The Ebola Outbreak

Moderator: Robert McMahon, Editor, CFR.org

August 5, 2014

Source Link

Speakers: John Campbell, Ralph Bunche Senior Fellow for Africa Policy Studies, Council on Foreign Relations, and Laurie Garrett, Senior Fellow for Global Health, Council on Foreign Relations

MCMAHON: Hello, everyone, and welcome to this Council on Foreign Relations on-the-record conference call on West Africa's Ebola outbreak. I'm Robert McMahon, editor of CFR.org, and I will be moderating today's call on an outbreak that has now killed close to 900 people in Liberia, Guinea, and Sierra Leone. 

We are very fortunate to have on hand CFR's senior fellow for global health, Laurie Garrett, and CFR senior fellow for Africa policy studies, John Campbell, to help us navigate the issues involved in confronting this outbreak both medically and in terms of African governance and capabilities. 

Laurie's coverage of Ebola in Africa dates back nearly 20 years to the country then known as Zaire. John Campbell, former U.S. ambassador to Nigeria, tracks developments throughout sub-Saharan Africa on his blog, Africa in Transition, with particular attention to Nigeria, where reports say a case of Ebola has recently been reported. I will begin with a 20-minute or so conversation with both Laurie and John before opening up the call to broader questions. It'll be an hour-long in total. 

And, Laurie, I wanted to kick off with you. The health professionals on the ground in West Africa are saying, you know, the outbreak is out of control. What is the latest state of play on efforts to bring it under control or at least to try to contain it? 

GARRETT: Thank you. It is, indeed, out of control. It has been for quite some time. I don't think it's clear that it ever was in control at any given moment since it first broke out in March in Guinea. 

The problem now is that we have burned-out health care workers, 550 from the largest contingent from Medecins Sans Frontieres, or Doctors Without Borders, which has issued plea after plea in recent days to the international community saying, "We are exhausted. We are terrified. We want to leave. Can somebody else please come in and take over?" 

You've had more than 60 health care workers succumb to the disease, including the most famous physicians in the battle against Ebola from Uganda, from Liberia, and from Sierra Leone. And we have seen resistance from the populations all over these three countries, but especially in Sierra Leone and Liberia, against all sorts of quarantine measures, efforts to remove the ailing from their households so that they don't infect household members and place them in quarantine, efforts to enforce quarantine, and efforts to deal with safe burials or cremations, rather than the traditional approaches of families preparing the bodies for burial and thereby getting exposed to the contaminating fluids. 

And at this point, you know, the military has been brought into help try to maintain some semblance of control, but every report I'm getting from the ground has health care workers describing themselves as in a state of fear, even of siege, feeling that the populations despise and loathe them, and that rumors are rife that they are actually deliberately infecting people, cutting off people's arms, and selling them on some alleged international market and even claims that there are health care workers who are foreign cannibals. 

"[T]he WHO is essentially bankrupt and has only the power of rhetoric … and … international health regulations … to try and move the ball forward."—Laurie Garrett 

MCMAHON: So you mentioned the appeal for help from MSF, among others, and they're one of the lead agencies on the ground there. There isn't any kind of international yet sort of rapid response team that gets called into play, but there are international organizations or large national organizations that are getting mobilized, isn't that right at this point? 

GARRETT: Well, it's true. There are a number of different groups. The CDC, our Centers for Disease Control and Prevention, is sending some time in the next couple of days 50 individuals on site to assist. But we don't have -- I know that there's a myth out there, and people believe that there's some kind of giant WHO office in Geneva stock full of specialized response equipment, skilled, talented health care workers, and they have their own special jet and they go swooping into epidemics. This is absolutely ludicrous. 

Not only do we not have any such thing, the WHO is essentially bankrupt and has only the power of rhetoric in order to try -- and of the international health regulations in order to try and move the ball forward. And that's going to be the big news this week. 

WHO is convening under its international health regulations process a special summit starting tomorrow in Geneva of scientific outside experts that will assess the current situation and decide if it constitutes an international public health emergency. If they so designate it, then a whole set of things are meant to mobilize in place. The international community is meant to go on full tilt to try and develop drugs and vaccines. There's meant to be border checks and perhaps some instructions to international flight carriers and travel agencies and so on, and the whole thing should rev up. 

But let's keep in mind, WHO has been running on a budget deficit. The World Health Assembly voted in their last session to cut the emergency epidemic response capacity of WHO. And if it weren't for this morning's announcement from the World Bank that it will put $200 million into the effort, we basically would have an effort on the ground in Guinea, Sierra Leone, and Liberia funded on fumes, volunteer donations, and, you know, a few hundred people who are being unpaid to risk their lives in the middle of this outbreak. 

