42 days later: Liberia declared Ebola-free

In a mid-November meeting of the incident management system team, which was responsible for managing Liberia’s Ebola response, the country’s assistant minister of health looked concerned. Tolbert Nyenswah, who heads the response, had just been briefed on a rise in cases from a remote village near the Sierra Leone border.

We were there in that meeting, where surveillance head Luke Bawo — whose team included veteran virus hunter Hans Rosling — gave us the data. Health teams reported people in the small community of Jene Wonde did not believe Ebola was real. Recent progress was under threat, and we feared a wider outbreak.

We had to get on top of flare-ups fast. That afternoon, we went with minister Nyenswah and his team to the heart of the outbreak. Nyenswah stood in the heat, next to the clinic still under construction, and questioned the village chief on what was needed. We inspected the school, now empty of pupils. Quarantined families had no food, so Dorbor Jallah, head of logistics, directed villagers to move stacks of chairs to clear space for supplies. At the next meeting, the minister gave “marching orders” to assembled partners and government officials to make sure Jene Wonde got what it needed.

Fast-forward seven months. Last Saturday, the World Health Organization announced the Ebola outbreak in Liberia was over. It’s an amazing accomplishment for a country that in September wondered if Ebola might jeopardize its very existence. There’s been well-deserved kudos for the people of Liberia, as well as international organizations like Médecins Sans Frontières — both essential to beating Ebola.

But the bits the media often miss are things like that November meeting. What we saw, working at the center of the response, was that it was government that got Liberia to where it is today. Indeed, we saw three things that made the government successful in leading the response.

1. Presidential leadership.

The role President Ellen Johnson Sirleaf played, taking some of the hardest decisions, was crucial. For example, as the crisis escalated in August and September, there was nowhere left to bury the dead in Liberia’s capital. Out of options, the government decided on cremation as an alternative. But cremation is culturally an anathema to many, so there was intense public and political pressure to go back to traditional burials.

Sirleaf decided to continue with cremation until a new cemetery could be opened. Doing this in the face of intense pressure removed the biggest risk in spreading the disease and was a big reason Liberia was able to turn the tide of transmission.

“Presidents were at the center of this response,” said David Nabarro, the U.N. secretary-general’s special envoy on Ebola, referring to the presidents of Liberia, Guinea and Sierra Leone. A president can’t manage a crisis day in, day out, but Sirleaf saw that the buck stopped with her for the most contentious issues.

2. Genuine and deep partnership between the government and the international community.

Everyone pulled together under the government’s leadership. As Peter Graaff who led the U.N.’s Ebola response in Liberia said, “There was recognition that the response had to be under the government. I had never seen that before, including in other crises, but even more generally. Somehow there was a shared credit between the government and internationals.”

This mattered because there needed to be a way to coordinate the response activities and the actors — national government, nongovernmental organizations and community leaders. Each had a crucial role to play, but government had to be at the helm to coordinate and arbitrate where there was disagreement — including among international organizations.

One place this worked well was the task force that managed the Greater Monrovia response, which the Tony Blair Africa Governance Initiative supported and which eventually tracked down those final cases. This was set up to position international experts alongside government, supporting government’s strategy.

3. Government worked with the international community to build a system to manage the response.

Ebola might appear to be a purely medical challenge, all about treatment units and doctors. But a successful response needed a host of other activities, including difficult logistics, detective-like investigations into how new cases happened, and monitoring every person an Ebola sufferer had been in contact with.

What eventually allowed the government to manage effectively were systems and processes to make decisions and coordinate actions — including the incident management system, which spotted the danger in Jene Wonde and moved fast to stamp it out.

So it was fitting that the official announcement that Liberia was Ebola-free was made Saturday at an incident management meeting, with a mixed team of Liberians and internationals round the table — and minister Nyenswah at the head.

The fight with Ebola isn’t over. In Sierra Leone and Guinea, teams like Liberia’s will be meeting today to go over the data and make the hundreds of small decisions that will ultimately eradicate Ebola. The tragedy in Nepal reminds us that the next crisis is always around the corner. The Liberian government’s experience holds important lessons for other governments dealing with complex emergencies that political leadership matters — and that management systems can matter as much as medical systems.

There are lessons for us in the development and humanitarian communities too. Often the default mode in crises is to see government as an obstacle to work around. We saw that you get better results when you support government to lead.

What lessons can Guinea and Sierra Leone learn from Liberia’s government-led response to the Ebola outbreak? Have your say below.

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