomatic activity at a very high level, trying to figure out how to coordinate and knit together across the county prefecture districts on these large border areas where there's huge vulnerability of importation or just not knowing what's going on. So as you move towards zero within Liberia, the bigger regional context becomes ever more important in understanding and beginning to get a better understanding and better control over that. And I know your president has been in the lead in trying to stir action in that area. Where is that leading in your view? That's a critical point. From day one has been on the minds of the president of Liberia. She's directed us as a team, the technical team, leading the response to give support to the rest of the two countries. And so I remember we took some PPEs. That's the personal protective equipment for Ebola. The spacesuit that people were provided some for civilian. We took some of our equipment and labs services provided into civilian. Our health care workers have been mobilizing to also support civilian so that we get to zero at the same time, likewise in Guinea. We have one of our counties in Nima. Nima had gone 62 days without Ebola. But then across the border with Guinea, you have a town called Lola. There was very active, huge transmission. They were reporting the 50 cases per day. And so somebody left from Lola, a 12-year-old child traveled because she had parents in Nima. So traveled from Guinea and got Nima infected. And similarly, in the Kalahum area, people will leave. And so right now we are very much concerned about Lofa that have gone more than 90 days with our single case. So the cross-border dimension is very, very, very, very much critical. We have to work together as a team. So to address that, we're working at a three-pronged approach. The technical team working together as one-pronged, the community engagement working together. And at the political level, the presidents, our head of states, President Selle, President Conte, and President Baku, working very closely together, having regular summits to the address and give us the support as technical people to move across border, move interventions across the three border areas. Because if you see right now, Liberia along all of the counties along the border area with Guinea and Sierra Leone for Liberia with Claire, there is no Ebola transmission taking place from the Liberia side of the border. But across in Guinea, in private to the Guigidu, there is active transmission still going on. And areas like our last county near the border that got Claire with transmission of disease was Grand Cape Mount. Grand Cape Mount has gone over 25 days without any transmission. So Liberia has been Claire with the border area. So our concentration is how can you go close to the Guinea border? And if there are cases in Guinea, you can bring them across Liberia, give them treatment in our treatment units, make our active case finders, our active case sessions, our contact phrasers, community health volunteers, community engagement, that kind of collaboration with Guinea, Liberia, and Sierra Leone with the cross-border support. It's part of the interventions. So we're working on that very closely. Could you just say a quick word about the trials and the field trials that are beginning on the vaccines in particular, but there's also a lot of work on therapeutics and on rapid tests. But the vaccines piece, it's historic. It's moving ahead at a very rapid pace. There's a lot of questions around this, can you say a few words about that? In Liberia, it's good you put me in this seat because back home, I'm always also in a hot seat about a vaccine trial, trying to give explanation to the public about what it's all about, what we need to do about that, why did we at this time carry on a vaccine trial? But basically, we are going to make history as a country. To find a permanent solution for Ebola in the world. And this is not the first time Liberia making history in the global public health community. In Liberia, we were able to carry on research for oncocytosis, river blindness. Today, we got 19 countries using the alpha-methane, the treatment for oncocytosis in the region. And we bear the highest breading of Ebola. And so it is very much important for us as a country to find a lasting solution for the disease. And the lasting solution from my public health background is immunization is the gold standard for prevention. Immunization has made us in the world to eradicate summa pots. My professor, D.A. Anderson and myself were in close discussion. He led the global efforts to eradicate summa pot in the world, here in the WHO Global Effort at Hopkins. And in the world, we were, he was one of my professors at the John Hopkins University. This is another one sitting right there, Professor Stig. And we eradicated summa pot in the world because of vaccination. Today, polio is also on the verge of eradication. We have three countries in the world that still having active polio transmission. Nigeria is one of those, but Nigeria is doing very well now with polio. Pakistan, Somalia, Indian did wear a few years ago to eradicate polio. And this is because of vaccination. In our expanded program on immunization, we have nine, nine different antigens. And the reason I'm giving this history is for us to have the confidence for the randomized clinical trial for