Learn about the evolving Ebola epidemic and its various aspects including disease prevention, management and treatment, response to the epidemic, ethical considerations, and the post-Ebola global health landscape.
OPTIONAL: Why Send an Army to Fight a Virus?
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Ebola Virus Disease: An Evolving Epidemic
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From the lesson
Introduction to Ebola
Upon completion of this module, learners will be able to:
Review the state of global public health prior to the 2014 Ebola epidemic.
Explore the etiology of Ebola and other viral hematic fevers.
Explain the epidemiology of the 2014 Ebola epidemic and why this outbreak is different than previous ones.
Explain why tropical forest-associated zoonotic pathogens like Ebola are emerging at an ever-increasing rate.
Recognize drivers of disease spillover from wildlife to people and discuss how to mitigate disease spillover.
Meet the Instructors
Dabney P. Evans, PhD, MPHAssistant Professor
Hubert Department of Global Health. Rollins School of Public Health. Director, Center for Humanitarian Emergencies.
Carlos del Rio, MDChair
Department of Global Health at the Rollins School of Public Health
In this lesson, we have a special presentation by Colonel Jim Sarnick,
Command Surgeon for the U.S army in Africa.
Colonel Sarnick is an army ranger who served in Iraq and Afghanistan,
and he's also a physician.
So his perspective on the issue of Ebola and global heath are truly unique.
Colonel Sarnick was the lead physician in the Army's response to
the West Africa Ebola outbreak and
we'll hear his talk entitled, Why Send An Army To Fight A Virus.
This presentation was recorded on February 4th,
2015 at the Rollins School of Public Health at Emory University.
>> What I want to talk with you about is, why send the army or
the Department of Defense to fight a virus?
First of all, know that the Department of Defense was not
the first federal agency involved in Liberia with the outbreak of Ebola.
You're familiar with that, right?
The USAID was involved there and
had been wor, they have a rep in the embassy and they had been tracking this
outbreak since February and March, and they had continued to provide support.
When it became clear that the virus spread was
potentially going to reach exponential proportions and spread,
and do you all remember those kind of very, very worrisome graphs?
And in fact, those graphs were true if we did nothing, right?
So those graphs pointing up caused the USAID to say,
listen in conjunction with the federal government,
we're going to declare this a disaster and then,
we're going to send a Disaster Assistance Response Team called a DART team, okay?
So a DART team from USAID went to Liberia,
worked out of the embassy, to try to aid in the response.
DoD is not involved right now, okay?
An important thing to understand about Liberia, it is, it was a nation formed by
freed slaves from the United States who wanted to go back to Africa, okay?
So, the important thing to know, though, is in their history,
they still saw the United States as a partner and family.
So, when a like, when most people outside of the United States talk about traveling
to America, they say I'm going to go to the US, or I'm going to go to, America.
Ask a Liberian, and he says,
I'm going to Charlotte, I'm going to San Antonio, right?
because he's got family and they've got connection there, and
there's a lot of dual citizenships there.
Okay, so, USAID sent a DART team to help in Liberia.
Now Libera has had a troubled past, and
really they're only about 11 years post civil-war.
So many of the systems and processes and
parts of the government were still fragile to include their healthcare systems.
In fact the vast majority of the healthcare systems could not operate
without the day to day presence of non-governmental organizations,
NGOs, okay?
But this was great, because that's what the DART team does.
They come in, really with a big bag of money from the United States, and say,
NGOs, we need your help, these are the requirements can you come and
meet these requirements?
Does that make sense?
That, that's really kind of, that's one of the instruments of national power,
if you will, right?
Is the financial means.
There was a problem with that model, though.
So in March, and April, and May, and June, as the disease continued to get worse,
there was tremendous risk to the NGOs who were in the country.
So samaritans' purse who ran JFK Hospital in Monrovia,
their largest hospital, said, the risk to our people is too great from Ebola.
And so they left and
then a number of NGOs started leaving as well because the risk was too great.
They saw the curve continuing to rise in the capital of Monrovia,
1.4 million people.
They saw the transmission increase and increase and increase.
So, if the NGO's left, or
the bulk of them except Médecins Sans Frontières and a few others.
