In 2014, an unprecedented outbreak of Ebola virus disease in Liberia, Sierra Leone, and Guinea shined a harsh spotlight on global capacity to deal effectively with a fast-moving epidemic that crossed international borders.  By the end of July, the outbreak had started to overwhelm health care systems in all three affected countries. In Liberia, health centers began to close, and President Ellen Sirleaf appealed for help from the United States. President Barack Obama tasked USAID’s Office of US Foreign Disaster Assistance (OFDA) to lead an interagency response. From early August 2014 to January 2016, an OFDA Disaster Assistance Response Team, or DART, deployed to Liberia to help coordinate efforts to stop the spread of infection. The DART was the first to involve a large-scale partnership with the US Centers for Disease Control and Prevention (CDC) to combat an infectious disease outbreak. Although the deployment, which scaled up earlier assistance, took place five months after the first reported cases and required extensive adaptation of standard practices, it succeeded in helping bring the epidemic under control: the total number of people infected—28,616—was well below the potential levels predicted by the CDC’s models. This US–focused case study highlights the challenges of making an interagency process work in the context of an infectious disease outbreak in areas where health systems are weak.

Jennifer Widner drafted this case study based on interviews from August 2016 to August 2017. The case is part of a series about the Liberian response to the 2014 Ebola outbreak, available through the Innovations for Successful Societies website. Case published June 2018. IBM’s Center for The Business of Government helped finance this case study.

The report “Responding to Global Health Crises: Lessons from the U.S. Response to the 2014-2016 West Africa Ebola Outbreak” is a version of the “All Hands on Deck” case produced in partnership with the IBM Center for The Business of Government. 

The DART was the first to involve a large-scale partnership with the U.S. Centers for Disease Control and Prevention (CDC) to combat an infectious disease outbreak. Although the deployment, which scaled up earlier assistance, took place five months after the first reported cases and required extensive adaptation of standard practices, it succeeded in helping bring the epidemic under control: the total number of people infected—28,616—was well below the potential levels predicted by the CDC’s models. This U.S.—focused case study highlights the challenges of making an interagency process work in the context of an infectious disease outbreak in areas where health systems are weak.

For more information on the IBM Center for The Business of Government, please visit: www.businessofgovernment.org

In mid 2014, health-care services in Liberia were being overwhelmed by the largest-ever outbreak of Ebola virus disease. Transmitted through contact with the bodily fluids of an infected person, the disease was spreading at a rate of 80 new cases per week by the end of July, killing up to 70% of the people it infected. The country’s fragile health-care system, damaged by a 14-year civil war, could not respond to all of the demands it faced. The rate of new infections rose, and schools and health facilities closed. Collaborating with international partners and five months into the epidemic, the Liberian government created a dedicated Incident Management System (IMS) to coordinate all elements of the country’s fight against the disease. The IMS team created a clear decision-making framework, provided responders with adequate infrastructure and technical support, and set up a coherent procedure for communicating with a frightened and anxious public. At the end of the outbreak, the question was whether Liberia’s approach had provided a model for managing responses to infectious disease outbreaks in other, similar settings or whether the approach had left room for making the system work better.

Leon Schreiber drafted this case study in consultation with Jennifer Widner of Princeton University based on interviews conducted in Monrovia, Liberia and London in November and December 2015.

Princeton University’s Grand Challenge supported the research and development of this case study, which is part of a series on public management challenges in the West African Ebola Outbreak response.

Timeline: West African Ebola Outbreak (poster infographic)

Timeline: West African Ebola Outbreak (page version)

When an outbreak of Ebola virus disease began to spill over national borders in West Africa in 2014, halting the epidemic depended as much on logistics as on addressing the medical challenge the virus posed. As the rate of infection in Liberia rose in June and July, J. Dorbor Jallah of the government’s Incident Management System knew that without chlorine, protective gear, and other critical items, it would be impossible for doctors and nurses to work safely. But Jallah faced obstacles at every level of the supply chain. Uncertain estimates of need, competing product standards, and limited vendor partnerships initially hampered procurement. Cargo volume strained capacity at ports of entry, and warehouse space was inadequate—or nonexistent. The country’s limited road network hampered the transport of materials to rural areas during the rainy season. At clinics, safe disposal of contaminated items presented additional difficulties. And to make matters worse, responding organizations all had different policies and approaches. After initial disarray, the Liberian government, international organizations, nonprofit groups, and private companies began cooperating to simulate some of the features of a centralized and integrated supply chain. The volume, speed, and responsiveness of delivery increased across Liberia—just as the epidemic began to wane. The experience triggered a search for innovations that could address similar constraints more effectively during any future infectious-disease outbreak whether in Liberia or elsewhere. 

David Paterson, Jennifer Widner, and staff drafted this case study based on interviews conducted in Liberia and other countries from 2015 to August 2016.

