As WHO Warns Ebola Death Toll is Underestimated, How Should Global Community Handle Dire Crisis?

August 15, 2014


Laurie Garrett

senior fellow for global health at the Council on Foreign Relations. She won a Pulitzer Prize in 1996 for her coverage of an Ebola outbreak. She is the author of two best-selling books, The Coming Plague: Newly Emerging Diseases in a World Out of Balance and Betrayal of Trust: The Collapse of Global Public Health.

Lawrence Gostin

university professor and faculty director at the O’Neill Institute for National and Global Health Law at Georgetown University.

Adia Benton

medical anthropologist at Brown University. She has conducted research on infectious disease in Sierra Leone over several years.

The World Health Organization is now saying the number of reported cases and deaths of Ebola in West Africa vastly underestimates the scale of the outbreak. The official death toll from the Ebola outbreak is now at 1,069 since February. Guinea has become the fourth country in Africa to declare a national health emergency as it battles the spread of the deadly Ebola virus in the worst outbreak since the disease was discovered in 1976. The outbreak began in Guinea, where it has killed 377 people. It has since spread to Liberia, Sierra Leone and Nigeria, which have all declared a national health emergency. We speak to three guests: Pulitzer Prize-winning journalist Laurie Garrett, senior fellow for global health at the Council on Foreign Relations; public health law professor Lawrence Gostin of Georgetown University; and medical anthropologist Adia Benton of Brown University, who has conducted research on infectious disease in Sierra Leone over several years.


This is a rush transcript. Copy may not be in its final form.

JUAN GONZÁLEZ: The World Health Organization is now saying the number of reported cases and deaths of Ebola in West Africa vastly underestimates the scale of the outbreak. The official death toll from the Ebola outbreak is now at 1,069 since February. Guinea has become the fourth country in Africa to declare a national health emergency as it battles the spread of the deadly Ebola virus in the worst outbreak since the disease was discovered in 1976. The outbreak began in Guinea, where it has killed 377 people. It has since spread to Liberia, Sierra Leone and Nigeria, which have all declared a national health emergency.

AMY GOODMAN: Last week, the World Health Organization said the unprecedented outbreak of the Ebola virus was an international public health emergency. Ebola’s initial flu-like symptoms can lead to external hemorrhaging and internal bleeding, which can lead to organ failure. The disease is highly infectious and can kill up to 90 percent of those afflicted. Patients have a better chance of survival if they receive early treatment. There is no cure for Ebola, but the first consignment of the experimental drug ZMapp has arrived in Liberia from the U.S. The World Health Organization has approved the distribution of unproven drugs to help address the Ebola outbreak. World Health Organization Assistant Director-General Marie-Paule Kieny said the decision was made despite tests that failed to prove the drugs are safe and effective.

MARIE-PAULE KIENY: For the first time, we have a range of potential treatments and vaccines that could be potent assets supporting our efforts to control Ebola virus disease. However, while several of these treatments have been proven to be very effective in nonhuman primates—and I mean mostly rhesus macaques—none have undergone the test in humans necessary for licensing as proven safe and effective treatments. That does not mean that they are not safe. It simply means we do not have the evidence from human studies to say that it is certain that they are safe and efficacious.

JUAN GONZÁLEZ: That was WHO Assistant Director-General Marie-Paule Kieny. The outbreak has sparked an international debate over the ethics of giving such untested drugs to the sick and of deciding who should get the drugs.

AMY GOODMAN: To talk about implications of the crisis, we’re joined by three guests.

Laurie Garrett is with us, senior fellow for global health at the Council on Foreign Relations. She won the Pulitzer Prize in 1996 for her coverage of an Ebola outbreak in what was then Zaire, now the Democratic Republic of Congo. She is the author of two best-selling books, The Coming Plague: Newly Emerging Diseases in a World Out of Balance and Betrayal of Trust: The Collapse of Global Public Health.

In Washington, D.C., we’re joined by Lawrence Gostin, university professor and faculty director at the O’Neill Institute for National and Global Health Law at Georgetown University, director of the World Health Organization Collaborating Center on Public Health Law and Human Rights.

