International Development Committee

Oral evidence: Responses to the Ebola crisis: Follow-up, HC 338
Tuesday 10 November 2015

Ordered by the House of Commons to be published on 10 November 2015.

Listen to the meeting: Tuesday 10 November 2015

Members present: Stephen Twigg (Chair); Fiona Bruce; Dr Lisa Cameron; Mrs Helen Grant; Fabian Hamilton; Jeremy Lefroy; Wendy Morton; Albert Owen

Questions 1-47

Witnesses: Andre Heller-Perache, Head of Programmes; Médecins Sans Frontières UK, Annie Wilkinson, Post Doctorate Researcher, Institute of Development Studies, and Dr Jeremy Farrar, Director, Wellcome Trust, gave evidence 

Q1   Chair: Good morning, everyone, and welcome to this evidence session following up the previous Committee’s inquiry on Ebola.  Welcome to Annie and to Andre.  Our third witness for the first session, Jeremy, has been delayed by train issues, but we are hoping he will be with us in time to join the panel.  We have two panels this morning.  The first will run through until about 11 o’clock and then we will take the second panel.  We have a number of questions from members of the Committee.  Sometimes there are questions that, by their nature, everyone should try to answer, but sometimes we will aim the questions at particular witnesses because we have quite a lot of questions we would like to get through. 

It is helpful, when you give your first answer, perhaps just to say a little bit about yourself and your organisation briefly at the beginning.  Thank you, both of you, for being here.  I shall pass over to Wendy for the first question.

Wendy Morton: We have been told many times about the slow response to the Ebola crisis from the World Health Organisation and the wider international community.  I wondered if you could explain to me why you feel the international community was so slow to understand the nature of the outbreak. 

Andre Heller Perache: I will take a stab at that.  My name is Andre Heller Perache.  I work with Médecins Sans Frontières.  I was our focal point for advocacy here within the United Kingdom, primarily over the first part of the outbreak where it was heading towards the peak.  I worked on the ground in Sierra Leone for about a month between November and December, right when it was really at the height of the epidemic. 

Regarding my understanding as to why it was that the world did not listen to the warnings, honestly, that is more the question that we were asking the world.  In fact, we did so repeatedly in our press releases, from the end of the month of June, through August and all the way into September, at which point our International President offered the speech that she did for the UN member states, sounding the alarm as loudly and clearly as we possibly could at that point.  Keep in mind that this is quite a bit after even the WHO, whom we perceived to be very late in recognising it as a health emergency of international concern, did so; it is another month on following that declaration. 

Effectively, we do not know, and this is what we would like to see improved upon in the future for outbreaks of this nature, or of any nature for that matter: that there is a reaction and there is a response.  But this is the question we were left asking ourselves.

Q2   Wendy Morton: Before I come to Annie, can I come back and ask you at what stage of the outbreak you think the international community should have been mobilised?  Was there a certain time point or another trigger point that you think should have resulted in mobilisation?

Andre Heller Perache: We think there should have been a lot more focus and attention on it, given that even in the early days of the outbreak we had explained that it was the largest outbreak of Ebola that we had ever faced.  This is even before the summer; this is in late spring.  Then, by mid‑summer, it was clear that the outbreak was not under control; basically, there were enough chains of transmission we were unable to track that we effectively had no idea what was going to happen next.  It was an unprecedented moment, and that was already obvious by mid‑summer, again.  That was the next higher level of this, and that is really what should have caused the trigger.  In July, there should have been a massive mobilisation, but, as it stands, it was not really until mid‑September that there was an effective mass mobilisation from powerful western Governments, as well as eastern Governments.

Q3   Wendy Morton: Can I turn to you, Annie, and ask you basically the same question?  Why do you think the international community was slow to respond?  Again, at what point do you think mobilisation should have been triggered?

Annie Wilkinson: I am a researcher at IDS.  I have been working in Sierra Leone since about 2009 researching Lassa fever, which is a similar viral haemorrhagic fever and affects exactly the same three countries that were most badly affected by Ebola.  I was in Sierra Leone three times during the outbreak: the first time, in July 2014, in Kenema, which is where the Lassa fever ward is based and where the initial Ebola cases were being managed in Sierra Leone; and then a number of times throughout the outbreak, so I feel I have seen the trajectory of the response and the outbreak. 

There has been a lot said about the slowness of WHO and some other organisations, both international agencies and Governments that were slow to respond.  One of the really big challenges, speaking from what I saw at the end of July in Kenema, when things were so clearly falling apart, was a big communication gap with Freetown and also between the country and regional offices of Government agencies and NGOs, and headquarters back in Geneva or London. 

A big challenge is that it goes against the interests of nations and sometimes particular people or political parties to admit things are out of control, so there are communication problems and there is also a vested interest in saying that things are fine.  We saw a lot of denial of the scale of the problem, and that was damaging.

Q4   Albert Owen: On internal communications, are you saying that the countries themselves, and Sierra Leone in particular, were in denial and not asking for help, or were they asking for help in a half‑hearted way and trying to deal with it themselves?

Annie Wilkinson: I cannot speak for what was being said at Government levels, but I can say what happened on the ground in Kenema. There are many different levels to this denial.  There were field workers reporting to their superiors who did not want to say that things were going really badly out in Kailahun or wherever, in more remote regions.  There were, reported in the press at least, both Guinean and Sierra Leonean Government officials saying things were not as bad.  I have also done research with the leaders of the local response in Kenema, who said they were pleading for assistance from central Government in Freetown.  There are lots of different levels to this denial, but we also know, from the reports and the assessment of WHO’s response, there were, again, issues of the gravity of the situation getting up.  It seems to have happened everywhere.

Q5   Albert Owen: I mentioned that because, this weekend, you had Government leaders from Sierra Leone saying that it was the international response that was slow, so it was interesting to hear your perspective on the internal dimension.

Annie Wilkinson: It is a mix of all.  It would not be fair to point the blame at one.

Andre Heller Perache: It is also worth pointing out that there is a certain tension between sovereignty of states in how they respond to a crisis like this and international health regulations.  At what point does an organisation like the WHO draw the line and refute the understanding of a crisis like this that is being offered by a state?  Is it their role to refute the state narrative and so on and so forth?  There are quite dense politics on that level.  Obviously, the ramifications and implications of declaring an Ebola emergency are massive for the economy and the people that are there.  It was quite a complex calculation that everyone was doing.

Q6   Jeremy Lefroy: We, the Committee, were in Bo in June last year.  I met a colleague with whom I used to work, who had come from Kenema, in Bo.  I remember, on that day in mid‑June, there had been many, many roadblocks on the way from Kenema to Bo, which implies that they were beginning, at that point, to step up the response internally.  Does it accord with your recollection and what you saw on the ground that, even in mid‑June, they were taking the movement of people within the country, from the east of the country, pretty seriously?

Annie Wilkinson: My timeline is a little different.  I remember leaving Kenema towards the end of July.  At that point, Dr Khan had fallen sick; he had not yet died, but he had fallen sick, and basically most of the Lassa fever ward nurses had also been infected.  There had been a huge riot in Kenema when we were there, and people wanting to burn the hospital down.  There were some roadblocks when we left, but they were pretty lax. 

It was after we left that the President declared a state of emergency, so this is, if I am remembering correctly, towards the end of July.  That did include some travel restrictions.  The quarantine of Kenema was seen, initially, quite angrily by Kenema residents, because, by that point, there was already Ebola in other parts of Sierra Leone and they felt they were being punished.  That plays into all sorts of regional politics as well, because it is an opposition home ground.  But, from my understanding, and also some research I have done recently, they then came to quite appreciate that quarantine and tried to fortify it themselves.  They found it to be protective in the end.  Maybe, from June towards the end of July, travel restrictions did begin to become more of a thing, but they were still pretty loose, I would say.

Q7   Dr Cameron: A large amount of the written evidence we have received has suggested that community engagement was really crucial in terms of outbreak control.  To what extent do you feel that that is the case and how would you define it on the ground level in terms of community engagement?

Annie Wilkinson: The other thing I have been working on for this is something called the Ebola Response Anthropology Platform, which is funded by DFID and the Wellcome Trust.  The idea was to network anthropologists and other social scientists to integrate and provide insights into the social and cultural dynamics that were clearly being so problematic.  A lot of the questions we have had and a lot of the work we have been doing has been around community engagement. 

For all the discussion of how slow the response was, another really important dimension to it is that, once it did start, it was slow to listen to local concerns and slow to respond in a way that was sensitive and flexible to that local context.  There was a lot of blame early on.  There was a lot of talk about communities, denial, superstitious beliefs and problematic traditional cultures.  That often obscured some of the very valid concerns that they had, which we know about, like unsafe or undignified conditions in hospitals or quarantined households.  But what was really damaging is that it prevented some meaningful and early engagement of local institutions and organisations, which could have made a more positive effort to the control by helping to develop more locally appropriate control measures. 

The response did learn and became more sensitive to local needs and conditions.  It came to include a broader range of stakeholders and to slightly change the conversation from blame to something more like: “Communities have the power to do this.”  But a big lesson for the future is that it should be like that from the beginning.  Epidemic responses should be designed to be inclusive, flexible and adaptive from the start, really.

