Reflections on Leadership and Governance from the Incident Manager of Liberia's Ebola Response

Abstract

The 2014-2016 epidemic of Ebola virus disease occurred in a region with a recent history of civil war, unstable health systems, and widespread poverty. Despite these contextual challenges, the national Ebola response in Liberia controlled transmission under strong leadership that was able to rapidly coordinate activities, to manage local and international players, and to adapt upon recognizing missteps. Such leadership has persisted to improve public health capacity in post-Ebola Liberia. This article highlights the progress made toward developing a resilient health security system with capacity to prevent, detect, and respond to disease threats before they reach epidemic level. In particular, Liberia's development of a Global Health Security Agenda roadmap, a Joint External Evaluation (JEE) report for International Health Regulation (2005) core capacities, and recent establishment of a National Public Health Institute are described. To better protect the country's population and the greater global community from health threats, emerging institutions and policies in Liberia will depend on leadership and governance that draws from the successes and lessons learned during the Ebola outbreak. The author provides insight based on his role as incident manager of Liberia's Ebola response.

The Ebola virus disease (EVD) epidemic that raged through West Africa in 2014-2016 was one of the most dramatic and important public health crises of the 21st century. It posed an existential threat to 3 countries and challenged international public health systems around the world. Leadership at multiple levels played a critical role in eventually controlling the epidemic. By the time the World Health Organization (WHO) concluded on March 29, 2016, that EVD was no longer a public health emergency of international concern,¹ 11,308 people had died among the 28,610 reported EVD cases.

In this article, I draw on my experience as incident manager of Liberia's response to the EVD outbreak. First, I consider the nature of the EVD crisis, given Liberia's history of civil war and its aftermath. Next, I describe efforts to develop a resilient health system in Liberia, after the EVD outbreak, including the legal establishment of a public health institute. Finally, I offer lessons learned for leadership and governance in light of these experiences.

Nature of the Ebola Crisis

The EVD outbreak in West Africa began in the southeastern forest of Guinea in December 2013, although EVD was not suspected until much later and not confirmed until March 2014.² By then, it was spreading across rural areas of Guinea, Liberia, and Sierra Leone, subsequently ravaging the more densely populated urban settings by mid-2014.

The outbreak was clearly exacerbated by the fact that it occurred in countries already under stress. In Liberia, the health system was still recovering from the devastation of more than 15 years of civil war. Liberia was continuing to face high levels of poverty (eg, average per capita income was US$690 in 2014),³ poor transportation infrastructure, unreliable power and communications networks, and limited access to a safe water supply. During the EVD outbreak, there were severe shortages of health workers, health facilities, pharmaceuticals, and other necessary materials, as well as funds to pay health workers.

In the year before the outbreak, there were 4 strikes by public health sector workers in Liberia, due to the government's inability to pay wages and provide appropriate housing at posts in rural areas. Health workers generally had no confidence in the system, nor did they trust health authorities. Given the high level of suspicion of the government in a post-conflict environment, a vicious circle of suspicion, miscommunication, mistrust, exposure to infectious dead bodies, and uncontrolled EVD transmission took hold.

At the same time, other governments closed their borders to Guinea, Liberia, and Sierra Leone, stopping trade and commerce and creating yet another vicious circle of loss of income, access to food, and heightening illness. The epidemic spiraled out of control, with EVD infecting an unprecedented number of people in West Africa, resulting in intense fear and turmoil throughout the subregion. Fear rapidly extended to other countries around the world.

The crisis threatened the cohesiveness of communities, local and national governments, and international organizations operating in West Africa. In Liberia, the national Ebola response was coordinated by the national incident management system (IMS), under the leadership of the incident manager. Liberia's coordination and response engaged community and county leadership throughout the course of the epidemic.

Developing a Resilient Health System

The need to rebuild Liberia's health system after the EVD crisis was profound. The goal was to develop a resilient health system that would not only restore the gains lost due to the EVD crisis, but also provide security for the people of Liberia by reducing risks from epidemics and other health threats. This, in turn, would accelerate progress toward universal health coverage by improving access to safe and high-quality services.

During the past 2 years, remarkable progress has occurred in building health security capacity to prevent, detect, and respond to disease threats. The Global Health Security Agenda (GHSA) strategic roadmap for Liberia is closely aligned with the Investment Plan for Building a Resilient Health System, aimed at developing and strengthening Liberia's capacity to address public health challenges and meet the needs of its population.⁴ Activities in the past year include workforce development, with more than 14,000 healthcare workers trained in infection prevention and control practices and 114 surveillance officers trained in the frontline field of epidemiology as of January 2017. Laboratory systems are being strengthened; personnel have been trained in biosafety and biosecurity; and diagnostic protocols for Ebola, yellow fever, Lassa fever, and cholera are being implemented in country.

