From January 19-27, we traveled to Liberia and Sierra Leone to engage with national leaders, health workers, citizens, non-governmental organization (NGO) implementers, international organizations, and United States, United Kingdom (UK), and other officials, including the African Union (AU), Chinese, and Cuban medical delegations. It was a moment of hope and nervous adjustment, as Ebola cases dropped suddenly and unexpectedly in Liberia, followed by reductions in Sierra Leone and Guinea.

We listened to the reflections of those who lived through and led the mobilization to roll back the unprecedented Ebola emergency, as it raged in the second half of 2014. We sought to understand the latest phase, as complicated efforts have begun to move beyond an emergency response and seek to achieve “zero” Ebola infections in 2015 — while safeguarding against new outbreaks. We discussed briefly early plans for long-term recovery. Across these different phases and concerns, we had a special interest in examining the US contribution.

The visit generated countless conversations with diverse experts who were remarkably gracious, insightful, and candid in their remarks. In this post we share select major impressions we carried home. These opinions are, of course, ours, and ours alone.

Examining Root Causes

First, it is critical to recall just how close Ebola came to winning in 2014 — and why. Unless root causes are ultimately fixed, the danger persists of a recurrent crisis in West Africa and similar regions. The most dangerous factors include: exceptionally weak in-country health capacities; unreliable international emergency response mechanisms; and corruption, malgovernance, and popular alienation.

The Ebola crisis was a harrowing roller-coaster that reached the very edge of a complete runaway catastrophe in August and September 2014. The disease’s impact was deepened of course by its exceptional lethality, its special ability to inspire fear and panic, and the fact that it was utterly alien to the entire region. It jumped rapidly and unexpectedly throughout the three core countries, including their densely populated coastal urban centers. It tore through acutely weak health systems, rapidly killing over 400 doctors, nurses, and other health workers, a shockingly large portion of a preciously small pool of trained health talent.

Ebola thrived given the wholesale absence of capacity within these three countries’ health systems to monitor, detect, and respond to outbreaks. Sierra Leone and Liberia, war-ravaged, and Guinea, a neighboring marginal state, were, collectively, a large exceptionally bare space when it came to preparedness.

Nor was there any effective international response early in the spring 2014, when concerted multilateral action might have halted the outbreak. What these nations saw instead were chaotic, fragmented, ad hoc, halting steps. The Africa regional World Health Organization (WHO) office was incompetent and obstructive. WHO in Geneva had no operational capacities and depleted leadership.  The UN Secretary General created the UN Mission for Ebola Emergency Response (UNMEER), but it got itself on the ground far too late to assert its crisis coordinating mandate in any meaningful way.

Other regional entities, The Economic Community of West African States (ECOWAS), the Mano River Union, the African Union, were of little assistance in the initial emergency. The US Centers for Disease Control and Prevention (CDC) made initial forays into the region in the spring, but to no immediate significant impact. The CDC’s influence expanded dramatically during and after CDC Director Thomas Frieden’s August visit to the region.

The conspicuous standout was Doctors Without Borders (MSF), which became established early in all three countries, courageously provided the bulk of care until new actors arrived in the last quarter of 2014, and voiced its alarm loudly, accurately, and consistently, starting in early 2014.

A crisis of internal governance in each of the Ebola countries created a stark barrier to action and indeed contributed to driving the epidemic underground. As the Ebola outbreak gained momentum, it exacerbated internal political tensions, provoked upheaval, and exposed deep skepticism, alienation and denial in Liberia, Guinea, and Sierra Leone. Pervasive corruption fueled all of these reactions.

Early Ebola outbreaks were concentrated in opposition strongholds, where popular mistrust and contempt for those in power were especially acute. Fear and resistance inexorably deepened, as governments in panic clumsily imposed coercive measures—quarantines, holding units—well before developing their capacities to deliver care. Often as vulnerable and frightened individuals entered quarantine sites, sick or possibly sick with Ebola, they and their family members feared this was merely a step to death.

The consequence of such governance problems was strategic delay: it took an extended period over the course of 2014 for governments, donors, NGOs, and community leaders to penetrate the distrust barrier and effectively reach citizens with appeals to cooperate actively with respect to isolation and containment, case investigation and contact tracing, safe burials, reporting of possible cases, hand washing, and social distancing.

