MEMORANDUMFOR AMBASSADOR SUSAN E.

RICE

THROUGH: AMY E. POPE

FROM: CHRISTOPHER M. KIRCHHOFF,Ph.D.

SUBJECT: NSC LESSONSLEARNED STUDY ON EBOLA

DATE: JULY 11, 2016

The Ebola epidemic in West Africa—one of the swiftest outbreaks of infectious disease since the
1918 Spanish Flu—claimed the lives of 11,000 and sickened more than 28,000. Yet it could
have been exponentially worse. Models suggested 1.4 million stood to be infected and that the
disease could have become endemic in West Africa, turning swaths of Liberia, Sierra Leone and
Guinea into a perennial hotzone. In this scenario Ebola would undoubtedly have spread to many
more countries around the world, further threatened the U.S. homeland, and potentially
contracted the global economy. The U.S.-led international response prevented that from
happening. Americans should be proud of the role our nation played at a moment of global peril.

It is sobering to note the odds are increasing that the United States will be called upon again in
the not too distant future to respond to another health crisis that threatens global security.
Population growth, urbanization, deforestation, the expansion of agriculture, the bunching of
species together in island ecosystems, global commerce flows, and an unsurpassed level of
intercontinental air travel are creating the very conditions for the next dangerous pathogen to
emerge. A strong scientific consensus exists that we will see more zoonotic pandemics and
infectious disease outbreaks going forward, as the present outbreak of Zika virus vividly
illustrates.

In recognition of this threat, President Obama called in his February 11, 2015 speech for us all to
study the lessons-learned from the U.S. response to the Ebola outbreak, with a view to being
better prepared to prevent and respond to the aftermath of future pandemic diseases. The
conclusions of this study—the product of a single researcher—are not definitive or exhaustive.
Rather, they are meant to bring into relief key elements of what the NSC staff and Federal
departments and agencies have learned and to spell out outstanding issues that require further
action. The report in this way is meant to inform deliberations about what specific steps the
Administration can take by itself and with the international community to enhance pandemic
preparedness, advance the Global Health Security Agenda, and further prepare for the potential
that terrorists could acquire and use a biological weapon. The report’s 21 findings and
recommendations feed directly into ongoing work being led by Deputy Homeland Security
Advisor Amy Pope to learn not only from Ebola but also from other global health crisis that
occurred during the Administration, including Middle Eastern Reparatory Syndrome (MERS)
and the Zika virus outbreak.

Methodologically, this study draws its findings from the work of 26 lessons learned teams and
one official history from eight departments, agencies, and offices across the Federal government
(see Appendix B for a full listing). While most agency lessons learned efforts were compiled by
small teams, the United States Agency for International Development has eight separate lessons
learned efforts underway, including a sophisticated assessment of the relative effectiveness of
different programmatic interventions in the field. A similarly sophisticated Department of
Defense effort interviewed over 300 people involved in Operation United Assistance, which
deployed 2,800 troops to West Africa at the height of the epidemic. The teams discussed their
findings with one another at NSC staff convened “lessons learned summits” in February, April,
and May 2015.

Collectively, these efforts have created a detailed portrait of the U.S. response, bringing into
relief its significant successes and notable failings. This document highlights those among them
that are most centrally related to capabilities within government that must be strengthened for the
U.S. to successfully contain a future outbreak of greater magnitude. Its narrative of policy
decisions and response actions is divided into three sections: the Early Response (March-July
2014); the Crisis Phase (August-December, 2014); and the Drive Towards Zero (January to June,
2015). It concludes with findings and recommendations, a list of reforms being contemplated by
departments and agencies, a timeline of the response, and a list of the federal lessons learned
efforts.

To ensure this account faithfully captures the historical narrative, it was reviewed by members of
the White House Ebola Task Force, former NSC Ebola Coordinator Ron Klain, CDC Director
Tom Frieden, USAID/OFDA Director Jeremy Konyndyk, Deputy Assistant Secretary of Defense
Anne Witkowsky, Joint Staff Ebola Coordinator Major General Steven Shepro, Deputy Secretary
of State Heather Higginbottom, NIH/NIAID Director Anthony Fauci, HHS Counselor Leslie
Dach, HHS Assistant Secretary Nicole Lurie, DHS Chief Medical Officer Kathryn Brinsfield,
former Deputy Homeland Security Advisor Rand Beers, and former NSC legal advisor James
Petrila.