Q8   Dr Cameron: Was it about, then, having communities involved at an early enough stage and on board, or were there particular barriers preventing that that we could learn from?

Annie Wilkinson: A particular barrier was the framing of communities and traditions being a problem.  If you see those people as the problem, then it is hard to include them.  Really, it should be a response that is built on seeking and integrating a broad range of perspectives and expertise.  In an epidemic response, alongside biomedical and epidemiological expertise, it should be social science, anthropology, and also, critically, local organisations, people and their voices, and the institutions that are already there and have tremendous capacity.  What we did see is a lot of local activity and local responses, from chieftain‑level taskforces and byelaws to village‑level limiting movement and encouraging people to report sicknesses.  Some of that just was not supported as much as it could have been and early enough.

Chair: Andre, did you want to add anything on that question?

Andre Heller Perache: There is not too much to add.  We see it the same way.  We conducted some research from a department we run out of London, which indicated a lot of the same things about a very strong link with uptake of control measures to curb transmission of the virus, empathetic communications and reinforcing the means of communications that exist on a local level.  I do not have anything to add.  That was very well said.

Q9   Wendy Morton: Do you think there is a link, then, between a country that has fragile or weak health structures and the role of the community?  What I am driving at is: where you have weaker systems, could the role of the community be greater?  The reason I ask is that Sierra Leone’s systems are less developed compared with some other African countries. 

Annie Wilkinson: When you are saying similar systems, you mean the health system. 

Wendy Morton: Yes—systems for reporting, systems for communicating.

Annie Wilkinson: In the absence of a strong public health system, you often have these informal networks and community‑based institutions, some of which might be civil society and some might be more traditional institutions, and there was a big gap between them and whatever skeleton state architecture there was.  Investment in linking those informal and formal sectors is very important.  In a country like Sierra Leone, which has historically suffered a lot, is very unequal and where there has been systematic underdevelopment, as some people have called it, there are political and economic reasons why the rhetoric about poor rural people is not inclusive.  It talks about how they are to blame and it can be quite stigmatising.  The way in which poverty and inequality run into how people interact and communicate, and what that means for how you can build those links between these formal and informal, is a challenge.

Q10   Fabian Hamilton: Can I follow on that theme?  Sierra Leone and Liberia have suffered for more than a decade from violent armed conflict.  I wondered how much you thought distrust of authority had played a very large role in hindering relief efforts.  Do you think that, in future public health emergencies like the Ebola crisis, we can build trust in local communities more quickly in order to stem the spread of disease and overcome that distrust of authority? 

Andre Heller Perache: The provision of critical services at the time of an outbreak is what maintains and builds that trust.  Having a place to go and seek care if someone is sick is one part of where that relationship is founded.  There is a strong link between trust and provision of service in a time of need.  That would be not just for the Ebola outbreak, but for regular sickness and normal medical emergencies that would arise along the way. 

Beyond that, it was mentioned previously that some of the mass measures that would target a certain area or community might have worked against that trust when they were initially put out.  This is something on which MSF had been vocal on numerous occasions in different ways, not in trying to tell people how to do the response, but more in trying to caution that some kinds of mass‑targeting measures to curb transmission might work against that trust‑building process and further obscure things from people. 

Trust with institutions is a complex question.  In this intervention, you not only had traditional systems that were somehow in play in regulating communities’ behaviour as the outbreak continued, but you also had the military as an institution; you had international actors with a presence that was much more than normal; and you had the Ministry of Health involved as well.  There was quite an orchestration of different bodies at play in this, which played out differently in different places, based on what local perceptions were and pre‑existing relationships with authorities previous to the outbreak.

Q11   Fabian Hamilton: Sorry, Annie, I know you want to come in on this.  By the very nature of controlling an outbreak like this, you have to have quite a lot of authoritarianism from the organisations that are trying to stem the spread.  Surely that would play into the hands of those who say, “All these authorities are the same.  They just want to tell us what to do, and we do not trust any of them.”  How do you differentiate those who are really trying to look after the future of public health and the individuals from the military authorities, who can be quite oppressive, certainly in the conflict situations that these countries have suffered?

Andre Heller Perache: I would not necessarily jump to conclusions about how different kinds of authorities are perceived.  We were quite concerned, in the case of Liberia, for example, with the arrival of a lot of American military, that there would be quite some fear and some pushback against that.  Yet, in reality, it did not happen that way in the end, and they were quite welcomed.  In terms of conceptions of how people would be responded to, it is not necessarily going to be as linear as “authority equals bad” or “force equals oppression”. 

There was a military side of the response that was command and control: getting results done quickly, deploying resources immediately.  There was a biomedical side of it, which was trying to offer the best kind of advice from a technical perspective in terms of what works biologically to counter the transmission of a virus like this.  Then there was a social side of it as well.  It was mentioned previously that the social side of the response may have required a bit more focus, and that might have also played better into the notion of trust.

Annie Wilkinson: When talking about trust, it is quite useful to make a distinction between strategic trust, which is built on your personal experiences of either a person or a hospital, say, and the more generalised trust you might have that other people are from the same moral community as you.  In this episode, both were lacking.  In terms of building a response, you can do certain things.  Over time, once hospitals became better, ambulances were cleaner and things, you did see that more experience‑based trust developing. 

To the general question, “Do you trust your Government and the people that provide the health services?”, I am not sure that rural populations in Sierra Leone necessarily distinguish that much between hospital authorities, military authorities and Government officials. 

Fabian Hamilton: That was my point.

Annie Wilkinson: That is a bigger development question about building the type of development that does not lead to abuses, corruption and huge inequalities, so people are left thinking, “We come from the same moral community here.  These people are out to help me rather than take advantage of me.”

Chair: We are going to move on now to look at some of the international structures in the light of Ebola.

Q12   Jeremy Lefroy: We have mentioned WHO a little bit.  We heard some comments from David Nabarro when we were in New York, and also spoke with the panel that is looking at the WHO at the moment.  I want to focus, though, on the international health regulations and whether you think they are fit for purpose at the moment.  Is it just a matter that they have not been implemented or do they need changing?

Andre Heller Perache: From our perspective, the IHR was so far from being fully implemented that that was clearly the first problem.  It is nice to come up with an agreement like that, but it is an entirely different thing to fully implement it in reality, particularly in resource‑poor countries.  Beyond that, there does exist a tension: from our understanding, there exists a tension between sovereignty and international health security.  We also view, beyond that, an additional tension too with the humanitarian response that would be involved in an outbreak. 

You have this tension between health security, national state interest and then human need and human suffering as well.  These things are not easy spaces to navigate.  We are not advocating taking a hammer to the regulations by any stretch, but, at the same time, implementing them is not something that is directly around the corner.  It will take a long time before we are there. 

Q13   Jeremy Lefroy: If I could just follow‑up specifically on the WHO, I attended the day conference at Lancaster House in October last year, when various commitments were made.  Dr Aylward from the WHO made certain commitments on behalf of the WHO, which were that they would scale up to 500 people over the next 30 to 60 days; that they would need to target, within 60 days, 70% case isolations and 70% safe burials; and that, if we hit that, the outbreak would turn around.  Did the WHO fulfil the kind of commitment or indication that was made in October, as far as you are aware?

Andre Heller Perache: Did the WHO fulfil the commitment?  The WHO was an actor, among others, that was working on the 70‑70‑60 plan.

Q14   Jeremy Lefroy: Was that fulfilled within that period, as far as you are aware?  I am just interested, because this was a fairly definitive statement made at that conference and it would be good to know if that actually happened as a result.

Andre Heller Perache: Previous to this, there was the creation of UNMEER.  UNMEER came around to take leadership in this on an international level, or that was the idea.  It was a new structure that was built beyond the WHO, where people might have looked to see the emergence of this kind of leadership body in the past.  But, in reality, the way co‑ordination played out at the field level was quite different, in terms of who called the shots and how the structures were set up, in Liberia, in Guinea and in Sierra Leone, in addition to the other countries that had a few cases emerge.  It was not a monolithic leadership that emerged at any point.  It was highly variable and, even within a country, it was variable based on who was who in what districts and what competences and leadership were present.  I am not sure if that speaks to your question somehow.

Q15   Jeremy Lefroy: That is very helpful.  You point out that it was under the UN.  David Nabarro at the time said, I think, that this was the first ever public health mission under the auspices of the UN.  Is that the case?  How do you think it worked out that the UN was involved on this scale and in this particular area, as they would not have been before?

Andre Heller Perache: In terms of thinking about UNMEER and how they were involved on that scale, as I previously stated, it was quite different.  DFID and the UK Government were very invested and engaged in Sierra Leone.  The authorities within Sierra Leone created their own structures as well, with some former military and military personnel working alongside district and national authorities and health authorities, as well as having advice from the CDC and the WHO.  It was really a hybrid response that was put into place.  The orchestration of it was totally different from one country to the next, to the next.  I am not really sure what else to say about that from a co‑ordination perspective.

Jeremy Lefroy: That is helpful.  Thank you.

Chair: Annie, did you want to say anything on that specific aspect?

Annie Wilkinson: No, not really.

