Tolbert Nyenswah

Tolbert G. Nyenswah

Q: This is Sam Robson. It is March 10th, 2017, and I'm here at the EOC [emergency operations center] in Monrovia, Liberia. I'm privileged to be meeting with Director-General Tolbert Nyenswah. Thank you so much for sitting with me for this project. This is part of our CDC Ebola Response Oral History Project. Can I ask you first, Director-General, would you mind saying "my name is," and then pronouncing your full name?

NYENSWAH: My name is Tolbert Geewleh Nyenswah.

Q: Can you tell me what your current position is?

NYENSWAH: I'm the director-general of the newly established National Public Health Institute of Liberia. This is the first time we have established a National Public Health Institute, and I'm the first director-general.

Q: It was really just a matter of weeks ago, is that right?

NYENSWAH: Right, just a matter of weeks ago.

Q: If you were to describe in just a few sentences, as short as possible, what 00:01:00your role was in combatting Ebola, what would you say?

NYENSWAH: I was the incident commander, head of the incident management system team that was set up by the government of Liberia at the very, very peak of the outbreak, when people were dying in the streets and everywhere across Monrovia. The entire world was terrified about the disease, and so I took the mantle of authority and was in charge of the command and control.

Q: I'm going to back up drastically for just a second. Can I ask your date of birth and where you were born?

NYENSWAH: I was born September 10th, 1974, in a village ten kilometers away from Greenville, in the southeastern county of Sinoe. I was born in Panama, the 00:02:00village name is Panama, in Sinoe County.

Q: Did you grow up in Sinoe County?

NYENSWAH: I grew up in Sinoe County. I went to elementary school there called Wolee Public School. Worked in my village eleven years. I went to Greenville, spent some time as a village boy. I came to town, went to [Harrison Grigsby United Methodist Junior High School], became a refugee in Ivory Coast. Finished up my high school in a refugee camp, and then moved back to Monrovia to go to college. Went to university, earned a bachelor's degree, went to law school, earned a law degree, and went to Johns Hopkins University, earned my master's degree.

Q: What was the master's degree?

NYENSWAH: I had my master's degree in public health.

[break]

NYENSWAH: So I grew up in the village, came to Monrovia from a refugee camp, a refugee boy. Village boy, became a refugee, and then came to Monrovia. Went to 00:03:00college, got my undergrad [undergraduate] degree in biology and chemistry, went to law school, got my law degree, and then got a scholarship from the Global Fund [to Fight AIDS, Tuberculosis and Malaria], went to John Hopkins in Baltimore, and got my master's in public health.

Q: Was there an area of health that you specifically focused on?

NYENSWAH: Yes. I was focused on human rights, health and human rights, focused on infectious disease outbreaks, and then focused on epidemiology.

Q: What year was that, that you went to do that?

NYENSWAH: Twenty eleven to 2012.

Q: Can you tell me what you were doing immediately before Ebola started heating up here?

NYENSWAH: Twenty twelve, immediately after my graduation in May, I came back to Monrovia, to Liberia. In fact, I was finishing up my program, and then in the last term of my program, I got appointed as assistant minister of health. From 00:04:00director in charge of the malaria program for nine years, appointed assistant minister of health, meaning I was the deputy chief medical officer of Liberia for disease prevention. It was less than two years in that position when Ebola struck. I was in charge of disease prevention, non-communicable and communicable diseases, and mental health, and then Ebola struck in May of 2014. I was in that role, handling the coordination, especially the communication piece during the outbreak--community engagement and social mobilization.

Q: Starting from when it started, can you just go from there and tell me what happened?

NYENSWAH: What happened was, if my memory serves me very well, we were 00:05:00struggling in the Ministry of Health [and Social Welfare] to organize an outbreak response because this was the first time in the history of this country that we were seeing a disease of such an outbreak nature. We had been dealing with measles, yellow fever outbreaks, polio, and all of those others, but there was no disease outbreak that [challenged] the health system at that magnitude. We were struggling in the corridors of the Ministry of Health, trying to organize a team to send them to the epicenter of the disease in Lofa County, where it started in 2014.

