Update on Ebola, Epidemiology, and Geo-intelligence

RADM Scott Giberson, Assistant US Surgeon General Commander, Commisioned Corp Ebola Response, moderated the panel discussion entitled “GEOINT and Epidemiology : The Role of Geospatial Intelligence in Health Crisis Analysis and Mission” at GEOINT 2015.

He  admitted that he didn’t know what geo-intelligence was when he first started working with the Ebola virus. “We were using geo-intelligence during the Ebola response and using NGA liaisons,” said Giberson. “I realized that it contributes to the overall strategy we had there. We are a small uniformed service. I could see the operational level and the boots-on-the-ground level: a wide span you don’t get in the other services.”

The Commission Corps of the USPHS have a separate, non-DOD armed service. The Coast Guard U.S. Public Health Service is not in the DOD, and not armed. NOAA is the seventh service of the Commissioned Corps.

There are 6700 officers spread worldwide.

Why use the Corps? Giberson said they had historical success against infectious disease. “We draw from expertise in many areas,” said Giberson, “It was beneficial for the White House to use them in the Ebola response. We had about 1,000 officers offer to go in during the first 24 hours. There were over 5,000 responses in the first week, specific to public health.”

There was a need for cultural fluency during this epidemic.

US Strategy and Commissioned Corp Mission

The Ebola epidemic in West Africa and the resulting humanitarian crisis was a top national security priority for the U.S. On September 9, 2014. The Corps signed a paper and began building a hospital in Monrovia.

This effort involved the CDC, DOD, USGS, White House, and DART (Disaster response team).

Giberson said: “Our goals were to

-ensure force protection and force health protection for all Corps officers deployed

-Establish and maintain an operationally relevant and functional 25 bed ETU

-Bolster international confidence to respond

-Deliver innovative resilient sustained response for the U.S. Government

Short term considerations for using GEOINT:

-Epidemiology – when you track the spread of disease, we could identify outbreaks of infection, surveillance

-Interagency coordination

-Take care of force health

-Communication

-Training

-Transportation – There were places with no roads, or with flooding to keep the Corps from getting to the victims.

-Weather patterns – dealing with extreme heat, humidity, flooding in rainy season (mobile unit flooding), dealing with contamination. It was very hard to keep clean, and there were many mosquitoes etc.”

Longer-term strategies:

-Capacity building

-Transition of MMU

-Used GEOINT daily for desired outcome. Courses of action implemented.

-GEOINT planning with partners

-Liberian Ministry of Health gathered intelligence

-U.S. Mission (embassy in Liberia)

-U.S. CDC

-Non-governmental and international partners:

Medecins Sans Frontieres (MSF)

International Medical Corps (IMC)

UN Mission on Emergency Ebola Resposne

DOD and NGA made public planning more effective.

“When we had two cases in the U.S., the country was in a tizzy,” said Giberson. “In Liberia they had 60 cases per day.”

Other countries responded after the clinic was opened. There was less international support for Sierra Leone.

“We sent a flight halfway across the Atlantic, with a real time satellite flight tracker, and we had some people with flu who were coming from the U.S. to Liberia, but we turned the plane around so they didn’t come,” said Giberson.

The mantra of the Corps was as follows: “Today I am healed, tomorrow I return to heal others.” In the silent war against disease, no truce is ever seen, noted Giberson. There is no more Ebola in Liberia, but some remains in Sierra Leone and Guinea.”

Giberson said the different agencies worked well together, in a way that superceded political barriers.

In the following panel discussions, participants were taking an “all disaster approach,” as the disease required constant monitoring of data.

“We had no disaster of Ebola in the U.S, in spite of media claims,” said Giberson. “Those heading up the effort don’t have to become scientists. We have expectations that each person needs to speak the others’ language, and there have to be common operating pictures. We have pathogen intelligence, one more thing enabling decision makers.”

Panel participants included, Karen Walsh, CEO of Blue Glass Development, Rob Schenkman, director of the U.S. Department of Health Services, Captain Michael Schmoyer USPHS, Department of Health and Human Services, and Rob Chapin, HHS.

Walsh said that the Ebola epidemic had begun much sooner that most people are aware of. On March 18^th, NGOs chartered a plane and went to health clinics and hospitals in Guinea, where they “couldn’t handle the location. The World Health Organization (WHO) publicly dismissed MSF’s call for action, saying they were reaching out to the global health community, declaring they were overwhelmed. WHO said MSFs were “overreacting.””

By August 1, 100,000 people had died and WHO announced that there was an Ebola epidemic. This was not declared by the U.S. MSF went to the UN and asked for help, saying they needed everything.