If I am a US Federal Agency, and I show up with a big bag of money and
the way that I operate is to engage with the NGO's and
say I need your help, can you do x and
I will give you y grant money to do that, do you see a problem with that?
Who do I give grant money to if there are no NGOs in the country, right?
So, in many ways it was a square peg in a round hole.
Great people trying to do wonderful things but the model that
they used broke down because the NGO's left because of the threat.
So as I paint that picture, understand that what started happening
in the country then, in the region was a tremendous build of despair.
So as the media continued to pour, to go over and over the,
the, the exponential growth, and now it's spreading to Guinea and
Sierra Leone and now they're worried about the spread to Cote d'Ivoire, and Senegal.
And then the transportation, where it could spread throughout all of Africa, and
quite frankly, all of the world,
because this was a disease that moved at the speed of transportation.
Now you see how it became a real threat, and that's why President Obama said
this Ebola outbreak in West Africa is a threat to National Security.
Because he saw the potential for the breakdown of the con,
the organizational and the governmental structures in Liberia, Sierra Leone, and
in Guinea and then if it spread, the breakdown on the Continent, and it was
just a matter of time until it spread to Europe, the US, South America as, as well.
It was a threat to national security and
that's why the president said we need to act and it was USAID that said we
need help, because we can not engage people to get the things done.
Hence, the decision to bring the DOD to bare.
Now, why the DOD?
Most people think about the Department of Defense like,
I'm the big army killer, right?
They think your job is to close with and destroy the enemy.
So why are you coming to fight a virus?
What I would ask you to do is think about it in this way.
The Department of Defense, in the big picture, does three things.
At the very end of the day, when everything breaks down,
we can compel an enemy to do something, right?
If I have a boot on their chest, and a knife at their throat, I can compel them.
Clearly, from the US doctrine standpoint, that is.
The last reserve, resort.
If you dial back one notch, what the Department of Defense is we can deter.
So, even before things get aggressive,
we can provide deterrence to prevent people from doing something.
Anybody remember MAD, mutually assured destruction, right?
From the nuclear threat.
Deterrence.
If you dial that back all the way,
what the DOD really does is assure.
So they can assure, they can deter or they can compel.
And in fact, what Liberia needed and the region needed and
the world needed was assurance and hope.
So, on the 14th of September, Africom,
which is a geographic command, the Department of
Defense splits up the world in geo, in geographic regions.
And the Africom leadership was giving a warner order, warning order,
be prepared to assist in the Ebola outbreak in Liberia.
We got that warning order as US Army Africa, so
you think there's the Army, the Navy, the Air Force,
the Marines and I am the lead physician for the US Army in Africa and
my two star general is the lead Army Commander for all engagements in Africa.
So, on the 14th of August, Africom got an order and
we got a warning order and my boss said, you know what?
I, I igno, I have been reading about Ebola, but
I really don't know what's going on.
So we need to do what's called a leader's recon.
That's really Army terms for saying, let's go down and see what's going on.
Let's understand the environment.
Let's develop some situational awareness.
One of the biggest mistakes people do in a disaster is they sprint to failure.
I'm here to help.
Well, what are you helping with?
I'm not sure, but I'm here.
Okay.
Well, while you're here figuring out what you're going to do,
where are you going to live?
Well, I just figured you'd put me up.
Oh, okay.
Who, who's going to feed you?
Well, I figured that you guys would, because you need help.
Well, who asked you to come help?
Do you see how that could compound a problem?
So before you just sprint some place to show up, you do a reconnaissance.
So we flew down to do a leaders recon.
We got on the ground, the intent was to be there for two days.
The Commanding General, his senior enlisted adviser, the Sergeant Major and
12 people that are affectionately known as the dirty dozen and
these were senior staff people on his staff.
The logistician, the engineer, the public affairs.
The physician and we went down just to understand the environment for two days.
As soon as we hit the ground, this was the 16th of September,
it just happened to coincide with President Obama saying,
we are going to send up to 3,000 troops to the, to Liberia.
As soon as we hit the ground,
it was a palpable feeling of despair that you walked into.
And we knew that this will, we were not going to be there for two days and
turn around and leave.
Because the impact of that on the Liberian people,
whose origin was from the United States.
