23 November 2014

Liberia: Journalists Pile On to Bash Ebola-Fighting Doctor

Photo: Heartt Foundation
Heartt founder Dr. Adamah Sirleaf (left) with orthopedic oncologist and Heartt volunteer Dr. Justin Bird at JFK Medical Center in Monrovia.
analysis

Washington, DC — This is a story about an American physician many in Liberia regard as a hero. It is about his volunteer group, called Heartt – Health Education and Relief through Teaching – which has helped train hundreds of medical professionals who built a post-conflict health system that enabled impoverished Liberia to lead Africa in reducing deaths of children under five.

It is also a story about how journalists from respected international media became an echo chamber for flawed reporting, even as their own news organizations promote themselves as more accurate, balanced and thorough than their upstart digital competition.

It started with a Wall Street Journal story with a headline about "Liberian Doctors" who are "Staying Away" from the "Ebola-Ravaged Country". The article focused on a single doctor who had decided "to pull his medical training group out of his homeland because of mounting risks to doctors there".

According to physicians interviewed by telephone for this analysis, including three who talked to Journal reporter Patrick McGroarty, his story had factual errors, misrepresentations, and quotes used out of context and without permission. Every medical professional contacted for this analysis says that the article missed an important story in favor of a sensationalized, incomplete and misleading version of the facts.

Surgeon David Knight of Connecticut, reached while attending a medical conference in California, says McGroarty called him for help in contacting the Heartt founder, and Knight arranged a telephone interview between the two. The tone of the resulting article was an unpleasant surprise, says Knight, a regular Heartt volunteer, who felt the reporter had concealed his intentions.

Dr. Knight was also dismayed by a copy-cat piece about the doctor in the Washington Post – what journalists call 'a story about a story' – headlined: "Here's why he's staying away from Ebola." Yet Post reporter Abby Ohlheiser never talked to the doctor or to his Liberian colleague, although she used quotes from both of them.

"I didn't know newspapers did that sort of thing."

"I didn't know newspapers did that sort of thing," Knight says.

The Liberian colleague quoted in both newspapers is Dr. Billy C. Johnson, chief medical officer at JFK Medical Center, the country's leading teaching hospital. Reached by phone in Monrovia, the capital, he said he had been wary of talking to the Journal reporter, because there have been so many inaccurate media accounts about Liberia.

But Johnson thought the story of JFK's successful reopening after staff deaths from Ebola should be told, so he agreed to talk on one condition. "I told the reporter nothing I said should be published without my consent. I wanted to be quoted correctly. He agreed and promised to take a tour of the hospital to see what we're accomplishing, but I never heard from him again." Instead, Dr. Johnson says, he was quoted without permission and in ways that distorted his views. "Very disappointing," he says. "Very unprofessional."

Journalists amplify the stories

The two articles generated over 3,600 social shares – including over 40 tweets by journalists from major news organizations on five continents, according to Muck Rack. At least 11 tweets were by Wall Street Journal staff, but others were by reporters, editors, producers or bureau chiefs at news organizations including Politico, Reuters, Al Jazeera, Bloomberg, Financial Times, Boston Globe, CNN, Associated Press, NBC, the New York Times and the BBC.

In addition, the Journal article was widely quoted in Liberian newspapers and discussed on talk radio, where it was used to attack President Ellen Johnson Sirleaf and to question the sincerity of her government's fight against Ebola – at a time when infectious disease specialists were warning that public trust in official prevention campaigns was essential to saving lives. The allegations against the doctor also have become a topic in the campaign for Liberia's legislative elections, scheduled for December.

What was the story's hook? The physician 'staying away from Ebola' is the son of Liberia's president. He was portrayed as more committed to a comfortable life in the United States than to the people of Liberia.

Who could resist the implied irony?

"Ouch," tweeted the Financial Times' Shawn Donnan. "Ellen Johnson Sirleaf's doctor son hasn't come home to help fight ebola."

Columnist and radio host Debbie Schlussel said "the First Son" of Liberia is among those who "won't leave America to go back to their infected country. So why are we letting in flights from their country?" [In fact, there were no such flights.]

"Ebola-ravaged Liberia desperately needs doctors. President Ellen Johnson Sirleaf's son, a doctor, refuses to go back," tweeted the Washington Post's Abby Phillip, retweeted by the Wall Street Journal's Gabrielle Steinhauser.

New York Times correspondent Rukmini Callimachi needed two tweets to express her indignation at the "disconnect between what [President] Sirleaf says…and what her family does."