Ebola vaccine on the way right now in Liberia to go ahead and for us to be hopeful that we can have a vaccine this year, promising vaccine for Ebola. So the two different vaccine trial and a placebo have already started in Liberia. We have a site at one of our hospitals that's ongoing. Before I left Liberia on Sunday, we had about 80 persons enrolled already in the trial. It is expected that by the first of March, we have the first 600 cohort enrolled in this vaccine trial and monitor the situation before we can enroll about 27,000 people as the study protocol calls for. And this is under the leadership of the Liberian government, the Ministry of Health, the partnership with the U.S. government, National Institute of Health, and the Liberian government, Liberia Institute of Biomedical Research carry on this partnership. We are hopeful that if this vaccine work, we can have a lasting solution for the rest of the world for Ebola. Thank you. Let's move to our audience. And therapeutic trials have also started with the Z-Map bra. Yes. So we hope concomitantly they can go along and we can have therapies and we can have vaccines. If they can work after the end of the year, if we can have a vaccine for Ebola, then I think we've made significant progress as a global public health community. Great. Thank you. We're going to take a number of comments and bundle them together. So please be patient. We'll do three or four, come back to Tolbert and then we'll do another round. We have about 35 minutes. We also have a number of people here who have been working very actively in Liberia and I would like to hear from them. Could you bring the microphone down, please? Just introduce yourself and be very succinct in your comment or question, please. Yes? Okay. Thank you. And good morning. Thank you for both of the comments that have been made. Please introduce yourself. I'm Jacob Hughes. I'm with HDI. HDI works in the Ministry of Health. In fact, we manage the pool fund that the Honorable Minister mentioned and our program manager is services deputy to Minister Nensua on the incident management system. The presentation was very enlightening about the very difficult experiences that the Liberian people have endured. As you move post-Ebola and you look to strengthen and rebuild the health systems, I wonder if you could share with us what you think are two or three of the key lessons that must be incorporated into the strengthening of the health systems to help prevent this in the future. Thank you. Dr. Lacey, can we get your any thought? I know you need to leave. Okay. And sir, and then behind you. Yes? Thank you. My name is Abdullah Dukley. I also work with the president and I just want to thank you for your great work. And I think your success was shown by the fact that the burial team people were wondering what they're gonna do because there's nobody to bury. So I think that, you know, that speaks pretty well for your success and you did a great job. Thank you. Thank you. It's great to see you. Yes. Good morning. My name is Dan Lucy. I'm a physician at Georgetown University and I had the honor to be able to work in Monrovia at MSF Ebola Hospital from October 30, November 14th and prior to that in Sierra Leone in August. First of all, I'd like to thank the minister for making time to come to the United States from Liberia in the midst of the beginning of the vaccine trials and so much other work that he's been involved with since the beginning of the epidemic. I really appreciate also, you mentioned the shocking number of healthcare workers in Liberia who've been infected with Ebola virus and those who have died. In fact, WHO this week put out their weekly update and I think it's around 830 healthcare workers in West Africa altogether who've been infected with the virus and almost 500 who have died. So I wonder if you could offer suggestions or ideas for how perhaps the region and the world could have helped more in terms of providing healthcare providers to take care of so many patients in Liberia and in the region, particularly as you mentioned during the terribly dark days of July and August and September. Thank you. Down in front here we have a person right here, yes. Honorable Yensua, that was such a dynamic recount of the Ebola outbreak in Liberia and the multinational approach by the people of Liberia to get us to zero. And so I commend you and your team on the work that has been done there. I am Faith Cooper, I'm actually an independent consultant but as a couple months ago I was with a DOD health center that implemented the US-African Disaster Preparedness Program. So I was in Liberia in April of 2014 and back there in July of 2014. Not necessarily related to Ebola but we were working with the government coincidentally, we were working with the government to help in the development of the National and Pandemic Preparedness Plan which was supported by US-African Disaster Preparedness Program. So my question is, one, my observation at the time while I was on the ground was just the behavior of our people, the Liberian people, I'm a Liberian native. They didn't believe that Ebola was real and that caused a spike in the disease. So I'm interested in hearing about their approach now moving forward. I'm also glad you touched on the regional capacity building because ultimately that is absolutely important for the region but my specific question