For the World Health Organization’s assistant director-general, readiness to attack disease outbreaks is a life-and-death imperative with multiple dimensions that have much in common with the U.S. military.
by Ms. Margaret C. Roth
As the World Health Organization’s (WHO) go-to expert for organizing major efforts against outbreaks of deadly disease, epidemiologist Dr. Bruce Aylward’s No. 1 job was ensuring the organization’s readiness to decisively defeat unpredictable enemies that can brutally decimate populations anywhere in the world. That means planning and executing a meticulous disease elimination or eradication strategy with the necessary personnel, logistics, research and development (R&D) and support systems and in partnership with multiple other international entities.
When the 2014 Ebola outbreak was out of control in West Africa and WHO was under fire for its sluggish response, the organization looked to Aylward for leadership. He greatly intensified the effort as special representative of the director-general from September 2014 through July 2016. Public health leaders credit Aylward with helping to turn the situation around, using essentially the same resources, by applying a precision and urgency that had been missing from WHO’s field response.
Before the Ebola outbreak, his enemy was polio. Aylward led the Global Polio Eradication Initiative partnership from 1998 to 2014, overseeing and managing the effort to build capacity—personnel, vaccines, etc.—in every polio-affected country in the world. The result was to reduce to two the number of countries where the highly infectious viral disease is still transmitted. He makes this accomplishment seem simple. “It’s a matter of how you’re organized and how you operate, right? And how you’re capacitated to execute your strategy.”
The 55-year-old Aylward, a native of Newfoundland, Canada, joined WHO in 1992, a year after earning a master of public health degree from what is now the Johns Hopkins Bloomberg School of Public Health. He earned his medical degree from Memorial University of Newfoundland in 1985 and completed a residency in internal medicine in Vancouver, B.C. He also received training at the London School of Hygiene and Tropical Medicine. In the course of his career, Aylward has authored more than 100 peer-reviewed scientific articles and book chapters and is a 2017 inductee into the Johns Hopkins Society of Scholars.
In many respects, Aylward’s approach to readiness mirrors that of DOD, which is why Army AL&T reached out to him at WHO’s Geneva headquarters for this July 21 interview. When we spoke with him by phone, he’d just completed an eight-month stint in the U.N. Office for the Coordination of Humanitarian Affairs (OCHA) to lead a newly established Change Management Unit there.
Dr. Bruce Aylward delivers his plan for an international response to the West Africa Ebola outbreak at a September 2014 press conference at the World Health Organization at Geneva. The first step in dealing with an emergency, says Aylward, “is break down the unknown, because we actually know a lot more than we often recognize that we know.” (U.N. photo by Jean-Marc Ferré)
Army AL&T: The U.S. Army’s operating statement, “Win in a Complex World,” looks at improving readiness through three particular paradigms—streamlined personnel, logistics and maintenance systems. How similar is this construct to what you look at when you’re looking to improve readiness?
Aylward: I think it’s actually fairly similar. With readiness, we think in terms of what our goal is to ensure that in a complex world, exactly as the military might say, you have the plans, processes, people and capacities in place to be able to respond rapidly to the unexpected hazards you face and emergencies that they give rise to. So we might use slightly different language, but it’s all about having a plan in place with the right personnel, logistics and maintenance systems, as you would say in the Army, to execute that plan.
Army AL&T: How do you plan for the unexpected? If you don’t really know what’s going to happen but can only conceptualize it, how do you actually build readiness in concrete terms?
Aylward: The first thing that we have to do is break down the unknown, because we actually know a lot more than we often recognize that we know. The first thing we tend to do is look at, OK, what are the possible hazards and groups of hazards?—and whether they are natural hazards or man-made, and then, within natural, whether it’s a biologic [hazard]. There are different groups of hazards. And the consequences of those hazards can be X, Y and Z.
From there you want to know, what are the vulnerabilities of different populations in different parts of the world? What are the capacities to address those? Very quickly you can build up a pretty good risk profile on which you can base your readiness work. Although the ‘where’ and ‘when’ something is going to happen are pretty unpredictable, especially with new infectious diseases, there are patterns over time that can help.
So we’ve got to be very careful about just saying, “Oh, it’s unknown.” We can build up pretty good risk profiles, though even then we can’t just put them on the shelf. In any given corner of the world, the geopolitics may have really changed, and now the whole risk for civil disturbance or conflict has changed, so you’ve got to update those risk profiles as well. While these risk profiles are helpful in terms of the ‘where’ something may happen, the ‘when’ is a little bit tougher, especially when it comes to predicting potential pandemics. Even then, we can track how the drivers of those risks are changing. What you’re left with at the end of all this is the unknown part. And even there, we often know more than we give ourselves credit for.
