In the Shadow of Ebola film screening and Q&A

LIBBY ROBIN: Hello and welcome to the National Museum of Australia. It’s fantastic to see so many faces here. We are really privileged to have an exclusive viewing of an international documentary film which has an amazing story. For people who don’t know me, my name is Libby Robin. I am a senior research fellow in the National Museum of Australia.

We’re going to have a short introduction to the film from our international guest and filmmaker Gregg Mitman. Then we will have the film, which is 27 minutes long, and then we’re going to have a Q&A and happily hear from you and have a bit of a talk about the stories that this film raises. I think it’s a very exciting film but it also has a really interesting back story. Without further ado, Professor Gregg Mitman from the University of Wisconsin in Madison is here is tell us about why he’s been in Liberia.

GREGG MITMAN: Thanks, Libby and thanks everyone for coming out for this. I’m a medical historian and environmental historian and have been working in Liberia for the past three years making a different film, making a different documentary. We were doing a film shoot in Liberia last June when the first Ebola cases appeared in Monrovia. Knowing what I knew about the public health infrastructure of Liberia at the time I was a bit concerned about where this would be headed. This was before there had been a lot of international media coverage. I left in early July before the epidemic really ramped up but one of my grad students, Emmanuel Urey, who is the subject of this film, stayed through the end of July and got one of the last commercial flights out. By late July, a number of commercial airlines - British Airways and other airlines - stopped their flights to Liberia.

We were quite disconcerted by the kind of media coverage that we saw coming out about the outbreak, about the epidemic, a coverage that really reinforced a lot of Western stereotypes about West Africa. Some of the initial coverage - at least in the US in places like the New York Times - focused on ‘the irrationality and superstition of West Africans for attacking international health care workers’, which really was ignorant of the history and culture in West Africa that was causing the outbreak to unfold the way it was, particularly the history of the civil war in Liberia and Sierra Leone which led toward great mistrust toward government.

Liberia has long been a place for American biomedical research going back to the 1920s when a Harvard medical expedition was there on behalf of Firestone, which was establishing the world’s largest rubber plantation, doing experimental drug testing on Indigenous populations. One of the members of that expedition, Max Theiler, would go on to win the Nobel prize for the development of the yellow fever vaccine work which began on that expedition. There has been through the history of Liberia a lot of suspicions about particularly American biomedical research workers working in Liberia, all of which shaped the unfolding outbreak.

My Liberian friends, colleagues and I made a decision in July to begin documenting the process, documenting what was happening on the ground, really trying to get a perspective from Liberians about how this was unfolding the way it was. We were seeing a lot of international coverage about international aid workers. We were seeing a lot of coverage about Liberians as victims. We were seeing very little coverage about what Liberians were doing themselves to really deal with this outbreak.

We began following this story in July and continued to shoot through November. We didn’t really know how this story was going to end, and then in January decided to complete the film. The film is a very collaborative medium. This film was made across three different countries: Liberia, the US and United Kingdom. Our Liberian cinematographer, Alexander Wiaplah, was on the front line getting a lot of this footage, really risking his life to be able to gather the voices and perspectives of Liberians. With that, I will let it run, and then afterwards Libby and I will be doing a Q&A.

I know that for Australians Liberia might seem quite remote as a country. There are Australian mining companies there – BHP. Liberia sits on the purest iron ore in West Africa. Now with the end of the civil war and post-war reconciliation and development, there is a lot of multinational companies in there interested in extracting natural resources. Australia was also the first developed country to issue a travel ban on West Africa and to deny visas for West Africans during the Ebola outbreak. So the outbreak does connect directly to what’s happened here. Thank you.

[Film played]

LIBBY ROBIN: Thank you, Gregg. I was very taken with this movie. Seeing it again – I’ve seen it twice now - Ebola is something we hear about as a disease that needs fixing, as something that’s about science. David Quammen has written an excellent book about Ebola, if you’re interested in the disease and the science. It’s like a detective story. What’s causing it? How can we cure it?

