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Story Publication logo February 17, 2015

Hearts, Minds, and Ebola: The US Army Drops in on Liberia


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To assist Liberia in containing Ebola, the US turned to its soldiers from Iraq and Afghanistan from...

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Achie Ponpon is a "Big Man" of West Point, a leader in the shantytown that sits on a sandy peninsula poking out into the Atlantic Ocean from Liberia's capital city of Monrovia. He is 30 years old, short and thin, his skin stretched like canvas on a wooden frame. As we walked along the beach on a sunny New Year's Eve morning this past December, Ponpon helpfully pointed to hazards. "Feces," he repeatedly said, and I repeatedly avoided stepping in it. The tide would eventually carry it all away.

Eighty thousand residents squeeze into West Point's .15 square miles, and there is no plumbing. It's an ideal spot for the spread of disease. Last August, at the height of the Ebola crisis in Liberia, West Point was quarantined. Police in riot gear marched in on the slum's sole road, pushing back anyone trying to escape. They set up a barbed wire gate, and for weeks, people on the outside would bring food and hand it through the fence to desperate and starving family members inside. When the quarantine was lifted, West Point celebrated a new Independence Day, dancing in the rain in the public square.

During our stroll, a US Army Blackhawk helicopter flew overhead. Pilots cruise over the coastline to enjoy the scenery while traveling in and out of their main Monrovia base. When the first soldiers arrived in early October, Ponpon traveled to Roberts International Airport to see them for himself. "The US Army, they bring hope," he said. "They should come to West Point. They should patrol in West Point. I feel warm when I see them, not political. They are only here to help."

* * *

On September 16, President Barack Obama announced that the US Army would deploy to Liberia. As if a war were coming, two weeks later the Washington Post ran the headline "The US Military's New Enemy: Ebola." But for most people — Americans and Liberians alike — it's not clear what the military has been doing there for the past four months. Blame it on Outbreak, World War Z, or any other film that involves a military response to a horrific virus.

The army's battle against Ebola did not look like a war. Helicopters flew no dead bodies or Ebola patients, or even blood samples. Combat medics treated no sick people. Soldiers didn't rescue victims from streets, or enforce quarantines, or provide armed security against mobs crazed by fear and illness.

Instead, the army put up Ebola Treatment Units (ETUs) and taught Liberians how to work in them. They set up blood labs in remote villages and hired local drivers to move supplies. Ponpon never encountered the army in West Point because most soldiers rarely left their bases.

The US Army's fight against Ebola in Liberia is not done, but it is wrapping up months earlier than planned. On February 10, the White House announced that the bulk of the military would come home by the end of April. Aid workers and military leaders alike point out that Liberian officials declared victory prematurely in Spring 2014, shortly before Ebola came roaring back. No one wants to be proven wrong again, so they are cautious.

"Cautiously optimistic," said Major General Gary Volesky, commander of Joint Task Force - United Assistance. While the US Agency for International Development (USAID) is in charge of the overall American effort in Liberia, Volesky's task force of nearly 3,000 soldiers from the 101st Airborne represents the most visible aspect of the response, which is the US government's largest-ever mobilization to fight a global health crisis.

Ebola has caused 9,200 deaths after an estimated 23,000 infections in West Africa; more than 85 percent of all Ebola deaths in recorded history have occurred in the last 11 months. In late September — two weeks after Obama announced he was sending troops to Liberia — a Liberian named Thomas Duncan who was visiting family in Dallas was diagnosed with Ebola, sparking a panic that gripped much of the US.

The latest outbreak is now nearly vanquished in Liberia. For its part, the US government has spent more than $1 billion. The army has already sent 1,500 soldiers home, and the ETUs they built sit mostly empty. Officials cite new-cases-per-day as the most important metric in tracking progress when battling a disease. When the army arrived in late October, there were 30 new confirmed Ebola cases per day in Liberia. In mid-January that number was down to one per day. By February the rate of new infections in the country had fallen even further.

* * *

Volesky is lean and ruddy, with a generous smile. He assumed command of the task force on October 25, five weeks after Obama announced the deployment of US troops to West Africa. Volesky didn't have time to study Liberian history in depth, or to become a student of the country's tribal affiliations and at-times rocky relationship with the US. So to get a sense of the current situation on the ground, he and some of his top staff instead did a video teleconference with several Non-Governmental Organizations (NGOs), including Médecins Sans Frontières/Doctors Without Borders (MSF).

Aid groups generally choose between one of two models when working in conflict zones. Some, such as the Red Cross, attempt to work with nearly everyone regardless of their history of violence or political leanings. (This includes attempts to open dialog with the Islamic State in Syria.) Other groups, like MSF, traditionally don't work with anyone carrying guns. But MSF broke that rule to meet with the US military on Ebola.