For example, although we keep getting surprised by new emerging infectious diseases, when we look at the major pandemic risks, they’re really related to two or three big groups of viruses, particularly flu viruses. When people talk about pandemics, they’re usually talking about pandemic flu. A second group are the coronavirus [of which severe acute respiratory syndrome (SARS) is an example], and a third group are what we call the filoviruses, of which Ebola is one. But if we know that it’s mainly those three groups, and we know how those viruses are transmitted, there’s other things we can do to start building readiness.
So there’s a lot we can do to reduce the unknown, to keep updating and even to start working around some of the areas of the unknown. I hate when I’m told, “Yeah, well, we don’t know what’s going to happen, so. …” Well, then, we better be even more prepared, frankly.
A safe burial site for Ebola victims in Freetown, Sierra Leone. To marshal a diverse coalition of international partners to action, Aylward laid out a straightforward goal to slow the outbreak: get 70 percent of dead bodies buried, and 70 percent of infected people into medical isolation, within 60 days. Prompt, safe burial is important because the Ebola virus can be transmitted to family members preparing a victim’s body for burial. (U.N. photo by Ari Gaitanis)
Army AL&T: And that’s where some of the past patterns of your experience come in.
Aylward: Yes, absolutely. Readiness really refers to being operationally ready to mount a response across a wide range of hazards, environments, and areas of different vulnerabilities and capacities. Another key part of this is planning, where the military makes a huge emphasis. It’s interesting, because in the humanitarian and public health worlds people often say, “We didn’t have time to plan because it was an emergency.” Well, militaries work in emergencies all the time, and the first thing they do is get a plan in place. In fact they already have a plan for most environments. But we also need to keep very broad groups of different actors working to a common purpose, so we need to have common plans, common simulations, joint responses. This is all part of what we do to ensure that we are at a state of operational readiness, not just in our own organization, and not just with our member states, but across that much broader set of actors that may end up being called on in a response.
Army AL&T: What would you say at this point are your biggest threats and your biggest unknowns?
Aylward: The biggest threats that we have to be ready to manage, as the World Health Organization, are in the area of infectious hazards and new and emerging pathogens, most importantly a new flu virus or respiratory-borne coronavirus. These are the ones that have the potential not just for a lot of illness and death, but also to move very, very quickly.
So a lot of the work we do is to build and maintain a combination of surveillance networks as well as laboratory and vaccine production capacities around the world to be able to detect, investigate, build the tools and respond to such events when they occur. Frequently people will say to me, “We need to be prepared for these things if and when they occur.” And I say, well, drop the “if,” right? The No. 1 principle is that they’re going to occur, we just don’t know when.
MAN IN CHARGE
Working with colleagues at the U.N.’s crisis control center in New York, Aylward lays out a strategy for getting the Ebola virus under control. Aylward had just been put in charge of WHO’s Ebola operations and saw a need for a clear, concrete, unifying goal “in that really scary period in the second half of 2014.” (Photo by Dr. David Nabarro, U.N. secretary-general special envoy on Ebola)
Army AL&T: Can you give me an example of how past patterns have helped you in framing and planning for these not-quite-unknown threats?
Aylward: Many people are surprised, but there have been hundreds and hundreds of newly detected pathogens in the last 50 years, many of which have crossed the animal-human interface. As a result, there’s been a huge amount of experience in dealing with new and emerging pathogens. Whether it was Legionnaires’ disease years ago, SARS virus, pandemic flu a few years ago, Ebola in West Africa and Zika most recently, with every one of these diseases and outbreaks, we get more and more experience. Even within many established diseases, we continue see new serotypes or new strains emerge.
All of these things help you basically test your machine: How good were we with after-action reviews? How good were we at the detection, at the investigation, at the response? Every single day, WHO is dealing with dozens of alerts for which it has to undertake an initial verification, to understand did this actually happen or not, and then decide whether it requires an investigation, etc. So the machinery is getting tested every single day.
Army AL&T: Have there been any recent improvements in the machinery?
Aylward: Following the Ebola response, we had two big events just last year. One, of course, was the emergence of Zika virus in the Americas and beyond. And the second one, that’s not recognized by as many people internationally but was a very, very alarming outbreak, was the big urban yellow fever outbreak in Angola and the Democratic Republic of the Congo last year.
These events happened as the new WHO Health Emergency Programme was being developed and rolled out. And the response was very, very different—the speed of the response—and the incident management system that was put in place after [the 2014 outbreak of] Ebola contributed greatly to the cross-organizational management of these Zika and yellow fever outbreaks in 2016. What we call our standard operating procedures for emergency management were operationalized, which got people on the ground faster, supplies out faster, etc.