Pfizer Inc. supported the research and development of this case, which is part of a series on public management challenges in the West African Ebola outbreak response.

Timeline: West African Ebola Outbreak (poster infographic)

Timeline: West African Ebola Outbreak (page version)

When Ebola crossed into Liberia in early 2014, the West African nation had few defenses. Because no effective vaccine was available at the time, the only way to limit the spread of the viral disease was to restrict physical contact with those who were infected, what they had touched, and the bodies of victims. But that advice countermanded the most basic of human instincts: to comfort a sick child, hug an ill relative, or shake hands with a friend or coworker. The challenge of changing human behavior was especially difficult because Liberia was still recovering from a long civil war. Public distrust of government, persistent rumors, linguistic diversity, and limited communication capacity hobbled efforts to send a clear public message and win citizens’ cooperation. After top-down tactics—including forcible quarantines of whole communities—failed to stem the rate of infection, a small team of Liberian officials, supported by international partners, realized that effective steps to contain the disease would require active participation by citizens themselves. The officials engaged Liberians in developing an information campaign and recruited people throughout the country to visit their neighbors door-to-door, explain the steps people could take to protect themselves, and respond to questions. Although the complexity of the Ebola response and the volatility of the outbreak had made it hard to measure the success of the social mobilization effort in reducing new infections, an analysis of timing together with anecdotal evidence strongly suggested that the effort helped save lives and contributed to the disease’s decline during the final months of 2014.

Leon Schreiber drafted this case study based on interviews conducted in Monrovia, Liberia in April and May 2016, with guidance and additional information provided by Jennifer Widner and Beatrice Godefroy.

Princeton University’s Health Grand Challenge supported the research and development of this case study, which is part of a series on public management challenges in the West African Ebola Outbreak response.

Timeline: West African Ebola Outbreak (poster infographic)

Timeline: West African Ebola Outbreak (page version)

When the first cases of Ebola virus disease appeared in Liberia at the end of March 2014, a critical first step in preventing an epidemic was to identify those who had contracted the virus. However, Liberia’s disease surveillance capacity remained feeble in the wake of a 14-year civil war that had weakened the health system, and citizens’ distrust of the government sometimes raised risks for public health teams dispatched to carry out that vital surveillance function. In August, as the number of new infections began to escalate, the government and its international partners shifted to a proactive strategy. Rather than wait for families to call for help, they began to engage local leaders and community health workers in hunting the disease. They also developed data management practices to more effectively track and analyze the evolution of the epidemic. By year-end, most of the new Ebola infections involved Liberians who were already under observation. In another important measure of success, the time between patients’ onsets of symptoms and their medical isolations shortened markedly. The ability to hunt down Ebola slowed the spread of the disease and helped bring an end to the epidemic in May 2015.

Leon Schreiber and Jennifer Widner drafted this case study based on interviews conducted in Monrovia, Liberia, in April and May 2016 and with international organizations from June to August 2016. Béatrice Godefroy provided initial guidance.

Princeton University’s Health Grand Challenge supported the research and development of this case study, which is part of a series on public management challenges in the West African Ebola Outbreak response.

Timeline: West African Ebola Outbreak (poster infographic)

Timeline: West African Ebola Outbreak (page version)

At the end of March 2014, the nongovernmental organization Médecins Sans Frontières warned that an Ebola virus disease outbreak on the border between Guinea and Liberia could unleash an epidemic of unprecedented scale. Its capacity still limited after a 14-year civil war, Liberia’s government was struggling to mobilize and coordinate the extra assistance its health ministry needed to respond. How to recruit, train, protect, and pay a labor force that included government employees, temporary workers, and many international volunteers were central concerns. In the best of times, coordinating this kind of skills supply chain would be challenging. But from June to the end of August, conditions became increasingly difficult. As the infection spread, many health workers died. In the absence of facilities and equipment that could provide protection, fear slowed recruitment—a problem made worse by severely constrained medical evacuation services and reduced airline access. Mobilizing personnel to respond raised questions about how to fulfill a duty of care toward employees, adhere to commitments to equality, and promote longer-term institutional sustainability. The Liberian government, UN agencies, and a wide variety of other organizations worked together to identify and deploy essential skills, develop shared practices, and find ways to pay Liberian temporary workers whose support was essential. UN organizations alone recruited and deployed 19,367 staff during the crisis, including Liberians, but questions remained about how to best meet the ethical and practical challenges that arose.

David Paterson and Jennifer Widner drafted this case study with advice from Béatrice Godefroy.

Princeton University’s Grand Challenges program supported the research and development of this case study, which is part of a series on public management challenges in the West African Ebola outbreak response.

Timeline: West African Ebola Outbreak (poster infographic)

Timeline: West African Ebola Outbreak (page version)