Q16   Chair: Let us move on to look at the reform of these structures in the light of Ebola.  Questions around WHO reform have been on the agenda for some time.  Would each of you like to comment on ways in which the structures internationally, including WHO, could be reformed for the future?  Annie, do you want to go first?

Annie Wilkinson: I have to say that is not my area of expertise. 

Chair: No worries.

Annie Wilkinson: Back to the last question, there is a tension: whether you create a parallel institution like UNMEER in the panic of emergency or whether you invest in organisations that you already have.  That is a choice that people have to make.  From what I saw on the ground, WHO seemed to be making quite a strong comeback and, in some of the districts that I saw, they sent some very competent people.  If I am honest, UNMEER was more absent, but I do not want to be held up to commenting too much on those individual cases.  Potentially, investing in institutions that you have and improving them is better.

Q17   Chair: Welcome Jeremy.  You arrived as I was asking that question, and I imagine you do want to respond, because the Wellcome Trust’s submission refers to some of these issues. I might give you a moment to catch your breath and see whether Andre would like to add anything on this particular aspect of reform of the international architecture. 

Andre Heller Perache: What we have voiced on a few occasions is returning to the basics with the WHO and having it be empowered to fulfil the mandate it has.  We do not view anything fundamentally wrong with that.  But there exists a common understanding today, which is observed from outside as well as inside the institution of the WHO, that funding has happened in such a way that has limited its flexibility in emergency response.  This is clearly a problem.  The ability to allocate resources and personnel who are appropriate and have the right amount of field‑level leadership and authority to execute a complex intervention like this one is absolutely crucial to mounting a response. 

The universal right to healthcare and emergency response is already enshrined within the mandate of the organisation, yet, as time has gone on, we understand that the funding, along with other political factors, has encouraged the WHO to take more of a technical role in an advisory capacity, and a less operational one.  Clearly, as was indicated in this outbreak, more operational leadership was required at an earlier stage in the game.  It did not happen.  If that is a structural issue, a capacity issue, a human failure, a cultural problem with the organisation, I am not sure.  In any case, structure is maybe too simple to look at.

Q18   Chair: Dr Farrar, earlier we had some questions around the slow international response.  Perhaps you might like to start by commenting on that and then addressing the question of reform going forward. 

Dr Farrar: Chair, I apologise for being late—Chiltern Railways.  Thank you for asking me to come to join you for what is a very important and very timely discussion.  As I am sure was rehearsed already by colleagues here, the response was slow, and inevitably the spotlight for that has turned on the World Health Organisation.  In our written evidence and other things I have written, as you know, I have been very critical of the World Health Organisation in its response, but it was by no means the only player in this that was slow to respond.  We all share responsibility for that slow response, with the possible exception of Médecins Sans Frontières, who were calling, earlier certainly than we were, to regard the epidemic we faced as different to all previous epidemics. 

I can come back to the slow response if you want, but, taking up your question about WHO reform, if now is not the time to reform the WHO, I do not believe there will ever be a time to do it.  I have been involved in each of the major epidemics of the last 12 years, going back to SARS.  I was very involved in that and lost a lot of very good friends during SARS.  We have called, after all of those, for reform, and yet we have not grasped that nettle after each of them.  This must surely now be the wakeup call that that is required. 

As you all know, we are in the last two years or so of Margaret Chan’s leadership.  We have to be very focused on what we are trying to reform in that two‑year period.  There is a much bigger job to be done around WHO reform, sorting out the relationship between headquarters, regional offices, national Governments and their member states, but we are not going to do that in the time that remains of the current Director‑General.  My focus and my advice would be to reform the issues related to epidemics, preparedness for and capacity to respond, because I think that is doable in the next two years.

Q19   Chair: What are the key priorities for achieving that in the next two years?

Dr Farrar: The key priority is to appreciate that these will happen with increasing frequency in the new world.  Climate change, migration, movement of people, urbanisation, different relationships between humans and animals and the agricultural sector will inevitably mean we have more epidemics.  The capacity to spread these around the world at a rate that we have not had before means we will be challenged by them wherever you live in the world, and we have seen that over the last 12 years.  My own preference is not to create yet another separate UN body, with its own bureaucracies and its own challenges of setting itself up.  You would all have retired, as I would have done, by the time that is achieved.  There is a need for urgency, because this does go back for a decade or more. 

My preference is that, within the umbrella of the World Health Organisation, an autonomous unit is set up with its own director and its own budget; it reports to the Director‑General, but it does so in a transparent way, so we move beyond corridor conversations, which can be denied or agreed to; and the advice of that body is made transparently available in the afternoon of the day it is made, as happens at the European CDC currently.  I would set that up.  It is going to have to get funded and, in order to attract the right sort of director, you will have to give it sufficient autonomy to allow that director to provide the leadership that is required.  I would base it within the overall structure of the WHO, but in a single entity as opposed to the current diffuse and separated entities that currently serve the WHO.

Q20   Jeremy Lefroy: One point that was made to us about the WHO, when we were taking evidence in New York, was the real lack of core funding and the fact that nations that are members of the WHO have been very lax in providing the core funding, which has resulted in them being unable to maintain the kind of structure and response that you have all been talking about.  Is that your perception as well?

Dr Farrar: It is not just perception; it is reality.  The figures speak for themselves.  But you are in a slightly vicious cycle here: there is a sense that the WHO is not performing well enough, and therefore people are less willing to give it the money required in order to do it, so you get a self‑fulfilling prophecy. 

It is also true that, over the 25 years I have worked externally but with the WHO, the quality of the individuals going to the WHO has got less over time, because there are other players in that global health space now.  Many years ago, instead of people potentially coming, like I have done, to the Wellcome Trust, to the Gates Foundation, to DFID or wherever else, they may well have ended up at the WHO.  As a result, we have not had the required leadership within the WHO that we perhaps had a decade or two decades ago.

Q21   Fiona Bruce: This is a question to Annie, initially.  Your institute has criticised the way DFID responded.  Was it a case of DFID needing to move faster or not looking far enough ahead into the future?

Annie Wilkinson: In some ways, DFID has played a very positive role in this, and their fairly enlightened approach to funding things like the anthropology platform is something that should applauded and encouraged.  They were slow, as Jeremy has said, as many people were slow.  The point we were trying to make in the evidence was that, towards the end of 2014, there were models and predictions saying there would be millions of cases, far above the current capacity for safe isolation.  One response to that was to put a lot of money into building medical facilities.  Faced with those kinds of predictions and this uncharted and scary territory, I have a lot of sympathy for that. 

But what those models did not show was how instrumental local organisation, local learning and responses and behaviour change were going to be.  Those were not as well supported.  You have quite a stark example in the fact that, by the time a lot of the treatment facilities were built, the epidemic was already beginning to turn around in some places.  You had empty beds that stayed empty for months, and then you also had local initiatives that were not being supported as adequately as they could be. 

A good example is burials.  Burials were a source of transmission and a constant source of tension, because, even once the safe and dignified burial policy had come out, it was still not seen as being appropriate for lots of people.  There were consistent concerns that people did not like being buried by strangers; they did not like being buried by the burial teams, who were often of an inappropriate age and gender. 

Some district teams set up things like a chieftain burial team, which meant that local people could be involved in the burials, but they were often not supported.  They did not have money for transport.  They did not have a means of transport.  They did not have the protection equipment they needed.  It just limited their response and their ability to make the kind of positive impact that they could have had.

Q22   Fiona Bruce: Could I broaden the question to the rest of the panel, and perhaps broaden the question itself and ask about the UK response generally?  Once this emergency became known, when we were in New York, David Nabarro spoke of the Prime Minister, the Foreign Secretary and the Secretary of State for International Development all immediately recognising that there was an issue.  He spoke about the UK military involvement, for example.  Perhaps Jeremy might have a comment as to how the UK responded once this emergency was made known, compared perhaps with other international responses and Governments.

Dr Farrar: Can I just pick up on one point?  While I agree with a lot of what Annie has said, it is easy in retrospect to look back and say we should not have built the treatment centres.  If you offer no treatment and no option for anybody to come to a treatment centre, it is very difficult to persuade people to come out of a community and be well looked after in treatment centres.  We built those treatment centres when the decision was made and laid out very publically, in October and November of last year.  Yes, in retrospect, some of them were not full to capacity, but I would have still supported their building at the time that decision was made, with incomplete data and the insecurity of knowing where the epidemic was going. 

The UK response, as with all responses, needs to be split and seen in the context of two phases.  The first phase, from December 2013 through until August 2014, was too slow, inadequate and not the robust response that we required.  From September onwards, decisions were made—not all of them were correct; I accept that—and actions were taken that ultimately made a huge difference to the epidemic curve and meant that, after months of their implementation, the epidemic curve was changed.  The epidemic curve did not just come down on its own; it came down because of actions people took.  We were too slow to take those actions, but, once taken in phase 2, they had a very profound impact.  From phase 2 onwards the UK—and I speak broadly about the UK here— along with MSF, deserves great credit. 

Andre Heller Perache: From our perspective, there were different approaches that could have been taken to responding to the epidemic as it was growing at the time as well.  When MSF made the call towards the UN member states for the deployment of joint teams to do biohazard containment, so teams that maybe would exist within the military realm to respond to some kind of a biological threat or chemical attack or something like this, we had imagined Governments getting more directly engaged, as opposed to funnelling resources through their development agencies. 