MCMAHON: So it has gotten a great deal of renewed attention in the United States with the arrival a few days ago of an American infected with the virus, and another American is due to arrive, I believe, today. There is a report of a possible Ebola case in New York City. To what extent do you see in America, you know, the United States seized of the issue, playing a bigger role and -- and also, what do we know about the treatment of these two Americans that may actually end up, you know, surviving and not dying from Ebola? 

GARRETT: Well, first of all, this epidemic has been boiling since March, but only garnered enormous public attention in the United States until there were Americans infected. I suppose that kind of speaks normally to how the United States views our foreign policy; it's only a matter of concern until one of us -- one of our citizens is affected. That's most unfortunate. 

The two individuals that were both volunteers for Samaritan's Purse and were on the ground and infected in their work have been airlifted to Atlanta, Georgia, where they are in a special isolation unit at Emory University's Medical Center. I think everybody knows that. They have both received an experimental treatment. One of them appears to be doing well. 

But I would caution everybody to recall that there is no statistical power whatsoever in an N of 1. One person does well on a drug. That equals one person might have done well because they were a healthy individual to begin with, might have been sheer shake of the dice. You have absolutely no evidence the drug was why the individual is doing better. And the same could be said when it's an N of 2. This is not statistical power, certainly not sufficient that it should result in spending millions of dollars to rev up production of one specific drug. 

There are quite a number of different Ebola experimental vaccines and drugs out there, but none of them have gone through clinical trials, none of them have been safety-tested by standards of our FDA, and though some might enter such safety trials in the calendar year 2014, none would be available for widespread use and commercial production for several years. 

MCMAHON: And that latest report, I think the fatality rate from this latest strain is close to 70 percent. Is that right, Laurie? 

GARRETT: That is, yes. 

MCMAHON: OK. So, John, I wanted to turn to you and ask you about the African responses. Laurie mentioned this kind of hysteria that's been brewing in the three countries we're looking at right now. And I was wondering if you could talk about the capacity of Africa's governance to help -- to help their own health care workers who are on the front lines and are -- are among the victims, but also to disseminate -- you know, disseminate information properly and to do the work of containment and quarantine that's so necessary at this point. 

CAMPBELL: Sure. Thank you very much, Bob. I think the first point to make is that Guinea, Sierra Leone, and Liberia are very, very weak states. All three are emerging from a protracted period of civil war. In parts of all three, the government's writ hardly runs. 

All three have very, very weak bureaucracies. And in all three, there is a major gulf between the government and those that are being governed. There's great suspicion amongst ordinary people of government authority. 

The second point to be made -- and I think this is really quite important -- is that all three are undergoing extremely rapid urbanization. It ranges from just under 40 percent to just under 50 percent in the case of Nigeria, where there has been at least one or perhaps two, two cases. That means what you have are people who essentially come out of a village culture now in larger and larger numbers, packing themselves in to urban slums where the transmission of disease, any disease, becomes easier than in villages where the population density is very low. 

When it comes to quarantine and to national boundaries, the boundaries of all three states are essentially lines drawn on a piece of paper, basically by the old colonial powers. None of these three governments really have control over their boundaries. Yes, it's perfectly true that there can be screening at airports, but the movement of most people among these three states tends to be on foot and on paths that are outside any government control. 

The central role, I think, that undeveloped or poor governance plays in the response to the Ebola crisis is illustrated by a particular instance where the government has stepped up to the plate and at least up to now appears to have done a good job. I'm talking about the state government of Lagos, not the Nigerian central government, but the state government of Lagos. 

MCMAHON: And Lagos is where? If I could just add, that's where the individual arrived from Liberia. Is that right, John? 

CAMPBELL: That's exactly right. Lagos also has -- some estimates are now -- 22 million people. It's one of the very largest cities in the world. And it is also one of the poorest. And yet in Lagos, a highly effective governor has been succeeded by another highly effective governor. And something approaching a social contract in Lagos is now emerging, a social contract in which people pay taxes and hold their governments accountable for providing services. 

In Lagos, the response to the arrival of a victim of Ebola who has since died was to put into effect immediately tracing operations to find everybody that he'd come into contact with and also a quarantine. Now, right now, the Lagos picture looks good. The question has to be, how long that that will last? 

Again, when you're talking about a city of 22 million people and with the porosity of boundaries and the movement of people, it's quite possible that even the authorities in Lagos will be overwhelmed. I certainly hope not, and it hasn't happened yet. 

MCMAHON: Now, I wanted to ask both of you also about something else that's occurring in the midst of this outbreak, which is a major -- a long-awaited U.S.-Africa summit taking place in Washington, D.C. Roughly 50 or so heads of state are in Washington. 

The Ebola outbreak is not an official agenda item. It's doubtless being discussed in side chambers, but still not having it be on the official bill, it has concerned a number of people. Laurie, you mentioned in -- I think it was a piece for cnn.com -- the importance of having, you know, the issue brought out into the fore and discussed. Can you talk a little bit about what ought to be discussed in terms of the -- of responses to Ebola amongst this gathering? 

