Bruce Aylward: Humanity vs. Ebola. The winning strategies in a terrifying war


Dr Bruce Aylward is the Assistant Director-General of a cluster which brings together WHO’s work in polio eradication and humanitarian response.Portrait of Bruce Aylward, ADG

A Canadian physician and epidemiologist, Dr Aylward is the author of some 100 peer-reviewed scientific articles and book chapters. Dr Aylward joined the World Health Organization in 1992 as a Medical Officer with the Expanded Programme on Immunization. He worked for seven years with national immunization programmes at the field level in the Middle East, western Pacific, Europe, North Africa and central and southeast Asia, before coming to WHO Headquarters in Geneva.

Since 1998, Dr Aylward has been responsible for the oversight and coordination of all polio eradication activities across WHO’s Regional Offices and the Global Polio Eradication Initiative partnership. He oversaw and managed the scale-up of the Global Polio Eradication Initiative, which since 1997 has expanded to operate in every polio-affected country of the world and reduced the number of polio-endemic countries to three. Since 2011, Dr Aylward has led WHO’s work in preparedness, readiness and response to humanitarian emergencies as the lead agency of the Global Health Cluster.

Dr Aylward received his medical training in Canada at the Memorial University of Newfoundland before undertaking specialist training in internal medicine in Vancouver, British Columbia, where he focused on infectious diseases, particularly HIV/AIDs. He then trained at the London School of Hygiene and Tropical Medicine and the Johns Hopkins School of Public Health, where he received a Diploma in Tropical Medicine and Hygiene and a Masters in Public Health (summa cum laude) respectively. During the course of his medical training, Dr Aylward travelled and worked in countries throughout South America, Africa and Asia.


0:11When I was invited to give this talk a couple of months ago, we discussed a number of titles with the organizers, and a lot of different items were kicked around and were discussed. But nobody suggested this one, and the reason for that was two months ago, Ebola was escalating exponentially and spreading over wider geographic areas than we had ever seen, and the world was terrified, concerned and alarmedby this disease, in a way we’ve not seen in recent history.

0:43But today, I can stand here and I can talk to you about beating Ebola because of people whom you’ve never heard of, people like Peter Clement, a Liberian doctor who’s working in Lofa County, a place that many of you have never heard of, probably, in Liberia. The reason that Lofa County is so important is because about five months ago, when the epidemic was just starting to escalate, Lofa County was right at the center, the epicenter of this epidemic. At that time, MSF and the treatment center there, they were seeing dozens of patients every single day, and these patients, these communities were becoming more and more terrified as time went by, with this disease and what it was doing to their families, to their communities, to their children, to their relatives. And so Peter Clement was charged with driving that 12-hour-long rough road from Monrovia, the capital, up to Lofa County, to try and help bring control to the escalating epidemic there.

1:52And what Peter found when he arrived was the terror that I just mentioned to you. So he sat down with the local chiefs, and he listened. And what he heard was heartbreaking. He heard about the devastation and the desperation of people affected by this disease. He heard the heartbreaking stories about not just the damage that Ebola did to people, but what it did to families and what it did to communities. And he listened to the local chiefs there and what they told him — They said, “When our children are sick, when our children are dying, we can’t hold them at a time when we want to be closest to them. When our relatives die, we can’t take care of them as our tradition demands. We are not allowed to wash the bodies to bury them the way our communities and our rituals demand. And for this reason, they were deeply disturbed, deeply alarmed and the entire epidemic was unraveling in front of them.

2:52People were turning on the healthcare workers who had come, the heroes who had come to try and help save the community, to help work with the community, and they were unable to access them. And what happened then was Peter explained to the leaders. The leaders listened. They turned the tables. And Peter explained what Ebola was. He explained what the disease was. He explained what it did to their communities. And he explained that Ebola threatened everything that made us human. Ebola means you can’t hold your children the way you would in this situation. You can’t bury your dead the way that you would. You have to trust these people in these space suits to do that for you.

3:34And ladies and gentlemen, what happened then was rather extraordinary: The community and the health workers, Peter, they sat down together and they put together a new plan for controlling Ebola in Lofa County. And the reason that this is such an important story, ladies and gentlemen, is because today, this county, which is right at the center of this epidemic you’ve been watching, you’ve been seeing in the newspapers, you’ve been seeing on the television screens, today Lofa County is nearly eight weeks without seeing a single case of Ebola. (Applause)

4:15Now, this doesn’t mean that the job is done, obviously. There’s still a huge risk that there will be additional cases there. But what it does teach us is that Ebola can be beaten. That’s the key thing. Even on this scale, even with the rapid kind of growth that we saw in this environment here, we now know Ebola can be beaten. When communities come together with health care workers, work together, that’s when this disease can be stopped.