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EXECUTIVE SUMMARY

Ebola at first spread unnoticed. Clusters of deaths that began in Guinea in late 2013 were not
recognized as Ebola for several months because the disease had never been seen so far West in
Africa and because the health system in Guinea was not capable of conducting the
biosurveillance necessary to detect and contain the outbreak of novel pathogens. Once the
outbreak of Ebola was confirmed by blood testing on March 23, 2014, international responders
from the World Health Organization and Centers for Disease Control mobilized immediately.
The widespread presumption among international and U.S. officials was that the outbreak would
be quickly contained as had prior outbreaks over the past 38 years. The number of cases ebbed
in May, 2014, but a sudden uptick of geographically distributed cases in June, 2014 made it clear
that early control measures, which at first appeared to work, had in fact failed spectacularly.

In retrospect, all the ingredients for the acceleration of transmission were present: colonial
borders that artificially separate a tri-state region of hyper-mobile individuals; communities
where a decade of civil conflict eroded trust of central authorities; the lack of biosurveillance,
laboratory capability and field epidemiologists; underdeveloped healthcare systems;
unfamiliarity with Ebola; limited medical literacy and a widespread reliance on traditional
healers; deeply rooted funerary practices that create the very conditions to spread Ebola across
entire communities; and extreme poverty. The failure to grasp what would make this outbreak so
deadly was widely lamented by those who were in the field in the initial months. “It's much
worse because we failed early,” one epidemiologist told White House officials.

Built into the U.S. government approach to the containment of infectious diseases abroad was the
assumption of a level of capability and competence in the WHO that turned out not to exist. By
August, 2014 it was clear the WHO had lost control of the epidemic and that the U.S. must rush
resources into West Africa to avoid a global catastrophe. The U.S. government was not well
postured to mount the response that became necessary. It had no standing doctrine for how to
combine the various deployable capabilities for fighting biological threats resident in HHS,
CDC, USAID, and DoD. There was little comprehension at the White House or among agencies
officials of what those capabilities actually were. At a moment when the epidemic was doubling
in size every three weeks, it took time for officials to figure out how the U.S. should respond.

What became the nation’s civil-military doctrine for how to fight Ebola came together quickly
after the President directed that Ebola be considered a tier one national security emergency and
ordered the deployment of 2,800 military personnel to West Africa as part of Operation United
Assistance. The eventual integration of personnel from CDC and USAID under an improvised
chain of command, with DoD working in support of thousands of civilian health workers, is one
of the response’s most significant doctrinal innovations.

The U.S. and international mobilization had immediate if unexpected effects. Transmission rates
in Liberia fell far faster than predicted, with community behavior and social mobilization
emerging as more potent factors in stopping Ebola than the build out of isolation and treatment
facilities at the core of the initial strategy. The heroic actions of U.S., international, and West
African responders effectively contained the epidemic in all three affected countries by January,
2015, with transmission slowly trailing off to zero by the end of 2015.

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Domestically, the federal government’s establishment of a nationwide Ebola treatment and
testing system, standing up a system of passenger funneling and screening at U.S. ports-of-entry,
and establishment of an active monitoring program effectively protected the public from being
exposed to Ebola. Nevertheless, Ebola cases in Dallas and New York showed how challenging a
domestic health incident can be to manage. Federal, state, and local authorities in Dallas
struggled to develop a working relationship that leveraged the expertise and authorities of each
effectively. The lack of an effective system of whole of government incident command structure
in response to a one-city, one hospital outbreak that nonetheless generated a tremendous amount
of media coverage contributed to oversights in personal protective equipment use, disinfection,
the collection, transport, and disposal of hazardous waste, the provision of social services for
those placed under quarantine, and post-event monitoring and travel restrictions for potentially
exposed health workers. The New York response was better managed, but the experience of
Ebola cases presenting in the U.S. revealed the need for a smoother sliding scale of escalation of
government response, from local authorities acting on their own to local authorities acting with
some federal assistance, to a declaration of a Public Health Emergency and the full activation by
DHS of the National Response Framework.