GARRETT: You know, I think we have to all recognize that we're now in a kind of perfect storm or whatever other cliche we want to use to describe worst-case scenario. We don't have a strategic plan. There is no strategic plan for how this epidemic will be brought under control. For what we will do if, indeed, that nightmare that John sort of painted of a 22 million population chaotic city that is Lagos comes to be a place of secondary transmission of this virus, we have no plan. 

Now, the WHO came up with a vague set of criteria of what they thought the three governments most affected should immediately do. And World Bank has committed resources to help those governments implement this. But we're hitting a point where every single health care worker on the ground is exhausted, terrified, burned out. What's the plan? From whence will other health care workers come? 

What is the scheme to assure health care workers that they will be safe, that they will not get the disease, they will not get killed or attacked by locals on the ground, that it is safe for them to respond? What will be the global strategy if this virus shows up in Dakar, in Durban, in Nairobi, in London, in Paris? We have no plan. 

But we have all the leaders of nearly every single African country, except, of course, the affected ones, because they can't possibly leave at this time, in Washington right now. What a golden opportunity to sit down and actually ask, what would a plan of action look like? What resources can be committed by the African Union? What resources can be committed in terms of United Nations peacekeepers or African Union peacekeepers? Who is going to hit the battle lines on this disease front? 

We don't have a plan. We should be taking advantage of this remarkable coincidental moment to use the Africa summit as a time to come up with such a plan. But as far as I can tell, it's not on the agenda. 

MCMAHON: John, could you talk a little bit about the summit and potentially missed opportunities or potentially opportunities that still exist? Because the summit goes on, I think, through tomorrow. 

CAMPBELL: It does go on through to tomorrow. The focus of the summit appears to be economic development, expansion of economic ties between the United States and Africa, increased investment, and so forth. But I would point out that Ebola is already having an impact on the economies of the countries that are affected. 

"When Ebola eventually burns itself out, there's a good chance it'll be replaced with something else."—John Campbell 

For example, one statistical study shows that the growth rate in Sierra Leone has already been cut by 1 percent. In other words, Ebola is a disease, but it's a disease with enormous economic and ultimately political consequences. The fact that the three chiefs of state of the countries most affected are not in Washington means that there is no particular focus for a discussion of Ebola. 

I think that's deplorable. I think the three chiefs of state were absolutely right not to go to Washington. If ever there was a time when they need to be with their own people, it is now. 

But the difficulty of introducing a new agenda item to almost 50 heads of state on a very short timeframe, the practical difficulties of doing this are very great, indeed. What I truly hope -- I passionately hope is that there are conversations going on, on the margins about how the international community should plan to respond to Ebola. 

One final point -- and then I'll get off my soapbox -- we're talking about Ebola right now. But there are plenty of other diseases that Laurie has written about that, in fact, can turn into pandemics pretty quickly. And I'm not terribly sure we've done very much deep thinking about how we are going to respond to them. In other words, when Ebola eventually burns itself out, there's a good chance it'll be replaced with something else. 

GARRETT: Well, and I would just add to that -- thank you, John, good point -- we don't have any plan at all and we never really have had, except as lip service, for what we do when a highly contagious, but more importantly highly fear-evoking microbe hits a major urban center. We've made movies about it. I participated in the script development for "Contagion," where we thought it through. There have been any number of tabletop exercises done by our Defense Department, CIA and so on, imagining such things. 

But the truth is, if this Ebola shows up in a city like Lagos, like Abuja, like any -- Dakar in Senegal and starts to evoke the kind of fearfulness responses that we're seeing in Sierra Leone, Liberia and Guinea already, all bets are off. We have no strategic plan. 

MCMAHON: John... 

CAMPBELL: Well, and all bets are off, because these then have political consequences. I mean, you have the breakdown of order. I mean, it goes on and on. 

MCMAHON: Well, thanks to both of you for framing the issues. At this point in the call, I just want to remind everyone, this is an on-the-record conference call, CFR conference call. We're speaking with Laurie Garrett, senior fellow for global health at the Council on Foreign Relations, and John Campbell, the Ralph Bunche Senior Fellow for Africa Policy Studies at the Council on Foreign Relations. 

And, Operator, I'd like to open up the call at this point to members on the line and hear your questions for our two expert speakers. 

OPERATOR: Yes, sir. At this time, we will open the floor for questions. If you would like to ask a question, please press the star key, followed by the one key on your touch-tone phone now. Questions will be taken in the order in which they were received. If at any time you would like to remove yourself from the questioning queue, you may press star, two. Again, ladies and gentlemen, if you would like to ask a question, please press star, one now. 

We are currently holding for questions. 