In the end, what we had was a bit of a hybrid in all of the countries, in terms of the way that things operated on the ground.  We had, in our minds, groups of people coming in hazmat suits, setting up some tents and getting to work immediately.  In the end, what wound up happening was a lot of training, which is very good, a lot of construction of the centres, co‑ordinating the response, focusing on the logistics and the ability to implement a strategic plan from a national level and then deliver on a local level. 

I suppose that, in some ways, what we had in mind when we made that call towards the UN member states did not quite manifest quite in that way.  It took a different course: a course more in parallel with the way humanitarian interventions function from an aid industry perspective.  We saw something similar to that.  In our experience, those take a number of months to tool up and come up to scale.  We see this in many humanitarian crises, whether in South Sudan related to conflict and refugees, or whether, in this case, in Sierra Leone related to this epidemic response.  We would have liked to see something a little bit different in the beginning. 

That being said, in the end, what the UK did, in terms of the role of leadership it played on the ground, the personnel and the way it integrated with local resources and conducted the response was very strong.  We emphasised that the construction was maybe too much and that something a little lighter would have been more appropriate, because it might have been a bit quicker, rather than the more elaborate centres that were made.  But they were building off the models that they had decided were the best ones to go with.  Construction of the centres was one thing; construction of community care centres was another.  There were a lot of different strategies that were getting played in parallel to one another as it went on. 

At different points, we have had different critiques, insights and comments on the ways that people could be focusing the resources.  At the end of the day, it was an unprecedented crisis.  We were in unknown territory collectively.  The leadership role that was played on the ground by the UK, along with the Sierra Leonean authorities, was key.  It was quite central to it.

Q23   Mrs Grant: You mentioned that you would have expected Governments to get more involved.  Could you just explain specifically how?

Andre Heller Perache: We did not have a direct plan and we did not really have the playbook that maybe strong states like the United States and the United Kingdom have in terms of what kind of responses they can deliver.  I suppose, in a way, we did not go in with a diagnostic of what was capable; we went in with a diagnostic of what would fix the problem that was in front of us.  What we had in mind was immediate deployment of some light hospital‑type structures or fixing up some buildings in existing health structures to be able to give the Ebola treatment in a really rapid way—very, very quickly; immediately—as opposed to the phase of training and then tooling up, construction of centres and then the centres coming online mainly at the end of November and in December.  It was really in the month of December that most came online in Sierra Leone.

There was an immediate turnaround.  It was not just that aspect of the Ebola response that was coming together in that period of time, but it was the whole response that was coming together.  There was much more co‑ordination.  There was much more activity on the other pillars of the response: surveillance, safe burials and so on. 

What we had imagined was more like a group of shock troops showing up, setting things up, getting to work immediately and treating patients.  In Liberia, for example, many of the military assets that were deployed were not used for transporting anything that could possibly be a contaminant.  Even personnel who had no symptoms whatsoever would not be transported back from an area where there was active transmission of the virus.  We felt like more direct engagement could have been possible.  In the end, we do not know what was possible.  We were just asking for what we thought was required for the problem that we saw in front of us.  That was not coming from an understanding of capabilities that exist within states like the United Kingdom.

Q24   Mrs Grant: It is more direct engagement and communication in relation to what the Government intended.  Is that what you are saying, rather than physically, practically creating hospital structures?  I am just a bit confused still in relation to quite where you are saying the deficiency might have been.

Andre Heller Perache: I will clarify.  What we wanted was for people to come, to set up hospitals and to start treating patients in the civilian population immediately.  What we wanted was, as quickly as humanly possible, for that to happen.  In the end, it was more of a whole‑system approach, a more holistic approach, a more aid‑system approach, working with local partners, with INGOs, with community groups, with different kinds of things to mount a response together.  We wanted an additional surge before that response happened.  We are not critical that that response did happen; we wanted that to happen also.  But what we wanted was some kind of an additional surge in the months of August, September and October to help.

Mrs Grant: I understand.  Thank you.

Q25   Albert Owen: Can I move forward to long‑term developments in Sierra Leone?  As you know, prior to the Ebola crisis, the development was fragile in the area.  What I am looking at really is what can be done in the future, so that the focus of attention does not just go away, so that there is this long‑term development in the country.  What can DFID do to ensure that that happens? 

Annie Wilkinson: In the years since the war, there has been a lot of investment into Sierra Leone.  In some senses, it was being applauded as a bit of a success story.  There were times when there was double‑figures growth.  But we have seen with this that some of that was potentially illusory.  I have mentioned the levels of inequality.  There was quite a lot of elite capture of that wealth. 

One of the other big things that happened this year is that iron ore prices have fallen and one of the biggest iron ore mines in Sierra Leone has gone bankrupt.  They have lost economically, as well as Ebola.  They have taken a big hit because of other broader economic forces.  The lesson is then that you need to have a more inclusive style of development that pays attention to expanding levels of inequality, which feed into all of the distrust, corruption and things we have been talking about that cause such a problem.  There are those broader socioeconomic conditions that made the health system so weak, because it has also been the focus of corruption scandals and things like that, and just the deep, deep distrust that we were discussing earlier.  A lot of political will needs to go into tackling those issues and they are not easy, but they need to be faced up to.

Q26   Albert Owen: Dr Farrar, do you want to comment on that?

Dr Farrar: I do not have much to add to that, really.  That is a good summary.  We do need to bear in mind, as you know very well, the history of Sierra Leone over the last decade, what it has come through and where it was going.  It was held up as a country moving in the right direction.  Off the top of my head, there was 20% economic growth in the year prior to Ebola.  Again, while you can criticise some elements of what DFID did, on the whole, DFID was moving and helping move the country in the right direction. 

Bearing in mind that this Ebola outbreak was totally unprecedented and devastating, it raised glaring issues around inequality, mistrust between communities, secret societies and a very, very, very fragile healthcare system.  But there would be many, many healthcare systems around the world that would not have coped with the challenges that it has gone through over the last 12 months.

Q27   Albert Owen: DFID has committed a lot of money.  The question really is how we focus attention on that to ensure it does go on the health systems, education and water treatment, for instance.  Do you have a comment on that?

Andre Heller Perache: We would just like to comment on also leaving a bit of space to invest in emergency response capacity within the system locally.  That would be building a system that was robust for its own sake as well: not subordinating it to building a strong health system because that is beneficial for the economy, the human development index and things like this, but really investing in health for the sake of health.  Again, what I worry about sometimes, when we talk about looking forward, is health being subordinated to economic development or now to health security as well, which is more about our health than it is about their health.  We should really focus on health for the sake of itself and building that infrastructure strongly.  In terms of prescriptions for how to do that in the future, we are an emergency medical organisation, not a development agency.

Albert Owen: You made your point well.

Chair: Thank you very much indeed to all three of you for coming today.  We are going to move on now to our second panel.  Thank you.

Examination of Witnesses

Witnesses: Dr Oliver Johnson, Former Programme Director, King’s Sierra Leone Partnership, and Professor John Edmunds, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, gave evidence.

Q28   Chair: Professor Edmunds and Dr Johnson, welcome.  Thank you for joining us.  We will follow the same procedure that we did with the first panel.  We have a number of questions.  Perhaps when you have the first opportunity to answer a question, just say a little bit about yourself. 

Wendy Morton: With cases reaching zero, which is excellent news—so this inquiry is even more timely—what is the situation like on the ground and in communities?  In particular, what has the toll of this crisis been on those who have been left behind? 

Dr Johnson: My name is Oliver.  My background is as a medical doctor, although I mainly worked in health policy and global health since graduating.  I was out in Sierra Leone for about a year and a half before the outbreak, working in the main hospital and medical school.  When the outbreak started, I became involved mainly in the clinical side of running a number of holding units, helping set up the command centres and advising a bit the Sierra Leone and British Governments.  I left in August; I know a bit about what has happened in the last couple of months from people back there. 

It is timely to have this meeting after Saturday’s announcement of the end of the outbreak.  A lot of people are prepared that one or two more cases could crop up, like in Liberia.  Largely, people feel confident that at least this outbreak has come to an end.  There is some good planning going on at the moment for what happens with possible resurgence of cases.  I feel pretty confident that we are on track to get there and there are some good structures being put in place for anything in the future. 

The impact is big, though, and it has come in a number of ways.  The health system has been hit very hard.  The hospital where I worked had about 10 consultant‑level doctors at the start of the outbreak, of whom three died.  11 out of the 12 doctors who were infected died.  Most of those were senior doctors.  They were some of the only teachers at the medical school, so the medical school has been hit very hard.  The nursing profession was hit very hard indeed.  In a country with a weak health workforce, this is huge and anyway, before this, the lack of senior health workers seemed like an unbridgeable gap to get over.  That is something that will need sustained and significant investment to try to help the country to overcome. 