Seen in retrospect, the Ebola outbreak amounts to a real life test of our ability to detect and
contain an infectious disease that threatens global security. The response in West Africa and at
home exposed weaknesses in preparedness and capability at the international level and in the
U.S. government. Because the way the world is developing makes epidemics more likely to
occur and spread rapidly in the future, epidemics must be considered one of the most pressing
threats to global security

While reform at the WHO and in other multilateral institutions is vital, the United States cannot
wait until deployable international capability comes online. The United States and willing
partner nations should maintain an interim global response capability as a bridge to whatever
investments are ultimately made at the international level. Merely maintaining the current scale
of response activities as a standing capability is likely not sufficient. Capacity during the Ebola
response was stretched so thin that at certain points in 2014 and 2015 USAID and CDC’s
standing and reserve capacity were maxed out. Had another disaster or disease outbreak
occurred, there would have been no one left to deploy. Moreover, future epidemics, especially
those that are airborne and transmissible before symptoms appear, are plausibly far more
dangerous than Ebola, which is hard to catch, easy to test for, and occurred in a region of the
world with minimal air connectivity.

To organize U.S. deployable capability, the NSC should create a roster of standing capabilities in
departments and agencies and consider creating an international equivalent of the National
Response Framework that imagines ways in which needed capabilities from different parts of the
federal government might be rapidly integrated in the next response, however it takes shape. .
The NSC should also be prepared to reinstate the Ebola Coordinator role. A single person
accountable to the President, and working within the NSC structure, is a model that works in
extremis cases. Likewise, the level of integration USAID, CDC, and DoD have now reached
should be perpetuated by mechanisms that facilitate joint planning, preparedness, and exercise
programs. Relatedly, the new concentration of foundations that work in the health and epidemic
space, who in aggregate contributed more resources to the Ebola response than many European

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 partners and the WHO, means the U.S. government needs to think about and maintain relations
with the foundation world as it does its major allies.

Summary of Findings and Recommendations

• The very dynamicsof globalizationand populationgrowth will lead to more pandemics,which

must appropriately be considered among the most serious threats to our homeland and to
internationalsecurity.
• The Ebola epidemic showcased substantial gaps of global preparedness and capacity in
infectious disease response. When the U.S. mobilizedafter the WHO failed to contain the
epidemic, gaps in preparednessand capacity surfaced in every major agency tasked with health
and security in the U.S. government.
• Merely maintainingthe current scale of response activities as a standing capability is likely
insufficient. As a first step to organize U.S. deployable capability, the NSC should create a
roster of standing capabilities in departments and agencies and consider creating an
internationalequivalent of the National Response Framework that imagines ways in which
needed capabilities from different places might be more cohesively integrated in the next
response,however it takes shape. A key part of that framework will be building upon the
“civil-military”doctrine for epidemic response developed for Ebola, but without DoD’s
“redlines” and with a view towards different scenarios.
• A single person accountable to the President for response efforts, working within the NSC
framework, is a model that works in extremis cases.
• Funding mechanisms and triggers for mobilizationshort of a Stafford Act declaration need to
be established.
• Vaccine and therapeutic liability,medevac capability, and hazardouswaste disposal are issues
that were raised but not solved by the Ebola response.
• Because the military,humanitarian,and health first responders do not meet up frequently,
exercising,table-tops, training, liaison officers, regular detailing of personnel,and senior
management exchanges are needed, both within governments and at the internationallevel.
• Health and non-healthagenciesneed a common language for situational awareness,a defined
set of triggers for when to mobilize,the ability to deploy interagency assessment teams to
monitor events long before they become crises, and a single system of situational reports.
• Greater study of populationbehavior change and social mobilizationis needed.
• The management of public perception and community behavior,both at home and abroad,
together with anthropologicalexpertise, is a fundamental part of any response.
• New mechanismsare needed to harnessbetter the potential contributionsof the private sector,
foundations,and the digital humanitariancommunity.
• Technology is a key part of enhancing effectiveness in the response,but epidemics most often
move too fast to try out good ideas in the field.
• Managementof the risk of disease spread by internationaltravelers is essential.
• Multi-national,cross-jurisdictional data systems and indicatorsof how pathogens are spreading
is one of the best ways to improve pandemic responses.
• Global humanitarianresponse capabilities are stretched to their limitsand need additional
capacity to handle the “new norm” of multiple crises occurring simultaneously.