Who looked at us as partners and brothers.
The imagery that that would have sent was we showed up, looked around and said, hey,
this is too hot for us, we're leaving.
So we stayed and we started to engage.
Remember, I said the DOD does three things.
They can assure, deter and compel.
What I will tell you is most importantly,
what the DOD brought to the fight against Ebola was hope.
The look on people's faces when they saw a 14 people wearing uniforms and
I was in my fatigues, what we call the army combat
uniform with the US patch on their shoulder was powerful.
I mean, it was palpable and powerful.
I saw smiles starting to come to people's faces, right?
And they were waving us, at us with five fingers not just one finger.
[LAUGH] That's a very good line, sir.
And it wasn't just among the people.
[COUGH] So when we walked into the embassy, so the lead representative for
the US Government in the country is the ambassador.
And the DART team that was handing out money to NGOs were there were no NGOs were
working out of the embassy.
And engaging with those people as well,
you felt this overwhelming sense of despair.
I did.
I'm an emergency medicine physician.
I just, let me just correct that,
I just happen to be an emergency medicine physician.
As Ken told you, I'm a soldier, who happens to be an officer,
who just happens to be an emergency medicine physician.
But that's one of the skills that, and I picked up on there very quickly.
In that embassy, the personnel normally come with their families and
they live there.
But they had an ordered withdrawal out the embassy, because of Ebola.
An ordered withdrawal doesn't mean a very well synchronized, efficient withdrawal.
It means, you will send your families home, because the risks is so great.
[COUGH] So now they had been three or four months without their families there,
compounded by the fact that President Sirleaf in order to help prevent
the spread of Ebola said, there will be no touching in the country.
There's no handshakes.
There's no hugs and this is in a very gregarious nation.
So you had an embassy that saw the numbers going up,
ordered withdrawal and no human contact.
I don't need to be a doctor to know that there's a concern there.
It didn't take a well trained soldier to figure that out.
It took a human to just engage people as a human and you felt that.
You can feel that from people when they're having difficulty and
just as an example of that hope that we brought.
One day, Ambassador Malac came off the elevator [COUGH] and as she stepped off,
I said, Ambassador, I know that we're not supposed to be touching or
giving hugs, but I'm a hugger and I really think that you could use one.
And she said, okay,
Jim and kind, she kind of did that smile, because okay, I'll placate, Jim.
And so, I gave, I gave her an embrace and if you ever given somebody a hug and
felt them kind of just collapse in your arms, right?
Like they just, like literally, you're supporting them.
That's what I felt and that hug lasted for about 20 seconds.
That's pretty good for hug time.
[LAUGH] You know what I mean?
And then she stepped back and she said, Jim, thank you.
Because I really needed that.
Hope, is one of the most important things that we brought to that environment,
to assure them that we were in this battle with them.
Now, that's kind of the strategic level,
from an operational level we were tasked to do four things.
We were tasked to provide some synchronization
of the DOD efforts on the ground.
Right? So we were what's often
referred to as mission command.
Because when you've got a lot of people racing all around,
there's a difference between motion and action, right?
You ever had a person on the team that's always racing around, but
not getting anything done?
Man, you're busy.
Yeah. You're busy doing a lot of nothing, but
you are always going.
So, the, you need somebody to synchronize, help synchronize that.
So that was one of our tasks.
The second task was to set up a, a supply chain going through Senegal so
that the US DOD could support the flow of logistics support to the response.
Because just the personal protective equipment by itself was a huge burden.
We were burning through thousands of sets of suits and
gloves and masks a day, and there wasn't a methodology to bring that in.
There were certain methods but they weren't coordinated,
let's just put it that way.
The other thing that we were tasked to do is to build up
to 17 Ebola treatment units.
So why was this important?
Remember the vast majority of the NGOs that were in the country had left,
except really for Médecins Sans Frontières.
And they set up some Ebola treatment units and
even though they may have had 100 beds or 150 beds, they were overflowing.
So people were driving up in taxis, dropping patients off and
driving out and there were people, because it may have been 150 bed Ebola treatment
unit they were running, but there was already 250 people in it.
And now people were stacking up on the outside.
So the visual representation, it, don't even think about, hey,
people aren't getting care.
