Liberia Shares Lessons from Ebola Epidemic

The country’s military played a key role in stopping the epidemic and organizing the country’s resources

BRIG. GEN. DANIEL ZIANKAHN
CHIEF OF STAFF/ARMED FORCES OF LIBERIA

MAJ. SCOTT POLASEK
SECURITY COOPERATION DIRECTORATE/WEST DESK OFFICER/U.S. ARMY

Liberia still feels the pain from the loss of more than 4,000 of its citizens to the Ebola epidemic. The 2014 outbreak devastated communities and forever changed the country.

The Armed Forces of Liberia (AFL) played a key support role in the eventual containment of the epidemic. The AFL learned many lessons that can inform future military responses, not only for Ebola outbreaks, but for other crises not traditionally supported by militaries.

Unfortunately, in the spring of 2014, governments and international experts did not foresee the tragedy that was about to unfold in Liberia. They believed that the epidemic would follow historical Ebola epidemiological patterns and be contained in a matter of weeks. Those expectations soon were shattered as this became the first time the Ebola virus spread through multiple countries and hit urban centers.

Cases steadily increased in early summer 2014. Initially the outbreak was confined to northern Liberia. There were 12 cases in May and 51 cases in June. The area of infection spread in July, and by the end of the month, there were 329 cases.

The number of cases exploded in August. By the end of the month, there were 1,378 cases of Ebola in Liberia, a 319 percent increase from the end of July. Ebola had spread to most of Liberia’s states and major urban centers. Even more worrying, disease experts estimated that if there was no intervention, there could be more than 100,000 Ebola cases in Liberia by the end of January 2015.

The severity of the outbreak led Liberian President Ellen Johnson Sirleaf to declare a state of emergency. Unfortunately, no adequate contingency plans existed for an Ebola epidemic of this magnitude. Compounding the problem was the Liberian people’s lack of understanding of infectious disease outbreaks. Most Liberians did not understand what Ebola was or how it was transmitted. Some did not even believe it was real.

This lack of comprehension was not limited to the civilian population. For example, hospitals became infection hot spots because of improper prevention protocols practiced by doctors and nurses. By the end of August, the situation was bleak, the response was confused and the Liberian people were afraid.

Yet September brought hope. The government of Liberia, with technical support from the World Health Organization, opened a 120-bed treatment unit, and the U.S. deployed 3,000 military personnel to Liberia.

This declaration of support from the international community provided courage to the Liberian people, a way forward and much-needed positive momentum.

Within a matter of days, the U.S. joined the AU and other organizations and began conducting combined operations with the AFL. Over the next three weeks, the AFL developed a plan to build, sustain and staff 17 treatment centers for Ebola victims. They established additional mobile laboratories to process blood samples of suspected Ebola victims. To address the high infection rate of health care workers, they began training them on how to treat patients infected with Ebola. The AFL and U.S. personnel also began building a state-of-the-art treatment center for health care workers to encourage international experts to come to Liberia.

Even more important than what they did in September is what they became: a team. Various governments, organizations and militaries formed a common goal. This team endeavored to blunt the growth of new cases per day. This was critical to prevent the worst-case scenario from occurring.

Work that began earnestly in September began to bear fruit in October. Ebola treatment centers became operational in the most affected areas. These centers created a firewall that contained the outbreak to affected communities. The additional test labs cut the time it took to process the blood samples of suspected Ebola patients from three days to two or three hours, USA Today reported. The government of Liberia developed an effective communication strategy that educated the population on what Ebola was, how it was transmitted and where to seek treatment. These efforts reduced the number of new cases.

Ebola containment operations switched from defensive to offensive operations in November and December. With assistance from international partners, the AFL completed the construction of the majority of the health care centers and completed the worker training. The team developed new methods to identify potential patients, test people at one of the mobile laboratories and place confirmed Ebola patients in treatment centers within a matter of hours. Most important, the Liberians understood what Ebola was, factors that lead to its transmission and the importance of seeking timely treatment.

These efforts led to a 60 percent decrease in new cases per day by New Year’s week, compared to the highs in August. The Liberian Ebola epidemic in 2014 could have been considerably worse if it had not been for international community support. Thanks to this support, the AFL played a key role in reducing the Ebola threat in Liberia.

LESSONS LEARNED 

There are numerous lessons learned from the 2014 Ebola epidemic. The following are the AFL’s top four:

Develop partnerships: Relationships were key to the successful containment of Ebola. For example, the strong partnerships the AFL had with U.S. political, military and health professionals predated the epidemic and enabled financial support, technical medical training and military logistical support. Complex problems, such as the Ebola outbreak, will be solved only when militaries collaborate with organizations that have vastly different expertise and cultures.

Support civilian authorities: Militaries are not accustomed to acting in a subordinate role to other government agencies and civilian organizations. Most of the organizations involved in this operation did not have the defined decision-making process to which militaries are accustomed. However, at no point did the AFL desire an official leadership role. Instead, the militaries applied influence and leadership through their ability to professionally plan, synchronize and execute large-scale complex operations. This is the best way to support its civilian leadership during a dire time of national crisis such as the Ebola epidemic. The principle concern of the military should be defending its nation, its values and supporting its civilian leadership.

Develop an agreed-upon end state: The key to containing Ebola was developing a team that sought the same end state: halting the spread of the Ebola virus. This goal overcame all bureaucratic rivalries by aligning organizations and resources to achieve the mission. Professional militaries should set the example for their civilian and government counterparts to follow.

Prevention is key: The saying, “an ounce of prevention is worth a pound of cure,” summarizes the importance of readiness. It is vital for the AFL and other militaries in the region not to lose the knowledge and best practices they’ve identified from the difficult experience of the Ebola outbreak. To be better prepared for future outbreaks, militaries should develop an epidemic response plan and conduct exercises that simulate that response. The military can also play a role in ongoing public education efforts to promote hygienic practices and educate Soldiers and civilians about the origins of Ebola and other diseases.

The World Health Organization declared Liberia Ebola-free on May 9, 2015. Since then Liberia has had other outbreaks of Ebola with many more likely in the future. These outbreaks were different because Liberia learned from the first epidemic. This time the responses were timely and effective. It is the AFL’s hope that African militaries also have learned lessons from the 2014 Ebola epidemic in Liberia.