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• Stopping an outbreak at the source before it becomes an epidemic is crucial, reinforcing the
need to accomplish the goals of the Global Health Security Agenda.

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THE EARLY RESPONSE (March – July, 2014)

On March 24, 2014, as part of routine briefing, National Security Council (NSC) staff informed
National Security Advisor Susan Rice of the first known outbreak in Guinea of Ebola, a Tier 1
select agent “with significant potential for mass casualties.” The President was informed shortly
thereafter. By the time Institute Pasteur had performed confirmatory testing of a blood sample
sent by Medicine Sans Frontier (MSF) on March 21, 2014, the hemorrhagic fever had sickened
80 and killed 59—most of whom were misdiagnosed as having malaria. While suspected cases
in Sierra Leone and Liberia were under investigation and there was suspicion by some that the
deadly Ebola Zaire strain had spread more widely in Guinea, the assessment of NSC staff at that
earliest moment reflected the view of CDC and the wider epidemiological community that Ebola
would be quickly contained, as had other outbreaks over the past 38 years. The NSC update
noted “we expect additional cases to be identified in the coming weeks and potentially in
neighboring regions,” but concluded “a response is underway and should able to control the
outbreak.” Statements by the World Health Organization (WHO) reflected this same
conventional wisdom. “There has never been an Ebola outbreak larger than a couple hundred
cases,” its spokesperson said.

Epidemiological tracing suggests this extraordinary chapter in epidemic disease was set in
motion four months earlier when a two-year old boy named Emile died on December 6, 2013 in
the Guinean village of Meliandou. He fell sick after playing under bats roosting in a nearby tree,
and passed on the disease to his mother, three-year old sister, grandmother, and the village healer
who cared for them. Two mourners who attended the grandmother’s funeral carried the virus to
their villages, from which it eventually spread to Guinea’s capital, Conakry.

Once the outbreak of Ebola was confirmed, WHO flowed personnel into Guinea from its Africa
regional office, country offices around Africa, and headquarters in Geneva. Internal protocols
placed the WHO’s Africa regional office—widely known as its weakest—in charge of the
response. CDC also deployed a team of five epidemiologists and public health specialists,
including one of its top experts on Ebola, to assist the Guinean Ministry of Health. The team
was onsite six days after the outbreak was confirmed. The mobilization was in many ways
routine, except for the novel location. Ebola had only before appeared in African nations further
east, in the Democratic Republic of Congo, Uganda, Sudan, and Gabon. The failure of the
Guinean health care system and international health community to recognize Ebola for over three
months is what the Defense Department lessons learned team characterized as “normalcy bias”—
the tendency to believe that since a novel crisis did not occur in the past, it will not occur in the
future.

The presumption that the WHO would and should direct the response, as it set out to do quite
publically, was widely shared by U.S. officials. Equally pervasive was the belief that this
outbreak would follow the trajectory of prior ones and be successfully contained once sufficient
control measures were established in affected communities. A strong consensus existed among
infectious disease experts that patient isolation, contact tracing, and safe burial, when
implemented correctly, stopped chains of transmission. The challenge in this case would be
working in communities where medical personnel and community leaders were not familiar with

7
Ebola since it had never occurred there before, and in areas in which high levels of distrust
existed towards authorities.

Throughout April, 2014 a small number of officials independently monitored events from the
Office of the Secretary of the Department of Health & Human Services (HHS), CDC, the
National Institutes of Health, the National Biosurveillance integration Center (NBIC) at the
Department of Homeland Security, DoD’s National Center for Medical Intelligence, and the
regional office within USAID’s Office of Foreign Disaster Assistance (OFDA) that monitors
Africa. During this time NSC staff sent periodic updates to National Security Advisor Rice. On
the whole, most communication in the White House about the outbreak was informational in
nature, updating leadership about the status of the outbreak and U.S. personnel deployed to West
Africa. The posture reflected the known epidemiological status of the outbreak, which while
widespread in isolated clusters was not yet alarming in scale. Though some inside and outside
government raised concerns about what remained unknown about the epidemic and whether
significant numbers of cases had gone undetected, the view of CDC officials on the ground and
WHO officials leading the response was that the outbreak was on its way to being contained.