is, the economic community of West African states mandates that all of its 15 member nations at some point must have a disaster management organization independent that oversees disaster management for the country. We were moving towards that progress in Liberia. How will this experience in Liberia contribute to the establishment of that entity that will take responsibility for disasters in the country? Let's take one other additional question in the back there, please. We'll come back to you in a moment. Yes, sir. Hi, my name is Charles Sharp. I'm with the Black Emergency Managers Association. I think she summed it up in terms of the disaster management, in terms of the emergency management network, Guinea, Liberia, Sierra Leone, for the West African nations, that needs to be established. I think your IMS system, that was outstanding setting that up, the coordination with all the stakeholders involved and that's gonna be a key to rebuilding your healthcare structure, especially from the community level and I wanna commend you for all the work that you've done. And one other thing with Dr. Lacey that he mentioned with the response to that and usually response worldwide is how are volunteers getting reimbursed and paid? I think you're leading towards that. I met with him at Georgetown and we discussed that. I didn't talk to you yesterday at the World Bank, but you mentioned that those plans you have in place, you're at that stage to build the Liberian National Emergency Management System or agency. That's all right. Thank you. Why don't we come back to Tolbert and then we'll do a second round, I promise. Okay? Thank you. These are very, very critical and important questions, salient points that you all raise and I'm happy to touch on them. And the issue of post Ebola lessons learned, I believe very strongly, one of the lessons learned that we need to take into rebuilding healthcare system is the issue of IPC. That's the effectual prevention and control. We need to have effectual prevention and control champions in all of our healthcare facilities. We need to have the PPEs in place that's gloves and make sure that we train every healthcare workers to use the effectual prevention control materials. That's a lesson learned. I know very well that the number of healthcare workers that died in Liberia did not die because they were providing services in the ETUs. They died from our normal healthcare facilities, clinics that they were giving services and these are rare top specialist physicians, some of them that died in our major hospitals and so effectual prevention control is very, very key in our healthcare facilities. Another lesson learned that we need to improve and take over is the issue of disease surveillance system. We need to build a real time surveillance system that will track every single outbreak, every single effectual disease, every single disease of epidemic potential in our healthcare system. Human resource for health. There were a lot of healthcare workers that were trained in the Ebola response. We use community health volunteers that provide services and contact raisers, active case finders. How can we put these people to work for us in the normal healthcare facilities? Another one, resource mobilization is key. As one of the lessons learned going forward to the post Ebola era, we spend millions of dollars during the emergency, during the emergency phase of the Ebola outbreak. These resources we need to have very, very concrete support for the healthcare system that can look at the six critical building blocks of our health system and if we do that, supporting our national health plan, the national resilient health system plan, before Ebola we had a 10-year national health plan, before Ebola we had an essential package of health services. We have the roadmap for the acceleration of the reduction of maternal mortality. These are all great, great plans that we need to have resources to support. So those are the lessons that we need to move forward. For human resource, he spoke about that. I think to have training, training is key. We need to train more healthcare workers, capacitate them. We need a change of real-time trainers, could be physicians that have the skills to go in our medical institutions. We did lost some of our professors that were teaching at the medical school. So some of the foreign medical teams, right now we're using some of them in our healthcare facilities. We need to get more to train our professional cadres of health workers, provide them not only post Ebola, but then train them over the year as a long-term plan for Liberia to have that kind of cater of healthcare workers in place. Behavior of people was critical. People died from the virus from the very beginning because of the dire. But we learned the hard way. Our citizens learned the hard way. A lot of people lost their lives before we got to realize that this disease is associated with behavior, protecting people, playing with their bodies. And so by the time they got to know and that community ownership got into the process, we began to turn the curve and bend the curve in the epidemic. So community ownership, community engagement is very good. But the disaster preparedness network that she spoke about, we're all working on that before the Ebola crisis with the US Department of Defense, through our Ministry of Defense, our Ministry