MCMAHON: OK. I guess I wanted to talk a little bit -- while we're waiting, I wanted to ask Laurie one more thing about the specific aspects of Ebola and, again, the -- how it spreads, because I think there's a bit -- especially coming from the U.S. and seeing the reports about the two patients coming to the U.S. and the possibility of a patient in New York City, how exactly it spreads. And it's not airborne, I guess we should start out by saying, but that it is -- it is transferred from the people who have close proximity to those infected. 

Laurie, could you talk a little bit about some of the specifics on how Ebola is spread? 

GARRETT: Sure. When I was in the Ebola epidemic in 1995 in Kikwit, Zaire, which is now the Democratic Republic of Congo, the situation was brought under control really by the heroes of the local Kikwit Red Cross. There were other international responders, but it was the Red Cross that stopped it. 

And how did they stop it? Two key interventions. One, find everyone in all of Kikwit, which was a large settlement of about -- almost 500,000 people, find every single person who had symptoms, and take them into quarantine. And, number two, remove all dead bodies so that they do not get processed by the family members, thereby exposing themselves to the contaminated fluid, and execute mass burials very deep in the ground where there would be no possibility of any individual or group exposure to the virus. 

The key is, you get it by contact with bodily fluids. And the individuals at their peak state of hemorrhage will actually be hemorrhaging external, as well as internally, and all of their tears, their -- everything from their nose, their mouth, their anus, genitals, everything, will have bodily fluid in it that contains live virus. 

So if an individual, for example, is wiping the brow of a loved one in the home instead of taking them into hospital, and happens to touch the fluids with their hands, and then touch their own nose or their own mouth or their own eye, they will infect themselves. It's as simple as that. 

Now, why would health care workers dressed in body suits that you've seen on television get infected? Because it is a hideously difficult thing to work inside of one of those suits. You know, it's a combination of acute claustrophobia and temperatures that have been measured as high as 120 degrees Fahrenheit inside the suit. 

It's easy under such conditions, when on top of everything else you're surrounded by grief and fearfulness and by hostile family members and so on. It's very easy to breach your own security and thereby somehow get yourself infected, either through puncturing your suit or improperly undressing from your security gown and accidentally exposing yourself to the contaminants on the outside of the security gown. 

MCMAHON: Thank you, Laurie. Operator, just wanted to check, are there any calls at this point on the line from CFR members? 

OPERATOR: Yes, sir. Our first question comes from Larry Brilliant with Skoll Global Threats. Sir, your line is now open. 

QUESTION: Hi. Can you hear me? 

MCMAHON: Yes, please go ahead. 

QUESTION: Hey, you guys did a really wonderful job. Thank you very much. And, Laurie, once again, your ability to both go into the reality of the human condition for the patients and for caregivers is just -- it's just remarkable. Thank you very much for that. 

Could I ask you to reflect a little bit on how this virus is behaving? Not just the epidemiology of it, the transmissibility of it, the R0, compared to previous outbreaks of Ebola. And also, the case fatality rate. You know, I've heard 70 percent. I've (inaudible) look a little bit closer to 55 percent or 60 percent, which would -- kind of reflect on those numbers and if we're seeing beads on a chain kind of outbreaks, you know, or some kind of more point source, just to give us an idea to compare this to the way the virus has behaved previously. And thank you. 

GARRETT: Great question, Larry, Larry Brilliant, who -- most of you have probably heard of him. He was very involved in the eradication of smallpox. Yeah, OK. The fatality rates -- you see press reports constantly going for the highball figure, saying, quote, "as high as 90 percent." We know that in 1976, the first recorded outbreak of this disease, which also was in Zaire at the time, that there were fatality experiences in some villages as high as 90 percent of those infected. 

But we also know, with every outbreak of Ebola, the fatality rate has waned with time. This is not because the virus changes. This is because the human behavior changes. And so fewer and fewer people are coming in contact physically with one another, just a combination of fearfulness and of hopefully appropriate public health measures taken. 

So you have a lower overall exposure rate and you get people into care, which even though we have no actual treatment or cure for this virus, palliative care can make a difference. One of the chief features of undergoing a hemorrhagic disease is that you become severely dehydrated, and people can literally go -- their whole body into shock from blood loss and dehydration. 

So hydrating alone can help lower the fatality rate. And, of course, getting people away from others so that they don't carry out behaviors that might ultimately be suicidal is also going to lower the fatality rate. 

As far as the likelihood of one person giving Ebola to another, historical experience shows it's around 1.5 percent to 2 percent as an R0, which is the way that epidemiologists compute the likelihood of spread. To put that in context, the R0 for smallpox was estimated to be somewhere between 5.5 and 6.0. So any one infected person statistically would infect 5.5 to 6.0 additional people. 

So an R0 of 1.0 to 1.5 doesn't sound too bad for Ebola. That sounds like a controllable outbreak. And, in fact, it is, if you can keep people from being exposed to other people. The problem is, the political dynamic on the ground and the social upheaval on the ground in these three countries, which is running exactly contrary to all the elements of would-be control of this outbreak. 