Visually, what that tells you is, oh my gosh, this place, tremendous despair.
Right? People are dying in place.
So, the direction that build up to 17 Ebola treatment units,
and these were based on, hey the numbers are just going to keep going up.
And the concept for
stopping an outbreak like this, I really shouldn't, you guys should be telling me,
not me telling you, but how do you st, how do you break the cycle of transmission?
In the disease?
Anybody?
So you take care of the sick, but
more importantly, you isolate them from the healthy, right?
So if I just keep focusing on taking care of the sick, if the,
if the contacts are still going on over here and the numbers keep growing.
I'm not going to stop the problem.
So the Ebola treatment units were really also a place where people could go to
contain the outbreak.
Remember before,
we had never seen an Ebola outbreak go into a large urban area before.
It had been in primarily very small towns, very small villages, and
the outbreak had burnt out on its own.
Independent of people's best efforts, right.
So one of the reasons we were told to build up to 17 Ebola treatment units is
hey, you gotta put these people some place to give them care,
but you gotta stop the cycle of transmission.
And because there was nobody out there that USAID could give money to to say hey,
could you do this.
They needed somebody to do that.
The fourth thing that we were asked to do is to train up to 500
people a week to work in an Ebola treatment unit.
So if I have a disaster or
an emergency, many people want to run to help.
But if you don't know how to help, you become more of a problem than an aid.
Does that make sense?
I know that General Keane understands this.
During his time, when he led, he was the commander, if you don't know this, for
the relief response in Haiti, after the earthquake.
People were coming all out of the eh, woodwork to help.
But, really what, they didn't know how to help.
They didn't bring their own life support, and so they became a problem.
So one of our task of training them was,
hey, when people when come back in the country we don't want you to get Ebola.
Does that make sense?
Okay.
Now, one of the things we found out very early on,
we didn't, this is when you just assess the area.
When military people go places, all right, so we've been in combat for
about 14 years in Afghanistan and Iraq.
To be honest, it's, it's pretty easy to fly into a failed state.
When you have the biggest guns around, and you just make up the rules.
Right, so the military would deal, deal was very use to being in Afghanistan and
Iraq, just showing up and trying to bring some order to the chaos there.
But they we're were in charge, why?
Because I had the biggest gun.
Very different in Liberia.
Because now you're going into a sovereign nation.
I'm not just saying I'm going to fly in and
bring 30,000 people whether you like it or not.
It's no, President Sirleaf, is it okay if we bring personnel in and
this is the flow that we want to bring them in, this is where we would like to
house them and this is what we think they're going to do.
But it needs to have approval from the sovereign nation.
And then, so, it's, it's not just that simple,
it's not like I'm working directly with the government, because I'm in direct
support of the lead federal agency, from the United States which is USAID.
So, very rapidly, you say, hey, first and foremost, this is not about me.
This is about the people dying of Ebola, and you've
got to learn how to build partnerships, consensus, and most importantly, trust.
And that's what a lot of the time was spent right up front.
Simple example.
Medicine sounds Fontease, Doctors Without Borders.
We're doing great work there.
However, as a whole, they essentially say, we want nothing to do with the military.
Right?
And there's, there's some deep seated personal feelings among some people, but
in, in general, it's a security issue for them.
Medicine Sans Frontiers said, we want the U.S. military to come in and help.
We need them to come in and help.
That doesn't mean that I've got carte blanc as soon as I show up,
because I still have this whole culture of people are going, you military guys,
I don't know.
You're scary.
Right?
So a big part of what we did was develop trust.
And just engage with them.
The second piece to that is, remember it's not about you, and
you don't have all the answers.
You're there to support the people who do have the answers.
So you sit down and you say, how can I help?
It's not, I'm here, I'm the 6' 3", 245 pound guy with all the scare badges and
you're going to do what I tell you to do.
That doesn't go over very well at all, right?
But if I say listen, I can bring some air support, logistic support and
medical training support.
Tell me what you need.
And then you guide me.
Please help me understand powerful words.
Remember seek first to understand and then to be understood?
Powerful in this environment.
So what it did is broke down barriers and we could get to work.
And we could get to work.