of Internal Affairs. We were trying to get a regional disaster network, pandemic preparedness plan that we were working on before the crisis. I think it's very much necessary and critical. The Ebola disease have a lot of survivors that we need to concentrate on. We had, the thing was Ebola disease was 90% case fatality rate, but the Liberian situation, we had like 50% case fatality rate. So a lot of persons that got infected from the virus did survive. We have about 1,400 Ebola survivors today in Liberia, including, we also have 3,000 plus offends that the Ebola disease created. The kids need our support, they need our blessing, they need our sacrosocial, as people of a civilized world to take care of them, these offends need our care. Do they face stigma, the survivors and the orphans? Of course, at certain time we had to create, we had to create a camp for them where we had to put some of them and give them that sacrosocial support because some of them lost their both parents, they lost their aunts, they lost their brothers, and so the government was providing support for some of them. So, and they face very, very huge stigma. One of the President's goal, President Selive's goal is to ensure that they can go to the same school like any other child. By being an Ebola orphan doesn't mean you should be stigmatized and sent to another school. So we're raising resources and trying to get international support, partnership also to support some of these offends that for 3,000 of them are not our ministry of general children and social protection. Thank you. There's a hand down. We could get a microphone down here. Hi, I'm Dr. Donna Wells, clandestine service essential intelligence agency. Can you talk about the income of Liberia's middle class? What do they live on? Thanks. Len and then behind. Hi, I'm Len Rippenstein from Johns Hopkins and we're very proud of you at Hopkins. Thank you. You mentioned, and many people have mentioned the weak health system and of course there's a civil war and you mentioned also the capacity building initiative after the war, the basic package. I'm sure you reflected, and it would be really interesting to hear your insights on digging down on what were the most specific impacts of the war and the healthcare building initiative that gave the possibilities to respond as you have. What were the strengths that were built out of the experience and conversely, what were the weaknesses that were revealed from the civil war and then the healthcare building initiative? Thank you. Are you done? Yes. Could you just hand the right behind you and right next to you? Yes. We'll take the two of you. Yes, please. Thank you. Thank you for this presentation. I'm O'Donnell with the International Crisis Group. I have two questions. The first one is regarding your role during the acute crisis phase. Do you have any comments on the urban control measures such as the role of security forces, quarantine, controversies? And also, how did the IMS and the Ministry of Health adjust in October and November after having been excluded from the initial planning talks of UNMIR in Accra? Thank you. Can you repeat that one? The second question? Accra one, yeah, I didn't get it. Yes, you know, how the IMS and the Ministry of Health adjust in October and November after being excluded from the initial planning talks of UNMIR? This was in the first week of October. Yes, exactly. When UNMIR had the planning talks in Accra and the governments were excluded. Oh, we didn't include it. We had Tony Banbury here last week in October to walk us through. And that was a very interesting sort of moment in the evolution. Yes, right here. We'll come back for another round. Yes. Hi, I'm Katie Broadwater. I'm with the Defense Department. I'm working on a suite of biosurveillance programs. I was wondering as the outbreak started, what did you find was the best method for disseminating information on the outbreak, not only to healthcare workers and professionals, but to the general public? And how do you plan to continue providing information as we approach human cases? Thank you. Why don't we come back to you, Tolbert. Okay, I will start from the last one. We used multiple channels of communication. We did not use one channel. At one point, we were using radio communication, going on the radio, Ebola is this, Ebola is that. This is how you prevent it. But at some point, we needed interpersonal communication. So RPC was also great. We had two RPCs. You have RPC for your facial prevention control and interpersonal communication. So with the multiple communication channel, RPC played a critical role. You cannot go on the radio, somebody lost their loved one from Ebola and say you are out of contact, you have to remain quarantine for 21 days so that you get to follow up. You need to go to them. First of all, showed your solidarity, gave that sacrosocial support to them. And so RPC was very, very much critical in the communication campaign. And when communities, after they got the information, the community did form their own tax forces. So there were tax forces all around the place from one community to another community. And people were going from house to house telling others about what the disease is and all that. So multiple communication channel, printings of flyers, getting information to healthcare workers, printing of posters, community engagement, town