Another important improvement in the machinery was the work that had been done across what we call the Interagency Standing Committee, or IASC, which is convened by the emergency relief coordinator of the United Nations to coordinate the international response to major natural disasters and man-made emergencies. In 2016, new protocols were developed so that the IASC would also deal with infectious hazards. So that piece of the machinery and the whole U.N. system kicked in more quickly. I have to say, the Ebola outbreak really brought new urgency to long-needed reform and improvements, not just within WHO and not just within its member states, but also within the whole international architecture that can be drawn on in such crises.
Dr. Bruce Aylward, right, speaks in June 2016 at a briefing to the United Nations General Assembly on the report from U.N. Secretary-General Ban Ki-moon, second from left, on strengthening the global health system. “The Ebola outbreak really brought new urgency to long-needed reform and improvements, not just within WHO and not just within its member states, but also within the whole international architecture,” Aylward told Army AL&T. (U.N. photo by Eskinder Debebe)
Army AL&T: How do you get all these organizations together and establish a common sense of readiness and motivation that brings them together to act efficiently and appropriately?
Aylward: The first thing that you’ve got to do is establish the necessary networks. WHO has been working for years to establish and support something called the Global Outbreak Alert and Response Network, which we’re secretariat to. We’re trying to tap all those great institutions like the U.S. CDC [Centers for Disease Control and Prevention], the E CDC [European Centre for Disease Prevention and Control], the Pasteur Institutes, the Public Health Agency of Canada, of China and of various other places, to create a network that can be used to provide international assistance in the investigation and response to infectious hazards.
Another network that we have set up is called the Emerging and Dangerous Pathogens Laboratory Network, which brings together leading laboratories at the international level that have the expertise to diagnose such pathogens safely and to put capacity on the ground, to do it locally if necessary. We are now developing new networks around emergency medical teams, health logistics, community mobilization and other aspects of response.
A second thing is getting these networks to common standards, language and processes. For example, with our emergency medical team network, we now have a standardized accreditation process which includes ensuring they can operate with our incident management system.
The next thing, of course, is testing these networks and systems. Again, this is so familiar to any military. Simulations, simulations, simulations—you just can’t do enough, whether it’s desktop exercises, field exercises or other types of simulations across those networks and different players. The final thing, and probably one of the most important, is actually using real events to create joint responses, joint opportunities. We will often mobilize a network even in relatively small outbreaks to make sure that this network is doing almost “live-fire” exercises.
In the case of infectious hazards, we have another great tool at our disposal called the International Health Regulations. This is like an international treaty that has been agreed to among the 190-plus member states of WHO on how they will identify outbreaks, notify WHO, facilitate investigations, and manage or cooperate together in the response to certain dangerous and emerging pathogens and other hazards as well.
All of these mechanisms have challenges and have problems. But the big lesson we’ve learned is that none of these things work if you don’t use them—you know, regularly test them and then rapidly operationalize them in crises. The problems are seldom the tools and the processes. It is more often just the sloth, let’s say, or lack of resources that have led to their lying idle for too long.
Army AL&T: That gets to the point of when these networks that are so important need to be set up.
Aylward: I think our experience in Ebola was that we hadn’t done enough of that in advance at some levels. We have to be clear: Even when you do look and plan ahead, you’re not always going to get it right. That’s why it’s so important to do these after-action reviews and evaluations and then put in place the additional capacities, networks, etc., that are needed. And that will continue to evolve over time as we come to understand hazards better, as we face new hazards and new crises.
We have to be open to learning these lessons. We learned the hard way that two gigantic networks that existed pre-Ebola weren’t able to work together optimally. We had the public health network, a lot of which I just referred to, but almost completely separate from that were the humanitarian networks that dealt with natural disasters and conflict situations. And so one of the big pieces of work that we did last fall, working with OCHA, was the development of what we call the L3 protocols for infectious hazards; a new set of common protocols that would stretch across the public health and emergency worlds to deal with major new outbreaks.
A mural at the outskirts of Monrovia, Liberia, during the Ebola outbreak that affected thousands of Liberians in 2014 and 2015. Aylward was put in charge of the international response to the outbreak after earlier WHO efforts—hobbled by years of budget and staffing cuts—were criticized as tentative and inadequate. (U.S. Army photo by U.S. Army Corps of Engineers, Savannah District)
Army AL&T: Did you work directly with the U.S. Army on Ebola?