My role during the early days from March up to July, August of 2014, I was the person doing the communications piece, telling the entire world that this was 00:06:00unprecedented. Mind you, I had just gotten my start in public health, and so I knew the implications of disease outbreaks, knew the implications of infectious diseases, knew the spread, distribution of diseases, and all of that. I was informing the population on preventive steps to take, what to do. But then the rumors of people that this was made up, this is not true--the population doubting and all of that. It had significant impact on the spread and the exponential increase in the number of cases that we were faced with. So that's what basically in the early stage I was engaged with, and then you found that high-level people were even going into the field. The minister of health [Walter T. Gwenigale], the chief medical officer [Bernice Dahn], the then-WHO [World Health Organization] country representative [Nestor Ndayimirije] was going in the field to see what was going on. We were all visiting communities, people 00:07:00getting sick and all of that. Then, the outbreak went out of hand. By July, August of 2014, there were serious, serious devastating effects. Dead bodies in the streets, sick people, no treatment units to go to--people were crowding up in front of treatment units.

Partners started coming in: CDC, WHO people. International partners tried to move in. At this time, there was no declaration yet of a Public Health Emergency of International Concern. WHO had not declared Ebola even to the extent that 00:08:00people were all--we could see visibly, people were getting sick and dying in the hundreds. We didn't see that urgency from the international community through WHO. You saw that NGOs [nongovernmental organizations] were even taking the lead in the response, supporting the Ministry of Health. MSF [Medecins Sans Frontieres] was one of those key NGOs that was in the lead when we went to coordination meetings in 2014. MSF was drawing the attention of WHO, "Look, this is the time for WHO to play her role as the lead international agency. We, as an NGO, this is not our role. We don't have the capacity to deal with this." And 00:09:00they were saying the same internationally, talking to the radio. I was also talking to the BBC [British Broadcasting Corporation] and CNN [Cable News Network], Al Jazeera, all the news channels, to draw the international community's attention. Then in August, I got appointed as the incident manager. August 11th, 2014.

Q: Can you tell me how that came about?

NYENSWAH: I will tell you. In August, a week before I got appointed, we were struggling with what kind of coordination mechanism to set up to deal with the Ebola crisis because there were so many coordination mechanisms that were set up. Ministry of Health on one hand, in Congo Town, at the Ministry of Health 00:10:00building here at the outskirts of Monrovia. The president of Liberia, Her Excellency Mrs. Ellen Johnson Sirleaf, had set up a national task force to deal with Ebola, made up of government officials and military people, members of the legislature. They were meeting, on the other hand, in the Executive Mansion. And at the General Services Agency is the government institution responsible for logistics and procurement. They were dealing with the logistics component of the outbreak. So you had three separate coordination units, and fragmentation, lack of coherence, no information sharing. Everybody was doing their own thing. Then, we came to one of the coordination meetings in August, between August 6th, 7th, 00:11:00we had our meeting. The minister of health then, Dr. Walter Gwenigale, and the WHO country representative, Dr. Nestor, Dr. Nestor Ndayimirije. Then CDC did send a small team of twenty people headed by Dr. Kevin [M.] De Cock. We all sat in a room. That meeting was chaired by the minister and the chief medical officer then, who is now the minister of health, Dr. Bernice Dahn. CDC said, "Look, the coordination is not working, so we need to set up a coordination mechanism called the 'incident management system,' and that incident management system should have an incident manager that is completely devoted to the Ebola 00:12:00outbreak." WHO on the other hand said the national coordination for Ebola should be their mechanism. But yet, we all agreed that the IMS [incident management system] should be the setup that we should go by.

