Ebolishing humanity? – Ft. Dr David Nabarro, UN Special Envoy on Ebola

OB:Now, Dr Nabarro the spread of Ebola is very much contingent on humans being a social species. It breeds on our need for rituals, our need for physical connection. And as such, I wonder if it really challenges everything that we cherish so much about humanity – you know, love, attachment, compassion, even altruism?

DN: Yes, I would agree that this virus has come into the lives and the livelihoods of people in West Africa, very much associated with aspects of their lifestyles, particularly rituals around illness, healing and unfortunately death. In particular, it's spread through funeral practices, which have unfortunately contributed to the size of the outbreak at this time.

OB:Now, I heard you and other public health professionals stress that separation of Ebola patients and Ebola victims is key for stemming the spread of this epidemic. But when you actually think about what it entails, you know, denying the warmth, the comforting touch to your sick child, or perhaps to your ailing parent, for weeks on end and perhaps till their death – I think that's a very, very high order for anyone who has basic attachments. I mean, it's one thing to recommend it, but I wonder if you yourself could imagine yourself in such a situation?

DN: Thank you for that. I agree with you that asking people, when they are ill, to be separated from those they love, and indeed asking the relatives to be separated from someone who is unwell, is very difficult. But I want to stress to the viewers that actually, the communities who are affected by Ebola right now are coming to terms with the reality, and if they are sick, they are voluntarily separating themselves from their families and going into places of isolation. And this is one of the contributing factors to the beginnings of a sign that the outbreak is coming under control.

OB: But Dr Nabarro, that may work for adults, but as we all know, one of the first victims of Ebola was a two year-old child. And we hear those horrifying stories about children being essentially abandoned in the middle of the street. You know, that's something that may actually challenge the very foundations of not only West African societies, but even western societies here. Because we do take please, and we do take pride in caring for the children, and to children, you cannot explain that it's Ebola and you have to leave it alone for a couple of weeks.

DN: Well that's why the response to the outbreak doesn't just mean putting people into large Ebola treatment centres. Now, we are increasingly focusing on community care and centres in the community which are close to peoples' homes, where children and family members can be cared for without being far away from their relatives. I quite appreciate what you are saying about how the treatment of the disease can undermine some of the realities of society, and for that reason, the treatment efforts are being adapted to how people like to live and relate to each other.

OB:Now, in our societies, we assign a very high moral value to charitable and humanitarian work. And people who are involved in such work – priests, doctors, volunteers – seem to be the most likely candidates for catching Ebola. I wonder if this outbreak could also have a major impact on what we mean by human solidarity, or on the humanitarian cause in general?

DN: So, we are seeing extraordinary responses to the outbreak from medical and nursing personnel, and you're right that they are also more likely to get the disease, because they're in contact with sick people. Sometimes it's really unfortunate that when they reach out to provide the helping hand, or the healing hand, they unfortunately also get infected with the virus. However, I'm not seeing any signs of health personnel refusing to provide assistance to people with Ebola. In fact, there are thousands of people volunteering to come and work in the affected countries, and what we're doing is trying to help them form into teams who can respond in a safe and effective way.

OB:Well, Dr Nabarro, maybe I'm misinformed, but I've read stories about doctors in Spain, as well as in West Africa, simply resigning and refusing to do their job because of the fear of catching Ebola. Now, I heard also a number of UN official praising the strong international response. And if you look at the survival rates, they vary dramatically for the Africans and the people from Western countries. For example, in some African neighbourhoods, the mortality rate is nine out of 10, while for the Americans so far, it is one out of nine. So, there seems to be a very, very large gap that doesn't really support this concept of human solidarity and global international response to Ebola?

DN: Well, we are working very hard to make sure that everybody, wherever they are, gets a very good chance of survival. I agree with you that with good care, there seems to be a survival rate of about 80%. We would like to see, in all Ebola treatment centres, certainly survival rates of at least 50%, and up towards 80% if people arrive early in the disease. I can tell you that several of the centres that I have visited in the affected countries, including some which involve African and Asian doctors providing care – the survival rates are certainly up in the 70% or 80% level. Please don't let anybody believe that there are two standards of care here. The important thing is to be sure that people get in for treatment early, then survival rates are much better.

OB:Well, Dr Nabarro, you just said that we shouldn't believe that there are two different standards of care. But there are certainly many different standards of living, and I think the standards of living have a direct contribution to a person's chances to withstand this virus. I mean, I know that you previously, in your previous capacity, focused on food scarcity. And it would seem that one of the reasons why Africans are so susceptible is because of the basic malnutrition, even though, as we all know, the world has enough food to feed everybody who is hungry?

DN: Well, I agree with you that there are very unfortunate differences in standard of living between people in parts of sub-Saharan Africa and people in Europe or North America, where I am at the moment. Let us bear in mind that there are also big standards in the quality of health services, and one of the reasons why we're working so hard to increase the quality of healthcare, particularly in developing countries, is to try to be sure that services are of the standard necessary to prevent this kind of disease outbreak from happening. This is a huge challenge, and one which all societies, and all countries need to be working for - access to health services for everybody, health security for everybody.