Callimachi's colleague, Pulitzer prize-winning columnist Nicholas Kristof, who has more than 600 thousand Facebook likes and over 1.5 million Twitter followers, spread the word far beyond its original audience with his tweet: "Liberia's president calls on health workers to come and fight Ebola; her son, a doctor, stays safely in the US".

Did the stories violate journalism ethics?

Media ethicists insist that telling the whole story is an essential component of accurate, fair reporting. National Public Radio's handbook is typical, when it cautions against "errors of omission and partial truths" and says that "stories delivered without the context to fully understand them are incomplete".

The subject of the two stories is Dr. James Adamah Sirleaf, an American citizen – a fact neither newspaper mentioned – who attended college and medical school in the United States, where he has practiced since 1990. Now heading the emergency department at a hospital in Albany, in the American state of Georgia, he spent much of his career in New England, where he was affiliated academically with the Yale University health-care system.

By the time Sirleaf earned his medical degree, Liberia was gripped by a brutal conflict that destroyed almost all the country's infrastructure, including schools and health facilities, killed an estimated 250,000 of its two million people and displaced 75 percent of the population, most of whom fled to neighboring countries. Shortly after a fragile peace took hold, Dr. Sirleaf visited Liberia, persuading other medical professionals to accompany him to see what they could do to help. That trip defined his life's mission.

Sirleaf and Senora Francis, a nurse from New England who was on the trip, founded Heartt to help rebuild the shattered country's health system. For nearly a decade – beginning before his mother became Liberia's president – Dr. Sirleaf, who has never been paid for his Heartt work, has recruited and sent over 500 medical professionals to Liberia, taking leave to make several trips a year himself.

Heartt's model is to partner with U.S. medical schools and hospitals, which send volunteers to teach and train a new generation of Liberian health-care professionals. Twenty top institutions, including Yale, University of Chicago, University of Massachusetts, Stanford and Harvard, send resident doctors and their attending physicians, who often arrive with equipment worth tens of thousands of dollars. Medical professionals from institutions unaffiliated with Heartt often pay their own way to volunteer in Liberia; Francis says she has seen Sirleaf dip into his own pocket to buy tickets for volunteers.

Nobody has died of Ebola at JFK Medical Center since Dr. Sirleaf helped re-open it at the epidemic's peak.

Dr. Wvannie Scott-McDonald, JFK Hospital's chief administrator, scoffs at media reports that Sirleaf has avoided Liberia because of Ebola. "He came – with his family! – when Ebola broke out in March and warned us about it," she says.

Sirleaf returned to Liberia during the peak of the epidemic in August. "He somehow found protective equipment for our staff when we were in crisis and doctors and nurses were dying, and we had to close to disinfect the whole hospital," Scott-McDonald says. "He personally helped us establish protocols so that we could re-open as safely as possible."

"I don't know what the situation would have been without his help," says Dr. Johnson, speaking after a night on call doing three emergency deliveries by Cesarean section. "The first ward to reopen was maternity," he says. "We haven't lost a mother since then," he says, despite the fact that the most difficult cases, such as obstructed labor, are referred to JFK.

Nor has a member of staff died of Ebola since Sirleaf and longtime Heartt volunteer, Dr. Simon Kotlyar, helped the medical center reopen in August. Scott-McDonald says the two emergency medicine specialists brought calm to an atmosphere of calamity.

"The health system was collapsing," Johnson says. "Peripheral hospitals had closed. [Sirleaf and Kotlyar] conducted workshops for doctors, lab technicians, cleaners - everybody. They trained everyone on Ebola triage methods, so we could protect both staff and patients. What they did gave staff the confidence to come back to work."

The same month, Sirleaf assisted Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention (CDC) and Dr. Tom Kenyon, director of CDC's Center for Global Health, on their initial visit to the region, helping them see the full scope of the epidemic in Liberia. Frieden returned with a message for President Barack Obama that Ebola was "spiraling out of control," a view administration insiders say encouraged the president to substantially increase the U.S. response.

Sirleaf has been "very committed to healthcare in Liberia for a long time" says Kenyon. "Dr. Sirleaf took leave from his practice the minute Dr. Frieden asked him to join him… His knowledge on the ground was very helpful."

Health professionals say the Journal and Post suggestions that Sirleaf could have decided to keep Heartt volunteers in Liberia is, at best, naïve and uninformed.

Dr. Sirleaf never had the choice to leave Heartt volunteers in Liberia as Ebola peaked.

Senora Francis, who now chairs Heartt's board and who visited Liberia in April to do extensive Ebola-prevention education, says leaving volunteers in hospitals as Ebola peaked was never an option. "Most of them are residents – which means that even though they are doctors, they are still students, supervised by their medical schools." She says the last regular volunteers left in June, as late as Heartt could push it, given evolving restrictions on travel to Ebola-affected areas by Heartt-affiliated institutions.