Late in the evening of August 10th, between August 9th and 10th of 2014, the healthcare workers staged a demonstration. They were leaving the ETUs [Ebola treatment units]. They didn't want to work. They met with the president at the Monrovia City Hall, and that meeting was not a very good meeting for the health authorities because there were a lot of complaints, there was a lot of trouble, there were strike actions even before the Ebola outbreak. Healthcare workers did 00:13:00not want to work. It was chaotic. In the midst of disease, you have strikes, you have government--all sort of things were going on in the country. The political system was threatened, the communities were terrified all over the place.

One evening, after that meeting at the city hall, I remember the president came to the Ministry of Health and met the minister, and I don't think she was happy about what was taking place in the country. Her Excellency, being a strong leader, told the minister, "Mr. Minister, you need to separate the health system from the Ebola response. I'm asking you that Mr. Tolbert Nyenswah should be appointed as the incident manager." So on August 11th, the minister of health called me, and he told me in his office, "The president has asked me to appoint 00:14:00you as the incident manager to take charge of the Ebola response, while the chief medical officer that is coordinating now should think about restoring the healthcare system." Because there were no places for immunizations, women could not give birth, people were giving birth in the streets, in homes, because healthcare facilities were rejecting people across the country. The president felt that it was devastating as a leader. She took the decision, Dr. Dahn should focus on restoration of healthcare, and I should take the lead on moving the respond forward. I asked the minister of health, "You have to reduce that into writing." So the minister of health wrote me and introduced me to all of the development partners and everybody for the coordination of the IMS system. I went home that evening and then called my wife, called my family and told them, 00:15:00"This thing is out of hand, people are dying. I have been asked to lead." The first thing was, my father had told me that, "Tolbert," from childhood up to the time I was in elementary school, he kept repeating, "you will lead our family, you will lead your community, you will lead Sinoe, you will be a leader, and you will save Liberia one day. You will be strong, and even the entire world." So when this came about and the president asked that I lead the response in the whole country, I reflected deeply and said [to myself], my father told me something about leadership, and I think this is the time.

So I sat down. The entire night I was reflecting on who should be on my team, 00:16:00how should I organize the team. There were very good people, very good technical people in the Ministry of Health: doctors, nurses, financial experts, logisticians, and people in other ministries and agencies that I knew had the skills. I started putting people in key positions, and I divided the response into thematic groups based on the incident management system. Because now I was speaking to MSF, I was speaking to CDC, and CDC had given me the organization chart of how an incident management system functioned. I put in key Liberians as chairs of thematic groups. Case management was thematic group number one. Epi [epidemiological] surveillance, psychosocial community engagement, logistics, 00:17:00watch, and the list goes on and on, how the incident command system would put people in place.

We developed the incident management system. We started having meetings. Eight A.M. is the operational meeting, and then 9:00 am every day, including Saturdays and Sundays. Key things we said we would tackle first were, number one, increase the isolation units to treat people. Number two, burial. Get all the dead bodies that were in the street and bury them. And let me tell you one moment that struck me. When we were looking for a place to bury people--because people were so terrified and afraid of the disease, nobody wanted to open up their cemetery to be buried, for Ebola dead bodies to be buried in a cemetery in Liberia. Everywhere we took a body, we were rejected. Agitation. Communities going on the rampage to reject healthcare workers. The ETUs were filled. The two ETUs we had, 00:18:00one at JFK [John F. Kennedy Medical Center], one at E-L-W-A [Eternal Love Winning Africa] Hospital, they were all filled to capacity with dead bodies.

So I ran to the shop, got two trucks, took the trucks with the burial team. We went in the community, Johnsonville community. We went with an excavator to dig the mass grave to bury up to seventy-five, eighty people at one day point. Bodies were in bags, like rice bags. Bodies were in the bags, and we moved with trucks, pickups, with an excavator. We had the military behind us to move in, to 00:19:00divide the community, and myself leading the team. We went to a wetland. The excavator got stuck in the wetland. We didn't have any means to dig, and what I told the team was we had to use our bare hands with shovels to dig holes to bury the eighty people. We did that in Johnsonville. I left at 2:00 am in the morning to bury those people, for us to have space to put other people in. That was the heart of the outbreak. That struck me. Just imagine the danger that we're faced with, having highly pathogenic dead bodies in a truck, and then you are digging holes to bury dead bodies.