Strengthening of surveillance systems has facilitated the reporting of priority diseases and conditions, with 99% of health facilities submitting complete and timely reports each week. Emergency operations centers have been established at the national level and in all 15 counties in Liberia, with improved capacity for response, as demonstrated by the rapid and robust response to 3 post-outbreak EVD flare-ups. Recently, an outbreak of meningococcal septicemia or bacterial infection in the blood was reported in the southeastern county of Sinoe. The outbreak killed 13 persons. The outbreak was detected in less than 12 hours after the county health team notified the National Public Health Institute of Liberia. Liberia has also enhanced collaborations with other countries in the region and had a successful cross-border meeting with Guinea and Sierra Leone. This resulted in agreements to improve surveillance and response efforts among the 3 countries.

Liberia volunteered for a Joint External Evaluation (JEE) and underwent an assessment in September 2016, led by WHO in collaboration with technical partners. The team assessed 19 technical areas, and the results highlighted progress in all domains, as well as strong political will and partnerships to develop core capacities.⁵ Areas with developed or demonstrated capacity included immunization, real-time surveillance and reporting, emergency response operations, linkages between public health and security authorities, medical countermeasures and personnel deployment, and risk communication. The assessment also identified areas for improvement, including antimicrobial resistance, food safety, emergency preparedness, and public health response at points of entry. Ongoing efforts will focus on continued strengthening of health security capacity in Liberia, for the benefit of the global community.

Using Law to Create a Public Health Institute

As part of the effort to respond to public health and global threats, a Public Health Institute of Liberia was established through legislation in 2017. The institute's vision is to be a center of excellence and innovation contributing to the creation of a resilient health system that reduces risk due to epidemics and other health threats and that promotes equitable health outcomes for all Liberians.

The institute has a 4-part mission: (1) assist the ministry of health in strengthening public health functions through capacity building, disease surveillance and response, and research; (2) build public health capacity, coordinate disease surveillance and emergency response, and conduct and coordinate research to inform policies that enhance the ability of the government of Liberia and counties to better respond to national threats and major causes of morbidity, mortality, and disability; (3) improve the health status of the Liberian population under the oversight of the ministry of health and in collaboration with relevant agencies and institutions of government; and (4) strengthen laboratory capacity to quickly detect and respond to outbreaks.

Through the institute, we will develop and coordinate a structure for public health training and education at the county and district levels, identify and facilitate advanced education and training outside Liberia, and assist in developing higher education in public health within Liberia. In addition, the institute will contribute to disease surveillance and response through public health and epidemic surveillance, problem investigation, control of risks and threats to public health, disaster risk mapping, development of national strategic plans to mitigate and respond to disasters and diseases of epidemic potential, and coordination of the response to emergencies and epidemics. Finally, the institute will conduct and coordinate research activities related to key health problems to facilitate decisions and implementation of research-oriented policies to mitigate risk.

Lessons for Leadership and Governance

Now that the EVD crisis is over, and we continue to build a resilient health system in Liberia, I have had the opportunity to reflect on the lessons I learned while leading the EVD response. It was the most challenging assignment of my life, and I believe there are several key principles about crisis leadership and governance that have practical relevance.

• There is no substitute for strong political leadership . The government's leadership in Liberia was supportive of the EVD response from the top to the bottom. As the IMS chair, I led the organization and coordination of the EVD response in every aspect, with the unwavering support of the president of Liberia and the Liberian citizens in general. I believe that governments must step up with staunch resolve and make management of a national crisis a priority on the political agenda. Political leaders must rapidly and simultaneously manage a multitude of activities and people. They must also effectively identify individuals who are content experts and who are well suited to assume a management role while embracing and respecting the cultural and political context of the country.

• To lead effectively, there must be a supporting cast . Teamwork is the recipe for successful leadership. Everyone on the team must play a specific role. Assured of the political support from Liberia's president and legislature, I managed the EVD crisis with an eye toward building a resilient health system—while at the same time responding to a critical health emergency—by delegating responsibility to thematic team leaders. These were key people with the skills and commitment to manage the crisis and move toward containment of EVD. I had oversight responsibility for the entire response, and all thematic leads reported directly to me every day, several times a day, keeping me abreast of all developments as they occurred. I needed to be on top of things and depended on others to be able to do so. Making rapid, concrete decisions was essential at all levels, from the IMS to the higher levels of government. I was there, available at all times, organizing every aspect of the response, performing the most difficult tasks, making the most difficult decisions, and solving complex problems. However, none of this could have been done well without the support of others.