And in Providence, Rhode Island, we’re joined by Adia Benton, a medical anthropologist at Brown University. She has conducted research on infectious disease in Sierra Leone over several years.

We welcome you all to Democracy Now! Let’s begin with Laurie Garrett. Laurie, just explain what Ebola is, for starters, and then talk about what you think we should understand about it.

LAURIE GARRETT: Ebola is an RNA virus that infects your endothelial cells, which are the linings of blood cells and vessels, capillaries, puncturing microscopic leaks in them, which grow with time, and you begin to lose all the fluids from your circulatory system into your body as a whole, out of your eyes, out of your nose, out of your mouth—every orifice of the body. Those fluids are filled with virus. And anyone who touches those fluids and then, you know, touches their eye or rubs their nose will become infected.

And some of the numbers being tossed around—I heard you say 90 percent mortality rate—these are gross exaggerations. But it is a truly horrible disease. In only one outbreak did the death toll reach 90 percent. That was 1976. I was in the 1995 outbreak, which until now was the largest. The current one is more than three times larger. And the death toll was closer to 70 percent. But it’s still—I mean, my goodness, you know, when you see an average flu in circulation and you think it’s a bad flu, you’re under 1 percent mortality rate, to put that in comparison.

JUAN GONZÁLEZ: And the response, the worldwide response, to this outbreak, how do you assess how that has gone so far?

LAURIE GARRETT: Outrageous. Outrageous. I have been stunned and flabbergasted since March, when this was first reported from Guinea. And I concur completely with the statements made by Médecins Sans Frontières, or Doctors Without Borders. They have consistently said, you know, "We’re the only ones out here. Help. Hello, everybody. There’s an Ebola epidemic going on. Hello. It’s spreading across a border. Oh, it’s spread another border. What are you all waiting for?" I have a piece right now in Foreign Policy that begins, "World, you just don’t get it." The scale of what we need to be doing versus what we are doing is, you know, log-scale differential. All healthcare workers are burned out.

Let’s put this in perspective—excuse me, there’s no water here. Put this in perspective. Before we had an epidemic, these three countries had three of the worst healthcare systems on the planet and the poorest people on the planet. And not one of those governments was spending more than $100 per capita annually on all forms of health, which in this country keeps a household stocked in aspirin and ibuprofen. And Liberia had about 200 physicians to service four million people. About half of those physicians were non-Liberians, foreigners. Ebola struck. A lot of those foreigners left town. They’re down now to 50 physicians to deal with everything. Now, as the Ebola crisis gets worse, cardiac patients are going untreated. Women are giving delivery without assistance. You’ve got automobile accidents with people’s legs cut off, and nobody will accept them into an ER. It’s so much bigger than people realize and that people accept.

What we need is hundreds of healthcare workers in these countries immediately—hundreds. And we’re getting dribs and drabs. And we don’t need—I know you have a lot of very motivated viewers and listeners. We don’t need the do-gooder who’s never been out in a crisis before. That’s very nice of you to volunteer, but you’re not necessary. We need people who have history of working under great trauma, who know how to work in the tropical heat, who know how to maintain personal infection control, and are prepared to deal with some psychologically devastating things.

JUAN GONZÁLEZ: And the implication of the disease spreading into Nigeria?

LAURIE GARRETT: Unbelievably important. Now, let’s be cautious. At this moment, we have no evidence of secondary transmission, so everybody that’s been proven to have Ebola in Nigeria got it directly from this one fellow, Patrick Sawyer, a Liberian businessman who flew for a meeting to Lagos and contaminated people who were part of his entourage and the medical providers who cared for him.

AMY GOODMAN: Liberian American, right?

LAURIE GARRETT: Liberian American. However, one of the nurses under quarantine, a suspect but not proven case, fled quarantine a couple of days ago, went to the city of Enugu, and now more than 120 people of her contacts are under observation. In addition, at least two of the individuals—one his escort and the other a physician—have died of Ebola in Lagos. The concern, of course, is if it gets beyond that circle, because you cannot ask for a more chaotic city than Lagos, Nigeria. Anybody that has ever been there knows there’s no such thing as a street map for most of the city. Contact tracing, finding, you know, who might have infected who? Oh, my goodness. And on top of it all, they have a national doctors’ strike, they have a civil war, and they have a national election—and, oh, yes, Boko Haram.