Q: Why did you say that?

NYENSWAH: The risk was high. The risks were high. People were in open trucks. 00:20:00There were decayed bodies. This is when the disease is highly transmissible, when somebody died and you go and touch the body. At that point, we were in danger, but we got safe.

Q: So you had to even use your own hands.

NYENSWAH: We used our shovels to bury them, but we had PPE [personal protective equipment] on anyway, so we were protected a little bit.

Q: It sounds also like a symbolic moment.

NYENSWAH: It was a symbolic moment. That moment, I remember, is when the president came to believe in my leadership, because she was on the telephone herself in the morning, 12:00 am, 1:00 am, up to 2:00, 3:00 am when we left that Johnsonville community when we buried the people. It's when that decision was made for cremation. When we left Johnsonville and had all the difficulties to 00:21:00bury the Ebola bodies, is when the president came out with a policy that we would cremate everybody that died from Ebola. That's how we opened the crematorium in August, September of 2014. Those are part of the moments that I remember very well.

Then we gathered the entire international community. The incident management system was now functioning well; WHO had now announced a Public Health Emergency of International Concern; the US government, President [Barack H.] Obama had now announced deploying US military colleagues; China, African Union, Cuba, West African health organizations, West African leaders now set up Ebola response, chaired by Togolese president Faure Gnassingbe Eyadema. The World Bank came in, 00:22:00Jim [Yong] Kim visited Liberia. The WHO director-general Margaret Chan [Fung Fu-chun] visited and met with us, UN secretary-general Ban Ki-moon visited, Tom [Thomas R.] Frieden, "the magic man," as I describe him. He turned the entire corner of the outbreak. When Tom Frieden visited Liberia in August, it was the turning point for the international community. He came in with a small team, visited us. We explained to CDC. He saw some of the dead people in the streets, he visited some communities, saw the very challenging response, and wrote a story, and talked to the US press. CDC had made a projection of the number of people that would have died--I think about one million--if nothing was done in 00:23:00Guinea, Liberia and Sierra Leone. That projection, that mathematical modeling, for me played a key role to draw the international community's attention. So Dr. Frieden is my international hero when it comes to the Ebola fight, and he made some great promises. "We will take care of burial." Global Communities came in from the USG [United States government] support. "The US military will build more Ebola treatment units." We did build about twenty-eight of them, close to nineteen were functional. We created from two burial teams to about seventy-plus burial teams in all fifteen counties. We [unclear] logistic basis across the whole country, to put logistics in. We trained over twenty to thirty thousand healthcare workers, community engagement, community volunteers. We touched over 00:24:00three to four million people in community engagement. We decreased the number of deaths that would have taken place in Liberia. We had about 4,800 deaths, Ebola confirmed, probable, and suspected, eleven thousand people got infected from the disease--suspected, probable, and confirmed cases. We brought the outbreak under control in a couple of months, and by May 9th, 2015, Liberia was declared Ebola-free. We had a jubilant--some of the pictures you see there was the declaration of the end of the Ebola outbreak celebration on May 11th. WHO declared us Ebola-free on May 9th. We had a celebration in all the streets in Liberia. Everywhere, people were--it was like declaring a war over.

But there were some missteps. There were some missteps that we need to understand. Number one, our initial approach to the outbreak in terms of communication was not adequate. The communications that we were sending out were frightening. People were saying ninety percent of people that would catch the disease would die because in a similar population in East Africa, ninety to one hundred percent would die. But with the scale of people, scale of cases that we had here in Liberia, at some point when we improved the outbreak, we got less than forty percent case fatality rate, which was also good. It gave people the feeling to come to the ETU. Before, people were afraid of the ETU.