There have also been impacts on the economy and this double hit they have had, as was mentioned earlier: the collapse of the economy from the mining sector coupled with the impacts of Ebola.  The impact that will have on tourism, flights and things is pretty crippling.  The education sector has been hit very hard, with the potential for a lot of lost schooling.  Everyone is trying hard to catch up now so they do not lose a whole year group of doctors, of graduates, but that is difficult.  Those are some of the significant effects.  That said, this is potentially one of those moments of renewal in terms of political priorities and international support, so maybe there is optimism now that we can learn from some of the mistakes before, and that is up to us.

Q29   Wendy Morton: Professor, would you like to add anything?

Professor Edmunds: Yes, I will introduce myself.  I am a professor of infectious disease modelling at the London School of Hygiene and Tropical Medicine.  My role during the epidemic was mainly analysing the data, giving an idea of situational awareness, projections of what might happen over the coming weeks or months and the potential impact of different control programmes and so on.  I am also dean of the Faculty of Epidemiology and Population Health at the school, and I was involved in facilitating our staff to volunteer to go out to West Africa and organising that.  This was an unprecedented emergency and we felt we had staff who could make a difference, so I was involved in doing that as well. 

In terms of the situation on the ground at the moment, let us not get carried away too much, because there are still cases occurring in Guinea—okay, at a very low level, but they are still occurring.  There was, I think, one last week.  It is at a very low level, but it is not eliminated from all three countries yet.  I agree that there may be a few subsequent late‑transmission events; that certainly cannot be ruled out.  I suspect that, if that occurs, it will be only one or two.  I do not expect large numbers of these late‑transmission events now.  I have tried to estimate the risk of that, and I do not think it is very large. 

In terms of rebuilding, there is an enormous task left to do.  It seems bizarre, but there are some good things to have come out of this in some senses.  If you go to Sierra Leone now and talk to people, then you have people who have had the mother of all crash courses in epidemiology and public health responses, and they really do know what they are doing.  With a bit of basic background training to give them the broader training, you have the building blocks of a responding force that could respond for the region in the future over the coming few years, because epidemics will strike.  There are things like that that are there, so it is not all doom and gloom.  Yes, there is a huge rebuilding task and the UK, I hope, would be very involved in that.  They must be.  But there is some good news as well, if you like.

Q30   Wendy Morton: You make a point about the lack of skills now due to the loss of skills, particularly in areas of expertise.  You mentioned healthcare, and I am imagining in education and teaching it will be exactly the same.  The process of rebuilding is going to be critical and at the heart of taking things forward.  Alongside all of that, I just wondered if you could perhaps give us an insight into the situation with regards to orphaned children, because we have heard and we read stories of families that have basically just been wiped out, for want of a better phrase. 

I was reading about FGM.  Cases of FGM fell dramatically during Ebola.  Is there a sign, then, that that is going to increase, or can something be done to try to keep those at a low level?  I also really sadly read a story in the newspaper about young women and girls who were turning to prostitution, to try to make a living post‑Ebola.  I appreciate I have thrown a lot into my question.  I suppose it is probably around not the skills now but the softer side of thing and people’s real day-to-day lives.

Professor Edmunds: It is true of not just Ebola but any of these major humanitarian crises that it is not just the health impact; it is the wider impact on people’s lives.  We forget that sometimes or very often.  I hope that there is a concerted effort to rebuild the economy, to rebuild education systems in Sierra Leone and elsewhere in West Africa.  But they are not the only countries suffering because of these sorts of humanitarian emergencies.  There are many others.

Dr Johnson: I would just add that, unfortunately, some of the things you outlined are worse because of Ebola, but a lot of them existed.  I know a lot of young Sierra Leoneans are orphans, and that was before Ebola.  In a sense, there are some community systems and extended families.  People are used to helping each other out in those situations.  There are organisations that have been there, trying to support orphans from the war and others, which will just need more support.  Unfortunately, this is going to fall into a wider group of people who are incredibly vulnerable in Sierra Leone and were before Ebola.

Q31   Fabian Hamilton: I wondered if you could tell us a bit about how well you think local communities were engaged in the efforts to bring Ebola under control.  I wonder whether the engagement of communities had developed at all during the course of the epidemic.  Do you think that those communities should have been engaged in a greater capacity at an earlier stage, because they are critical to bringing the whole outbreak under control?

Professor Edmunds: You are right: they are critical to bringing the whole outbreak under control.  The other aspect of the response—the building of the hospital beds and other facilities—was very important, but the real key was changing communities’ behaviour and acceptance of different policies to reduce their risk.  That was the real key to bringing this epidemic under control; I am sure of it.  It is very difficult to put a finger on it accurately to quantify the impact of that.  We tried, and that will be a subsequent research question for the next few years, so I cannot give you accurate estimates, but, unquestionably in my mind, that played a really key role. 

At the beginning, many mistakes were made, partly out of good will.  A lot of different agents and actors came in, perhaps too many, so getting a consistent and accurate message across was very difficult.  There were plenty of problems and mistakes that were made, without a shadow of a doubt.

What happened subsequently is that people learnt to work with the communities rather than trying to take a slightly more authoritarian response.  That is probably a lesson for the future: that we should take a little more time to work with the communities and build our response around them, rather than trying to impose it.  I think that is something: take a little more time.  I know that, in an epidemic when things are moving very fast, there is huge pressure to act quickly, but under these circumstances that pressure to act quickly perhaps was counterproductive, in some senses.

Q32   Fabian Hamilton: Was there ever a sense that the communities were a blockage to stemming the tide of the outbreak?

Professor Edmunds: I do not think that is a very helpful way to think about it.

Fabian Hamilton: I agree, but I wonder whether there was.

Professor Edmunds: That is how we were thinking about it in the early part of the epidemic, and it is the wrong way to think about it.  It is their lives, so work with them to help them see the best way to protect themselves.

Dr Johnson: I would agree with a lot of that.  At the beginning, the community engagement was not strong and there was a slight tendency, where there was community engagement, just to try to tell communities what they should be saying and thinking.  If I think of the early days, there were meetings quite early on where, for example, all the traditional healers in the country and the traditional healers union were brought in by the Government to try to engage them on the issue.  My impression was that those meetings would have been quite a lot of telling traditional healers how they should act, but there were efforts. 

One of the challenges is that I am not sure community engagement had been very strong in the delivery of Government services in Sierra Leone prior the outbreak.  In the hospital where I worked, there was not always a great relationship between patients and staff, in the way we would expect in terms of doctor‑patient relationships or, for example, having patients on the board of the hospital or doing feedback surveys from patients.  The sort of structures we are used to did not really exist in any way, so I am not sure there was a strong baseline to work from, from the Sierra Leone Government’s point of view. 

There was a lot of progress, though, when the President personally became involved and started engaging with some of the traditional structures, and the British Foreign Office was encouraging of this.  He really started to engage with paramount chiefs, going out to the different districts and using those chieftain‑level structures better.  That had an important impact.  Within the response, the shift from safe burials to safe and dignified burials was a very significant shift.  You could see all of us very quickly catching up.  It was a catch‑up and we should have been there at the beginning. 

Similarly, the NERC briefings as to what was going on in the cases started to engage much better with communities in the later stage of the final outbreaks and, where there were traditional beliefs, engaged in those traditional beliefs.  Where there was a patient gone missing who had turned into a snake, they did not aggressively try to disavow the idea that a patient could turn into a snake.  They would engage more with the idea of the community on that, and try to work with them on their belief systems in a way that was much more effective.  But it was catch‑up, and part of that is because a lot of the people involved were not the normal players.  I am not a humanitarian.  I am not an infectious disease doctor, neither were the British Army.  A lot of us were catching up. 

By the end it was good.  If we had had that from the beginning, it would have been much better.  I agree that there was a real sense of communities being a blockage, which at times I probably shared.  It was unhelpful, and that is an important little learning.

Q33   Mrs Grant: This is a question for both of you.  Some of it has been covered in the last couple of questions, but can you just set out the main lessons that have been learned as a result of the outbreak and how can those lessons be applied usefully in the future? 

Professor Edmunds: There are the obvious lessons about responding far, far, far more quickly and finding a way to respond.  Where there may be blockages because of difficulties within a country or at country level, there must be a way round that and we must ensure that there is a way round that.  In the earlier discussion about reform of the WHO, one hopes that those sorts of things would help in that in the future.  That is the most obvious one.  This epidemic would not have got out of control if we had acted much more quickly, so that is the first thing. 

There are other lessons.  As we mentioned just now, the community engagement is key.  Frankly, it is key to every public health measure.  It does not matter where you are, whether you are in Lambeth or Liberia.  To get people to engage in public health, you need to talk to people: to mothers to get their children vaccinated or whatever it might be.  I think we forget that.  We think that, if we provide a system, people will use it, and they will not necessarily.  It is that behavioural science part of it.  There needs to be far more investment in the science around that, and then also in implementation during outbreaks, but not just during outbreaks, in other preventative measures and so on.  That is one major one. 

There are some lessons we have learnt about control of Ebola and so on, which are more specific just to Ebola.  We have now got to a stage where there is a potential for vaccines to be available.  We now have to think about how we might deploy those in the future and plan for that.  That is going on.  We are involved in that sort of work at the moment.

