Archie C. Gbessay, coordinator of the Active Case Finders and Awareness Team in West Point, a large slum in Monrovia, Liberia, discusses efforts to combat Ebola with his team in a school classroom in September. (Michel du Cille/The Washington Post)

The news out of West Africa in recent days — good and bad — has demonstrated a fundamental challenge in the fight against Ebola: The virus is more nimble than the human response to it. The landscape of infection and disease has changed dramatically in recent weeks, even as institutions have largely stuck to blueprints drafted months ago.

The looming question now is whether governments and other organizations can find a way to become as agile as the virus, which has vanished suddenly in some hard-hit places while erupting just as quickly in new locations.

The first Ebola treatment unit built in Liberia by the U.S. military is expected to open in the coming days, about two months after President Obama announced that he would send troops to supplement the civilian effort against the disease. But even before that first ETU has become operational, Liberia has seen a sharp drop in new infections and has empty beds in Ebola wards. The new ETUs, temporary structures that can’t easily be used for anything else, may not treat many patients.

Up the coast of West Africa, Sierra Leone has made far less progress in the fight against Ebola. The country had three times as many new infections as Liberia in the most recent three-week monitoring period, according to the World Health Organization. The United States has sent troops to Liberia but not to Sierra Leone.

Thousands more U.S. troops are to join the American mission to fight Ebola in Liberia. (Reuters)

Guinea, the third West African country hit hard by the virus, is another landscape entirely. It is bigger than Liberia and Sierra Leone combined. There was a drop in cases in the capital, Conakry, over the summer, but the virus recently surfaced again in some neighborhoods. In addition, hot spots continue to pop up in remote places, and health workers still encounter community resistance.

As the epidemic enters this new phase, officials say the strategy must be more aggressive: looking for Ebola “brush fires” and recognizing that “sparks are igniting all over,” as Thomas Frieden, director of the Centers for Disease Control and Prevention, said in an interview last week.

The contagion has to be tracked to the last patient and obliterated lest it flare anew.

“We need the large U.N. aid agencies and bureaucracies to also work with a nimbleness, and adapt on the spot and on the fly and reroute resources,” Samantha Power, the U.S. ambassador to the United Nations, who recently toured the affected region, said in an interview Friday. “Nothing you achieve in Liberia is sustainable unless you contain and end the virus in Guinea and Sierra Leone.”

More needs to be done to eradicate the deadly Ebola virus in West Africa, according to Samantha Power, the U.S. ambassador to the United Nations, who visited Ghana during a trip to West African countries hit by the disease. (Reuters)

In a speech in Brussels after her trip to West Africa, Power pointed out the inertial forces that often hamper big bureaucracies in situations like this: “We tend to plot out static, long-term plans to respond to the outbreak and then stick to them, rather than developing fluid structures that can move with the virus.”

Changing with the outbreak

Officials involved in the response want to push ahead with the existing plan to build many ETUs in Liberia, for one obvious reason: Ebola has been known to subside for a while and then come roaring back, as it did in the spring. It’s a better-safe-than-sorry approach.

“We don’t want to take the foot off the gas pedal until we’re absolutely sure,” said Jeremy Konyndyk, a top official with the U.S. Agency for International Development who joined Power on her tour.

At the same time, U.S. officials are looking for ways to adapt that plan, for example by opening units in new locations and with only a small number of beds. This approach would mimic the brush-fire pattern of the epidemic at the moment.


A Lofa County health department burial team rolls down a dirt road with the body of Gulu Mulbah, 45, in Voinjama, Liberia, on Friday. The team members took Mulbah’s body to his home, where, wearing protective suits, gloves and goggles, they buried him in his back yard. (Michel du Cille/The Washington Post)

“As we’re dealing with this devious, adaptive virus as it is moving out in the real world, we have come to realize that 17 100-bed units are less needed,” Power said in the interview. Instead, what is needed is “a large number of 10-bed treatment units geographically dispersed to where the epidemic is now and where contact tracing suggests the virus might move.”

U.S. officials also recognize that Guinea has not received enough support, so the United States is funding three ETUs there through the U.N. World Food Program, she said.

Many major challenges remain, not least of which is staffing the health facilities. International aid groups continue to struggle to find the thousands of health-care workers needed for the effort. They are hard to come by, given the grueling work conditions, the unusually terrifying nature of Ebola and concerns that volunteers will be quarantined upon returning home. Adding to that is concern that the facilities won’t be in the places they’re needed most, said Sophie Delaunay, executive director of the U.S. arm of Doctors Without Borders.

“At the moment, our main concern is less about staffing those facilities and more about the necessity to adapt the response based on the development of the outbreak,” she said.