Ebola is characterized by the hiccups in the beginning stages, according to Walsh. “It was September 9^th by the time the Obama administration acted on the information,” said Walsh. “What stopped us from having the data we needed for action to take place?”

Captain Michael Schmoyer USPHS, Dept. Health and Human Services, spoke on “How to Set up an Ebola Treatment Unit, The creation of the Monrovia Medical Unit.”

Schmoyer said that they were “trying to work with ministries of health for responsiveness. We were reliant on that ask for help and when we were allowed to go help. We worked with the application of GEOINT and what it allowed us to do.”

Schmoyer had done two deployments in Liberia before this one as the NGA liaison at the Department of Human and Health Services. Challenges on this tour included getting transportation routes for potential health care workers, being able to take into consideration the different health care sectors, and the fact that this situation was changing on an hourly basis.

“On September 16, we were told we could go, and didn’t get going until October 1,” said Schmoyer. From September 22 to October 22, this epidemic was a U.S. national security priority, and U.S. public health services were asked to give support to health care workers, to any NGOs. As they began to see the collapse of the health care system in Liberia, NGOs and health care workers needed to know there was somewhere to go in case they got sick there.

“We had to know transportation routes, how to be connected to other support organizations, our proposed sites, and how would we get workers to use them, and get them out of the country if we needed to,” said Schmoyer. “We had people from all over the world, providing support, and we wanted to make sure we could be a bastion of support if they needed it.”

This was the first time there had been an Ebola outbreak in a large urban center, and there was no plan for an Ebola treatment center from the U.S. government.

“How can we change doctrine? How can we take this and change it to support Ebola infection?” asked Schmoyer.

Schmoyer believed they reached out early on, and had some relationships in place, and created doctrine. In the future he said they need to involve stakeholders as early as possible. Bureaucracy is slow and needs to become more efficient and quicker acting for the future.

Rob Chapin of HHS said they had an app in place that was as “open source as possible” that had transitioned from 9-12 physical servers to virtual servers. They could get information to those who needed to know.

As an “NGA guy,” and cartographer, Chapin said he knew they could help a lot.

“We don’t operate in the open as an intelligence agency,” he said. “We support the military on the ground, and we were able to provide intelligence through the ranks and ramping up the effort. We needed to get this information up on the net without passwords, etc. We have a lot of experience that we could provide using ArcGIS Online, and could spin up a web presence on the web which we presented to the public on October 23. We were able to put only 20% of our holdings on the web, others were licensed in such a way that were strict about how we used the information. We had airports, seaports, locations of hospitals, interacting daily with folks on the ground, and non-government organizations asking for quick turnaround support. DigitalGlobe and Google Earth made much data available.”

Chapin said “Lessons learned” included: they had 25,000 hits, fairly significant for web site put up by an intelligence agency. “It took us 2 weeks to get the site put up. We had to deal with bureaucracy, and we were working closely with the best legal organizations in the NGA to figure out the least number of risky ways to get this mission accomplished. Because of the lessons learned with Ebola, we were up within 24 hours in Nepal with a site.”

In terms of information collected on the ground by NGOs, they had to ask, how can the integrity of data be checked? NGOs were working with the Minister of Health themselves, and CDC (for validation of data), and field epidemiological checking data. “We didn’t know that was peak until several months later because we had no validation of suspected cases and confirmed cases,” said Chapin.

From the NGO side, data collection was tough, and in the effort to do something collection gets missed. Problems arise because language barrier questions are not understood. The decision window of when to deploy is a very big issue, and there are sovereignty issues and economic issues.

“We could’ve contained the outbreak in a rural setting,” said Chapin, “but we did not act sooner. Karen does work on megacities, what would’ve happened if this had occurred in a megacity?”

When do we do something? Look at the scope of responsibilities, said Chapin. American borders could be penetrated with this epidemic. If it had hit a megacity, the classified information they were unable to put on the internet was not enough or the right type to prevent a major outbreak. “You’d need all unclassified data to support a megacity,” said Chapin.

“Ebola is containable,” said Walsh. “It’s not airborne yet. Change that now into an Avian influenza, SARS, and it does get into a megacity. When we do a lot of mapping exercises around the globe, nations are not willing to show us where their sewage and water systems are. It’s part of their intelligence network. Put that into a megacity where utilities are not traceable, and how do you stop transportation networks, and what would be a reasonable death count and when do you let people die?”

She pointed to wildlife tracking as a valuable resource, because there are diseases that are migratory in pattern, “It’s valuable whether done for illegal tracking or poaching, or bushmeat consumption. For example, in an economic downturn people are eating bushmeat more.”