4:42But how did Ebola end up in Lofa County in the first place? Well, for that, we have to go back 12 months, to the start of this epidemic. And as many of you know, this virus went undetected, it evaded detection for three or four months when it began. That’s because this is not a disease of West Africa, it’s a disease of Central Africa, half a continent away. People hadn’t seen the disease before; health workers hadn’t seen the disease before. They didn’t know what they were dealing with, and to make it even more complicated, the virus itself was causing a symptom, a type of a presentation that wasn’t classical of the disease. So people didn’t even recognize the disease, people who knew Ebola. For that reason it evaded detection for some time,

5:27But contrary to public belief sometimes these days, once the virus was detected, there was a rapid surge in of support. MSF rapidly set up an Ebola treatment center, as many of you know, in the area. The World Health Organization and the partners that it works with deployed eventually hundreds of people over the next two months to be able to help track the virus. The problem, ladies and gentlemen, is by then, this virus, well known now as Ebola, had spread too far. It had already outstripped what was one of the largest responses that had been mounted so far to an Ebola outbreak.

6:04By the middle of the year, not just Guinea but now Sierra Leone and Liberia were also infected. As the virus was spreading geographically, the numbers were increasing and at this time, not only were hundreds of people infected and dying of the disease, but as importantly, the front line responders, the people who had gone to try and help, the health care workers, the other responders were also sick and dying by the dozens. The presidents of these countries recognized the emergencies. They met right around that time, they agreed on common action and they put together an emergency joint operation center in Conakry to try and work together to finish this disease and get it stopped, to implement the strategies we talked about.

6:53But what happened then was something we had never seen before with Ebola. What happened then was the virus, or someone sick with the virus, boarded an airplane, flew to another country, and for the first time, we saw in another distant country the virus pop up again. This time it was in Nigeria, in the teeming metropolis of Lagos, 21 million people. Now the virus was in that environment. And as you can anticipate, there was international alarm, international concern on a scale that we hadn’t seen in recent years caused by a disease like this. The World Health Organization immediately called together an expert panel, looked at the situation, declared an international emergency. And in doing so, the expectation would be that there would be a huge outpouring of international assistance to help these countries which were in so much trouble and concern at that time.

7:50But what we saw was something very different. There was some great response. A number of countries came to assist — many, many NGOs and others, as you know, but at the same time, the opposite happened in many places. Alarm escalated, and very soon these countries found themselves not receiving the support they needed, but increasingly isolated. What we saw was commercial airlines started flying into these countries and people who hadn’t even been exposed to the virus were no longer allowed to travel. This cause not only problems, obviously, for the countries themselves, but also for the response. Those organizations that were trying to bring people in, to try and help them respond to the outbreak, they could not get people on airplanes, they could not get them into the countries to be able to respond. In that situation, ladies and gentleman, a virus like Ebola takes advantage.

8:44And what we saw then was something also we hadn’t seen before. Not only did this virus continue in the places where they’d already become infected, but then it started to escalate and we saw the case numbers that you see here, something we’d never seen before on such a scale, an exponential increase of Ebola cases not just in these countries or the areas already infected in these countries but also spreading further and deeper into these countries. Ladies and gentleman, this was one of the most concerning international emergencies in public health we’ve ever seen.

9:21And what happened in these countries then, many of you saw, again, on the television, read about in the newspapers, we saw the health system start to collapse under the weight of this epidemic. We saw the schools begin to close, markets no longer started, no longer functioned the way that they should in these countries. We saw that misinformation and misperceptions started to spread even faster through the communities, which became even more alarmed about the situation. They started to recoil from those people that you saw in those space suits, as they call them, who had come to help them. And then the situation deteriorated even further. The countries had to declare a state of emergency. Large populations needed to be quarantined in some areas, and then riots broke out. It was a very, very terrifying situation.

10:10Around the world, many people began to ask, can we ever stop Ebola when it starts to spread like this?And they started to ask, how well do we really know this virus? The reality is we don’t know Ebola extremely well. It’s a relatively modern disease in terms of what we know about it. We’ve known the disease only for 40 years, since it first popped up in Central Africa in 1976. But despite that, we do know many things: We know that this virus probably survives in a type of a bat. We know that it probably enters a human population when we come in contact with a wild animal that has been infected with the virus and probably sickened by it. Then we know that the virus spreads from person to person through contaminated body fluids. And as you’ve all seen, we know the horrific disease that it then causes in humans, where we see this disease cause severe fevers, diarrhea, vomiting, and then unfortunately, in 70 percent of the cases or often more, death. This is a very dangerous, debilitating, and deadly disease.

11:19But despite the fact that we’ve not known this disease for a particularly long time, and we don’t know everything about it, we do know how to stop this disease. There are four things that are critical to stopping Ebola. First and foremost, the communities have got to understand this disease, they’ve got to understand how it spreads and how to stop it.

11:39And then we’ve got to be able to have systems that can find every single case, every contact of those cases, and begin to track the transmission chains so that you can stop transmission. We have to have treatment centers, specialized Ebola treatment centers, where the workers can be protected as they try to provide support to the people who are infected, so that they might survive the disease. And then for those who do die, we have to ensure there is a safe, but at the same time dignified, burial process, so that there is no spread at that time as well.