Stanford's guidelines prohibit such travel, for example. University of Massachusetts pediatrician and long-time Heartt volunteer Dr. Patricia McQuilkin is in Liberia now to coordinate work funded by the Paul G. Allen Family Foundation's anti-Ebola efforts, but she and a colleague from Boston Children's Hospital are restricted by their institutions from doing clinical work while there. Harvard and Yale require permission from university provosts for exceptions to their guidelines against visiting the region. "To contribute effectively in-country entails great personal risk and requires complex logistical support, which only a few aid organizations and governments are capable of providing," says Harvard. "Only clinicians with the highest level of readiness—personal, mental, and professional—should even consider traveling."

It is doubtful that any Heartt resident could qualify for a waiver of restrictions. David Knight, who has been taking half a dozen young surgeons with him to Liberia twice a year, says that a residency review committee at his Connecticut hospital oversees its participation in the Heartt program. "They've approved my going there with residents," he says, about the pre-Ebola period. "But one of the requirements is that you have to have evacuation insurance." And medical insurers are excluding Ebola from evacuation coverage.

The estimated cost of an evacuation, providing one could be arranged, is $150,000 to $200,000. Treatment for Ebola at a U.S. facility raises the likely cost of becoming ill to over half a million dollars. Heartt, despite its sizable impact, relies on in-kind donations and has never had that amount of money to spend.

"The media reflect a lack of understanding of international health and who does what," says Dr. Kotlyar, who worked with Sirleaf in the Yale health system and helped establish Heartt's innovative program that combines short rotations with continuance of care. Kotlyar says only a handful of international humanitarian organizations are equipped to do Ebola treatment, and that for the academic institutions that supply Heartt's volunteers, "this is well beyond their scope of practice".

Kotlyar, who left Yale to join a medical center in Colorado, was able to accompany Sirleaf to Liberia in August, helping JFK to reopen and briefing legislators on measures to prevent the spread of Ebola in their constituencies. He says such visits are increasingly hard, even for individuals, due to the difficulty of getting leave and permission from their institutions and to quarantine requirements upon their return. But like other senior Heartt personal, he says Ebola has been an enforced, temporary obstacle – "not an abandonment" – and that Heartt will return in full force.

Helping now, leaving a legacy

The Wall Street Journal article predicts "most foreign know-how" will disappear when Ebola subsides, and says "Dr. Sirleaf's decision [to leave Liberia] speaks to the challenge of not only containing this epidemic but also of preventing the next one."

The reporter got it backwards, according to Dr. Philip Ireland, who is still recovering after being pronounced free of Ebola – the only survivor among the Liberian doctors infected at JFK. "My class was in medical school when Heartt was just taking off," he says. "Their clinical work and their academic training have made such an impact. Most of my procedural skills were learned from Heartt residents and attendings."

"Building capacity is what the organization is about and what our primary focus is," says Kotlyar. Heartt volunteers have taught student doctors, nurses and technicians, prepared curriculum materials, performed hands-on surgeries and other advanced procedures with young Liberian doctors, and helped establish administrative systems. Unlike the skills of organizations devoted to patient treatment, Heartt's know-how does not leave with its volunteers.

There are many reasons why Ebola has affected the region so disastrously, including that it had never been seen there before. Its presenting symptoms mimic many common illnesses, and international infectious disease experts - like those in the World Health Organization - did not recognize the virus's potential to spread widely and failed to respond effectively. But the fact that Liberia has made as much progress in containment as it has, however fragile, may be due in part to the work of Heartt, both over the past decade and in recent months.

Health-care providers say Heartt has substantially increased its contributions during Ebola – not decreased them as the Post article alleged – collecting, shipping and distributing hundreds of thousands of pounds of supplies and protective gear that enable health-care workers in at least two ETU's, 10 community health centers and eight hospitals to stay on the job.

Errors of fact in the Wall Street Journal story include portraying JFK as having only one doctor at its Ebola treatment unit (ETU), reinforcing the story line that Dr. Sirleaf was needed there. JFK officials say that there was never Ebola treatment at JFK, that the facility pictured in the Journal story is a temporary holding area on the edge of the sprawling grounds, unrelated to the medical center, and was in the process of moving to a Department of Defense facility when the reporter visited. They say the doctor pictured and quoted as running JFK's ETU is not a JFK employee.

That and other mistakes suggest a lack of conscientious fact-checking. The larger point, according to Heartt supporters, is that Dr. Sirleaf's time would be ill-spent as a clinician treating Ebola patients.