MCMAHON: Larry, thank you for that question. Operator, do we have another question, please? 

OPERATOR: Yes, sir. Our next question comes from Edwin Smith with University of Southern California. 

QUESTION: I'd like to thank Laurie and John for this good presentation. I'm very grateful to hear the kind of information that's coming out. I'm curious from either of you what a strategy would look like. Laurie says there's no strategy at all. I'm wondering what a -- what are the barebones of a strategy that might be workable internationally? I can understand the domestic -- the local strategies that might be undertaken, but what would an international strategy look like? 

GARRETT: Well, let me offer some of the public health pieces, and then I'm going to hand it over to John to talk about politics and economics. A strategic plan should reflect on our failures in the past to try not to repeat them. In 2009, we had an outbreak of H1N1 influenza, sometimes referred to as swine flu. It originated in the United States, but exploded in Mexico. Mexico followed all the rules of the game. They told the whole world, "We have it." They were completely transparent and open. They tried to bring it under control, and the response of the international community was, "Woah, shut the borders to Mexico. Don't let any Mexican planes land anywhere. Penalize Mexico for having this outbreak." 

That sent a message to the whole world, "Wow, don't comply with regulations. Don't try and be a good global citizen in an outbreak because the rest of the world is going to really not be kind to you for doing so." 

H1N1 also showed us that we can't make vaccine rapidly. We certainly can't make it equitably accessible to the whole world. It goes to the rich countries first and to hell with the poor countries. 

And it showed us that we don't have strategic ways of saying, "This is an appropriate government response to scary disease, this is not." Rather, it ends up being about each country kind of coming up with their own plans, plans that often contradict even their immediate neighbor countries. 

We should be right now asking, what are the lessons from H1N1 that we can apply, right now asking, who's in charge? Is it WHO? Is WHO going to be the global leader if this thing spread to Nigeria, if this thing gets out of these three countries? Is it WHO? We don't -- you know, we haven't had a sort of all-hands-on-deck raise your hands and say yes. That moment has not happened. 

And if it is WHO, then how does a weakened agency running on a $1.2 billion budget deficit take charge? Perhaps we should have a global moment to consider what that looks like. 

John? 

MCMAHON: John, over to you. 

CAMPBELL: You know, the issues are extraordinarily difficult. The issues are difficult because in many cases we're dealing with very weak states, which are defensive. Their governments are defensive about their own positions even amongst their own people. 

However, in Africa, there are multi-state organizations. I'm thinking, for example, of things like the African Union or the Economic Community of West African States, that could be the venue for governments to come together and to start to work out particular protocols that could be used. 

It's easier, of course, where states are strong. For example, in Western Europe, there is the mechanism provided by the E.U. I would have thought that in the Western Hemisphere it would be -- it would be logical and certainly doable for Canada, the United States, Mexico, and the various Caribbean countries to meet together to work out such protocols. But, again, central to all of this is governance and the strength of governance. And where those two qualities are extremely weak, it gets difficult to put together a multinational strategy. 

MCMAHON: And that's weak -- and the weak is in -- weakness is in West Africa, at this point, as you have said? 

CAMPBELL: Yes. Yes. 

MCMAHON: Well, thank you for that question. Operator, do we have another question, please? 

OPERATOR: Yes, sir. Our next question comes from Sandra Torry with USA Today. 

QUESTION: Hi, good morning. Thanks so much for doing this. I need to go back to the fatality statistics. I know you said that the 90 percent is too high, but is there some percentage we can use based on those who've gotten the virus and who have died that's a better number? 

GARRETT: Yes. First of all, when you look at the numbers right now, the tendency would be for you to do your own calculation, just take whatever's the latest reported case load and divide it into the latest reported death toll, and you come up with a percentage. And if you do that, you get somewhere around 55 percent, 56 percent. 

But that is probably a false number for two reasons. First, we know people are keeping their loved ones out of hospitals, so they are not confirmed cases. So we're missing a lot of data. 

And then the other problem is, what the death toll at any given moment is does not tell you what the death toll will be ultimately for each individual after the full treatment course is run. So it's I think fair to use a ballpark figure of 70 percent -- that's seven-zero percent -- that certainly ranks as one of the most lethal outbreaks in modern history. 

MCMAHON: And, Laurie, the one you -- sorry, go ahead. 

QUESTION: The follow-up is, you talked about a course of treatment. Is there some point time-wise or whatever where, you know, a person makes it out of the woods? Or is it kind of different for anyone who gets it? 

GARRETT: Oh, yes, indeed. In fact, the governments of West Africa have got to great pains to show people that there have been cases of individuals who've fully recovered, walk out of the hospital, and try to tell the community, "Bring your loved ones in, there is treatment." And when we say treatment, we don't mean curative care. We don't mean a specific drug. But as I previously described, the kind of palliative care, the hydration, even providing oxygen can make a difference. 