Intervening Big

Second, a full catastrophe was only averted after the United States and UK each ‘came in big,’ in Liberia and Sierra Leone, respectively, beginning in late September and early October. However uncomfortable it may be, the truth is that Sierra Leone and Liberia were rescued through muscular, external military-led interventions. The US was less brazen than the UK, and carefully respectful of its lead civilian agency, the USAID Disaster Assistance Response Team, and its partners in the Liberian Ministry of Health. But at base, the US and UK militaries fulfilled the same essential function — intervening ‘big’ to staunch the crisis.

In each country, it took a military-style hybrid humanitarian/public health intervention, combining military might with external civilian agencies and abundant, quick disbursing finances to reverse the situation. Sovereign sensitivities were temporarily shelved. Restoring sovereignty and national government control, and improving the quality of governance, would await action until later.

In effect, the interventions both rolled back Ebola and inadvertently rescued (at least temporarily) both governments from their separate existential moments of reckoning. Well before the US and UK interventions delivered actual care and treatment, they were nonetheless profoundly forceful in intangible ways, fundamentally altering the psychological and political context. In the late 90’s and early years of the 21st century, the UK and US intervened in various ways to end, respectively, Sierra Leone’s and Liberia’s devastating internal wars. Their re-entry in 2014 signaled that larger powers were again attempting to manage an unraveling crisis.

That step—more than any other action in the halls of the UN Security Council, the African Union, the WHO—made possible the urgent entry of implementing NGOs and health personnel; the importation of mobile laboratories, ambulances, and key commodities; the deployment of burial teams; the communication campaigns to change behaviors around social distancing, hand-washing, isolating and reporting possible cases, and safe burials; and the construction of treatment units and community care facilities. The military-style intervention created the discipline and command structure, under which it became possible to erect incident management systems, half a dozen ‘pillars’ or working groups to develop the operational protocols, and county or district-based operational commands.

Happily, predictions of violent instability were not borne out. The shared memory in both Liberia and Sierra Leone of the chaos and violence of their protracted internal wars was a factor. The US and UK interventions, and the relief that followed, were stabilizing. Quick decisions by the World Bank, International Monetary Fund (IMF), European Union (EU), and the African Development Bank to provide a life-line of budgetary support, including payment of civil servant salaries, were quietly very important in stemming panic. The same was true of the World Food Program’s quick action to deliver food relief to over 1.3 million.

Of the three Ebola countries, Guinea did not experience an external intervention and is, arguably, the wildcard in the region going forward. By comparison with Liberia and Sierra Leone, it has a weaker incident management system, poorer quality of data, transparency and oversight, and weaker case investigation, contact tracing, and safe burials. Fear and resistance remain serious obstacles. As its national electoral cycle unfolds, the national leadership seems increasingly less engaged.

Striving For Zero

Third, a new phase has opened of intensified disease detective work, in hopes of reaching “zero” new cases of Ebola. That is likely to be a long, complicated fight that stretches across 2015 and perhaps beyond. While striving for “zero,” we need to prepare actively for the possibility that Ebola will be endemic to the region over the long term.

The picture today is very positive, dynamic, quite nervous, and uncertain. Ebola cases have dropped significantly, to 124 cases in the last week of January, across Guinea, Liberia, and Sierra Leone combined. Why exactly this is happening is not entirely understood, but no doubt behavior has changed, the quick proliferation of burial teams was critically important, and a new public health infrastructure is in place that did not exist at the height of the crisis in August and September of 2014.

The consensus seems to be that we are not witnessing a simple, linear decline of Ebola cases; a different, more wave-like and variable pattern is quite probable, including recurrent ‘pop-up’ outbreaks spread across the region. In the face of the recent dramatic drop in cases, the focus has shifted swiftly and fundamentally away from large scale treatment units to handle massive emergency outbreaks.

To move to ‘zero’ new infections—an ambitious goal, with an uncertain time line—requires higher quality, more granular case investigations and precise tracing of people who have been in close contact with individuals symptomatic with Ebola. At present, though, these contact lists remain incomplete and problematic. This leaves authorities with limited knowledge of where outbreaks actually originate. The percentage of new Ebola cases which appear on established contact lists is quite low: while in the region, we heard 8 percent for Sierra Leone, 30 percent for Guinea, and 40 percent for Liberia.

Work has begun to downsize and repurpose large expensive Ebola treatment units to provide broader health service benefits. Community care centers and holding units are also being decommissioned. What is needed now is a continued steady state of readiness, nimble rapid response capacities to respond to disparate outbreaks, and a successful return of skilled health workers back into national health systems. Each of these transitions will be difficult and complicated.