In early May, 2014 the epidemic seemed to have waned. Though a few cases remained in the
forest region of Guinea, Liberia had not recorded a case in four weeks and Sierra Leone appeared
to remain Ebola free. Reflecting confidence that the epidemic was effectively contained, on May
19, 2014 WHO Director General Margaret Chan mentioned Ebola only in passing in her address
to the World Health Assembly in Geneva. WHO officials in West Africa communicated to CDC
their confidence in being able to conclude control measures and that CDC teams were no longer
needed in the region. To officials in Atlanta, there was a feeling that WHO wanted to
demonstrate its independence and that CDC was being “pushed out.” WHO assertion of control,
one White House official noted, later extended to other U.N. Agencies, including the Office for
the Coordination of Humanitarian Affairs, which WHO did not request to become part of the
response when caseloads rose to crisis levels.

At this very moment chains of transmission escaped notice as Ebola spread widely across the
porous borders joining Liberia, Sierra Leone, and Guinea. WHO officials would later write in
the New England Journal of Medicine that “modest further intervention efforts at that point could
have achieved control.” Exactly how its spread was missed remains a point of contention among
epidemiologists to this day. The significance of Ebola presenting for the first time in an urban
context, and in a tri-state region that was a nexus of commerce and transport, were
underappreciated. So too was the prospect that Ebola could have been circulating farther West
than typically thought. Though a consensus has not yet formed in the medical literature, and the
finding may well be incorrect, the retesting of archival blood samples for the presence of Ebola
antibodies point to the possibility that Ebola outbreaks had previously occurred, but not been
recognized, in Guinea and Sierra Leone. In other words, Ebola might have been circulating in
West Africa animal reservoirs and in isolated human cases all along, a circumstance that, if
known, would have helped health authorities identify the outbreak earlier.

In retrospect, all the ingredients for the acceleration of transmission were present: colonial
borders artificially separate a tri-state region of hyper-mobile individuals; communitieswhere a
decade of civil conflict eroded trust of central authorities; the lack of biosurveillance,laboratory

8
capability, and field epidemiologists; underdeveloped healthcare systems; unfamiliarity with
Ebola; limited medical literacy and a widespread reliance on traditional healers; deeply rooted
funerary practices that create the very conditions to spread Ebola across entire communities; and
extreme poverty. By one count Liberia had 51 doctors to treat a population of four million. Its
average per capita healthcare expenditure was under $50. Though Guinea had a modestly
stronger public health capacity, the healthcare system in Sierra Leone was not significantly
different. The failure to grasp what would make this outbreak so deadly was widely lamented by
those who were in the field in the initial months. “It's much worse because we failed early,” one
epidemiologist told White House officials.

It would not be until early summer, when suspected and confirmed cases in West Africa
suddenly trended upwards, that the policy conversation about Ebola moved more fully into an
interagency process. On June 21, 2014, Medicines Sans Frontier (MSF)’s Director of Operations
noted the spread of Ebola at more than 60 known locations meant the epidemic was “out of
control” and that “we have reached our limits.” MSF’s call for international mobilization was
widely repeated in press accounts and captured the attention of NSC staff. The White House
held its first Interagency Policy Committee (IPC) meeting on Ebola on June 27, 2014, with the
NSC Director for Humanitarian Affairs stepping into the role that would ordinarily have been
filled by the NSC Director for Global Health, a position that was gapped from May to
September, 2014. The uptick in cases that had by then been detected among a widening
geographic distribution of clusters made it clear that early control measures, which at first
appeared to work, had in fact failed spectacularly. In-kind support was already being provided to
the WHO by different parts of USAID and DoD, but it was for the most part ad hoc and
uncoordinated. The White House and State Department moved to figure out what was being
provided and also address the concerns of U.S. Embassies in the region, who were frustrated by
the lack of clarity about what the U.S. could or should be doing to augment the response and how
they should protect their personnel from infection.