One of my particular challenges not only in the country but
also back home was just the fearbola that we faced.
Right?
I mean how many news trucks do you think were outside in front of Emory when
you had your first patient show up?
One?
Okay, maybe there was a lot, maybe there was two.
>> [LAUGH] >> Right?
No, I mean it was like rampant, fearbola.
The pr, for me it was very frustrating because I'm a physician and
I know the science behind Ebola.
Right?
Most importantly, if you're not symptomatic, you're not.
Exactly.
So although the incubation may be 21 days, even if I know that
General Keen has got Ebola, if he doesn't have a fever, if he doesn't have nausea or
vomiting or body aches, doesn't have a sore throat, he's not infectious.
Right? So we can swap high fives, and
I can give him a hug all day, and I won't get Ebola.
And the other thing about Ebola is it's not airborne spread.
Right?
So just the education piece was very powerful.
But we had to educate more to our own people, the soldiers coming in were
reading the same thing on the blogs, and the same thing from CNN.
Going [SOUND] right?
And then their, their spouses are going, [SOUND].
And then their spouse's friends, who sends their kids to school with them,
are going [SOUND], I don't want to send my kids to school with your kids,
when your spouse gets back.
Because he's going to come back from that place that had that disease.
And nobody knows how it spreads.
So, he's going to come back with it.
He's going to have it for three weeks, and no one's going to know, and
my kid's going to die, because they go to daycare with your kid.
I mean, literally.
So, that informational piece was very, very, very powerful.
And I, I had to just sit down with people and say,
look, this is very similar to HIV.
And very similar to hepatitis.
It's spread through direct contact with bodily fluids.
Right?
The interesting part is, back in the 70s,
we went through this same fear, HIV issue, as well.
I'm like, sorry.
I can't stay away.
I don't know.
Can't touch you.
You know let me see your blood test first, right?
So, that in, instructional piece was, took up a lot of my time, as well.
But it was important, because people couldn't focus on the mission
if they were worried about their own well-being.
Okay?
The next piece that was difficult was, I was asked to train up to 500 people.
And these were people that could come from anywhere in the world to help fight Ebola.
All right?
So, people from Cuba came in to help fight.
People from China came in to help flight.
A whole bunch of different NGO's came in.
I had the Bundeswehr, the German Army come in partnered with the German Red Cross
to help fight Ebola.
Right?
But they needed to be trained.
So I thought okay, my orders were clear.
Train up to 500 people.
Based on a plan of instruction agreed to by World Health Organization and
Medecins Sans Frontieres.
I said okay, simple, please just give me this plan of instruction and
I'll get to training.
There was no plan of instruction and
in fact the two organizations were at odds, on what was the right way to train.
So we go back to that building trust.
Building a little consensus.
Sitting down at the little table around a little bowl of jello.
And at the end of the day I said okay, this is as close as we can get.
What most people don't know is that those two organizations went to Geneva to try to
figure this out.
And one of those two walked out of the discussions.
So we said, this is as good as we're going to get, and I said okay.
We're going to go to the government of Liberia,
because we're in a sovereign country, and they're going to choose, because we
got to do something, and we put it into play and then started training them.
I have been talking primarily about, kind of, medical responses.
We talked about hope and assurance.
I think it's important, when we talk about a response to a virus,
an epidemic or a disaster, that we talk about the real threats.
So when we brought forces, or NGOs, or CNN camera crews,
to Liberia, everybody was concerned about what?
Ebola.
Is not a trick, right.
I'm not a smart guy.
I can carry heavy things but I'm not a smart guy.
So I'm trying to keep this simple for me.
Ebola.
But that wasn't the biggest threat, right.
Because unless you're in direct patient contact, and
getting bodily fluids with a symptomatic patient, you're not going to get it.
What was the real concern for people going to Liberia.
From an infectious disease standpoint it was malaria, right?
Plasmodium Falsiperum, and it kills quickly there,
and even if you're taking chemoprophylaxis you can still develop malaria there.
And I really didn't believe that.
I mean I kind of knew it.
You read it.
But you go, hey really?
If they got Malaria it's because they were not taking their Chemoprophylaxis.
Right? It's a compliance issue.
Until I talked with four physicians who were working
in the United Nation's Military or, United States Mission in Liberia.