There is a heightened focus on putting in place reliable infection controls — especially as efforts move ahead to reopen clinics, hospitals, and schools, many of which were contaminated and which remain at risk of persons symptomatic with Ebola walking through the door.

Attention has turned also to the broader regional context: how to better understand and manage cross-border importation of Ebola? Progress in this critical area is uncertain; there is no regional structure, no clear regional game plan, and no dedicated significant resources to motivate and support enhanced cross-border collaborations.

Perhaps most important of all, officials recognize they need to consolidate the continued cooperation and trust of community leaders. That task will not be made any easier as the Ebola cases decline in number and the perceived threat subsides. Special care is needed to ensure that population-wide communications do not prematurely suggest that zero is right around the corner. It is easy to imagine a dangerous reverse scenario: if there is complacency, if there is a backsliding in the reporting of Ebola cases, if there is a return to unsafe burials, if widespread distrust and skepticism of government again cloud local calculations, the Ebola epidemic could suddenly re-escalate.

US Engagement in 2015

In Liberia, as well as Sierra Leone and Guinea, the United States has earned widespread popular credit and gratitude for its multiple contributions to the Ebola response. The US military has been able to fulfill its core mission and begin an orderly phase down, transitioning responsibilities to other US agencies, NGOs, and international organizations.

US diplomats in the Ebola capitals have been indefatigable. Interagency cooperation in Washington and in the region has been exemplary. Increasingly, US attention is now turning to the next phase of engagement, supported by the ample funding contained in the $5.4 billion emergency supplemental passed by Congress in December 2014.

Thanks to the Obama administration leadership and bipartisan support in Congress, there are sufficient resources available for the next two years to support evolving programs in West Africa. The CDC and USAID are each poised to make additional major contributions. US-supported vaccine field trials, the largest such trials in history, are set to begin.

The problem is not money, political will or commitment. It is how to spend money wisely and plan effectively for a future where US engagement is smart and sustained, and does not fall off suddenly in two years, after the emergency phase has passed.

It will be important not to rush US spending decisions, simply to meet spending deadlines set in Washington. Far more important is to be patient and nimble, guided by evolving realities on the ground and the advice of the US embassies. With continued risk of unforeseen outbreaks and other setbacks, progress towards “zero” is likely to be slow and uncertain.

If “zero” or “close to zero” are ever to be achieved in this next phase, US policymakers must pay close attention to forging a coherent region-wide approach. The United States is in a position to press for a lead organization to be designated and empowered to integrate communications, case investigation/contact tracing, care and treatment, data-sharing, and use of laboratories across borders. Through its strong CDC and USAID presence, the United States is able to operate quite effectively across the region, and offer substantial technical and financial support to a region-wide initiative.

The United States needs to focus on multiple national recovery plans still in their early stages. Liberia, Sierra Leone, and Guinea—motivated to restore national government control and seize the moment while donor interest is still high—are variously preparing such plans for discussion at international meetings planned for March in Brussels, sponsored by the EU and United Nations (UN), in April at the World Bank/IMF spring meetings in Washington D.C., and later in the spring at a session hosted by the UN Secretary General.

Most important for the US at this moment, is to help shape and focus these plans on select top priorities over the next 12 to 18 months with carefully-projected costs. These priorities should include serious requirements for financial management and accountability, and close monitoring of service delivery, recruitment, training, and retention of staff. A core of donor countries and multilateral organizations will be the pivotal supporters of any recovery: the US, UK, World Bank, and EU. In the health sector, the Global Fund and Gavi, the vaccine alliance, will be very important, provided they have the confidence to re-engage at a substantial level.

A Turning Point

Our visit came after 22,487 persons had contracted Ebola and 8,979 persons had died of the disease as of January 21, 2015. Our visit came on the heels of $2 billion in emergency assistance (of which the US contribution exceeded $800 million) and hundreds of millions of dollars in US and UK military investments. And it came at a nervous but promising turning point in the epidemic.

Ebola’s preventable crisis has certainly generated many hard lessons, which will attract intense debate and analysis in the coming years. As the crisis recedes, attention will inexorably return to whether the will exists in Liberia, Sierra Leone, and Guinea to build durable health systems with external support — and whether that can be accomplished while improving national governance. It also remains to be seen whether the will exists globally to create a reliable and competent international system to detect and respond to emerging future threats.