Dr Johnson: One would be that, with the structures that the Ebola response inherited in the country, it was a very bad starting place in terms of how fragmented the health system was and some of the structures around that.  Although the British Government has talked of and is better than some donors in having a whole‑system approach, if you are just focusing on maternal and child health, HIV, TB and malaria, or if you are sitting in the Ministry of Health trying to work out how to deal with workforce issues, that is not a whole‑system approach. The hospital where I worked isolated about 800 Ebola patients but received no DFID funding before Ebola because it is an adult hospital and adult hospitals do not get funded by aid agencies because it is not considered a priority.  As a consequence, this was not as functional an institution as it could have been. 

I do not want to criticise DFID too much, because DFID is a lot better than other donors and there was some work on cleaning up the payroll and looking at the supply chain that was whole‑system, but we could further.  That would have allowed a central system within Government for a health system that could have responded much more effectively to that.  It was very difficult with so few doctors and nurses to really mount an effective local response. 

There is some learning from the UK Government.  The rapidity of how DFID responded, once it came in in September, was incredible, with blank checks in terms of financial support for people on the ground.  But I remember, in June, putting in a request to DFID for £7,500 to set up about eight isolation units over the course of a month.  That was for supplies and staffing—£7,500.  I could not get a penny from the British Government, despite repeatedly asking.  I could not get £7,500. If I had been able to do that, that would have had the impact of hundreds of thousands of pounds later on.  That was in late June and that was despite raising this with a number of people, and it is because DFID lacks any mechanism to get small amounts of money flexibly on the ground.  The Irish Embassy gave us money.  They had the capacity to write us a €2,000 check.  At that moment in time, as a small organisation, that had impact.

Mrs Grant: So more flexibility within DFID is needed.

Professor Edmunds: That unquestionably needs to happen.  You discussed earlier about treatment centre beds being built long after the epidemic had passed.  That did happen, and that is because that was what the contract said: they had to build a treatment centre.  By the time the contracts got signed and so on, the epidemic may have passed.  It would have been better, in some instances, though not very many—I agree with Jeremy; I think it was right to build those beds—it would have been better to do something else.  Some flexible funding is essential.  The epidemic does not care what the contract says.  The virus does not care.  That really does need to be addressed.

Dr Johnson: As I was saying, there was a big difference post‑September, when the taskforce came out, when Donal came out, when I do not think I could have felt more supported.  When my car broke down, Donal lent me his car because I had to get somewhere in a hurry.  The British Government did everything they could do to be really supportive to us.  In terms of the financing, they did gymnastics in terms of very big bureaucratic processes.  On the ground, I felt that that was much better, than it was before then.  My question is: if this were to happen again tomorrow and there was not that emergency infrastructure in place, would I be able to get £7,500 in an emergency?  Maybe DFID specifically has an Ebola fund now, but, in terms of flexibility, that would be an important lesson. 

There is another point about to what extent Britain was ever really able to maximise its engagement with its own public health expertise.  I do not think we ever had effective British public health engagement.  If you compare the engagement of, say, the CDC in America and the number of infectious disease epidemiologists they had deployed in the field and the senior role they had in working on their response, we did not have an equivalent in the British Government.  DFID itself does not have a big team of epidemiologists.  As to the engagement from Public Health England on the ground, I can think of two who came out, but not for a long period of time, with some seniority, but there was never a very experienced epidemiologist out for six months on the very senior leadership team. 

There is a question around how we can really engage with public health.  For the labs side of Public Health England, there were problems trying to set up a lab in a very challenging situation, but, at the end of the day, they got it together and they did a good job, by and large.  But the epidemiology side was a weakness that needs to be structurally addressed in some way. 

There is another issue, which is what I felt was a bit of a market failure.  DFID relies on NGOs to provide its services.  There was a point at which no NGO wanted to do it.  MSF wanted to do it but had run out of capacity and had set a very high standard.  MSF had scared a lot of NGOs because it seemed like what MSF was doing was so difficult, so a lot of usual NGOs just said, “We are evacuating.  We cannot be in the clinical space.”  That is a problem.  Britain does not have a deployable team for health emergencies.  Merlin has gone.  Merlin has not been effectively replaced.  MSF and British Red Cross do not do deployments in the same way as some of their equivalent branches elsewhere do.  Where does that leave Britain in terms of being able to deploy NGO health emergency teams in the future? 

But there was some really good stuff as well.  The extent to which the British leadership was co‑ordinated within itself, with a clear lead, linking in with the Foreign Office, Public Health England, DFID and the army was impressive.  The flexibility once that team came out is something to be preserved.  The engagement with science was quite impressive and there is a lot to learn from.  Then there are all the lessons about the WHO and UN that have been mentioned.

Chair: We are going to move on now to some questions relating to the health system itself, particularly in Sierra Leone. 

Q34   Jeremy Lefroy: Oliver, I must declare that we know each other from two or three years ago in Sierra Leone.  You have covered some of these issues, but I wanted to touch on one or two more.  Just in terms of a deployable team, I remember from the Lancaster House conference that the Cubans said they were going to send a lot of people out there.  Did that happen and was that effective?  They seemed to have a medical brigade that was on standby.

Dr Johnson: Yes, they did deploy a team very quickly and they were out in the field with the WHO.  There were challenges associated with it.  They were not all very young, the team that was deployed, so they provided a certain degree of support themselves.  There was a lack of clarity about exactly what they would be doing in the field.  There were language issues to do with the fact that most of them spoke very limited English.  But they did succeed in deploying a team very quickly.  There were lessons in whether they were the right people and how they were used, but, yes, there was very rapidly a Cuban team out there.

Jeremy Lefroy:  They had the ability to do that.

Dr Johnson: As did the Chinese, sending in an army team very, very quickly.  They arrived in early September and were doing clinical work very quickly. 

Q35   Jeremy Lefroy: So that something for us to learn in the UK.

Dr Johnson:  Potentially.  With both of those groups, I do not know that they were as effective as they could have been, but they did get out in the field quickly.  There is an issue with force protection.  I had a similar impression to colleagues from MSF.  King’s called for British military involvement.  We wrote to the relevant Secretary of State.  I was on the media expecting, similarly to what MSF colleagues have said, there would have been a hazmat team on the ground, quickly setting up units. 

I have learnt now that the British military would not ever have done that.  There was no group in Sierra Leone I met that had a higher level of force protection than the British Army, who were very, very cautious, understandably, about having any contact with Ebola.  They would not come to my hospital for a long time, for example to my office, because it was considered an unsafe area.  To an extent, it was unlikely the British were going to be able to do what the Chinese did—and they had their own force protection issues.  In general, I have learnt a lot about how likely it is that state or Government individuals will be put in harm’s way in that situation.

Q36   Jeremy Lefroy: Just coming on to the broader question of health systems, you talked about certain programmes.  There was a malaria bed‑net distribution programme going on in June last year right across the country, and it seemed to be relatively effective.  We went into a fairly remote village and saw the bed nets in use and operational.  But you said that perhaps this slightly silo‑based approach had not helped to strengthen the Sierra Leonean health system.  Is that correct?

Dr Johnson: There were strong pockets and weak pockets.  For example, the malaria team is much stronger in Sierra Leone because of that investment, but, if you look at the directorate of hospitals, that was one man.  He is overseeing all the Government hospitals in the country personally.  He has no effective aid.  He was not able on his computer to immediately give me a list of the medical superintendents of the country.  When we were trying to get information out to the different hospitals about how to prepare for Ebola, my team had to spent quite a lot of time helping them even to get that group together, because that directorate was so unsupported. 

I do not criticise the individual, because how can you possibly do that job as one man, compared to I do not know how many hundred people who would do that job in this country? You will see some parts of the Ministry that are well‑funded and effective: HIV/AIDS, maternal and child health.  That is good, but there are other parts that also could do with some investment in those sorts of structures.

Q37   Jeremy Lefroy: Do you think that donors, and indeed the Sierra Leonean Government, are recognising now the importance of a much stronger health system?

Dr Johnson: I think the Government do to some extent.  In comments to DFID in the past, I have said we cannot want it more than they do.  The Government need to really want this and set out the plan, and only at that point can DFID fund it.  DFID funding cannot go before that very clear commitment from the Sierra Leone Government in the detail of exactly what they want to do within their health system.  It is getting the right balance there.  The new DFID plan looks good.  There are always more areas for thinking systems‑wise, so I would just encourage that journey to continue, if possible.

Jeremy Lefroy: Professor Edmunds, I do not know if you have any comments on that.

Professor Edmunds: In relation to epidemic response, then it is probably unrealistic to expect Sierra Leone and the other countries in the region to have a very well functioning epidemic surveillance system and response—the sort of things we might have in this country.  There is a role for improving health systems and surveillance of diseases, including infectious diseases, more generally, but, certainly in the short or medium term, we do not really expect that to be sufficient to be able to tackle these sorts of public health emergencies that do come up from time to time: cholera epidemics, Ebola, Lassa fever or whatever it might be.  We need to strengthen not just the country’s health systems but our ability to respond as a player, as well as the WHO’s ability to respond.  Do not just rely on investment in health systems in Sierra Leone and other countries, because that will not really be sufficient to be able to protect their populations, certainly in the medium term.