The United States has historic ties with Liberia, which was founded by African Americans in the first half of the 19th century. Reflecting colonial-era connections, Britain is focused on Sierra Leone, and France is concentrating on Guinea.

“The crisis is accelerating,” said Sia Dean, a nurse who runs a company in Sierra Leone with her husband, Charles Dean II, and who spoke via Skype at an Ebola conference in Washington last week.

She said that five doctors and dozens of nurses have died in Sierra Leone and that there are not enough ambulances to pick up the dead in Freetown, the capital. The British are taking too long to build the ETUs, she said, adding, “Time is against us.”


Liberian health workers load the bodies of six Ebola victims into the back of a pickup truck outside Redemption Hospital in Monrovia, the capital. (Michel du Cille/The Washington Post)

The situation in Guinea also remains tenuous. The forested areas where the outbreak began late last year are still a challenge. They often are difficult to reach. And skepticism runs high, meaning health workers often must forge relationships with local leaders before they can earn the trust of residents.

“The first people who show up can’t be wearing spacesuits,” said Michael Kinzer, the CDC’s team leader in the country.

Mounting a major response

The Pentagon’s plan, announced in September, was largely crafted by the Army’s Africa Command, based in Germany.

The ETU building process has taken longer than expected, in part because the rainy season and a lack of heavy-duty construction equipment and other infrastructure have slowed things down. The Army also has been hampered by the lack of a place to house soldiers. Some set up camp in hotel rooms pending the construction of living quarters at a Liberian military facility.

The Army in recent days finished its first field hospital, designed solely for health-care workers who become sick treating Ebola patients. That achievement reflects the step-by-step requirements of mounting a major response to an epidemic: Volunteers have to know that they’ll be cared for if they contract the disease. The United States and Britain also have focused on creating medical-evacuation options for sick workers.

Obama on Wednesday asked Congress for $6 billion to supplement about $1 billion already committed by the United States to fight Ebola in West Africa and domestically. The United States has had only one Ebola case in recent days, and New York’s Bellevue Hospital announced Monday that the patient, Craig Spencer, is free of the virus and will be released Tuesday.

The president’s request will be the subject of hearings this week on Capitol Hill, starting Wednesday afternoon, when top administration officials will testify before the Senate Appropriations Committee.

The funding would be used to send more U.S. civilian teams and supplies to fight the outbreak in Guinea and Sierra Leone. A chunk of money also would go toward upgrading more than 50 hospitals in the United States to ensure that they have good infection-control measures if Ebola is brought to this country again. Many of those hospitals are located near the five U.S. airports where passengers from West Africa are required to arrive.

The CDC also will stockpile $2.7 million in personal protective equipment that it can deliver to U.S. hospitals caring for Ebola patients. That includes nearly 6,000 disposable gowns, more than 6,000 respirators and 55,000 pairs of gloves — enough gear for 250 days of treatment.


Outreach sees success

What has worked well in West Africa, officials say, has been communication — broadcasting the message over and over that Ebola is not a hoax or a scam, and that its spread can be contained through adjustments in behavior, particularly in funeral practices that included repeated washing of the body.

In Guinea, an Israeli cellphone company agreed to give free airtime to imams on Fridays so they could send text messages to congregants telling them about Ebola prevention.

A new public-awareness campaign in Sierra Leone will feature one “big idea” per week, starting this week with “Safe Burials Save Lives.” Targeting local media outlets and opinion leaders, the campaign is full of common-sense advice, such as not touching the bodily fluids of sick people and assuming that anyone who is sick could have Ebola.

Freetown has a new Ebola response call center, and residents are asked to call 117 when someone is suspected of having Ebola or when an infected person dies. On the wall of the call center is a map of Freetown. Red pins mark the spots where bodies have been reported. When teams bury a body, blue pins replace the red ones. When Power visited Oct. 28, the map showed one red pin surrounded by a sea of blue.


This is the largest outbreak of the Ebola virus in history.

A key effort is the enlistment of grass-roots women’s groups. In Grand Bassa County, Liberia, the Bassa County Women’s Development Association has been training women and religious leaders since August to spread the message.

“We have been working here with them for a very long time, and they know what we tell them,” said Martha Karnga, the group’s executive director. The message is working, she said. “They understand because we see them practice hand-washing in the buckets.”

Power has called the Ebola epidemic the greatest public health crisis of our time, and in Friday’s interview she said there is no time for traditional funding proposals or elaborately crafted plans.

“We’re building the airplane as we fly it,” Power said. “We’re deciding how to allocate the spare parts depending on the signals on the control panel.”