But your film is not like that at all, Gregg, because you’re an historian. Can you tell us a bit about the different motivation that you have when you are working from the bottom up, from people from where you are trying to perhaps cure a disease? The World Health Organisation has just announced that this disease is no longer epidemic. You won’t get that piece of paper at the airport saying Ebola any more, I think, as of Sunday. Just tell us a little bit about the other end of things, how you start from the other end.

GREGG MITMAN: I teach courses on global health. One of the things that I always try to impress upon my students is that the biology is easy, it’s the social that’s hard. One of the things in terms of why the outbreak unfolded the way it did was a real lack of understanding about the cultural and social dimensions of it and the ways in which the history of the civil war and the issues around infrastructure really shaped what was possible and not possible.

When dealing with an outbreak like this, the biggest challenge is: How do you build trust? How do you build trust among people? How do you build community trust? When you have people walking into communities in these scary-looking Hazmat suits in an area where Ebola had not been known, had not been seen before, it’s why we see in the film initially there’s a lot of disbelief and fear.

Also we saw the consequences of what quarantines and travel bans mean. I suspect that if we did a militarised quarantine in a developed country, the same thing would have happened.

LIBBY ROBIN: It cut people off from food, in fact, and made things much worse for them. But it was worse in Liberia because they already had bad relations with the police and the border control because of the civil war.

GREGG MITMAN: Correct.

LIBBY ROBIN: That is something that people who think there should be a one size fits all quarantine solution all around the world - like the World Health Organisation says this is the way it should be done - maybe we need films like this to explain that the local people are going to respond differently, that the Hazmat suits are themselves scary.

GREGG MITMAN: Right. One of the things that’s happened in the context of global health since the 1980s, through what’s called structural adjustment and the way in which World Bank has given money to developing countries, is there’s been a lot of focus on what’s called vertical programs - a focus on targeting single diseases like malaria, polio or things like that without an attention to the basic medical infrastructure and public health infrastructure. Had that been in place, I think the way in which the outbreak happened would have been quite different. You’ll see widely varying figures about how many doctors were actually in Liberia at the time, anywhere between 50 and 200. This is for a population of 3.5 million people. So we’re looking at one doctor per 100,000 people at the time of the outbreak.

QUESTION: One of the things I was interested in was a comment made by the President of Liberia when she said this is a transnational disease. I guess I was thinking about the issue of the transnational when she said this is a transnational disease but also thinking about the responses of closing borders – exclusion. That is such a typical response: we are going to close these borders. You see that within Liberia we’re going to have quarantine and then in the US, and then thinking about the need to have a transnational responses which is what eventually happens. I wonder if you could comment a bit on that. I think that’s an interesting issue around borders. I also wondered about how different or similar the situation in Sierra Leone was, because they also had a long civil war there not so long ago.

GREGG MITMAN: The issues around quarantines and travel bans are deeply tied to issues around trade and trading partners. For example, with the 2003 SARS epidemic, which was a much more contagious disease, it’s respiratory. During the SARS epidemic there was never any discussion of a travel ban. Why is that? One of the reasons is because China was a major US trading partner. What do quarantines do? They really damage economic trade.

West Africa is not an active trading partner of the US or other nations. Its economies are so small that it’s easy to think about quarantines and travel bans on because it’s really not going to impact other countries economically, although it had a huge impact on places like Liberia, Sierra Leone and Guinea where food prices really escalated and you had all these other ripple effects. I think questions of quarantines and travel bans are deeply tied to issues around trade. We see that throughout the history of epidemics across the globe going back into the eighteenth century really.

Things happened very similarly in Sierra Leone, although the post-colonial politics really shaped the way in which it was handled on the ground - Sierra Leone being a former British colony. Liberia was the first independent free republic in Africa. It was never a colony. It has long relied on close relationships to the US because it was founded – or it was partly founded by free blacks that were sent there by American colonisation societies in the 1820s, but when they arrived there were already 16 Indigenous groups there. So it’s a little misleading to say Liberia was founded by free blacks from America. The post-colonial politics certainly shaped the way in which the international community responded - Guinea obviously being connected to France.