What Adamah [Dr. Sirleaf] is doing maximizes his effectiveness, both in country and out," says longtime Heartt volunteer Dr. Justin Bird, an orthopedic oncologist at M.D. Anderson Cancer Center in Houston, Texas. "He's doing what he should do. The need in Liberia is so vast that one person being there is helpful, but not enough. You really need a network supporting people on the ground. That's what Heartt is."

We don't want Dr. Sirleaf treating Ebola.

JFK's head doctor, Billy Johnson, agrees. He says the Wall Street Journal's suggestion that Heartt volunteers could have stayed in Liberia is as wrong as the quote attributed to him saying they should return to treat Ebola. "Adamah should continue to do what he's doing," he says firmly. "We don't want him in an ETU."

Dr. Scott-McDonald is equally emphatic. "People on the front lines need people in the back to get them the resources they need to win the war," she says.

At issue is more than Ebola, says Kotlyar. "We know that in complex emergencies, mortality from all of the regular things that people are afflicted with skyrockets," he says. Tuberculosis, measles, HIV, unattended childbirths and road accidents still happen. Malaria was already killing as many as 2000 Liberians a year, most of them children. "If those people can't get access to care, those numbers dwarf the mortality from Ebola cases," Kotlyar says. "But those aren't sexy and those aren't fun for the media to cover, so they go unrecognized."

Scott-McDonald says that since Sirleaf and Kotlyar helped the hospital reopen, in the maternity ward alone over 2000 women have registered for pre-natal services, and there have been nearly 500 deliveries. "The protocols they taught us provided such relief," she says. "They give the staff the confidence to work."

In contrast to those views by medical professionals, journalists' tweets and comments about the Wall Street Journal article reflect the strong impression that Dr. Sirleaf not only has refused to be in Ebola-affected Liberia but has chosen to use his medical skills to benefit Americans rather than Liberians.

"I guess it struck me as sort of interesting that the president is trying to persuade – and indeed I'm encouraging – medical professionals to go help out in west Africa, and the president's son himself doesn't want to join that effort," said columnist Kristof when asked by telephone about his tweet. "This is generally true in sub-Saharan Africa, that there's been a brain-drain that is a form of foreign aid from Africa to the U.S., and it strikes me as an interesting part of the puzzle that the president's son doesn't join the effort. I don't think one can hold it against the president. We aren't responsible for the decisions of our kids. But it strikes me as worth reporting."

Sirleaf, when pressed in a telephone interview, agreed with Johnson that Journal reporter McGroarty asked leading questions and conflated the answers, resulting in serious misrepresentations of what was said. But Sirleaf doesn't want to dwell on the details.

"They can say what they want about me," he says, but he does worry about an adverse effect on Heartt, as do other Heartt volunteers and their Liberian beneficiaries. In an online, social media environment, articles don't disappear, and reputations are easily damaged.

Journal and Post execs barred reporters and editors from talking.

Balanced reporting would include reactions from the Wall Street Journal and the Washington Post to the anger and concern of their stories' subjects. Both reporters were reached by telephone, in Johannesburg and Washington D.C. respectively. But corporate communications officials for the two newspapers declined to allow reporters or editors from their companies to speak on the record.

In an era when mainstream media are searching for a sustainable business model, it may be difficult to resist tactics that have fueled digital media revenues, such as attention-grabbing headlines, tabloid-like stories and editorial pressure for fast reporting and social media visibility at the cost of context and thoroughness. It's worth asking what is lost when a story is highly successful at creating a coveted 'buzz' but misses the larger picture.

"If the reporter had done investigative journalism and written an objective article," says Ebola survivor Dr. Ireland, "you wouldn't have this criticism of Dr. Sirleaf. You should tell the truth. If his mother weren't president, you wouldn't have all these people claiming he refuses to come."

Meanwhile, despite all her challenges, plus the additional stress of attacks on a doctor and organization whose help she needs, Dr. Scott-McDonald finds consolation in the daily miracle of life at JFK. She confesses that when she visits the maternity unit and a mother is in labor, "I try to hang around to hear the baby's first cry. Then I say, 'Welcome, new Liberian.'"

AllAfrica reported on the work of Heartt at JFK in 2010, in an article by Boakai Fofana, who manages the Monrovia office, and Shreya Prasad, who is now completing her medical degree at the University of North Carolina: Heartt Brings Hearts and Brains to Help Close Health Gap. Tami Hultman wonders whether the journalists and editors who circulated the Wall Street Journal and Washington Post criticism of Dr. Sirleaf to their nearly two million followers will as enthusiastically share this article.

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