OB:Now, taking that from an individual to a collective level, a leaked WHO report showed that the traditional ways of containing the spread of this disease don't work well in areas where countries have long, porous borders. And yet, this seems to be the trajectory that globalisation is taking – I mean erasing borders, turning the world into one big village. And I wonder if, from a public health perspective, it really makes sense to try to keep the borders intact, both literally and metaphorically?

DN: Well, we are not in favour, any of us, of countries trying to deal with an infectious disease by closing their borders. We say that the responsibility for reducing transmission lies with the authorities in ports of departure – please don't let people with fever or other signs of infectious disease to get on aeroplanes, or ships, or other conveyances. We're also very keen indeed that there is a recognition that with globalisation, diseases like Ebola will become more prevalent, and that means that every nation needs to have satisfactory systems for health security, and also implementation of the international health regulations.

OB:Now this border discussion is already taking place in the United States, where three states have introduced mandatory quarantine measures. And I think that's just a very early sign of more things to come. I think we'll inevitably have to have a debate about the balance between individual freedoms and the so-called public good. I wonder, where do you stand on that issue?

DN: Thank you. I want to stress that often the initial reaction to an infectious disease, especially one with a high fatality rate, is to take extreme measures, basically because of fear about the nature of the disease and a lack of full understanding about how it's transmitted. I'm encouraging all societies everywhere to discuss the issues around Ebola, just as you're doing on this program, and then to think very hard about the appropriate measures to reduce the risks to public health. In general, that does not mean closing borders, but it does mean trying to be sure to identify people who are at risk, and then ensuring that they, and only they, are kept in some kind of surveillance situation, so that if they are unwell, they can rapidly get treatment.

OB:Now, Dr Nabarro, you just made references to some countries overreacting due to fear of Ebola, but I also heard you make references to Hollywood blockbusters about epidemics. And in your testimony before the UN General Assembly, you actually said that this is more extreme than any film you have ever seen. And in most of those movies, quarantine efforts end up turning into what are essentially concentration camps. If Ebola indeed turns out to be as virulent as it is sometimes predicted, would it also encroach on what we consider to be inalienable human rights? You know, the freedom of movement, the right to decide on your own destiny, on your own course of treatment etc?

DN: Thank you for pointing this out. My concern about the situation at the moment is to see just how dramatic the reduction in abilities of people to travel to and from the Ebola-affected regions of this world have become. There are very few airlines now flying into Guinea, Sierra Leone and Liberia. There's also a great deal of stigmatisation of people from these countries. And yes, there has been some application of quarantine, in many cases recognising that this can be associated with hardship. I think, as the weeks have advanced, so governments and local authorities have realised that movement restrictions and some degree of separation of people who are at risk of illness, can be done without necessarily causing hardship, by making sure that people do have access to food, to water, to other basic needs, to telecommunications so they can contact their relatives, and so on. So I say, when applying these separation measures, please do so in ways that ensure that people have access to their basic needs and dignity.

OB:Dr Nabarro, we have to take a very short beak but when we come back - conspiracy theories always feed on uncertainty but if history is anything to go by, don't we have reasons to be suspicious about both Ebola and the response to it? That's coming up in a moment on Worlds Apart.

OB:Welcome back to Worlds Apart where we are discussing the Ebola outbreak with Dr. David Nabarro, the UN Special Envoy on Ebola. Now, switching gears a little bit, Dr Nabarro, the global economy is still a bit sluggish in the aftermath of the financial crisis, and many countries are looking for potential sources of growth. And it seems like the vaccine market can offer this much-needed push. It's already worth around $24 billion, it is projected to grow at about 15% per year until 2018. And I wonder how do we make sure that the fear of Ebola that we all share is not being capitalised upon? Because in the past, we've already seen how lots of money was made on other public health emergencies – the swine flu outbreak a couple of years ago was one example of that.

DN: Thank you for pointing out that there could be situations where health risk is exploited. But I want to stress to you that at the moment, we're doing everything we can to encourage vaccine manufacturers to complete phase II and phase III trials of candidate vaccines for Ebola virus, to prevent people who are exposed from getting the disease. This is urgently needed, and to help make this happen, there is a need for finance to support the companies, to speed up production and to help address some of the risks associated with rapid production. We do need vaccine manufacturers to enter into this market, and I'm glad to see that some are doing so.

OB:Now, I've seen the projection figures by the Centre for Disease Control – up to 550,000 cases in Sierra Leone and Liberia by January 2015, if no additional interventions are made. And, correct me if I'm wrong, but I think 500,000 is roughly how many people die each year from the common flu. And if we add to that other pretty common viruses, that figure be in the millions, perhaps many millions. By putting so much emphasis and so many resources in fighting Ebola, aren't we actually robbing the victims of other diseases, of other viruses, from much-needed attention and from much-needed treatment?