Aylward: Although I became involved in the Ebola response as far back as March [2014], most of that early work was at the headquarters levels. I spent almost all of 2015 and much of 2016 on the ground in West Africa. Consequently I [personally] had less to do with the U.S. Army on the ground in the early days, but my teams did work with the U.S. Army, especially around the planning and then building of the Ebola treatment centers in Liberia that would be needed if this thing were really to get out of control.
What was really impressive was that the Army was well integrated into the civilian machinery that was actually running the response, and it was playing a role that was very well appreciated. A number of our colleagues at CDC also reported a lot of support from the U.S. military on critical logistics, because getting to some of these infected areas was a real challenge—those Black Hawks came in real handy to rapidly get to some of the remote areas where they needed to immediately understand [the nature of the] disease.
I’m sure there were some problems that I didn’t see in the civ-mil cooperation, but I really think we are moving in the right direction, which tends to be where I focus. I think we all came out of the Ebola crisis with a new, very much needed and very healthy respect for the capabilities, access and approaches of both sides.
Army AL&T: In the scale-up to the Ebola program, what did you see, and what did you prioritize in terms of what needed to be done first?
Aylward: I think the biggest single thing that I brought to the Ebola crisis was the combination of my understanding of epidemiology and disease eradication, as well as the world of humanitarian emergencies in which I worked. I could kind of bridge that gap across the humanitarian world, which mainly dealt with natural disaster response and conflicts, and the public health world that dealt with infectious disease emergencies. Because of that background I could also translate what are sometimes complex epidemiologic and disease control principles into some very simple approaches that could help unite a massive number of players with very diverse backgrounds to a common purpose.
I remember taking a big whiteboard [in September 2014] on one of the upper floors of the U.N. in New York, and writing “70/70/60.” I said, look, our goal, with all of these assets that we have, is to get 70 percent of the dead bodies carefully and quickly buried, and 70 percent of the infected people quickly into medical isolation, within 60 days. If we can achieve those two targets within the next 60 days, we will change the course of this epidemic and bend this exponentially growing epidemic curve.
I was really trying to take all that complex epidemiology and Ebola control knowledge and simplify it into something like 70/70/60, which was a clear, concrete goal. And that ended up being, certainly in that really scary period in the second half of 2014, what drove the international response.
Liberian Soldiers attach fencing at an Ebola treatment unit being built in support of Operation United Assistance in Gbediah, Liberia, in December 2014. United Assistance was the DOD operation to provide command and control, logistics, training and engineering support to U.S. Agency for International Development-led efforts to contain the Ebola virus outbreak in West Africa. (U.S. Army photo by Sgt. 1st Class Brien Vorhees, 55th Signal Company (Combat Camera))
Army AL&T: Is this a question, too, of your own personal leadership style?
Aylward: That’s probably the most difficult question you’ve asked. Although all the people who have worked for me would probably say, “You must be joking,” I tend to believe I have a very adaptive leadership style: from demanding control when necessary—when I, rarely, think it’s very, very necessary—to providing a much more facilitative approach. I was described [in a December 2014 news article] as taking charge of our [Ebola] response like a general. But that makes people think of a command-and-control approach. I think my approach is much more to enable and facilitate really good technical people to be able to have the amazing impact that they can by freeing them from whatever is holding them back, whether that’s administrative, managerial, political barriers, or whatever.
I do have a certain capacity or inclination to be able to take complex ideas and problems and break them down quickly into manageable and understandable approaches and interventions, and then be able to mobilize—probably with a lot of energy—our troops behind them. But in terms of a single descriptor, I think I’ve had to be a very different leader in very different situations, and what I’ve tried to do is adapt the style to the context and challenges.
Army AL&T: Well, it’s precisely the bigness of the things you’ve taken on that led us to you. What’s your motivation? What’s your attraction to these huge problems?
Aylward: Well, it’s funny—I’ve usually had these problems thrust on me. I don’t remember actually applying or asking to do any of those things. But the big motivator has always been the unequal access that I’ve seen and continue to see [to] some really basic health services. It’s really what motivates me, gets me out of bed every day. When I ran the polio eradication initiative, I remember one of my good friends who was part of my management team would sometimes come to my office about 8 o’clock at night, close the door and ask, “Will you remind me again why are we still doing this?” “Because we haven’t reached all the kids.” It’s as simple as that.
I have one kid. He’s got all his vaccinations. He’s got all of everything. And, you know, a lot more kids could get a lot more of everything if we had the determination and smart, committed people working to ensure that were the case. It’s just getting the enlightened, hardworking [people] in the positions to be able to lead that way.