Despite the uptick in cases, two prevailing assumptions about the leadership and scope of the
response remained intact through the end of June, 2014. It was still assumed that WHO
personnel on the ground—who continued to assert their leadership of the response—would
spearhead the assessments of what was needed to contain the now significantly larger outbreak
and that WHO would form the core command and control architecture to direct responders. It
was also still thought that the epidemic could be contained without the possibility of catastrophic
intensification. As a USAID official noted, there was not yet the recognition in the U.S.
government of the mission that would come. Toward the end of June, 2014, NSC officials were
beginning to recognize that the WHO was not playing the leadership and coordination role that
was necessary, but the focus became improving rather than supplanting the WHO response by
forcing greater centralization and pressuring WHO to dispatch additional personnel from
Geneva. A WHO estimate in mid-July projected a need for $20 million dollars to continue
containment though the end of 2014. The estimate was revised upward two weeks later as the
magnitude of cases came into focus.

Meanwhile,as June shifted to July, Ebola came barreling into Monrovia. One of the first
infected patients to reach the Liberian capital sought care at Redemptionhospital at a time when
doctors there did not assume patients presenting with fever should be treated as potential Ebola

9
cases, given the many endemic diseases its symptoms overlap. The results were disastrous.
Within two weeks, many of Redemption’s medical staff lay dead or dying. Healthcare delivery
ceased as medical professionals fell victim to the disease. Parts of the hospital were sealed, and
riots erupted outside over the refusal of doctors to return the highly infectious bodies of Ebola
victims to their families. Other clinics and hospitals in Monrovia experienced similar infections
among healthcare workers as more cases entered the healthcare system. In the span of four
weeks, Monrovia’s clinics and hospitals almost completely collapsed under the sudden burden of
caring for highly infectious patients. The increased infections and deaths among healthcare
workers in Liberia and Sierra Leone and the forced closure of other key hospital facilities, such
as Kenema, in Sierra Leone, crossed thresholds that alarmed public health experts worldwide.

In July, 2014 the tempo of decision-making accelerated at the White House, CDC, HHS, and
USAID. The WHO called for emergency meetings in Accra, Ghana, July 2-3, which was seen
by NSC staff as something of a “last chance” for the WHO to organize itself sufficiently and
rigorously identify needs. The NSC staff began frequent Ebola strategy meetings at the sub- IPC
level, with HHS agreeing to coordinate the U.S. response to requests from the emergency WHO
meeting in Accra as they had for WHO’s first appeal in March. On July 9, 2014 CDC activated
its Emergency Operations Center for Ebola on the floor of the CDC operations center in Atlanta,
at level 3, its lowest level of mobilization, and at the request of the NSC began to develop a
proposal for how overall U.S. government coordination could occur. CDC committed to sending
dozens of additional disease control specialists to West Africa by the end of July. On July 17,
the tally of reported cases from the region exceeded 1,000. Five days later, the NSC staff led an
IPC to finalize a framework for the division of labor among Federal agencies and departments
involved in the response.

As the number of the sick rose, there was a struggle to erect Ebola Treatment Units (ETUs) that
could contain infectious patients and adequately protect those who treat them. At ELWA
hospital, near the stadium in Monrovia, the chapel was outfitted as a makeshift ETUwith a
capacity of eight beds. The medical director there recalled looking up on the Internet procedures
for donning and doffing personal protective equipment in what amounted to a crash course in
how to safely treat Ebola patients. It was in this facility in late July that American healthcare
workers Kent Brantly and Nancy Writebol became infected. Its subsequent collapse after the
healthcare worker infections was a seminal event for USAID’sOffice of Foreign Disaster
Assistane (OFDA), who was then involved in discussions to fund the ETU’s sponsor,
Samaritan’s Purse. The OFDA Director later said this was when he knew they had to “go in
big,” as the absence of treatment beds effectively left Monrovia undefended from the outbreak.