AMY GOODMAN: Adia Benton, you have been in Sierra Leone over the years conducting research on infectious disease there. You’re a medical anthropologist at Brown University. Can you share your view on what should be done right now and how we are looking at this issue?

ADIA BENTON: Well, I absolutely agree with Laurie Garrett’s concerns. We certainly need more health workers on the ground. We need much more protective gear. Many of the health workers that I’ve been watching on Twitter are curious about how they’re going to continue to do their work or how they’re going to be protected if they are to head to the front lines. I don’t want to underestimate the importance and significance of this disease and of this outbreak. I’ve been worried about being alarmist, without—but also being able to sound the alarm, because the panic—we have to also keep in mind that we don’t want people to panic. We want people to do the jobs that need to be done, which is to have an influx of health workers who can actually do the job, who understand how to work in an outbreak situation and who know how to do infection control. I do have some friends at the CDC who have been deployed, and they’re going to be helping with coordinating data efforts, but I haven’t heard from nearly as many of my medical friends who are doing the same. So this is something that I think is really fundamentally important.

Before—and I think Laurie Garrett pointed out, before this outbreak, the health system was woefully inadequate, and it was always perceived to be a place where you go either when you’re seriously sick or if you maybe were not—and obviously you weren’t sure if you were going to live or die. And so, for this disease or this outbreak to have overwhelmed the health system, I think, has been a serious problem for everyone. I think there are also significant—I think there’s—right now they’re cordoning off Kenema and Kailahun district, which are the hardest hit in Sierra Leone. And that’s causing all kinds of other economic and sort of health and political problems. And those are things that we also should be concerned about and concerned with, because that’s ultimately going to affect how people on the ground are responding to the response to this outbreak.

JUAN GONZÁLEZ: Yeah, I’d like to ask Lawrence Gostin of Georgetown—this whole issue of quarantining, in especially large communities, has created quite a bit of controversy on the ground there, as well. Could you talk about that? Because you’ve specialized in trying to look at quarantine efforts.

LAWRENCE GOSTIN: Yeah, I mean, they have tried to use a cordon sanitaire, which is basically a very large guarded area, but they’ve used a almost Medieval form of quarantine, with soldiers, blockades. People who are in the quarantine area are very frightened, and I think deservedly so. And they’re frightened not only because they are in a hot spot, a hot zone of Ebola, but also with roads blocked. Food is expensive and getting scarce. There are no medical supplies. And basic needs, psychosocial and medical needs, are not being met. And so, this is a really inhumane way of trying to do that. We never should have come to this. I think that Ebola is a disease that can be contained if you’ve got a strong health system, but we’ve provided no international assistance of the level and sustainability that’s needed to build health systems in the world’s poorest countries. And this is what happens. And now we have these large quarantine areas. If we did want to do a quarantine, we have to do a small quarantine, a modern quarantine, where we provide humane care, where we give people incentives to stay where they are, psychosocial support, education, nutritious food, medical care, and it’s not policed by armed soldiers. The militarization of a disease isn’t usually what works. It just causes a lot of fear and panic.

AMY GOODMAN: Laurie Garrett?

LAURIE GARRETT: I’m going to have to very much disagree with Larry on this. You know, we’re old friends, but, Larry, I don’t think you’re right. Here’s why. First of all, I was in the Ebola epidemic in '95, and we in fact did do a cordon sanitaire. It was the only thing that worked. And it's often ignored. Mobutu was the brutal dictator at the time, and he simply summarily cut the whole region off with soldiers, surrounding Kikwit, blocking the highway, no airplanes, etc. The people were stranded, terrified—exactly as Larry is describing. Within that cordon sanitaire district, which enclosed about 500,000 people, individual isolation centers were also set up. And the Red Cross removed every single ailing person from the families, regardless of objections, which sometimes became violent. Many of those Red Cross volunteers themselves contracted Ebola as a result of those altercations. And they would bring them into quarantine hospital facilities. We have no other tool. We don’t have anything else.