Additional missteps are the way we dealt with the community. Remember the West 00:26:00Point community. I remember the story about West Point. It's another story that people want to know. West Point happened in a way that I remember very well. There was no Ebola treatment unit, so we found a schoolhouse in the West Point community, and the West Point people agreed to use the schoolhouse for only the cases as a transit unit. But other communities knew that there was a unit at West Point. They started trucking their sick people into West Point. The community got agitated, ransacked, stoned the transit unit. The military went in, started firing, and somebody lost their life. It was a terrible moment. Another moment I remember, when we were short of ETUs, we opened Redemption Hospital in New Kru Town as a treatment unit. Redemption was jam-packed with 00:27:00over 180 people that were infected by other diseases than Ebola. But then we opened another healthcare facility, WHO supported the opening of Island Clinic. The day Island was opened, we admitted 180 people the same day, and about half of the people died. I could see how devastating it was with the Ebola crisis.

Some other missteps were the coordination from the beginning was poor. In any outbreak response, political leadership and coordination is very, very key. When we got that right, then we started getting a lot of success stories. Number one, the way we reopened schools was a great success story. Liberia lost about 150 school days because the schools were closed down. We had to reopen schools, put 00:28:00in WASH [water, sanitation, and hygiene] services, develop school openings, safe materials. This was a political time where Liberia should have gone into midterm election with their senators. Those who were already in positions in the Senate [of Liberia] wanted the government to postpone the election. Those who wanted to be elected to the government said our election should be held. I was under pressure as the incident manager to develop a protocol that would keep people safe for us to have the election, and we did work with the National Elections Commission and other international partners, Global Communities, to have that election. We did conduct the election when Ebola was going on. That's one of the key success stories, we were able to save the people, save the government. But there were tremendous efforts that we put into the Ebola fight as a person. We were having meetings day and night. Going to the field, visiting burial sites, 00:29:00going to every county, flying on the US Marine helicopter, the military, to move from one county to another county. We worked very closely with the US--this is one situation that I saw the military working for civilians, and it went very, very well in executing the activities.

Q: Can you tell me, Director-General Nyenswah, how do you feel that Ebola personally changed you?

NYENSWAH: Up to now, I'm always in an emergency mode. I feel even to the extent that we are now into development mode and restoring healthcare, trying to build 00:30:00resilient healthcare services, I feel that things should be done very, very urgently and fast. So it has changed because one moment that you waste is the life of somebody. If an ambulance is not going to pick up somebody, or if there is no food in the ETU, or healthcare workers don't have the needed personal protective equipment to do their job--we lost about 180 healthcare workers from the Ebola crisis, reaching from specialists, nurses, hygienists and all of that. So personally, I now look at health as important, disease control as key, preventing diseases as one of the important steps, because we saw what one 00:31:00disease, Ebola, did to the environment of Liberia. Not only Liberia, the sub-region and globally. The entire world was terrified about this. It's changed my way of looking at dealing with health issues.

Q: Was there any final memory or reflection that you'd like to share before we conclude the interview?

NYENSWAH: International cooperation is key. We are interconnected globally when it comes to disease control and prevention. The kind of tremendous support we got from the United States government and other governments during the outbreak, when we got things right--I told you the worst moments, and now is the time to talk about the very best, the good time when we got things under control, where 00:32:00logistics were no longer the problem. The United States government had the military here. They had deployed a lot of US-based NGOs and other NGOs that were giving us support in burial. Global Communities was there, USAID [United States Agency for International Development], UNICEF [United Nations Children's Fund], OFDA [Office of US Foreign Disaster Assistance], the Public Health Service of the United States. We worked with all of these people. WHO came in big time with very, very important individuals like Peter Graaff, WHO representative Alex Gasasira. We worked with Tony [Anthony] Banbury. Dr. David Nabarro is a key United Nations guy that is another guy who I respect and admire greatly, because he was able to coordinate the UN system very, very well. All of the UN systems 00:33:00came together and created an organization called UNMEER, United Nations [Mission for] Ebola [Emergency] Response, the first time for the UN to have a health mission. It was in Liberia, Guinea, and Sierra Leone, and the guy who was in charge of that coordination as the UN envoy for Ebola, Dr. David Nabarro, played a very, very important role in the outbreak. We worked very, very closely. He was in the field here. We rode a helicopter from one community to another community, flew into Sierra Leone, flew into Guinea, because when the Liberian outbreak was over, they wanted me to go to Sierra Leone and Guinea and give lessons from Liberia and those strategies that Liberia used to get rid of the outbreak. I did go to the other countries to provide leadership as to how we 00:34:00managed to get to zero very quickly in Liberia. We shared those lessons and views that worked for us.

