Health Diplomacy Lessons from the Last Ebola Outbreak
The reduced U.S. capacity to respond to infectious diseases makes the current crisis more challenging.
The World Health Organization (WHO) may have declared the current Ebola outbreak in Africa a public health emergency of international concern faster than it did during the last crisis in 2014, but the virus spread undetected for weeks before that. A rare type known as Bundibugyo in the eastern Democratic Republic of the Congo (DRC) has already claimed at least 134 suspected deaths, with more than 500 suspected cases.
In 2014, the Obama administration mounted an unprecedented effort to combat Ebola in West Africa. While experts from the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) played a critical role, most of the decisions that would prove truly consequential for the mission’s success had to do with policy and diplomacy.
Can the lessons from that response, which helped save tens of thousands of lives, contain and end the current crisis? It’s difficult to be optimistic when many crucial elements that made a difference 12 years ago have changed: the Trump administration pulled the United States from the WHO, dismantled the U.S. Agency for International Development, and fired hundreds of experts and diplomats from the CDC, HHS and the State Department.
One of the key officials during the 2014 effort was Jimmy Kolker, assistant secretary for global affairs at HHS. A former Foreign Service officer, Kolker had served as ambassador to Uganda when the George W. Bush administration launched the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 and spearheaded its implementation in the African country.
Today, Kolker teaches at the Washington International Diplomatic Academy, which I lead, and wrote the chapter on health diplomacy in “Diplomatic Tradecraft,” the book I co-wrote and edited.
His first-hand account of the 2014 Ebola response is as instructive as it is insightful, and I’m including it below.
The WHO was overwhelmed as it tried to help Liberia, Guinea and Sierra Leone deal with an Ebola outbreak in 2014. The virus was spread by contact with bodily fluids and had a fatality rate between 25 percent and 90 percent in past outbreaks, depending on the circumstances and the response.
Being deferential to the affected countries’ governments, which tried to avoid acknowledging the severity of the disease for weeks, the WHO delayed declaring a health emergency.
In Washington, the first questions the White House asked us at HHS were, “What are the U.S. interests?” and “Is this our problem?” Although two American aid workers had been infected with Ebola in Liberia and we evacuated them to the United States, there had been no domestic transmissions and the immediate risk for Americans was almost nonexistent.
So was the crisis in West Africa our problem to solve? CDC personnel flew to West Africa to assist with response efforts, including surveillance, contact-tracing, data management, laboratory testing and health education. But what about treatment of infected patients?
Based on reports from the field, our experts projected that the spread of Ebola was outstripping any ability to treat it, and that it posed a serious threat to all of Africa, with substantial risk to Europe and North America, due to travel patterns. It became apparent that, sooner or later, the virus would cross the Atlantic unless we did something. But what would be the most effective approach?
The charity Doctors Without Borders was treating about half of the Ebola patients in the three African countries, and its physicians and nurses needed to double the number of treatment centers. They knew that additional health workers, especially from overseas, would be much more likely to step up if there were a modern facility where they could receive skilled care in case they got infected.
Since such a center did not exist, it had to be built. In spite of its longtime reluctance to cooperate with armed forces, the charity became an unlikely advocate for using the U.S. military’s logistical capacity to deliver materials for treatment facilities, including an Ebola-care field hospital.
President Barack Obama authorized the military to help build rural treatment outfits and a more sophisticated center in Liberia. Britain and France would convert existing hospitals in Sierra Leone and Guinea, respectively.
The facility in Liberia would be staffed by the U.S. Public Health Service (PHS), a uniformed corps of about 6,000 with military rank, under HHS authority. Its members had full-time jobs, and we could deploy only a limited number at a time — we decided on 75 for six-week rotations. But before they could go to Liberia, there were 16 conditions we had to fulfill. Some of them were medical, such as specialized training for Ebola, but most had to be addressed by diplomats and policymakers.
We had to arrange authorization for the PHS workers to practice medicine and prescribe medication in Liberia. We had to determine whether the new center would provide the same standard of care as the few U.S. hospitals that offered Ebola treatment, as well as who would have access to the facility if infected with the virus. It was supposed to be only for health workers who themselves needed advanced care.
But who counted as a health worker? Did a cleaner at a rural clinic count? What about a financial officer for a health organization with an office in the capital, Monrovia?
We decided that a cleaner should be eligible, but not the financial officer. There were other urgent questions that had to be answered: Who would provide security at the new hospital? Where would the PHS staff be housed? How would they be transported? How would they get fresh water? The U.S. Embassy took the lead on making those arrangements, and my office in Washington provided guidance on other potential scenarios that could arise.
Even before the facility opened, it gave confidence to health workers from several countries that they would have access to excellent care if they contracted Ebola, and hundreds of them went to Liberia to treat those who had fallen ill. In the end, thousands of patients received treatment thanks for the unified U.S.-Liberian response to the crisis.
While we consulted with scientists and medical experts every step of the way, the majority of the decisions we faced were policy and diplomatic ones. We made them with help from the U.S. ambassador to Liberia, Deborah Malac, and her embassy colleagues, as we balanced resources, ethics and expectations.
By the time the Liberian government declared an end to the epidemic in 2016, 4,810 Liberians had died, a number that was much lower than expected at the start of the outbreak. In the United States, in addition to the two health workers mentioned above, 11 people were treated for Ebola, most of whom had been infected in West Africa. Two of them died.
Both The Diplomacy Notebook and The Diplomacy Podcast are free, but you can show your support by making a donation to help us continue to produce unique and timely content.
Nicholas Kralev is the founder and executive director of the Washington International Diplomatic Academy, and a former Financial Times and Washington Times correspondent. His books include “Diplomatic Tradecraft,” “America’s Other Army” and “Diplomats in the Trenches.”