hall meetings, focus group discussions, all of those took place. But what is critical is the community ownership is very, very much critical. Once the community knew that this is a very contagious disease, they can turn the tab at themselves. There were times that the community had to put their own roadblocks. If you got in a taxi cab or in a commercial bus and got into a county, the community people would come out and quarantine you, community self-quarantine, because they got the information and you got sick, they would call the ambulance very quickly to get you to the health facilities. So that community ownership was also critical in the information campaign. Security quarantine did not work well. It wasn't one of the strategies that those as we were dealing with the crisis in Liberia, we had less than learn what worked and what didn't work. Security quarantine wasn't one of them that worked very well. So we had to change that strategy. Community quarantine did work. They'll say, okay, we the community would take the initiative, we don't have to be police by meditator, we don't have to be police by a security personnel. We can understand and then when they themselves got engaged, when they themselves owned the situation, then we started to see a great, great level of improvement. The O'Meer situation, O'Meer was planning as a UN agency, as O'Meer, but what we did was when the planning meeting was over, whatsoever was developed in Accra, in Liberia, we worked with the O'Meer crisis manager, Mr. Peter Graff and his boss, Mr. Tony Banbury, who I know very, very well because we worked together. We were able to own our plan as a country. So we did work together, strategize together, change some of the indicators that were playing in Accra and made it a Liberian UN plan. And that was in dust at our president advisory council meeting. The president of Liberia chaired a council called the PACE, the presidential Ebola council, chaired by Madam President. And that plan was presented to the president who were able to adapt that plan with our own Liberian based on the context in Liberia. With the strength and weaknesses in the health system, the Ebola did expose the weakness of our health system. We thought we were doing the right things. We thought we have a strong system, though it was not that strong, but coming from war with all of the efforts that we made, getting MDG4 under control, our supply chain system tried to improve. We were training a lot of medical doctors, we were training nurses, we were trying to also look at all of the building blocks of our health system. But when Ebola struck, we knew that it has exposed our healthcare system. So there's a lot of work to do with the healthcare system. But what was also the strength was that there were a lot of trained people that knew what to do. So when the Ebola crisis started, we did not wait for the international community to come before we start. We already started dealing with the situation. Even before the international help came in September, the care started to bend because we did work with our people and that also helped in dealing with the situation. Thank you. We've got a lot of hands up. Let's start in the back over on this side here in the back row. There's two gentlemen there. Hi, Brett Sedgwick from Global Communities. Thank you very much for coming. And you've been a great partner of ours during the implementation of the response. And I wanted to ask about the mix of implementation approaches of the response. One being implementers that are coordinated by the IMS and by the government and then the other with support being given directly to the government to implement itself. It's something that we thought was really interesting how that was very mixed in its approaches. And I wanted to get your thoughts on effectiveness on both sides of the clinical and non-clinical side of the response. Thank you. Could you just, I'm just in front of you. Yes. Okay. There. Hello, Mr. Minister. My name's Jerry Martin. I'm the director of a new AID program called Preparedness and Response. And we're focused on looking at emerging pandemic threats originating in zoonotic diseases. And of course Ebola is a zoonotic disease. I'd be interested in your opinions and thoughts about in the post-Ebola world in Liberia. What approach do you see it being taken to read for preparedness and response for diseases that may be of unknown origin? And what lessons have you learned from the Ebola outbreak? Just hand it to the woman next to you there, please. Thank you. Thank you. Hi, Erin Taylor from Georgetown. I was wondering if you could talk a little bit about how women and children were uniquely impacted and perhaps what planning you're thinking about relating to women and children going forward. Thank you. And hand it right to Paul in front of you there, please. Hi, my name is Paul Emer. I'm a retired Foreign Service Health Officer with USAID. Just had a couple of quick questions that you might have some insight on. One is the response in Liberia seems to have been different than the response in Guinea, particularly on community social mobilization and communication and so forth. And I'm just wondering if you can, you must have had some experience with Guinea as well in the other countries without criticizing if you can tell us how it was that you were able to be more effective in your