When the teleconference was done, Colonel Ned Bailey, the commander of the 101st Airborne's military hospital, turned to Volesky. "That was historic," he told his boss.

Upon arrival, Volesky established his headquarters at the Barclay Training Center, home of Liberia's Ministry of Defense in central Monrovia. The post lies on the beach in a depression between two hills: To the east is the abandoned Executive Mansion, to the west the bombed and looted Ducor Palace Hotel, both decaying monuments to 25 years of political unrest, including a brutal 13-year civil war.

Much of the planning for the army's response was completed by military engineers from the European-headquartered Africa Command before soldiers arrived. The Liberian government asked the US to build one ETU per county, for a total of 15. An initial plan to build 17 ETUs was downsized almost immediately, as Liberian officials realized that infection rates had already begun to drop. Volesky's engineers estimated they had the capacity to build about three ETUs a month. To speed construction, and to avoid needlessly deploying more soldiers, the Army Corps of Engineers contracted out much of the work.

In the end, uniformed soldiers built four Ebola treatment centers themselves, in Tubmanburg, Sinje, Buchanan, and Gbediah, towns that are all close to Monrovia. The 11 other ETUs in more inaccessible locations were constructed by large American engineering firms like Fluor. After the army finishes construction, it can take weeks for USAID and their NGO partners to staff, outfit, and customize the army's basic clinic for Ebola treatment. With the outbreak waning, the Liberian government has charged that the response was too late. US officials counter that they are giving the Liberian government the capacity to fight a future outbreak on their own. Once the rainy season comes, however, the wood frames and fabric structures of the ETUs won't last last long without regular maintenance.

The second major piece of the US Army's mission has been preparing medical personnel to safely work in an ETU, teaching them how to correctly use safety gear — most healthcare workers who became infected did so because they removed their Tyvek hoods incorrectly — and deliver effective care without accidentally contaminating themselves. At the start of the outbreak, before protocols were standardized, healthcare workers were 100 times more likely to get Ebola than average citizens.

Bailey's teams traveled to 12 small villages to give classes, but most of the training occurred at the National Police Training Center in eastern Monrovia, a half-abandoned collection of barracks built years ago by the United Nations. A partially completed indoor basketball court was converted into a mock-up ETU, where students were led through drills.

In total, the army has trained 1,539 healthcare workers — a mixture of locals and international staff — including 136 Cubans. "Fortunately, they arrived after the president's embargo announcement," Bailey said.

Every nurse, spray team member, ETU administrator, and government official with whom I spoke agreed that the training was excellent and went far beyond the courses provided by the US Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO).

"The training was very vigorous," said Joyce Garblah, the health services administrator for Grand Bassa County, home of Liberia's third largest city, Buchanan. "If you made a mistake in a spot, and then made the same mistake… you were dropped."

Though army medics taught others how to use gear, they never had to use it themselves. A standing order from Volesky prohibits every soldier from so much as entering an ETU.

"I don't feel like we've fought Ebola," said Staff Sergeant Jason Smith, a veteran of both Iraq and Afghanistan who was in charge of one of the training teams. "I feel like we've enabled people to fight Ebola."

* * *

Most soldiers had very limited interaction with local Liberians. Sequestered behind the concrete walls of the Barclay Training Center, and with few opportunities to leave — there are occasional trips to the US Embassy for cheeseburgers and a swim in the pool — the soldiers would cluster at the southern gate and enjoy the breeze.

"I'm not on guard duty," said Captain Peter Hendrickson one oppressively hot and humid day while standing by the gate. "I just like to look at the ocean."

The soldiers call the gate Redemption Gate, and the beach Redemption Beach. A few feet away from where Hendrickson and others stood, young boys played soccer in the sand. In 1980, coup d'etat leader Samuel Doe, the head of the People's Redemption Council, had 13 members of the cabinet of the previous government paraded naked through the streets, tied to poles, and then shot on the same beach.

The only base where soldiers are regularly allowed to leave is 100 miles south of Monrovia at the main port of Buchanan, a town dominated by container ships and an iron ore rail yard. Logistics soldiers stationed at Buchanan drive military trucks between the port and the international airport an hour away. They're also allowed to go running on a single quiet paved road outside of town.

"The difference between Liberia and my combat tour experiences was that we are not trying to win the hearts and minds of the people — we already have them," said Sergeant Major Robert Mattson, who oversees operations at the port.

That's mostly true.

"With so many of them here, we are asking ourselves, what are they still doing here?" Garblah, the local Liberian health administrator, told me. "They are on the road a lot, bringing huge equipment, lots of stuff in containers — I don't know what are in those containers. When we ask, they say they are here to construct the ETU, but now the ETU construction is completed, and we are still seeing them. So for me I don't really know why they are still here. Maybe you could ask them?"