DN: In public health, there are always choices that have to be made. I want to be very clear that the reason why there is a lot of emphasis put on this Ebola outbreak is simply to try to catch it at an early stage, before it spreads and covers and affects either the whole of the African continent, or even spreads to other continents in a significant way. So what we're doing now is investing significant significant amounts at an early stage, in order to prevent long-term major economic and societal impact at a later stage. Much better to do it now, and get it done properly, than to do it half measures, and then have to deal with a continuing set of outbreaks associated with Ebola, lasting a number of years.

OB:Now, Dr Nabarro, I'm not a big fan of conspiracy theories, but I think we have to address some of them. The response to Ebola has so far relied heavily on military and peacekeeping capacity, and I'm sure you know geopolitics is highly charged at this point of time. Do you see any potential danger stemming not from Ebola, but rather from the militarised response to Ebola? Because there are many forces that are not keen on seeing either American or, let's say, British forces on that continent. You know, Boko Haram in Nigeria being one of them. Could this public health emergency turn into an emergency of a different kind?

DN: Thank you for making these points. Up to now, I have just seen an incredible sense of gratitude on the part of the governments and people of the affected countries, that the international community is coming in and providing assistance. There are indeed some military assets being used, but that is fundamentally for logistics and construction purposes, and there is again, as far as I can tell, very low engagement of military force. I can make no comment at all on the security challenges associated with the use of military personnel. But what I can say is that there have been some instances where communities that have not received support from their governments or from the outside world have felt very frustrated. So it's kind of the other way around – I believe that this external support is being treated with very, very great gratitude and appreciation by the people of the affected countries.

OB:But Dr Nabarro, in one of your recent public appearances you were talking about the fact that this international response to Ebola is based on a different model of command and control. You actually said that the UN may have “a unitary command but not a unified control.” And one can certainly see the benefits of this sort of approach – you know, cutting down on bureaucracy and facilitating a faster response. But you can also see vulnerabilities in foreign military troops being present on the continent with multiple security challenges. So, I wonder if, while countries are joining forces in fighting Ebola, whether their roles and rules, including the rules of engagement, have to be defined a bit more clearly? Whether there should be, indeed, not only a unified control, but also an international agreement on what the rules of operation really are?

DN: Well, thank you for that question. I want to stress that as far as I can tell, from studying the way in which different groups are working together, there is a quite exceptional level of high quality coordination and mutual acceptance of operating procedures. Yes, there is unitary command, and that comes from the national governments. Everybody who is involved in the response is working for, and on behalf of the people and governments of the nations. In terms of the control part, that is being agreed and negotiated through coordination structures that involve the UN and others. And again, I think it is a very high standard. You know, it's not possible in these kinds of situations for any group to impose measures on others – that's just not how things work. Instead, it has to be done by mutual consent, and that's what we have – consent to accept the command of the national authorities, consent to be coordinated, and consent to function in synergy.

OB:Well, Dr Nabarro, I guess what I mean is not imposing the will of one country onto others, but rather using this situation for one country's national interest. For example, there have been a number of cases of public health emergencies being used as a cover for special operations. One of them being the CIA involvement in the polio vaccination program, in order to obtain DNA samples of Osama Bin Laden. And I think you would agree with me that many public health experts believe that that greatly undermined the global campaign to eradicate polio. Now, again, I wonder if there is any way to ensure that all countries that are involved in responding to Ebola indeed focus on the disease, rather than also pursuing their interests, for example national security interests?

DN: I can't answer that question, I don't know anything about those issues...

OB:And Dr Nabarro, very, very quickly, in the aftermath of that CIA operation, a number of Islamic clerics in Asia, as well as in Africa, in Nigeria for example, condemned polio vaccination programs as a plot to spread AIDS and other diseases. And I think we see similar conspiracy theories spreading around West Africa – a number of doctors in Guinea have already been killed because people thought that they came into the communities to infect them with the disease. And there was recently an article in the LA Times that quoted a local police officer in Guinea, who said that people in the countryside believe that Ebola was “an invention of white people to kill black people.” I wonder, how do you really combat these types of beliefs, how do you instil confidence in the medical profession in that part of the world that until recently had very little, if any, contact with doctors?

DN: Firstly, I want to stress that the communities who are being helped are extremely grateful for the help that they are receiving, whether it is from national or international personnel. There have been some situations where communities have been frightened and confused, perhaps because they've lost people and don't understand why they died. And yes, there have been some attacks. But as far as I know, they have not been attacks on international personnel, they have more been attacks on national personnel. And they are attacks based on confusion and misunderstanding, rather than any more substantial concern of the kind that you've just mentioned. And I want to stress that we've had absolutely no evidence of systematic targeting or concern about international personnel.

OB:Ok, Dr Nabarro, I really appreciate your time and your being on the show.

DN: Thank you very much, bye bye.

OB:And to our viewers, please chime in with your views on our Facebook, Twitter and YouTube pages, and I hope to see you again, same place, same time, here on Worlds Apart.