Now, my real problem is, first of all, I agree with Larry: We waited way too long to get to this point. So now it’s draconian.


LAURIE GARRETT: And secondly, now what’s happening, de facto, is that because the rest of Africa does not believe that Sierra Leone, Guinea and Liberia are behaving in a competent fashion and doesn’t trust that they can stop the epidemic, essentially, a de facto cordon sanitaire is around all three countries. They’ve lost all their trade. Abidjan will no longer ship goods out of the three countries, which pretty much landlocks their trade. They have no more airplane flight landings going on anywhere in the world. So, the failure to use the tool of cordon sanitaire strategically early in the epidemic, and now because of the attacks on healthcare workers, in many cases life-threatening, against MSF and other medical providers by angry mobs, yes, you had to have the military come in. You can’t ask MSF to keep risking their lives—they’re already risking their life to be in front of a virus. And now you’re asking them to also put up with people who come in with machetes and guns and try to kill them? No. They need military protection.

AMY GOODMAN: We have to break, and we’re going to come back to this discussion.


AMY GOODMAN: Laurie Garrett is the Pulitzer Prize-winning journalist who won the Pulitzer Prize for reporting on the Ebola outbreak in now Democratic Republic of Zaire [Congo]. We’re also joined by Georgetown University professor Larry Gostin, as well as Brown medical anthropologist Adia Benton. Stay with us.


AMY GOODMAN: This is Democracy Now!,, The War and Peace Report. I’m Amy Goodman, with Juan González. Our guests are Adia Benton of Brown University, Pulitzer Prize-winning journalist Laurie Garrett and Professor Lawrence Gostin of Georgetown, who also works with the World Health Organization. Professor Gostin, you wanted to respond to Laurie Garrett.

LAWRENCE GOSTIN: I wanted to respond, because I’m not against a cordon sanitaire, but I’ve talked to the CDC, I’ve talked to WHO, and I think there is wide agreement that it needs to be smarter. You can’t have a health crisis turn into a human rights crisis. You have to provide food. You have to provide medical care. You have to provide psychosocial support. And you need to provide secure, but also safe and sterile, isolation equipment, with personal protection equipment. And that’s what a smart sanitaire is. And I don’t see that on the ground in those three countries.

JUAN GONZÁLEZ: Adia Benton, I’d like to ask you also about another issue that’s come up, the ethical issue of administering a drug that has really not been fully tested now and administering it to the populations there in Africa, as the United States is trying to rapidly manufacture this drug. What are some of the ethical questions that it raises for you?

ADIA BENTON: Well, I mean, so we don’t actually know the efficacy of the drugs. We don’t know the efficacy of the drugs—that’s the first piece. But we also aren’t sure how much there is and how that system is going to be—how those drugs are going to be disseminated or distributed. I think, as the other two guests have alluded, there is this suspicion and mistrust of certain kinds of interventions. And I think this is applicable to these questions about cordon sanitaire, as well, is you really have to understand the local context, you have to understand what the history of experimentation is, you have to understand what the history of intervention is, before you can roll these things out. Karen Grépin at NYU has suggested that it might be the perfect opportunity to actually test the efficacy of these drugs, because not everyone can get them. So, I think the ethical thing is: If you do something, if you administer the drug and people die, then it looks bad; if you don’t give it to people, and it offers a promise and a hope, it also looks bad. So, that’s something that people are dealing with right now when they’re thinking about the ethical considerations. There’s also—

AMY GOODMAN: The New York Times had a very interesting piece about the leading doctor in Sierra Leone dealing with Ebola, considered a national hero, Dr. Sheik Umar Khan, who got Ebola. They were weighing whether to give him the ZMapp drug, the very drug that may well have just saved these two American workers, who are now at Emory. And the description in the article of the doctors speaking through the night: "Should we give him this? It hasn’t been tested on humans. What if he were to die of a drug we administered?" Particularly Médecins Sans Frontières, Doctors Without Borders, deeply concerned. They decided not to. He died a few days later. And then the optics of it, going to two white doctors who were brought back to Emory. Laurie Garrett?