MCMAHON: Thanks for that question. Operator, do we have another question, please? 

OPERATOR: Yes, sir. Our next question comes from Sean McIntosh with U.S. Embassy. 

QUESTION: Hi, hello. Hello. My question is for Ambassador Campbell, and it's Nigeria-specific. Want to know, should the Ebola actually spread to Nigeria, knowing that the cases have been found in Nigeria, but not an actual domestic case, should it spread to Nigeria, to what extent do you see this contributing to the existing security concerns in the country, you know, given Boko Haram, upcoming national elections, and the endemic corruption? And also, how do you feel that the U.S. government should prioritize handling the Ebola crisis in light of these other security concerns? Thank you. 

CAMPBELL: Well, thus far, there has been an Ebola case only in -- only one and only in Lagos. If, in fact, the disease arrives in Lagos with a vengeance, then clearly it's going to have destabilizing consequences. At that point, what the United States can do will be dependent in large part on what the Nigerian authorities ask us to do. And that gets very tricky. 

We've had or seen the case of the 300 schoolgirls kidnapped in northern Nigeria. We've seen numerous countries offering to provide assistance. And yet getting that offer translated into something practical and concrete on the ground is dependent upon the Nigerian authorities, who have been relatively slow to act. So what we would be able to do, if there was a widespread outbreak of Ebola in Lagos, is going to depend on the Nigerian authorities. 

MCMAHON: And, John, I think it's been estimated that up to a third of Nigerian territory might not be in the control of the central government, partly under control of Boko Haram. Is that correct? 

CAMPBELL: Well, the figures are squishy. Perhaps better to say that Boko Haram is able to operate freely without constraint in a part of northern Nigeria that's as big as, say, the state of Rhode Island. 

GARRETT: Another... 

(CROSSTALK) 

MCMAHON: OK. And they have been -- they have been hostile to polio workers and things like that, as -- as well. Is that right? 

CAMPBELL: Oh, yes, absolutely. 

GARRETT: That's what I was going to say, that, you know, this whole problem that we're facing across the Islamic world, especially in Pakistan, leading to the assassinations of polio vaccinators actually originated in northern Nigeria when a couple of imams decided that it was possible that the CIA had put either HIV or sterilizing agents into polio vaccines targeting Muslims. And this has -- there are many reasons why this has taken on a new life, but a huge unknown for us right now is how Boko Haram sees itself in the context of, you know, sort of global mobilized health campaigns and whether -- if there were Ebola in northern Nigeria, Boko Haram would be as obstructive as many are now being on the ground in Sierra Leone and Liberia. 

CAMPBELL: My own estimate is that it would be. Boko Haram is intrinsically opposed to Western science and to Western medicine. The one possible silver lining in this very gloomy cloud is that Lagos -- Lagos, about half the population of Lagos is Muslim, but it's a very different kind of Islam than you find in northern Nigeria. It's broadly tolerant. Muslims there intermarry regularly with Christians. And there is not the hostility to western science that you find in the north. 

MCMAHON: Thank you. And then just a reminder to all on this call, this is an on-the-record CFR call on the Ebola outbreak with CFR senior fellows Laurie Garrett and John Campbell. And, Operator, I'd like to see if there's any other questions from members on the line. 

OPERATOR: Yes, sir. Our next question comes from Christopher Graves with Ogilvy Public Relations. 

QUESTION: Hi there. This is Chris Graves. Question about what appears to be an information and communications disaster, as well. From what Laurie was saying, for example, the great suspicion now turned against the health care workers, what is being done, could be done in terms of information to alleviate some of this? And whom would the people trust? Because coming from wrong sources, it will only lead to greater conspiracy theories. 

GARRETT: Yeah, well, this -- if there's any word that's been bandied around a great deal by people trying to figure out what to do about this outbreak, it is the word communication. Trying to figure out a way to do reasonable communication that breaks down all these suspicions is proving very difficult. 

To begin with, the populations in these three countries run about 50 percent illiterate. So handing out leaflets is not likely to, you know, be a particularly effective tool. You do see billboards now all over the main cities in Monrovia and Freetown, especially, saying Ebola is real, you must believe in Ebola, and so on. Again, I don't know how effective they are for illiterate individuals. 

But I think you have the additional problem that the sort of Western style of doing a media campaign around any given issue, whether it's don't smoke or vote for John Jones, our style of approaching these things is just not what is needed on the ground. What's needed is really direct communication that begins by identifying key community leaders, village by village, neighborhood by neighborhood. Who are the influence-makers? Who are the individuals that everyone else follows and obeys for one reason or another, whether they are religious, political, gangsters, whoever they are? And winning them over step by tedious step. 