And they said yeah, we were all taking our Chemoprophylaxis, regularly.
And we all got Malaria.
So I said whoa, okay this is scary.
So the biggest threat from an infectious standpoint, was Malaria.
So I had to try to get everyone's mind off of Ebola, and say Malaria.
And then from a trauma standpoint was motor vehicle accidents, right.
There's no good lights.
No one was following traffic directions whatsoever.
If you've ever driven around the continent, right, if you think Rome is bad
for traffic, come on down to the continent, right.
It's a completely different thing.
So what I had to do for the people is say, hey listen.
What is your plan if you get in a car accident?
So, when people come from this area, from Atlanta,
and they say, I'm going to go to Liberia to help.
You come with all your preconceived notions and
systems that you think are going to be in place.
Well if I get in a car accident, I'll just pick up the phone and call 911 and
then the ambulance will come.
And if I really need it, I'll get life flighted.
Back to Emory.
Yeah, we just take that for granted, but
in fact, there is no EMS system there.
Not only that, but none of the hospitals you would feel comfortable
going to anyways, because they had Ebola patients moving all in and out,
and there was no trauma system in response.
I'm going to make this even simpler for you.
There is no marking systems on the houses in the country, so
that I can draw a grid to say, go to this location.
You don't go to 345th Main Street,
because none of the houses are marked and the roads are terrible.
Like, okay, it's going to take you six hours to travel 40 kilometers.
These were becoming the real threats, actually,
that we had to deal with, when we went there.
And so how did the DOD help with that?
Well we brought in radios so we could communicate rapidly.
We brought in some aircraft, so not only we could move around the battlefield, and
it's a battlefield because it was a fight against the virus.
This is an easy way for me to look at it.
And it provided the president of the country,
the sovereign nation to get out and see what was going on.
We provided logistics support and
we brought in our own medical capability, to take care of our folks.
I'm going to talk about one more issue about bringing some hope
back to the country and why the DOD was the right tool to do that.
So remember all the NGOs were leaving the country because of the risk of Ebola and
not only that, the healthcare professionals in Liberia that were working
in the Ebola treatment units started to strike because the risk was so great.
They weren't getting paid on time and they felt, well,
I'm going in to take care of people but if I get sick, I'm going to die as well, and
the rate of infections was highest among Ebola caregivers.
So the other thing that the DOD was directed to do was build a medical
facility that would be staffed by the Public Health Service to
treat any person who developed
Ebola in the country there, that anybody who had came for
the response, you could have a place to go to get treated.
This is about assurance,
so now it wasn't all the NGOs that had left that now started to
turn around to come back because they were assured that there would be care there.
But now we saw all the multi-national partners now start to flow in.
And one of the first things they would do, is they would come to me and my boss and
say we're really worried about if our people get in a car accident
or if they get Malaria.
Can we go to this medical facility that you've built up for the Ebola caregivers?
We said, of course.
But they got more specific.
Hey, we've been working together downrange in Afghanistan for the last 13 years
as part of a collation could we do that same kind of thing here so
that my country doesn't have to bring in whole bunch of power generation and
a whole bunch of more tents and a whole bunch, and another hospital.
Can we just snaplink into you?
And we can burden share.
If you need a surgeon, I'll send a person, or
if you need a laboratory person, I can send that.
So what we built there was an on the ground coalition and
it was from an assurance standpoint.
So why spring the army to fight a virus?
Well, there was nobody else there at the time that was able to respond and
ultimately we brought a great deal of assurance.
The interesting last little piece that I will share with
you is USAID works off of grants.
So they give grants to NGOs to get certain things done.
But they don't contract with a certain organization.
So the other thing that the DOD brought would, was contracting agents.
So we could no kidding sit down with ano, another, partner and
say, hey do you have the ability to build an Ebola treatment unit?
And there were contractors, builders there that said yeah, we can do that.
So now they had someone to write a contract with them to say,
here's a statement of work, I want you to go do this.
And so although we were tasked to built 17 Ebola treatment units,
we didn't build the vast majority with them,
because we couldn't built them at the pace they needed them.
But if I reached out to a number of contractors and
we worked together, we could build them up rapidly.
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