Tracking the migratory patterns of birds can help provide analysis on how long it takes for a virus can get from place to place. Having one central data source will help streamline the data distribution process. 105 NGOs came to Monrovia, and thus it’s not U.S. centric, said Walsh. “Partnership has to be global. If you give data you better know you will get something in return.”

With the bird flu in Indonesia, certain data was never released by the Indonesian government because it would affect tourism and the chicken business. Chicken is one of their staple foods.

Ending Ebola

Dr. Bruce Aylward, who worked for the World Health Organization (WHO) for almost 25 years, was a key force in stopping polio in Africa. A year ago, he called Jack Dangermond to say, WHO had recruited him to lead the Ebola effort. “Over the last 12 months, we’ve been struggling with the greatest challenge in public health with Ebola,” said Dr. Aylward. “There is an extraordinary international and national response, and the role of GIS has been to steer response over the past 12 months. This crisis is not over. It may have disappeared from our TV screens but is very much part of these countries in West Africa. GIS is very important to help us get this finished.”

Aylward makes it clear that we don’t know much about this disease but what is known is chilling. It can kill 90% of the people it infects, there is no vaccine and no cure. It has only been known about for approximately 30 years. In 1976, it appeared in an infected animal, and there were 2 dozen outbreaks in between 1976 – 2012. “We didn’t know how to diagnose it. By really engaging and educating these communities about this disease, finding every case, and getting them into the treatment center, and tracing their contacts, we could break the chain of transmission,” said Dr. Aylward. There is a great need to ensure safe burials. “This disease is one of the most unforgiving we know of. It doesn’t allow families to care for their sick without getting sick themselves. They can’t bury their dead safely.”

When Ebola hit West Africa in 2014, the outbreak began similarly to the way it happened in central Africa originally, and may have come from an infected bat. The virus did something different this time. “The virus took advantage of the fact no one had seen it before and when they finally began to know about it, it had already spread across over 26,000 people, 11,000 people dead,” said Dr. Aylward.
“Stopping the outbreak would require extraordinary international and national response.”

Cultural problems were on the horizon as specially clad teams would have to come and carry away the dead which proved terrifying to the people in the small villages. This is a beautiful area, but the terrain isolates villages and also fed the rumor mill of who was coming to help and what the disease actually was.

By August, the disease had begun to increase exponentially, with a very different profile than it had had in past outbreaks. This was followed by international panic, as it was found in a person in Nigeria who had traveled from Liberia. By that time, 10 countries had experienced the disease. The CDC predicted 1 million people would be dead within six months from Ebola.

What ensued was the declaration of an international emergency to create a major response to get these countries under control. Instead of the type of help needed, airlines stopped flying into the affected countries, economies ground to a halt and countries were isolated.

In September of 2014, the secretary general of the United Nations went to the UN Security Council and declared this a crisis, and the UN Mission for Ebola Emergency Response was formed. This supported the NGOs who were already working on the ground to help stop the crisis.

The target set for the UN on September 23^rd was to reverse the projection of the CDC, have 70% safe burials, isolate 70% of the infectious cases over the next 60 days, in which time a huge number of Ebola treatment centers were built.

Safe burials were calculated with GIS modeling tools. Using drive time analysis, the teams could calculate that patients could be within 1-2 hours of a treatment center.

An effort to find every case and make sure they were properly treated and managed was spearheaded by UNICEF. “We had to shift to the next point of strategy, we had to find every single case, contact related to the case, at a time when people were very suspicious of the response,” said Aylward. “They were hiding cases and corpses so they could bury and care for them themselves.” This required searching for cases house by house to stop the transmission chains of disease in the countries affected.

The virus had twice reached zero before it took off and soared, because it existed in villages that WHO and other organizations hadn’t found yet. The disease has not been completely eradicated because there is a “long tail of contact tracing that still remains in corners of these countries,” said Aylward. “We have not finished the job, and cannot finish it without skills. The closer we get to zero the more important GIS response becomes.” The virus needs to be eradicated so that it can’t soar again.

They have a new tool just developed to guide this final aspect of the program of finding every single case. They will be able to target infected areas and see where the most recent contacts are.

There is difficulty getting to zero cases because of community distrust, financial gaps, the rainy season (current) and imperfect information. “We have much better information due to GIS. Almost all this can found on our web portal,” said Aylward. “We’re still very short of expertise we need to get the job done. We may have one mapper, sometimes two. What’s most important, I’d want about a dozen GIS experts out in the field.”

While Ebola is no longer front page news, airlines are not flying to Liberia, Sierra Leona and New Guinea. They are still affected and things have “ground to a halt.”

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