QUESTION: Congratulations. I enjoyed particularly a film coming from the ground up. You had the tremendous advantage in that you had a local technician who appreciated the significance of epidemiology. The only other comment I would make is that it would have been tremendous if you could have had an extra element in there from outside Monrovia but I realise that that probably would have been impossible to generate.

I’m ex-UN, and to me it’s a really classic case of epidemiology of a contagious disease. I wasn’t in West Africa at the time, but it seems to me that it was really very sad while NGOs were screaming - not for days but for months – the World Health Organisation really didn’t respond properly for months and I am embarrassed to say that our government here responded in, to my mind, exactly the wrong way. I don’t have a question; I just have those comments.

GREGG MITMAN: Thank you for your comments. We did have footage from what was happening in rural communities. When you said outside Monrovia, I didn’t know if you meant in the rural landscape - yes. Because of length we weren’t able to include that material, but it was quite interesting in the ways in which rural villages were dealing with the outbreak. They enacted their own quarantine measures towards strangers. Going back to the way they dealt with strangers during the civil war and also probably, although I can’t verify this, a kind of memory about the ways in which rural communities dealt with other diseases like smallpox.

One village that we had been filming in made it a requirement that, if you were a stranger to the community, you couldn’t come into the village and you would have to reside on the edge of the village, and not have direct contact with people for three weeks before you were allowed into the community. We heard a lot about irrationality and superstition, but communities were responding on the ground level in really effective ways.

QUESTION: I was very struck by the introduction of 250,000 people dying in the civil war. I thought it was a really impacting way to bring history into what was shaping the experience of Ebola. I am wondering if you can reflect on the comparison at the end - it says 8,400 people died from Ebola - and the mammoth global response to the Ebola crisis as opposed to the civil war.

GREGG MITMAN: Interesting. The statistics now, to bring the film up to date, is 11,000 people died and 26,000 people infected. One of the things that we saw so often is basically a lot of Liberians were referring to Ebola as the invisible war. It was a lot more frightening than the civil war because they said at least in the civil war you knew where the enemy was coming from and you could run in the other direction. But in the case of Ebola, that wasn’t true.

The other thing that was so disconcerting in terms of the memory of the war is things like road blocks, which were instituted during the war, those were the places where people were killed. So road blocks were a very threatening place for Liberians who had lived through the war and that just invoked that kind of memory.

In terms of the differential response, the UN peacekeeping force was 15,000 troops that were sent there in 2003 - there is now about 7000 - but so much of that focus was on getting guns out of the population. It was all about trying to eliminate violence in terms of direct conflict without any real attention to public health infrastructure. If some of those resources had gone into that, I think we would have seen this quite differently.

Similarly, the way in which we are living in a global world now of biosecurity which has a very militarised approach to epidemics, what does the US do? We send troops. What does Cuba do? They send doctors. When people ask me: ‘If you were advising Obama what would you have said?’ I would have said, ‘Send money to those Liberian hip-hop artists, musicians and community leaders who were actively on the ground building trust and getting the message out, not sending the military.’

QUESTION: There are just so many points of discussion from that short film, it’s extraordinary. One of the things that really struck me was the issues around barrier nursing. There are a lot of depictions of breakdown of barrier nursing clearly depicted there. Even in a country like Australia we have problems with barrier nursing. Isn’t it now - when outside organisations such as the United Nations and places like Australia - we should be on the ground now teaching these people and educating them prior to any more outbreaks of Ebola or anything else?

GREGG MITMAN: I couldn’t agree more. It’s a fantastic observation. Now Ebola is out of the headlines it’ll be forgotten, yet the medical capacity and infrastructure is still not there. All we need is another resurgence, and the whole thing is going to happen all over again.