community mobilization efforts than maybe some of the other countries that we've heard about were. And the second question is in terms of the US response, which I think we're all proud of, we have seen some reporting here in the US, some criticism saying, not criticism, but saying that it was late. And I'm just wondering if you can comment a little bit on that from your perspective on the ground. Was it late or wasn't it late and how did it work and how many centers got built? Thanks Paul. Can you, that woman, just to your, thank you. Hi, thank you so much. I'm with the Corporate Council on Africa and I was just wondering if you could speak a little bit to the private sector response, both in terms of NGO nonprofits and more especially the business sector. How did they respond? What type of partnerships have you seen and what would you like to see from the private sector moving forward to build a stronger health system? Thank you. Let's come up here, please. And then we're gonna come back to you, Tolber. Hello, thank you so much. We stack them up on you. Thank you so much for your time and perspective this morning. I was wondering if you could- Please identify yourself. Oh, I'm Christine and I work at the National Institute of Health. And I was wondering if you could speak a little bit more upon the psychological remnants of the Scarababola in your community and the stigmatization of orphans that you mentioned. And if you could speak more upon the experience of battling the fear and anxiety that ignited in your community and the outbreak of Ebola in different ways that you learn to incite hope in the challenge of this aggressive disease. Thank you. Okay, thank you. Again, the coordination of the respond clinical and not clinical, I think it's a very, very interesting one. What guided us was one strategy, one program, one respond. That was the slogan, that was the goal. So all of our international partners that came in to help in the respond in Liberia, the message was one respond, one strategy, one program, under the leadership of the government, under the leadership of the president. So the president of Liberia got very, very much involved. We saw that uniqueness, coordination, togetherness of the people of Liberia, government and the people, when we got to know that this was a common enemy. And so under the leadership of President Sehli, she did empower us as Liberian who have the technical know-how as public health experts to work with our international colleagues with also public health knowledge to deal with this situation. At the very beginning, it was a bit difficult. It was a bit chaotic because you had, this was or this is a health respond. This is a public health crisis. So it has to be dealt with by the Ministry of Health of Liberia. So the government did realize that and the president did put the Ministry of Health in charge. So we developed the temante areas that I mentioned to you, case management, laboratory temante area, psychosocial support temante area, social mobilization, epi-surveillance. All of these temante areas, our international partners has taken the areas. So one IMS with these temante areas, we did work together as a team. So when I chaired the IMS meeting, if they are issued with lab, I put CDC on the spot. I said CDC, you are the expert for lab here. You brought the labs, you're here to work with our Liberian team, I need a presentation in the IMS meeting of what happened, why the cases were not tested in 24 hours. And CDC knew that they were in charge of lab with our team. They knew as much that they had the support, they had the resources, they took responsibility as an institution. If they were issued with awareness, social mobilization, and look in the face of the country representative of UNICEF and say look, they were mobilized resources for UNICEF to support the response with social mobilization, that's not a clinical part. If they were issued with clinical part like treating people in the Ebola treatment units, I heard WHO and MSF accountable in the IMS meeting and say look, as a government, people are not being treated, people are rejected in the street, we need to get these Ebola treatment units in place immediately to treat people. And so with also epic surveillance, WHO and CDC were also in charge. So my CDC colleagues epidemiologist, we ask them we have to do this. So that's how the cohesiveness of the response, the one response, one strategy, that's how when it came to logistics, we asked the BFP, chaired by a librarian, co-chaired by the BFP. So the lock cluster was giving support if we needed to move PPEs to the counties, we got the plane, we got the boat, we got the vehicles to move those things. So it was a unique response in Liberia with the great support from our international partner because we had it accountable and we're still holding it accountable. If there are areas, we didn't have the resources out of country, we know the world did mobilize resources from the US government. So those agency on the field that we're implementing safe and dignified barriers. You have the IFRC, the International Federation of the Recurs, and there's a US NGO called Global Community sponsored by USAID, played a very, very critical role in their body management. In less than a month, we were able to establish 74 barrier teams with logistics in all of our counties. So I can, in my IMS meeting, if