U.S. Army and Marine Corps personnel prepare to board a U.S. Marine Corps MV-22 aircraft in October 2014 after surveying the site of a future Ebola treatment unit near Barclayville, Liberia. The U.S. military forces in West Africa during the Ebola outbreak worked well with the civilian machinery running the response, Aylward says, adding that U.S. aircraft “came in real handy getting out to some of these remote areas.” (U.S. Army Africa photo by Pfc. Craig Philbrick)
Army AL&T: This is a sort of a more cosmic question: Is there anything to be learned from epidemiology and its mission about organizational change, about how ideas and practices can be made contagious?
Aylward: I thought your last question was the most difficult one. It’s probably this one. When you think about epidemiology, it’s really about looking at the drivers that make a disease behave the way it does in a population. What are the causes and the drivers and other factors? And how can you influence those factors to [obtain] better outcomes?
When you look at big change processes, people often think it’s about making institutional changes and structural changes, but it’s not. It’s about people, right? You need to get a group of people moving in a different direction. To do this you have to understand the drivers behind their behaviors, and then you’ve got to figure out what levers you can pull, just like the different [disease] control measures you could pull to be able to effect a very different outcome in a particular population.
It’s a funny way to look at change, and probably something I do without even realizing it. Too often when we think about changing organizations, we think about what kind of business does it do? How do we restructure it to deliver that business? How do we change its processes, etc.? That’s all important, but the real change comes when the people change and they say, we want to achieve those kinds of results and we want to change the way we work to achieve those results. That means changing the direction of a population and being able to effect the right drivers to do it.
So I guess there are things to be learned from epidemiology and its focus on data, and a systematic and scientific approach. With organizational change you’ve got to be systematic, data-driven, etc. But, at the same time, the one thing that isn’t there in epidemiology that’s got to be there in any kind of a change process is a very clear vision of a better future for an organization and its population. That really is at the heart of change, that’s the big driver, right? And that’s got to be there
MARGARET C. ROTH is an editor of Army AL&T magazine. She has more than a decade of experience in writing about the Army and more than three decades’ experience in journalism and public relations. Roth is a MG Keith L. Ware Public Affairs Award winner and a co-author of the book “Operation Just Cause: The Storming of Panama.” She holds a B.A. in Russian language and linguistics from the University of Virginia.
This article is published in the October – December 2017 Army AL&T magazine.
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ONLINE EXTRAS
Bio of Dr. Bruce Aylward: http://www.who.int/dg/adg/aylward/en/
TED Talk: “Humanity vs. Ebola. How we could win a terrifying war,” by Dr. Bruce Aylward: https://www.ted.com/talks/bruce_aylward_humanity_vs_ebola_the_winning_strategies_in_a_terrifying_war
TED Talk: “How we’ll stop polio for good,” by Dr. Bruce Aylward: https://www.ted.com/talks/bruce_aylward_how_we_ll_stop_polio
“A new world, a new agenda for humanity,” WHO commentary by Dr. Bruce Aylward, May 22, 2016: http://www.who.int/mediacentre/commentaries/new-agenda-for-humanity/en/
“Ebola global response was ‘too slow’, say health experts,” BBC News, Nov. 23, 2015: http://www.bbc.com/news/health-34877787
“Report by the Director-General to the Special Session of the Executive Board on Ebola,” Dr. Margaret Chan, WHO director-general, Jan. 25, 2015: http://www.who.int/dg/speeches/2015/executive-board-ebola/en/
“In fighting Ebola, Canadian credited with energizing WHO response,” by John Zarocostas, McClatchy Foreign Staff, Dec. 1, 2014: http://www.mcclatchydc.com/news/nation-world/world/article24776914.html
“WHO doctor Bruce Aylward on response to Ebola outbreak,” CBC News, Nov. 7, 2014: http://www.cbc.ca/news/canada/newfoundland-labrador/who-doctor-bruce-aylward-on-response-to-ebola-outbreak-1.2826430
“Military preps a quick-strike team for Ebola response in United States,” by Ben Brumfield and Eliott C. McLaughlin, CNN, Oct. 19, 2014: http://www.cnn.com/2014/10/19/health/us-ebola/index.html
“U.S. military will lead $750 million fight against Ebola in West Africa,” by Lena H. Sun and Juliet Eilperin, The Washington Post, Sept. 16, 2014: https://www.washingtonpost.com/national/health-science/us-military-to-lead-ebola-fight/2014/09/15/69db3da0-3d32-11e4-b0ea-8141703bbf6f_story.html?utm_term=.721568b92698
“Cuts at W.H.O. Hurt Response to Ebola Crisis,” by Sheri Fink, The New York Times, Sept. 3, 2014: https://www.nytimes.com/2014/09/04/world/africa/cuts-at-who-hurt-response-to-ebola-crisis.html