• Governments must take ownership of their response . This is true even when they are assisted by others from the international community. No one had more at stake than the government and people of Liberia. While the eyes of the international community were focused on WHO and the US Centers for Disease Control and Prevention (CDC) for guidance, the eyes of WHO and CDC were focused on me, as the incident manager, and the entire Liberian leadership. When the situation looked grim, the international community was inclined to blame the government and Liberian people. When the situation began to steadily improve, people praised the incredible leadership demonstrated by Liberians in conducting every aspect of the EVD response in Liberia. Through our national leadership model, we were able to contain EVD. This experience taught me that countries and governments must recognize their own strengths and be more self-reliant in times of crisis. People are galvanized when their lives, and the lives of those in their country, are on the line.

• Systems and structures must be put in place early by the government . This should be done with support from international partners, while the government is in the lead and free to make decisions in the best interest of its people. As the IMS chair, I made major decisions to promote the EVD response and effectively manage mechanisms for coordination, reporting, tracking, and other related activities. My strategy was to keep it simple, get things started, and adapt where necessary to move the process along. We constantly needed to relay information to those in authority to facilitate their decision making. Flexibility is critical; during the response, we changed a lot of the response initiatives. We learned by doing, making adjustments or modifications in our strategic profile when indicated, and always kept culture, traditions, and political contexts in perspective.

• Relationships with international partners must be managed well . International partnerships, expertise, and financing facilitate national crisis response for countries that are resource constrained. International partners need to be involved in key decision-making processes. If they are not at the table when these decisions are made, the process of achieving desired results may be slow moving or not moving at all. If the partners participate in decision making and consensus, desired results will manifest more quickly. However, international partners must be respectful of a government's decisions and priorities while making their contribution. They must be held accountable with regard to resource allocation, design, and implementation of response activities, taking into consideration the culture, tradition, and political context of the people they have come to assist.

In my leadership role, I insisted that our international partners perform their roles in line with our national strategy for the response. Looking back, I believe that the EVD response was most effective when our government and international partners worked collaboratively. This occurred when we were conferring jointly on solving problems, and when the government was confident in requesting or delegating responsibility to an international partner in instances where the national team did not have the technical capacity in a specific area. At best, this meant integrating domestic and international teams to work together. For example, developing a new data system or investigating a new case, with nationals in the lead working closely with international partners, illustrated how to best build teams.

• Leadership comes from within, but opportunities to lead come from the outside . I believe that one is innately endowed with leadership abilities. Before my appointment as national IMS chair, I was an assistant minister of health, reporting to the deputy minister, who reports to the overall minister of health, who reports to Liberia's president. Despite my more junior position, I was singled out by President Ellen Johnson Sirleaf and given sole authority to lead the national EVD response. This meant that I was suddenly directing the work of more senior authority figures from the ministry of health as well as a range of other government ministries. This also meant that I reported directly to the president, that I attended cabinet sessions, and that I participated in meetings with other presidents and heads of international agencies. There was a risk that others could undermine my leadership, or that I might be reticent in making hard or unpopular decisions. However, I took the reins decisively and immediately instituted a structure for service delivery, in which I defined clear roles for the international partners and the Liberian nationals who led different elements of the response.

Although it is obvious that the best person for the job should have the requisite skill sets, it is not always clear what the right skills are in a novel crisis situation. Seniority or even technical skills are not necessarily the most important characteristics to look for in a national crisis manager. National crisis managers should be leaders capable of bringing together and usng a wide range of resources to facilitate making rapid, appropriate, and correct decisions. Crisis managers should be able to prioritize, quickly and effectively recognize those issues that are not readily solvable, and present pressing concerns to the main coordination body (like the IMS) for immediate discussion and urgent action.

• Mistakes will be made, and it is important to learn from them . During Liberia's response to EVD, some mistakes were made, and they need to be acknowledged and used for learning. Of course, it is important to be able to recognize a threat like EVD and respond immediately—something that depends on timely and reliable information, as well as leadership and systems in place. The response would have been enhanced by much greater human and technical investment early on in all aspects of data management, including selection of the most appropriate data base, informatics, and communication infrastructure. Greater efficiency might have been realized with more extensive support for administrative systems such as personnel and payroll management and empowered logistic and financial capacity under the IMS. Finally, essentially no research was conducted during the epidemic about public health or clinical care management—a consequence of the demands of the response, but also a missed opportunity to learn. One of the priorities after the crisis has been to build a sustainable public health surveillance system to be better prepared to identify and respond to crises and to learn from them more systematically.

Conclusion

The West African EVD epidemic affected some of the most vulnerable populations in the world and challenged leaders from remote villages in Liberia to national governments and international bodies. In this article, I shared my experiences as the leader of Liberia's EVD response, and reflections about lessons learned. I believe that law is critical to public health practice, as evidenced by Liberia's legislation to establish a public health institute. At the same time, creating a strong and resilient health system infrastructure helps to build public health capacity, which can further promote the use of public health law. Based on my own experiences, I believe that governments must prioritize and strengthen their public health and healthcare systems to address the globalization of emerging infectious disease threats.

References

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