12:15So we do know how to stop Ebola, and these strategies work, ladies and gentlemen. The virus was stopped in Nigeria by these four strategies and the people implementing them, obviously. It was stopped in Senegal, where it had spread, and also in the other countries that were affected by this virus, in this outbreak. So there’s no question that these strategies actually work. The big question, ladies and gentlemen, was whether these strategies could work on this scale, in this situation, with so many countries affected with the kind of exponential growth that you saw.

12:51That was the big question that we were facing just two or three months ago. Today we know the answer to that question. And we know that answer because of the extraordinary work of an incredible group of NGOs, of governments, of local leaders, of U.N. agencies and many humanitarian and other organizations that came and joined the fight to try and stop Ebola in West Africa.

13:15But what had to be done there was slightly different. These countries took those strategies I just showed you; the community engagement, the case finding, contact tracing, etc., and they turned them on their head. There was so much disease, they approached it differently. What they decided to do was they would first try and slow down this epidemic by rapidly building as many beds as possible in specialized treatment centers so that they could prevent the disease from spreading from those were infected. They would rapidly build out many, many burial teams so that they could safely deal with the dead, and with that, they would try and slow this outbreak to see if it could actually then be controlled using the classic approach of case finding and contact tracing. And when I went to West Africa about three months ago,when I was there what I saw was extraordinary. I saw presidents opening emergency operation centers themselves against Ebola so that they could personally coordinate and oversee and champion this surge of international support to try and stop this disease. We saw militaries from within those countries and from far beyond coming in to help build Ebola treatment centers that could be used to isolate those who were sick. We saw the Red Cross movement working with its partner agencies on the ground there to help train the communities so that they could actually safely bury their dead in a dignified manner themselves. And we saw the U.N. agencies, the World Food Program, build a tremendous air bridge that could get responders to every single corner of these countries rapidly to be able to implement the strategies that we just talked about.

14:55What we saw, ladies and gentlemen, which was probably most impressive, was this incredible work by the governments, by the leaders in these countries, with the communities, to try to ensure people understood this disease, understood the extraordinary things they would have to do to try and stop Ebola. And as a result, ladies and gentlemen, we saw something that we did not know only two or three months earlier, whether or not it would be possible. What we saw was what you see now in this graph,when we took stock on December 1. What we saw was we could bend that curve, so to speak, change this exponential growth, and bring some hope back to the ability to control this outbreak. And for this reason, ladies and gentlemen, there’s absolutely no question now that we can catch up with this outbreak in West Africa and we can beat Ebola.

15:48The big question, though, that many people are asking, even when they saw this curve, they said, “Well, hang on a minute — that’s great you can slow it down, but can you actually drive it down to zero?” We already answered that question back at the beginning of this talk, when I spoke about Lofa County in Liberia. We told you the story how Lofa County got to a situation where they have not seen Ebola for eight weeks. But there are similar stories from the other countries as well. From Gueckedou in Guinea,the first area where the first case was actually diagnosed.

16:22We’ve seen very, very few cases in the last couple of months, and here in Kenema, in Sierra Leone, another area in the epicenter, we have not seen the virus for more than a couple of weeks — way too early to declare victory, obviously, but evidence, ladies and gentlemen, not only can the response catch up to the disease, but this disease can be driven to zero.

16:45The challenge now, of course, is doing this on the scale needed right across these three countries, and that is a huge challenge. Because when you’ve been at something for this long, on this scale, two other big threats come in to join the virus. The first of those is complacency, the risk that as this disease curve starts to bend, the media look elsewhere, the world looks elsewhere. Complacency always a risk.

17:15And the other risk, of course, is when you’ve been working so hard for so long, and slept so few hours over the past months, people are tired, people become fatigued, and these new risks start to creep into the response. Ladies and gentlemen, I can tell you today I’ve just come back from West Africa. The people of these countries, the leaders of these countries, they are not complacent. They want to drive Ebola to zero in their countries. And these people, yes, they’re tired, but they are not fatigued. They have an energy, they have a courage, they have the strength to get this finished.

17:51What they need, ladies and gentlemen, at this point, is the unwavering support of the international community, to stand with them, to bolster and bring even more support at this time, to get the job finished. Because finishing Ebola right now means turning the tables on this virus, and beginning to hunt it.

18:10Remember, this virus, this whole crisis, rather, started with one case, and is going to finish with one case.But it will only finish if those countries have got enough epidemiologists, enough health workers, enough logisticians and enough other people working with them to be able to find every one of those cases, track their contacts and make sure that this disease stops once and for all.

18:35Ladies and gentleman, Ebola can be beaten. Now we need you to take this story out to tell it to the people who will listen and educate them on what it means to beat Ebola, and more importantly, we need you to advocate with the people who can help us bring the resources we need to these countries, to beat this disease. There are a lot of people out there who will survive and will thrive, in part because of what you do to help us beat Ebola.

19:03Thank you.