Q38   Jeremy Lefroy: I have one quick question, from a slightly different angle.  Did you notice some engagement in terms of response from the Sierra Leonean diaspora?  For instance, we had a number of organisations in the UK that seemed to be really trying to do what they could, obviously under difficult circumstances.  Did you see that in the work that you were doing?

Dr Johnson: It was most noticeable where members of diaspora went back to take a role in the response.  In particular at the NERC, there were a number of members of the diaspora who got involved in leadership roles, who were very important and deserve a lot of credit: people like Obi Sesay, Yvonne Aki-Sawyerr and others.  In terms of the smaller diaspora groups, there was a lot of effort and there were certainly some supplies arriving, but the scale of what was happening was possibly bigger than the smaller diaspora groups could meaningfully contribute to.  There was useful work in awareness‑raising, but it is very difficult for a small organisation in the UK, once the full humanitarian thing has come into swing, to provide donations, for example, that are so timely.  But the people who went out and got involved were important, and some of the awareness‑raising was very important.

Professor Edmunds: They had a role, particularly, in community engagement.  Going back to my earlier comments, some of that was well meaning but perhaps misplaced at times, but it improved over time.

Q39   Jeremy Lefroy: Did you feel that DFID engaged with them?  I remember working with one particular diaspora group here that was supplying food and meals, and eventually DFID did engage with them, but it took a little bit of time.  Do you think DFID should perhaps look more, in a case like this, at trying to engage with diaspora groups at an early stage, given that they are often likely to have some of the experience that is needed?

Professor Edmunds: In hindsight, you could say that, yes.  I could see that, at the time, DFID probably had other priorities.  But, yes, with hindsight, you would probably make better use of them.

Dr Johnson: Maybe, in a very targeted way.  For example, if we had been able to mobilise more Sierra Leonean diaspora health workers or other people to go back and be involved as individuals, they would have had a very unique role.  The challenge is that some of the diaspora groups do not always have the experience with reporting structures, financial templates and how to put together bids.  It is therefore a lot of work for DFID to help guide them through the process that is needed, understandably, for accountability and sometimes on a relatively small scale.  Given how much was going on at the time, it is understandable that DFID was stretched to capacity on some very large‑scale things.  That is understandable, but maybe DFID could think very carefully about where the diaspora has a USP, a really unique contribution, and maximise that.

Q40   Albert Owen: Dr Johnson, as somebody who was there from before the epidemic and also during it, I just wanted to put on record my thanks to you and all the medics for the excellent frontline work you have done.  But how did the control and treatment of Ebola have an effect on other, more normal illnesses?  If it was negative, what can be done in the future to ensure that the health system comes up to a relatively strong state?

Dr Johnson: That is really important.  We are still working out some of the data on the excess mortality—the number of extra deaths there were—because of Ebola from things like malaria or surgical problems, but it seems to have been significant.  I would not be surprised if it was greater than the burden of Ebola itself.  The hospital where I was based we kept open.  Because we were able early on to implement screening at the front gate, we were able to open a holding unit within the hospital, so that anyone with a fever or with compatible symptoms could immediately be isolated, and quite early on we were able to start improving infection‑prevention control.  That could have been replicated elsewhere.  Not as many services as I would have liked in the hospital stayed open, but emergency surgery did.  The medical ward stayed open. 

Unfortunately, by comparison, the children’s hospital, which normally would have had up to perhaps 200 very sick children in it, closed for several months because it was not able to engage equivalent support in terms of holding units.  Eventually, when it did, it reopened, but for two months there was no children’s hospital in the capital city.  That could have been avoided if there had been organisations willing and able to go alongside the Government to support them to make this hospital safe. 

There was a big programme early on, supported by the British Government as well as other donors, at the peripheral health units to improve triage and safety.  A lot of those did stay open, partly as a result, so there was a mixed success.  A lot more could have been done.  Very few agencies feel it is effective or safe to work inside Government institutions in an emergency.  I would argue that hopefully the work the King’s group did demonstrates that it is possible.  We were working in eight Government hospitals.  We managed about 1,500 Ebola patients, but none of our international team became sick or infected at that time or at any time, so it is possible to do that. 

My learning from it would be that we should, as much as possible, try to deliver health services through existing and Government health institutions.  Pre‑existing relationships are important.  It was very important that I already had a relationship in those sites.  Encouraging those sorts of long-term partnerships can be critical, so there is a wider lesson in engaging with Government.

Q41   Albert Owen: Do you and your colleagues have any input into the forward planning in any way?  Is there a way that you can contribute to the reopening of the children’s hospital and how it should develop?

Dr Johnson: We were quite involved at the time, talking with both Government and the hospital superintendents, but also with the WHO and the British Government, in terms of trying to direct support.  The British Government did listen.  It was the British Government that funded us to be doing the work we were doing.  They supported Partners In Health to do somewhat similar work, working more in Government sites in Port Loko and elsewhere.  Yes, we have been able to contribute to that, and we are certainly putting in mechanisms now so that there are permanent isolation facilities for any very infectious disease, including Ebola and Lassa fever, in future outbreaks, so that those will hopefully be more resilient to shocks in future.  But we need to see a lot more of it.

Albert Owen: Professor Edmunds, would you like to add?

Professor Edmunds: Trying to calculate how many extra deaths may have occurred will take us some time.  There have been some estimates for malaria, which suggested that about as many deaths from malaria occurred as a result of the interruption of malaria services as occurred due to Ebola.  It will take us some time, and we will probably never know accurately how many extra deaths from other causes may have arisen.  There are two things that really come from that.  Because of the devastating impact that these kinds of epidemics have on health systems, it shows how important it is to react very, very quickly to stop that sort of thing happening, to stop it getting out of control and health systems generally shutting down. 

Secondly, we do now have a promising vaccine candidate, and that will be of huge importance in the future for controlling these epidemics and helping to protect healthcare workers, to enable them to stay open in these sorts of outbreaks in the future.  That is one of the major benefits to have come out of this epidemic.  That vaccine is not licensed yet.  It will take some considerable work still to get it licensed, but at least it is a good long way along that track now.  That is one positive thing that has come out of this.

Dr Johnson: One more point I would make is that the response pulled a lot of health workers out of normal health facilities as well.  For example, I strongly advised that the community care centres be built attached to and as part of existing health institutions, so that the staff could, if there were no cases for a week, be in the health institution; if a case walked in, they could revert across.  Where that did not happen, you saw all the resources of the primary healthcare unit sucked in.  Kerry Town had over 40 community health officers.  One community health officer would normally provide healthcare for a whole set of villages, and 40 of them are suddenly pulled into the centre, so robbing Peter to pay Paul.  Recognising limited resources and how we use them was an important component of that opening or closure of services.

Q42   Dr Cameron: I initially wanted to pay tribute to the Aberdeen Women’s Centre in Freetown and also, on behalf of the Committee, to wish Scottish nurse Pauline Cafferkey well in her recovery in hospital.  Given all the financial resources and investment that has been fed in in terms of crisis, how will we be able to ensure the resources that are there now can continue to contribute to strengthening the healthcare system?  Can the new centres that have been built be adapted for use?

Professor Edmunds: I am not quite sure what you are asking.  How can we ensure we do a good job in building up the new systems?

Q43   Dr Cameron: Yes, and can the facilities that are already there now or the investment that has been put in be adapted in order to ensure that they are usable?

Professor Edmunds: Oliver would know better about that, but I would imagine much of it is not particularly adaptable.  Nevertheless, I will leave that to Oliver.  One thing that should be brought to the Committee’s attention is that I do not think DFID have publicised their exact plans, so I do not think NGOs can bid yet.  The money has been approved, as far as I know.  The NGOs—Save the Children and others—still do not know what the rules are and how they can go about bidding for the next tranche of money to help the recovery phase.  They need to get on with that.  That is one thing you need to be aware of. 

There is a wider issue about building health systems so that they are resilient to these sorts of things.  DFID have been very good at trying to do that.  One of the strengths of UK aid has been taking a wider approach over the last 10 or 15 years, rather than focusing on individual vertical programmes, which can be dangerous.  I would encourage that they carry on with the approach they have taken.  A more holistic, health‑systems type approach is the right way to do this now, as it always was, and I would encourage them to carry on. 

Of course, there needs to be some investment in epidemic response, but let us not get too carried away and put a huge amount of investment in some kind of epidemic response mode in Sierra Leone that might sit there doing little.  It needs to be a much wider response.

Dr Johnson: We need to pick carefully, because the operating budget of the health system is very small.  Therefore, we have to choose carefully.  The one I think of is that there is a lot of emphasis put on building an ambulance system, with all of these ambulances.  How do we make use of the ambulances?  The fuel costs are very significant.  To fill a tank of fuel is maybe 300,000 leones, which would provide care for a number of patients if that money was redirected.  We have to be very strategic in which bits we say we want to keep and where we have to say, “Actually, this is not affordable and we might have to let some things go.”  That is one thing I would say. 

But I agree with you: the bits we can maintain we need to be thoughtful of.  I agree that a funding gap from DFID between the response and the long‑term recovery would be catastrophic, because very few agencies are able to cover the funding gap and so everything goes, and then suddenly you lose those individuals who built up relationships with local partners and those programmes get stopped.  There is a real loss in that, so making sure there is not a gap is important. 