Another memory is the African Union involvement. It was the first time that the African Union had set up ASEOWA, African Union Support to the Ebola [Outbreak] in West Africa. EU [European Union] played a critical role; Cuba, China built ETUs, the European Union came in with other organizations, Germany built ETUs. I think that international coordination and cooperation was very, very enthusiastic, fantastic, and got the outbreak under control. Government leadership, government political leadership in any outbreak response is key. Her Excellency, President Sirleaf. Had it [not] been her, Liberia would have seen a 00:35:00lot of deaths because the politics was too much. The infighting was too much. But she came in as the leader and said, "There is an incident management system, I'm supporting the incident commander, he is doing a great job, we should all support him." Then we started a success story. Today, you see I was honored. The [Liberian] president did honor me to give me another star of [the Humane Order of] African Redemption in the rank of grand commander. That's one of the very, very high-level honors that people who do extraordinary jobs receive.

Q: There's a plaque on the wall here.

NYENSWAH: I notice that some weeks, I don't sleep in the same room with my wife, especially when I go--my kids, my wife, we were all here in Monrovia in the same house. But when I went to the field, maybe attended a burial site or visited an 00:36:00ETU, I would sleep in another room in the house for a week or three weeks to go through the incubation period to see whether or not I would manifest any signs or symptoms of the disease. Because I prefer dying alone than my kids and my wife, all of us dying together. It was like a personal sacrifice. It was like a personal sacrifice that all of us as a team, we worked together as a great team to get Ebola out of this country.

If it were something that I would do to advise the entire world to respond to outbreaks, [how they should] do it differently, would most be accuracy for everybody to survive, but community engagement was very, very key. At some point, all of the communities came together, were forming community task forces. I was going from one community to launch a task force, going to another 00:37:00community to launch a task force. Across the country, people came together. Dead body management was something that we also--because what [allowed] the disease faster to expose people is dead body management. We got that right. People changed their behavior, especially from our Muslim colleagues who were bathing dead bodies, those kind of funeral rituals and all of that played a key role. Then the media--I had the media to deal with. I had to give press conferences two, three times a week at the Ministry of Information, [Cultural Affairs, and Tourism] to give information to the world on what was happening in Liberia. But today, we now have restored our healthcare system. We have a resilient healthcare plan that we are deliberating; immunization services are back; 00:38:00delivery into facilities is back. You were listening to the presentation this morning. I saw you in the meeting on some of those things that we are taking care of now, monitoring about eleven infectious diseases that we call "priority diseases" in the country. The National Public Health Institute has established. For me, if we had an institute of public health three years back before the outbreak, we wouldn't have had the kind of devastating effect that we had during the Ebola outbreak that we lost over four thousand people in Liberia, healthcare workers 150-plus, the entire region got over twenty-eight thousand cases and eleven thousand deaths. I think globally, we need to do something for disease outbreaks, because Ebola will not be the last. There is some pathogen out there that will start somewhere that we have to deal with.

Q: Director-General Nyenswah, thank you so much for your time. I know you have 00:39:00other appointments to run off to, and I very much appreciate you making time for this interview. Thank you.

NYENSWAH: Thank you, Sam. Thank you very, very much, and thanks for coming out. We'll hope we can archive this for the rest of the world. Don't hesitate to reach out any time that maybe you want additional--I'm writing a book, and I hope it can be a best-reading book tomorrow. [laughter]

Q: I can't wait. Thank you.

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