The problem is, it's dangerous work. It's not only dangerous because people will disagree with you and throw rocks at you. It's dangerous because you don't know who's infected, in terms of any given community meeting you go wading into. 

I think this has just reached levels where all the simple solutions are -- have been tried and failed. And it's time now for something very new, very dynamic in terms of communicating risk to people. 

MCMAHON: John, would you like to add on the information campaign? 

CAMPBELL: Well, this is a particularly awkward time for West Africa. The very rapid rates of urbanization means, for example, that very many people are now outside of the traditional village structures, which means that identifying who they will listen to is really hard. 

Then, there is the additional problem of, what language do you communicate in? I mean, the percentage of people in West Africa who speak English or French is extremely small. In Nigeria alone, it's said that there are 350 different languages. So you've got -- you've got real practical issues that have to be addressed, as well. 

MCMAHON: Thank you for that question. Operator, do we have another question, please? 

OPERATOR: Yes, sir. Our next question comes from John Stremlau with the Carter Center. 

QUESTION: Further to the points just made, there's an anecdote that I've seen out of Liberia where we have -- of active programs that may be instructive. That is that the traditional chiefs have taken upon themselves to really speak out in the vernacular on radio about this threat and how to deal with it. By contrast, I've seen reports from church leaders who have played up this is the -- this is the curse of God, this is sinfulness being punished, this is homosexuality that's been a problem. It speaks to Laurie's need, I think, for a strategy that does reach down into the communities and differentiates and highlights those voices that are credible and will speak out and are speaking out, at least in this case, so there is both good news and bad news out of Liberia as we see it. 

GARRETT: I think that's an excellent point. And one of the really positive things that I would love to see happen from the Carter Center, from a host of different institutions that have influence in the religious communities, would be to, in fact, come up with ways to reach out to religious leaders regarding, you know, what does the Bible actually say about disease? What does the Bible actually instruct? What does the Koran say? 

And to try and dispel the mythologizing, the finger-pointing, the -- you know, you are sick because you are evil stuff, and, of course, that gets to another key point that I must apologize for overlooking up until this point, and that is that we all talk about a virus, and everybody on this phone call has some concept in your head of what a virus is. You may even have a visual image in your mind of what Ebola looks like because you've seen so much press coverage with the micrographs displayed. 

And you think you understand when I say something like the virus is in the bodily fluids, what that means. But you are dealing with a situation now in populations where there is no germ theory of disease. There is no virus. There is no difference between a virus and a bacteria. There is no "something in the bodily fluids." It's evil spirits. 

And you are in a place where just about every single living person has a reason, because of the horrors of what happened during their civil wars, has a reason to believe that somebody else wants to take revenge against their clan, their family, or them as an individual, because of evil deeds done to someone else's family during those horrible civil war years. 

And so here you have governments trying to figure out how to go out and tell people there is a virus, it's a new virus, it's a terrible virus, protect yourself, and the people are saying, "Virus shmirus, this is all about, you know, that guy's grandfather, you know, stole land from my grandfather, and I am sending him an evil spirit and praying that his family, his whole clan dies of this disease, because I want revenge for that stolen property." 

MCMAHON: John, would you like to add anything to that? 

CAMPBELL: No, that's an extremely accurate, I think, depiction of what the mindset can be. Diseases are not caused by bacteria or germs. Diseases are caused by witchcraft. 

MCMAHON: You know, John, the mention of trying to come up with some sort of information campaign also makes me think about the major U.S.-funded broadcaster in Africa, which is the Voice of America. Is it overstating its ability to say maybe Voice of America could mount a special information campaign in this area? 

CAMPBELL: The Voice of America could. And I think it could have an impact, if it was done in conjunction with Deutsche Welle, the BBC's Hausa service, and so forth, yes. However, we should not overstate what the effectiveness of this might be. But it's worth doing. 

MCMAHON: Thank you. And thanks for that question. Operator, do we have another question, please? 

OPERATOR: Yes, sir. Our next question comes from Andrew Simmons with the New York Times. 

QUESTION: Hi. Thank you both very much for doing this today. I'm just wondering, you know, John, you said that, you know, it would be very difficult at this point and in the summit. And, you know, these leaders probably don't have, like, their health ministers or high-level aides who would be dealing with the outbreak, you know, at the summit with them. So, I mean, what do you both think could, you know, reasonably or, you know, be done to sort of come up with a unified strategy during this summit that can also then be implemented effectively, given that most of the -- you know, the health-focused people in these, you know, various cabinets might not actually be, like, on the plane with their leaders? 

MCMAHON: John, you want to kick that off? 

CAMPBELL: Sure. Well, I would suggest that what you can do in the essentially 24 hours that remain, a little more than 24 hours that remain in the summit, is you could arrive at a consensus that -- that this is an extremely important issue, that it must be addressed, and that we have to come up with a structure to do so. 

