ebola-lessons-cover-print.pdf 1 2/11/19 10:52 AM C M Y CM MY CY CMY K Struggling with Scale: Ebola’s Lessons for the Next Pandemic Jeremy Konyndyk Struggling with Scale: Ebola’s Lessons for the Next Pandemic Jeremy Konyndyk Center for Global Development. 2019. Creative Commons Attribution-NonCommercial 4.0 Center for Global Development 2055 L Street, NW Fifth Floor Washington, DC 20036 www.cgdev.org Photo credits Cover: USAID/ Morgana Wingard Page 5: UN Photo/Martine Perret Page 11: Official White House photo/Pete Souza Page 29: Official DHS/CBP photo/Josh Denmark Page 35: US Air Force/Staff Sgt. Gustavo Gonzalez Page 43: UN Photo/Ari Gaitanis Page 59: USAID/Morgana Wingard Contents Author’s Note . iv Executive Summary . .v Overview ........................................................................................v Summary of Key Findings ..........................................................................v Introduction . .1 Why Does This Research Matter? ....................................................................2 Research Approach .............................................................................. 3 1 . An Ebola Refresher . .5 2 . Mobilizing the US Government Response . 11 Phase 1: Defaulting to Plan A (March–May 2014) ......................................................12 Phase 2: From Outbreak to Disaster, from Complacency to Alarm (June–August 2014) .....................14 Phase 3: Struggling with Scale (September–December 2014) . 20 3 . The Travel Restrictions Debate . 29 4 . “Operations Outstripping Policy”: The Role of the Pentagon . 35 5 . Mobilizing the International Response . 43 6 . Cross-Cutting Lessons . 51 Proactively Adapting to Scale ..................................................................... 52 Seeing beyond Institutional Divides ................................................................55 Recognizing the Importance of the Human Element ..................................................57 7 . Getting Ready for the Next Crisis . 59 General Strategy ................................................................................ 60 US Government Response ....................................................................... 62 Travel Restrictions .............................................................................. 64 The Pentagon’s Role ............................................................................. 65 The International System ........................................................................ 66 Appendix . I . Interview Questions . 69 iii Author’s Note This report explores how the US government and US government and UN policymakers who were closely United Nations (UN) system dealt with the 2014–15 West involved in leading the Ebola response. I am grateful Africa Ebola crisis and addresses the operational and for their input and guidance. Quotes are lightly edited policy challenges in building a massive multinational for clarity and are unattributed in keeping with the outbreak response. It is not intended to be a full-spec- interview ground rules. trum history of the outbreak, nor should it be read to I am indebted to Olivia Nesbit, who provided stellar suggest that international responders were the only research support to the project. I am grateful as well factor in ensuring the eventual success of the response. to the numerous colleagues who reviewed early drafts Ownership of the response by the countries them- of the report and provided important and thoughtful selves, by governments and community members, was feedback. the foundation of success and should be understood Finally, this report would not have been possible with- as a sine qua non of the effectiveness of the eventual out generous financial support from the Open Philan- international response effort. thropy Project, who recognized the importance of The analysis in this report is informed by a series of exploring the operational and policy dimensions of not-for-attribution interviews with high-level former catastrophic disease risks. iv Executive Summary Overview 1. Operationalizing the US government response 2. Balancing the politics and the science of travel The next global pandemic is a matter of when, not if. restrictions Preparing for this inevitability requires that policy- 3. Defining the role of a reluctant military makers understand not just the science of limiting dis- 4. Coordinating complex international partnerships ease transmission or engineering a drug, but also the practical challenges of expanding a response strategy The report draws on interviews with 19 high-level US to a regional or global level. Achieving success at such and UN policymakers, a desk review of after-action scales is largely an issue of operational, strategic, and reports, and the author’s own experiences while lead- policy choices—areas of pandemic preparedness that ing the response efforts of the US Agency for Interna- remain underexplored. tional Development (USAID). The response to the 2014–2015 Ebola outbreak in West Africa illuminates these challenges and highlights Summary of Key Findings steps toward better preparedness. Ebola was a known Design of the Ebola Response disease whose basic transmission pathways and con- trol strategies were understood. Yet traditional Ebola The process of adjusting the Ebola response operation control strategies were premised on small, non-urban to a suitable scale was slow and reactive. The United outbreaks, and they rapidly proved inadequate as the States did not deploy an augmented disaster response disease reached urban environments, forcing policy- team until several months after transmission had makers to develop new strategies and operational plat- started to dramatically accelerate, and it did not deploy forms for containing the outbreak, which generated military assets until more than another month after unique policy challenges and political pressures. Lack- that. The UN was similarly slow in classifying the out- ing a blueprint for controlling Ebola at scale, response break as a Public Health Emergency of International leaders scrambled to catch up as the disease began Concern and in announcing an enhanced response. threatening the wider West African region. These delays afforded the disease an enormous head start, greatly complicating the task of containing it. This report explores the lessons of the Ebola outbreak Even when the United States and UN expanded their through the lens of the US and UN policymakers who efforts, there was little understanding of what strate- were forced to construct an unprecedented response gies and structures would prove most useful. in real time. It tells the story of their choices around four major policy challenges: v In a future pandemic, the world is unlikely to have better articulated and tied to training, exercises, the luxury of a protracted real-time planning process. and cross-institutional relationship building. The US government and UN system should invest and n Leadership structures and competencies. As strat- engage in advance planning across several major oper- egy shifts and operational composition expands, ational elements, including the following: the type of leadership required to effectively n Trigger indicators. The US and UN should invest in manage the response changes as well. A complex mechanisms for systematically monitoring and response operation will entail multiple areas assessing the adequacy of an outbreak response of expertise—medical, logistical, behavioral, operation relative to the trajectory of an out- political—that no single person will possess. An break, and tying this to thresholds at which an effective leader will need process management elevated response would be triggered. Indica- expertise and political savvy, while leaning on tors might include factors such as mass infec- and enabling a team that possesses a range of tions of health workers, accelerating spread of a relevant expertise. Given this diversity of play- disease with no available medical countermea- ers, leaders will need to focus on aligning and sures, inability to trace and monitor contacts enabling the component parts of the response of infected people, severe disruptions to in situ without second-guessing their respective areas health systems, or major second-order impacts of expertise. Structural choices matter as well: on economic and political stability. constructing a new leadership institution in real time, as the UN attempted to do for Ebola, is n Strategic shifts. There is an urgent need for more likely to be more cumbersome and less effective rigorous advance planning across different dis- than the US government’s approach of iterating ease scenarios to determine how containment from existing systems and relationships. strategies will need to change at different scales of transmission. Some tactics that work on a modest scale may be amenable to rapid expan- Mobilizing the US Government Response sion, but others will hit bottlenecks as logisti- Ebola laid bare the inadequacies in US government cal challenges and personnel limitations assert preparedness to manage a major global outbreak. themselves. The Ebola experience suggests The structures for managing the international and strongly that behavior-centered interventions domestic elements of a disease threat proved to be may prove more rapidly scalable than traditional disconnected, with inconsistent authorities, inade- medical interventions, which tend to be more quate contingency planning, and insufficiently nimble labor-intensive