But Buchanan chief education officer Edwin Kwakpae echoed sentiments I heard from far more Liberians.

"We have seen the US military in the street here," he said. "I don't go very close to them. I have not spoken to any of them. But I have heard that they have come to help us with this epidemic. So we thank them for that. I see them pass there, near my office…I wave to them."

In Monrovia, schools are open, markets are full, taxis carry passengers, people again shake hands, and once-ubiquitous chlorine wash buckets are disappearing. Local Liberians almost universally give credit to the US military. They just do so from afar.

* * *

Liberia was settled in the early 1800s by free black Americans who modeled their government on that of the United States. (Monrovia is named after US President James Monroe.) The idea for Liberia was championed in the US by both progressives and slave owners who felt everyone would be a lot happier with free black Americans in Africa. Nevertheless, Liberians felt a kinship with the United States. The feeling, however, did not appear to be mutual.

In 1847, Britain began to annex portions of Liberia — still a private colony largely controlled by a US group known as the American Colonization Society — adjacent to Britain's colony of Sierra Leone. Seeking an ally against the Brits, Liberia asked to be formally named a colony of the United States. When America refused, Liberia instead declared independence to avoid being consumed by Britain. For the remainder of the 19th century, Liberia repeatedly asked America for military assistance to deal with invasive neighbors and European colonial powers. The US repeatedly said no.

When Doe was overthrown in 1990 — the start of 13 years of nearly continuous civil war that would claim the lives of more than 500,000 people — US Marines landed only long enough to evacuate American citizens and Lebanese businessmen. The same thing happened in 1996 and 2003; Secretary of State Madeleine Albright said it was the policy of the United States to let Africa solve African problems. According to reports from the time, Charles Taylor, the rebel commander and eventual president of Liberia, said that if the US had deployed a battalion of marines in central Monrovia, he would have surrendered, ending the fighting before it began.

* * *

Many international aid workers will admit, when pressed, that they weren't prepared for the scope of the Ebola crisis in Liberia.

Thomas Boegli is a Swiss logistics expert with the International Committee for the Red Cross in Geneva who recently completed a tour in Monrovia where he consolidated Red Cross warehouses. "Most groups will grudgingly admit that they were too small and too little," he said. "But now that we have built, we won't be caught again. The world is aware of what happened here. The Red Cross will be in Liberia forever."

That too-small response began in the spring and early summer of 2014, and continued as caseloads began to rise through June and July. By August, quarantines were in place, including the one police enforced in West Point with razor wire and batons. Whole villages were cordoned off in the interior of the country. Dead bodies lay abandoned in the streets.

A number of public health interventions ultimately reversed this trend, but according to a recent CDC report, the isolation of patients was the decisive factor, and data suggests that the seriousness of the outbreak bore a simple inverse relationship to the number of ETU beds in the country: the more beds there were, the lower the rate of new infections. The beds that initially turned the tide were in ETUs constructed by aid organizations and the Liberians themselves.

When Ebola crossed over from Guinea into Lofa County, in far northern Liberia, in March of 2014, MSF set up an isolation ward almost immediately. In April, another center was established in Monrovia at an old chapel that would come to be known as ELWA1, after the Eternal Love Winning Africa ministries compound it occupied. MSF took over the management of ELWA1 in the summer, and as the number of cases of Ebola grew, the facility quickly became overwhelmed.

Other ETUs would open, but not quickly enough to keep up with the rate of infection. According to WHO, in July there were 30 new confirmed cases of Ebola a day in Liberia, nearly all of them in Monrovia, and only 100 isolation beds for Ebola patients in the city. The Liberian government opened ELWA2 on July 20, then shut down the massive JFK Memorial Hospital to convert it into an ETU on August 17.

USAID sent a Disaster Assistance Response Team (DART) to West Africa on August 6. The team consisted of only 40 or so bureaucrats and managers spread between Liberia, Sierra Leone, and Guinea — but they leveraged more than 10,000 aid workers, including almost 5,000 in Liberia alone, by partnering with NGOs.

Other US agencies arrived, including the CDC, which began testing blood in late August. As MSF began construction on a third ETU dubbed ELWA3, the situation grew worse: more than 50 new confirmed cases of Ebola a day in late August, 70 per day in early September.

Then, finally, the number of ETU beds started keeping up with infection. USAID opened its first ETU on September 17 in the town of Bong. Ebola patients from rural areas had been spreading the disease as they attempted to travel to Monrovia for treatment; opening a site outside of the capitol reduced migration and therefore infection. On September 20, the Liberian government opened the Island Clinic ETU just north of West Point. At about the same time, ELWA1 and ELWA2 enlarged their capacities. Monrovia now had 500 beds in four main ETUs.