But I don't think we can go much beyond that, simply because there isn't time. And as the questioner pointed out, most of the African leaders who are in Washington now will not have their health experts with them. 

MCMAHON: Laurie, anything to add? 

"I think the most immediate need right now is leadership. Who's in charge? Where does that leadership go up the food chain hierarchy on the international response barometer?"—Laurie Garrett 

GARRETT: I would go a little further. I do think that there are some joint agreements that could be reached. Unfortunately, there's not any intention to put them on the table, but agreements regarding some real basic things, like, will African countries start closing their borders? Should African countries shut their airports down to traffic from certain flights from certain locations? Are there going to be mobilizations of health care workers from Country A to Country B? Under what sorts of premise? And how might they be executed? 

I don't think these are decisions that have to be made only with the presence of a minister of health in the room. And I would add to it, a commitment of resources is never something decided by a minister of health in any African country. It's always decided by the minister of finance, and all the finance ministers are in Washington right now. 

MCMAHON: Thank you for that question. Operator, do we have another question, please? 

OPERATOR: Yes, sir. Our next question comes from Daniel Drezner with Tufts University. 

QUESTION: Yes, thanks. A lot of my questions were already asked, but I guess I'd follow up on the question about the summit, which is -- for lack of a better way of putting it -- how reluctant are, in fact, the heads of state to talk about the Ebola outbreak in general? I mean, I assume one of the purposes of this summit is to try to recast the image of sub-Saharan Africa as -- rather than a place of poverty and disease, rather, you know, a place with some of the fastest-growing economies in the world. 

So could -- even if we wanted to bring this up at the summit, will there be reluctance from the heads of state themselves? 

MCMAHON: John, you want to kick off again? 

CAMPBELL: Yeah, sure. Yeah, I think that's exactly right. There would be reluctance. Again, I go back to the point that African heads of state are products of a particular political situation. They have numerous stakeholders. To take a decision that has important consequences like, for example, shutting down air traffic from one African country to another, that's more going to be a difficult decision for an African chief of state to make unless or until he has prepared the ground with the stakeholders that are involved. All of that I think promotes an outlook in which there would -- especially with such short notice -- be a reluctance to actually move to concrete steps. 

MCMAHON: Laurie, anything else to add on that? 

GARRETT: I think that nails it. 

MCMAHON: OK, I think we can maybe squeeze in one more question. Operator, do we have another question, please? 

OPERATOR: Yes, sir. Our next question comes from Josh Busby with University of Texas. 

QUESTION: Yes, thanks for taking the call and your comments today. I guess my question is, Laurie, you spoke of the Doctors Without Borders' exhaustion and, at the same time, the lack of there being some rapid reaction force that the World Health Organization can send. And so in light of that conundrum, other than mobilization of local militaries, which are likely to not have the expertise necessary to bring the public health lens to this, what else would you recommend in terms of some international response? Is there some WHO capability that could be mobilized, CDC, or something else? 

GARRETT: I think we're seeing already all the sort of usual suspects, if you will, to use a cliche, mobilized. You know, the Institut Pasteur from Paris, the CDC from Atlanta, the London School of Hygiene and Tropical Medicine in London, the big players have mobilized to some degree. But almost all of them have seen their own budgets cut and their own capacities diminished. 

I mean, it says a lot that a volunteer organization is the lead responder, Medecins Sans Frontieres. It says a lot that we're looking at groups that many of you maybe never had heard of before, like Samaritan's Purse, on the ground. You know, Mercy Corps, World Vision, I think the problem -- if this continues in this sort of ad hoc way with extraordinary organizations taking radical measures to assist, often at great personal health risk for every single individual, the risk we run in countries that are so weakly governed is that we'll have a chaotic response, we'll have NGOs at counter purposes with one another, we'll have inappropriate mobilization of scarce resources. 

I think the most immediate need right now is leadership. Who's in charge? Where does that leadership go up the food chain hierarchy on the international response barometer? If we get to a neighbor country affected, if we get to a major city like Lagos affected, where is the chain of command? To me, that's absolutely paramount and comes way before you start asking, where do we find more Medecins Sans Frontieres volunteers? 

MCMAHON: John, how about a last word on the leadership front? 

CAMPBELL: Well, Laurie I think has sketched out very nicely the constraints that the WHO and other international organizations face. It's really easy to bash international organizations, just as it's really easy to bash national governments, unless or until you really need them, such as you do when you have something like Ebola. 

MCMAHON: And on that note, we are going to conclude this CFR on-the-record conference call on the Ebola outbreak. I want to extend a great thanks to John Campbell, the senior fellow for Africa policy studies at CFR, and Laurie Garrett, senior fellow for global health. This is the conclusion of the CFR on-the-record conference call. Thanks, all, for taking part. 

OPERATOR: Thank you. Ladies and gentlemen, this concludes today's teleconference. You may now disconnect.