I mentioned that Liberia has long been a place for American biomedical research since Firestone was there in the 1920s. There was a Liberian Institute of Biomedical Research that was established in the 1950s funded by Firestone and the American government. Yet all of that work was just work that was done by Americans. There was no effort really to build medical capacity and training within the country. So that’s the consequence that we see when you have a country where there is 50 to 200 doctors. Absolutely what’s needed is to focus on building medical capacity and knowledge within Liberia, and nursing is a huge one.

LIBBY ROBIN: And perhaps even more urgently they seem to be worried about food right now. It’s some sort of structure for coping with aftermath, the after-burn of these events and the trauma.

GREGG MITMAN: Unfortunately but in a sad way we were gratified to see a lot of the issues we pointed to in this film around food insecurity and so forth have turned out to be true. There was a recent social survey done by a group at MIT in Monrovia, and the largest issue right now facing people living in Monrovia is food insecurity and hunger -

LIBBY ROBIN: And water.

GREGG MITMAN: And water.

QUESTION: Thank you very much for your film. I was wondering whether you had any figures on brain drain as a consequence of the civil war and whether that was also perhaps a contributing factor in the lack of trained personnel.

GREGG MITMAN: Absolutely. During the civil war, which lasted from 1989 to 2003, those that had the means and education left. There’s a large Liberian diaspora community in the United States. So a lot of that medical knowledge left as well, and that has certainly shaped the way in which the outbreak unfolded the way it did.

QUESTION: Thank you very much for the film, most enjoyable. I have a comment and a question. I was working in Rwanda late last year when the epidemic was at its height and, by contrast, the public reaction there with what we had in the west in Australia, for example, there wasn’t the sense of panic. There wasn’t the border closure. Yes, there were strict quarantine provisions in place. But the Rwandans, with the relatively insignificant medical resources they had, immediately sent a team of 14 medicos to West Africa to try to contain it. It was interesting the fact that from the west we were having the panic that the Ebola is upon us. There was concern and there were precautions, but nowhere near the sense of panic that was here.

The question that I have is: your film showed us very much the work of the local people - medical staff, community workers and what have you. What was the real impact when the international community got its act together? Is that what really was able to turn the tide in terms of the current situation?

GREGG MITMAN: It’s an excellent question. I don’t think we can ever really know. But it’s interesting if you look at the epidemiological curve, in the case of Liberia the numbers of new cases and deaths really start dropping by early to mid-October. This was before the first Ebola treatment unit was built by the Americans. There is some indication in recent analyses that have been coming out it was community organisation and mobilisation at the community level within Liberia that really began to stem, to turn the tide.

Certainly once you had Ebola treatment units there, that would greatly impact survival rates of people because they were getting adequate medical treatment, they were getting intravenous fluids and so forth. I don’t think we can say it was one over the other. Obviously it was a combination of that.

But what was so important to us was that that side of the community mobilisation we hadn’t been seeing in the Western press coverage; we were always seeing the focus on the heroism of international aid workers - Fantastic that they were there. Médecins sans Frontières was really out and front in dealing with this. It’s really fantastic that they were there. But we really felt there was a major missing element to the story, and that was what was happening on the ground.

LIBBY ROBIN: We will take this as the last question because we are getting close to time.

QUESTION: I was just wondering if there is any chance of getting a copy of the film on video.

GREGG MITMAN: A slightly shorter version of this film will be released online through American ITVS, independent lens. It is part of the PBS or Corporation for Public Broadcasting in the US. It will be released online in late June and will be available free for anyone to watch.

LIBBY ROBIN: We will make sure that the details about that are put on the National Museum of Australia website so you can follow it up in late June. I just wanted to thank you all for coming and for a great set of questions and thank Gregg very much. This is one of the many collaborations between the Centre for Environmental History - and this is an interesting environment because it’s the environment within we’re talking about - and the National Museum of Australia through research. I have a little parcel for you, Gregg. It’s a parcel of three books that are other collaborations between the Centre for Environmental History and the National Museum of Australia. Thanks so much for coming.

GREGG MITMAN: Thank you so much. Thanks everyone. [applause]

For the latest on the film see: https://www.facebook.com/intheshadowofebola/info?tab=page_info