Three days later, using infection rates from August, the CDC announced that at the current rate of infection, there would be 1.5 million cases of Ebola in Liberia in three months. But the outlook would turn out to be wildly inaccurate. A later CDC report would cite mid-September as the worst of the outbreak. Every trend line improved from there.

When things seemed most dire is when the crisis was actually turning the corner. But given the chaotic nature of an undertaking like fighting Ebola in West Africa, it would have been nearly impossible for officials to see this. And so in the middle of that key week, Obama announced the deployment of the 101st Airborne. The announcement that America was intervening coincided exactly with the disease receding — a significant fact for many Liberians, even if the two weren't necessarily related.

"Island Clinic was the tipping point, no doubt," said Sister Barbara Brilliant of the ETU opened by the Liberian government on September 20. Brilliant, the dean of the Mother Patern College of Health Sciences and a pillar of the fragile Liberian medical system, is seated in her spacious office in the diplomatic quarter of Monrovia. With short grey hair, round glasses, and a traditional African shirt in place of a habit, Brilliant is a nun who acts like a CEO. In the hour we spent together, she was a multi-tasking machine: signing forms, answering radio calls, directing staff, and giving orders on the phone in a New England accent untouched by 37 years spent living in Liberia.

The Catholic diocese of Monrovia runs 18 hospitals and clinics. The cornerstone of the system, Catholic Hospital, had to close during the worst of the crisis after nine staff members died within three weeks. But 14 clinics stayed open, and that's the sort of thing Brilliant credits for ending the Ebola crisis.

"These private little places, all over the country, they did the hero work by simply staying open," she said. "They triaged, directed people away from the ETUs that didn't need to be there. People were scared, they had no equipment, but they stayed open anyway."

Those small clinics also drove public education campaigns, teaching people to look for the signs and symptoms of the disease; Ebola Is Real billboards still dominate advertising space in Liberia.

"When it got bad here, it was because of the burials," she said, referencing the Liberian funeral rites that involve elaborate washing and dressing rituals. It took months to convince the majority of families to cease handling dead bodies.

USAID and WHO opened their second ETU, at the former Ministry of Defense, on October 31, giving Monrovia another 200 beds. Ten days later, the US military opened its first ETU in Tubmanburg, which had been under construction by the Armed Forces of Liberia before the US Army arrived. At that point, there were 30 confirmed new Ebola cases a day in Liberia — down from a high of 70.

The first ETU the US Army built from start to finish was in Buchanan. They finished it November 22, but the local NGO who staffed it didn't begin accepting patients until December 22. Buchanan's last confirmed new case of Ebola had been on December 12.

Still, Brilliant gives credit to the US Army. "I don't think by ourselves we could have done it," she said. "People were scared. We couldn't get people in [for treatment] or the ETUs open."

Other countries opened treatment centers as well — Cuba, China, Germany — but Brilliant said that for locals, the only country that mattered was the US: "Liberia is America's stepchild. Once they announced the army was coming, everyone felt better."

Gerry D. Momoh works in a body removal team for the Liberian Red Cross. In July and August, he said that he personally picked up 40 bodies a day from just one ETU. "There were finally enough ETUs in October," he said, his assessment dovetailing with what statistics show. "But when the army said they were coming, that is when we had hope."

* * *

A country is officially declared free of a disease only when there are no new cases for twice as long as its incubation cycle; Liberia will be officially Ebola-free when 42 days have passed without a new case. The clock hasn't started ticking yet, and outside of Monrovia, ETUs are still opening. But their purpose doesn't necessarily have anything to do with the current outbreak.

"What it gives is the future capacity for Liberia to deal with those cases on the outside of the city — that first line of defense," Volesky said. "So now Liberia has a capability of dealing with it on their own instead of calling DOD to come back in."

As an example of the system working, Volesky cited Grand Cape Mount, a county near the Sierra Leone border. In December, a local imam began practicing a ritualistic laying-on of hands to cure Ebola; in the process, he infected more than 50 people before he and much of his family died of the disease. The ETU there, in the small hamlet of Sinje, became the busiest in the country, containing the outbreak locally.

The challenge, according to Brilliant, is now to transition Liberia out of what has become a healthcare system that effectively treats only Ebola. The German ETU, for example, is attempting to convert into a small hospital and use its isolation wards for other diseases.

Volesky did multiple tours in Iraq and Afghanistan. I asked him — probably unfairly — if it felt good to be winning for a change. He set his jaw.

"Maybe I'm a little jaded, but I feel we've won everywhere we've gone," he said. "I felt we won in Iraq. I felt we won in Afghanistan. I guess winning is how you define it."

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