LAURIE GARRETT: Well, first of all, we don’t have any idea if this drug works. I mean, I’m with her all the way on that. And we have an N of one—one individual who received drug is up and walking around. Another, as far as I know, is still ambulatory. And that one could have been the lucky 30 percent survivors of Ebola. There’s no reason to believe that the drug necessarily is why—

AMY GOODMAN: It’s true the Spanish priest got it and died.

LAURIE GARRETT: And died. The second really big concern is this drug that everybody is talking about, ZMapp—and then there are two other drugs and at least three vaccines that are all rushing through processes at the moment—this drug is made in a process that requires that it be in a cold chain all the time, until the moment of delivery to the patient. That means you have to have refrigeration, every step of the way temperature-controlled. It’s a very unstable biological formulation. This isn’t a pill. This isn’t a simple sera or a simple chemical. And this means that you could have a break in your cold chain and actually do harm to someone.

And I worry because, as your guest was saying, you know, this is the region that had the most brutal civil wars, back to back, that we have seen in modern time, where child soldiers were deployed to go cut off the arms and legs of their own relatives, where the term "blood diamonds" originated. And, you know, Charles Taylor, the former leader of Liberia, is one of the few truly convicted war criminals now serving time for the horrors that he carried out. So when you hear that people say, "You can’t go to the hospital because they cut off legs there," or, "Don’t go to the hospital because the white people are cannibals," or, "Don’t go to the hospital because they will inject you with something that will kill you," these are valid rumors to people. They believe it because they’ve had a history where all those things actually happened.

And everybody has reason to think that, you know, Amy’s family has evil spirits to conjure against my family, because one of my relatives killed one of her relatives just 10 years ago. And as a result, the idea that you’re going to walk in with a dangerous, unknown drug or, worse yet, vaccine, and tell people that don’t understand germ theory, 50 percent of whom are illiterate, you know, "This is experimental. We’re not sure if it will work. Just because I’m injecting it into you doesn’t mean you’re protected," how many are going to run back and say, "They’re giving us the disease. They’re injecting the disease in the hospital"? I mean, I think we haven’t even begun to scratch the surface of all the possible ramifications of this.

AMY GOODMAN: Very quickly, Professor Benton, your response?

ADIA BENTON: I mean, this—but people want care, right? So, the issue with Dr. Khan, for example, he was actually the perfect kind of person to give informed consent. There are people who are sick—nurses, doctors—who can give informed consent. I don’t want to underestimate the significance of the war in this, but there are other kinds of things that happened during the war and before the war that engendered this kind of mistrust. So, people may be illiterate, but they are also people who wish that their healthcare systems were better and could deliver the level of care that might actually get them through this thing. Unfortunately, they had a health system that was broken before the war and during it and after it. And so, this is why I say, that’s why the—especially when you’re talking about quarantine, you have to understand the local context. You have to understand—you have to meet people where they are.

And there are people who can say, "We don’t know if this thing works." People use therapies that don’t work all the time when they go to traditional healers, but they are looking for something that is efficacious and that will make them better. So this is another piece of the puzzle that absolutely has to be addressed. You have to meet people where they are. You have to provide them with the best care possible.

AMY GOODMAN: Professor Gostin, we have to give you the last word on this issue today.

LAWRENCE GOSTIN: Well, I mean, I think it’s true that—I mean, human beings all have a yearning to be cared for, wherever they are, whatever their experiences are. And so, the optics of this was really bad, because it went to potentially three white foreign aid workers. For me, I would have had ethical criteria in place. I would have given preference to African healthcare workers. I would have gone with consent. And most of all, I would have asked the people involved and the national leaders. This wasn’t done transparently. It was behind closed doors. We need to get this out in the open, and we need to involve the communities at risk.

AMY GOODMAN: Well, this is a discussion we’ll certainly continue to have. Georgetown University professor Lawrence Gostin, Pulitzer Prize-winning journalist Laurie Garrett and Brown University professor Adia Benton, thanks so much for being with us.

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