a body stayed more than 24 hours and was not picked up from the community and buried, global community have to answer questions why is it working? Or IFRC have to tell me the next day, why is this county not picking all their dead bodies on time? So that was a response that we managed and work with our partners. And I think it worked very well. We can get to zero soon with that coordination of the response. Post Ebola preparedness and response, why less in learning? Why we still battling Ebola? We're working with our international partners again, like CDC, the Center for Disease Control has an agency called the CDC Foundation, and also working with eHealth as we speak, we're now building permanent emergency operations center for Liberia. And in each of our counties, we are working with them to build EOCs in those counties that will sell for preparedness and response. So we're leveraging the Ebola crisis to rebuild our health care system with that also. Women and children were highly affected, very highly affected women and children. Our market women were very much moving from one country to another. We have Liberian market women flying from Liberia up to Dubai, flying from Liberia into China, into the United States, into the region, in Guinea, in Ghana. Liberian women will get on the airplane, go and buy their produce, get it to the market in Liberia. Guess what happened? All of the airplanes stopped flying to Liberia during the Ebola crisis except SM Brussels that are came where. I don't know how you have me at this forum. SM Brussels didn't fly me here because everybody was afraid of Ebola. So that affected women. Our countries closed borders. Ghanaian closed their border. Guinea closed the border. Senegalese closed their border. At some point market women cannot travel to go to one country to get their produce to the market in Liberia. That affected their economic and social impact. Children got infected. Their mothers, parents died. They are today, often, 3,000 of them. That's a critical problem that the government face. We're working together as a region, the Manor River Union, Guinea, Liberia, and Sierra Leone. There are things that are working very well in Guinea that we're learning lessons from. There are things working in Liberia very well that Guinea is also learning from. And the fact that Liberia is getting to zero LA put a pressure on Guinea and Sierra Leone to also get to zero. They also put pressure on partners, organizations, and countries, bilateral partners that support in those countries. So they are learning that we're learning from each other as countries to move forward. But I think the major thing is working together in the community, that community engagement component, not with meditary. It cannot solve the problem, not with force. So our six-star countries, some of them still have a resistance and agitation. Force cannot do it. You just have to get a community involved and make sure that they do the right thing. The US respond. Somebody asks whether or not it came late. The entire world came late to the Ebola crisis. The entire world came very late to the Ebola crisis. The World Health Organization made a mistake. That's one of the lessons that we have to learn as the global health community. Disease have no boundary. If it is in Southeast Asia, if it is in Europe, if it is in America, especially countries that don't have the capacity. Developing countries, especially South Saharan African countries, have system weak. We knew the Ebola crisis since 1976. And we knew very well it was the first time it was entering capital cities with huge population. The world would have intervened in March and April and June or May, but we intervened late. So the whole world is a lesson learned. Banking Moon, the Secretary General of the United Nations, visited Liberia. We sat together. We had discussions. The World Bank president did visit Liberia, USAID administrator, and my message to all of them, including you, one or two of you in Morrovia, that the world came late. But when they came, they came very big. They came very big. The United States government came very big to the rescue of Liberia. We did appreciate that. I'm very, very optimistic that the president of Liberia did appreciate his U.S. government by deploring the military, by building our laboratory system for Ebola, for getting us to zero on time. It's because of the support that the U.S. government did send from all walks of life. USAID was there. CDC came in with epidemiologists. We had the U.S. military moving in with logistics, at which it was done in March or April. We would have lost 3,000. We would have lost 8,000 lives in the region. 20,000 people wouldn't have been affected from the Ebola virus disease today. They came late. They came huge and supported us. And we appreciate that. Tolbert, I think that's a very resounding, compelling conclusion to our 90 minutes together this morning. Thank you so much for being so compassionate and candid and detailed in taking on all of these multitudinous issues with such clarity and such sensitivity. And thank you for the leadership that you have demonstrated and sustained over many months. Your contribution is just enormous. And the story that you tell is a very positive story at the end of the day. And so thank you so much for being with us. Congratulations on the results of this. Thank you. Thank you.