Rebuilding Liberian Public Health: A Q&A with Tolbert Nyenswah

Community Health Workers with Ebola prevention kits walking through West Point in Monrovia, Liberia
Image credit
Community Health Workers with Ebola prevention kits walking through West Point in Monrovia, Liberia. Image: Morgana Wingard/UNDP Courtesy of Flickr/Creative Commons License

After the devastating Ebola outbreak in 2014 and 2015, Liberia began to rebuild its health system. The need to strengthen Liberian expertise in infectious disease preparedness and response and a host of other areas became obvious. Cue the creation of the National Public Health Institute of Liberia, which was established by the Liberian government in December 2016. The Institute will collaborate with and advise the Ministry of Health on infectious disease control, environmental health, occupational health and safety, and other issues.

Tasked with launching the Institute is its first director-general Tolbert Nyenswah, a former Deputy Minister of Health for Disease Surveillance and Epidemic Control who led the country’s response to Ebola. In a wide-ranging Skype interview with GHN last Friday, Nyenswah shared his plans for the Institute and its priorities in the coming years. 

How will you go about setting up the new National Public Health Institute? Where do you start?
We are currently doing a comprehensive assessment to look at how the system is organized from national level, to districts, to the county level and do an independent evaluation of the administrative system, technical system, human resources system. That will give me a complete report in the next 1-2 quarters. If you have that baseline, then you can see what are the needs in various areas and departments of the Public Health Institute.

Will the Institute be advising the Ministry of Health or taking on some of its roles?
The Institute will focus on infectious disease epidemiology [and] laboratory and public health diagnosis. Clinical diagnosis will still be the role of the Ministry of Health, but infectious disease outbreak response, environmental and occupational health safety will be a key function of the Institute. Public health and medical research and training and capacity building—these functions will be the function of the Public Health Institute. The Institute would also serve as the key advisor to Ministry of Health on evidenced-based policy decisions.

One of the things we can start with immediately is a review maternal deaths records. In 2016 alone, we had over 300-plus maternal deaths reported in the country. This is the tip of the iceberg because there is a lot of underreporting. Part of what the Institute would do that the Ministry is not doing is investigate these deaths, do maternal death audits on what is causing these deaths and make recommendations to the Ministry of Health.

When will the Institute be fully up and running?
We are not starting from scratch really. We have bits and pieces of the puzzle that are coming together. We will have the linkages established between the Ministry of Health, and the Institute will be in place within 6 to 12 months. Infectious disease epidemiology, the laboratory system, occupational health and safety, environmental health research—all of these will take shape within 6 to 12 months. That is the speed with which we are moving. Right now, we have a national reference laboratory—its capacity is being strengthened right now. We can safely test right now about 7 out of the 11 priority diseases—cholera, yellow fever, Lassa fever, Ebola…

We are not starting flat on the ground but it will take us some time to put the pieces together to really function as we want to see it … to make it a center of excellence of public health in Liberia.

Tolbert Nyenswah
Image credit
Tolbert Nyenswah. Image by Chris Hartlove

How large will the Institute ultimately be?
To get us to full capacity, we have done already a strategic plan. We want to scale up on a yearly basis. We want to send 5-10 Liberians out to work on their PhDs [in other countries] in the next 4 to 5 years so they return and become faculty for the University of Liberia and for private MPH programs in the country.

We are still working on the baseline. I don't know how many for environmental health, how many infectious disease specialists that we’ll need, water quality and vector control people. My goal is we can have scientists in every department, 5-6 trained people, qualified PhDs and masters. In the next 5 years, we want to have a core of trained scientists who are Liberians who can partner with schools like Johns Hopkins and research institutions in Australia. And look at some south-south collaborations also with Malians, South Africans…

You must be proud of this work.
I’m proud because it was done in record time. The reason is the Ebola situation provided a platform for this. If I were to tell people in the Ministry of Health 5 years back, we should establish a public health institute—trust me, I don’t think [they]would have seen this as being important. But after the Ebola outbreak, which killed 4,800 Liberians and with 11,000 confirmed or suspected cases, and having seen the international responders from the CDC and the African CDC and the China CDC—that context [makes clear] the necessity.

Will this be fully funded by the Liberian government?
The Liberian government is making some seed money available. A lot of the top management team, including myself, are being paid by the Liberian government. There are elements of the Institute that also have partners … for biomedical and public health research. The NIH is highly committed to supporting infectious disease research. The CDC is on the ground and has a country office here. WHO oversaw the establishment of the Institute from its inception. We did study tours in Thailand and in Norway. WHO supported that.

Will chronic disease be a priority for the Institute?
It is a key priority. We are looking at cancer screening. We are looking at prevention. This morning I had a partnership meeting. What I told them is … 60 to 70% of our work should be prevention, prevention, prevention. Every intervention that is done, 60% of that should be focused on disease prevention and control. And noncommunicable diseases are topping the list because right now a lot of people are coming down with diabetes, hypertension, stroke—the epidemiologic transition. We have a lot of infectious diseases but look at the hospital and health management information data, a lot of women are coming down with breast cancer. And road traffic injuries are key for us. Food safety, water, sanitation and hygiene. These are key priorities of the Institute.

Had the Institute been established a decade ago, would it have made a difference in the 2014-15 Ebola outbreak?
If this Institute was established before the 2014-15 Ebola outbreak, I am of the opinion this [outbreak] would not have had the devastating effect, the unprecedented deaths that we saw. We wouldn’t have seen that. Even before the establishment of this Institute, we created a department in the Ministry of Health. I was deputy Minister of Health for disease surveillance and epidemic control. And we see in less than 1 year the progress we made and the response to the outbreak. We had 3 later flare-ups of Ebola after the big one. Those flare-ups did not [extend to] more than 6 cases of Ebola, and we were able to contain them.

In the last year, we have had 10 outbreaks of Lassa fever in the country. We contained them. We have had measles outbreaks all over the place. We contained them. We now can deal with infectious disease effectively. We are training health care workers in infection prevention and control. We are setting up the kind of system that is needed. I’m sure the Public Health Institute will make a difference in Liberia and the region. We want to take these skills—after we have understood our own problems—we can go to our neighbors in Sierra Leone and Guinea and have cross border interactions.

Back in September 2016, you were named the first Bloomberg Hopkins Emerging Leader Award winner. What did that mean to you?
It was one of the very, very important honors. I was excited and thrilled by the award. Today, to tell you, Brian, part of that award is being used right now for the establishment of the Public Health Institute. The award is benefiting public health in the next generation to come. 

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