There are some examples of where the British do this well.  The £50,000 funding we had for Ebola we used to build a 12‑bed, permanent new isolation unit that could be used for Ebola but also for tuberculosis, diarrhoeal diseases or other things and be reactivated in future.  It was built within the main hospital.  Somewhere like Kerry Town is more challenging, because it is a very large, very rural site.  Where there were discussions at the time on those things, they have been done well.  There has been a real effort to hand over into permanent sites, into universities and into medical labs some of the lab work and the equipment, and to train people to use it. 

There have been efforts to do this well.  The British have been thoughtful of it, but we could think more now, in general with emergencies, how we could build infrastructure that is going to have a longer‑term purpose, because, where we did it, it has been really effective and useful.

Q44   Fiona Bruce: Our last Committee expressed concern about the numbers of Sierra Leone health workers working in the UK.  I would like to ask how the UK’s medical recruitment practices may have affected the health systems in countries like Sierra Leone and how we could prevent this in the future, if it is a negative impact that you state.

Dr Johnson: I work for King’s, which is an NHS Trust as well as a university, and we certainly have many times more Sierra Leonean mental health nurses at King’s than there are in Sierra Leone, so I see both sides of that.  It is definitely an issue.  When I looked at the medical school graduate book of where the medical graduates are, the vast majority are in the US and the UK; they are not in Sierra Leone.  That said, I have not come across a lot of very aggressive recruitment from the NHS in Sierra Leone.  Some agencies try; certainly the NHS itself I have not seen attempt that. 

The issue is more how we convince Sierra Leoneans to want to stay, rather than how we stop them from coming here, because there are also legitimate human rights issues around saying to a Sierra Leonean doctor, “You are not allowed to come and want a better life, or to travel to get training overseas.”  For me, the issue is how we make Sierra Leonean doctors want to stay, and a lot of them do.  It is where their families are.  It is where they grew up.  They prefer the food.  There are lots of reasons why they might stay. 

A lot of it is around training opportunities.  A lot of people feel they have no opportunity to progress professionally, so it is enabling that.  For example, we have been doing work to enable doctors to get specialist training to become surgeons or specialist physicians, by bringing in international experts for a period of time to train up a new generation of leadership, who could then take over that training programme.  We are hoping that is the sort of thing DFID will support to make it a better reason for staying.  There is a lot of talk about building accommodation in rural areas.  There is a lot of talk about salaries and increasing the amount and quality of undergraduate training. 

We do know what the reasons are why people are leaving, but, if the British Government were to really look at those and to invest in those as a package, then people would hopefully want to stay.  That is how I would address the issue.  I could not agree more that the fact so many people are leaving is catastrophic and it is often some of the best people.  Some of the best people leave, and unfortunately some of the best people died, because they were the ones who were the bravest.  We often see the real leaders not on the ground where we need them most.

Q45   Chair: I have a final question.  Professor Edmunds referred to the development of a vaccine for Ebola that is now being trialled.  In their evidence to us, ActionAid UK suggested that the vaccine should have been developed at a much earlier stage and the crisis might therefore never have happened.  Do you agree with that and, if you do agree with it, what are the barriers that meant that the vaccine was not developed?

Professor Edmunds: We should have gone through phase I trials.  I do not know how familiar the Committee is with how clinical trials work.  Phase I trials are the first trials that are done in humans, and they are usually done in very healthy volunteers.  There is no reason why we could not have done that before this epidemic.  There are other vaccine candidates now for other similar diseases and we should be looking at making sure that we get them up through at least that stage. 

You cannot do a vaccine trial without the cases being there to look at.  It is impossible to get the phase III trials done unless there is an outbreak happening.  I was involved with a couple of the vaccine trials, but in particular the one in Guinea, which was successful.  One thing we did there, and the reason why that trial was successful, was that we came up with a novel way of running and doing a vaccine trial.  I would hope that the kind of method we employed would be used in future to help get future vaccines through trials, but you need the cases to occur.  I know that sounds a bit brutal. 

Chair: No, I understand.

Professor Edmunds: You need an outbreak to occur.  There are lessons that we probably have learnt, to ensure that that is the case. 

As a side issue, I should say that that trial was sponsored by the WHO.  The main driving force behind that trial was the WHO.  They made that trial happen from start to finish.  Although the WHO have been roundly criticised for many different things, they made that happen, so they should be applauded for that. 

The third thing I should say about vaccines is that they are not a magic bullet.  They will not solve everything.  There are roles for vaccines in the future, protecting healthcare workers probably being one of the most important, but it is wrong to assume that, just because we have a vaccine, we will be able to do away with Ebola.  We will not.  By the time the vaccine programme comes on stream, cases will have already occurred.  It is an adjunct to existing control policies, rather than a replacement for control policies.  We will still be controlling Ebola in the future primarily with the methods that we used for this epidemic, which is contract tracing and so on and so forth.  The vaccine will hopefully come in and help reduce cases, but it will not replace that as our primary response; I am sure of that. 

That is also true of the other vaccines that we may develop.  It will take us many years to develop these vaccines.  Even if we pick on a handful of diseases and we get these things through phase I studies, we will still have to wait for outbreaks to occur so we can test them in a real‑life setting, so they will be ready not for the next epidemic, but the one after that perhaps.  It is a very long‑term thing, so we still need to keep our emergency response mode.  That will still be the main focus for controlling not just Ebola but many other similar kinds of infections into the future.

Q46   Chair: Do you think there are ways in which the system can provide better incentives for research into neglected tropical diseases?

Professor Edmunds: Yes. The only reason we have these candidates at the moment is really because of the nervousness of the Americans from a bioterrorism point of view.  That is why we have some candidates for several of these viral haemorrhagic fevers and so on.  It is more of a health security issue as to why we have some of these vaccine candidates, rather than, as Andre mentioned earlier, for the health of people. 

It can be done.  We can develop vaccines, even for markets we would not expect.  It was done for meningitis A.  That is the first vaccine that has been developed and licensed exclusively, really, for Africa, where they have had these major meningitis outbreaks across the Sahel in Africa.  We can do it if we get the incentives right, and I think we should do it.  We should have more focus on people’s health, rather than health security, and make sure that we do develop the appropriate vaccines. 

It is not just vaccines.  As I said, you need these other systems in place, but also other ways of treating patients as they arise.  One of the failures of this epidemic is that I am not sure we really did enough research on the best way to support patients when they were ill.  It was mostly just in response mode, trying to cope with them, with very little research done on how best to treat them.  Also, the opportunity has now been lost to do that research.  Even looking through medical records is a very difficult thing to do.  Many, many records have been lost and are being lost and destroyed as we speak.  The opportunity to even look back and work out the best way to treat an Ebola patient has not been lost completely but has sadly been diminished, unfortunately.

Dr Johnson: I would just add that I agree with all Professor Edmunds’ points about the vaccine.  Overall, it is very impressive that they got as far as they did in that space of time.  It is a record, but I agree there are learnings to be had.  I have also heard excellent things about the WHO team.  There were pockets of the WHO that were really effective.  It is just that, as a whole, it did not come together, but there were one or two pockets that should be commended.  I also agree with the point that there was a lot of emphasis on very exciting new drugs—ZMapp and other things.  The reality is that we still cannot really agree on the difference between IV fluids and oral fluids.  Is that important?  On certain other basic treatments, how important are they?  Some of the research was quite probably pharmaceutical heavy and not enough on the ground, saying, “What are the questions you need answering?” 

I have another really important example of a technology we should have deployed as the British and failed to do, and it probably would be my single biggest criticism of the British Government.  The Defence Science and Technology Laboratory of the MOD had developed a rapid diagnostic test for Ebola.  We field tested it, in partnership with Public Health England, and found it to be very effective.  It identified every single Ebola case that we put it to.  It also picked up some people who did not have Ebola, but that was manageable.  It played a very important role for us in the field and it is, in our opinion, superior to the other rapid diagnostic tests that are out there, because it does not need to be kept refrigerated. 

But we were completely unable, having done a trial, published it and found it to be very effective, to get it deployed.  My understanding is that it was because of wrangling and disagreements within different parts of the British Government between the MOD, DFID and other areas linked to funding.  At the end of the day, we have asked questions in Parliament about it.  I have had many conversations with different people.  It is an issue of leadership, and of who had paid for the research and who was going to pay for things ongoing.  It was a real disappointment to me that there was a piece of science that should have gone forwards and did not. 

Chair: We have the DFID Secretary of State, but with officials from other Departments, including the MOD, giving evidence later this month, so we will make sure that those questions are put directly to her and to the officials. 

Q47   Jeremy Lefroy: When did you become aware of the existence of this RDT?

Dr Johnson: Late autumn 2014.  We did the study in, I think, December 2014, but it was some time—I think October, November—after the Public Health England labs team first came out that they mentioned it to us.

Chair: Can I just say a big thank you to both of you?  It has been enormously helpful for our inquiry.  I am really grateful to you for all that you have done, but also for coming today to give evidence.  Thank you.

              Oral evidence: Responses to the Ebola crisis: Follow-up, HC 338                            21