The first virus exportation event beyond Liberia, Sierra Leone, and Guinea occurred on July 20,
2014 when an infected man flew from Monrovia to Lagos, Nigeria, while symptomatic, and was
later confirmed to have Ebola, leading to a frantic effort to contain a potential cluster in Africa’s
largest mega-city. In perhaps the most significant unsung success of the response, CDC rushed
in field epidemiologists, mobilized Nigerian epidemiologists trained by CDC, worked with the
Nigerian government to establish effective incident command, and pivoted leadership and staff
from the CDC Nigerian Polio Eradiation Program. Vice President Biden also pressured Nigerian
President Jonathan Goodluck to accelerate his government’s response on the margins of the
Africa Leaders summit. In fourteen days, an Ebola Treatment Unit was constructed, 2,300 health
care staff were trained, and health care workers traced 800 contacts, performed 19,000 home

10
visits of these contacts, and screened 150,000travelersat airports. The mobilizationstopped
transmissionafter 19 secondary cases in three generations of spread across two cities. Had the
index patient not presentedin a well-run private hospital in the capital city (one of the few
facilities open as government healthcare worker were on strike and most state run hospitals were
closed), it is entirely possible a large-scaleresponse would have been requiredin Nigeria as
well—a potentially catastrophic development given that security concerns in the north would
have substantially complicatedany internationalresponse.

The virus later made its way to Mali and Senegal,and later Spain, the United States, the United
Kingdom,and Italy,but was contained with only minimalspread after rapid mitigationefforts by
the U.S., affected governments,and internationalhealth community. Meanwhile,aid
organizationsand multinationalbusinesses in the mining,coca, and tapioca industries began
evacuatingnon-essential personneland shutting down operations,leading to a series of
consultationsbetween the WHO, CDC, and the governmentsof India and the Philippines,among
others, about how to ensure returningmigrant workers did not bring home the virus along with
them.

On July 22, 2014 NSC staff received a harrowingfield report,passed on by CDC leadership,
from a CDC official traveling in Kenema,the third largest city in Sierra Leone. The official
described chaos in local hospitals and clinics. At Kenema GovernmentHospital,there were
“bodies strewn on the side of the entrance to one of the three wards,” nearly half the nursesfrom
the Ebola response unit were themselvessick with Ebola,and hospital workers were struggling
to care for a number of symptomatic orphaned children dropped off by ambulance drivers. The
official recommendedthe establishment of an emergency operationscenter, a call to the
internationalcommunity for clinical workers and lab personnel,a humanitarianrelief effort
focused on orphans, and the placement of quality control officers to focus on infectioncontrol
and to determine the cause of transmissionamong the staff and ambulance drivers, none of
whose cases had been investigatedto date. The official also cited dangerous working conditions
and insufficientdecontaminationprotocols in the few onsite labs capable of testing Ebola
samples, which he noted would require substantial outside help to safely process the number that
now needed to be tested. The field report,which was the first granular account of the crisis
shared with the NSC, drove home to NSC staff and leadershipthe gravity of the situation and the
potentialsteps needed to turn it around.

On July 23, 2014 the American doctor Kent Brantly,who was working in ELWA’smakeshift
ETU in Monrovia,was confirmed to be Ebola positive. With no Ebola patient having been
transported by air, State Department officials were faced with the sudden decision of whether he
could be safely evacuated to a hospital in the United States to receive a higher level of care.
When he got the call, the State Departmentofficial responsiblefor aeromedical evacuations
knew he had an unprecedentedsituation on his hands. Curious about who the doctor requesting
evacuationwas, the official found a picture on the Internet of Brantly standing with his family.
He later told colleagues that he knew we had to help. The evacuationwas quickly approved and
coordinated,but in a surprise to officials at the White House,there was no airplane in the U.S.
government inventory able to safely transport a patient with a hemorrhagicfever. The private
aeromedicalevacuationcompany Phoenix Air Group was quickly contacted and used a
specializedGulfstream jet, kept on contract by the CDC, for the transport. Brantly arrived in
Atlanta for treatment at Emory UniversityHospital on August 2, 2014. A nurse practitioner

11
working at the same facility, Nancy Writebol, fell ill several days later, and was evacuated by
Phoenix Air to Emory as well.

Shortly thereafter, State’s Office of Medical Services signed a new contract for use of the only
aircraft then capable of safely evacuating symptomatic Ebola patients. In one of State’s most
important contributions to the response, it subsequently created a framework for donors and
other nations to use this capability on a reimbursable basis. The capability became a key policy
tool for recruitment of health care workers into the response. Until a DoD aeromedical
evacuation capability that used pods placed in C-130 or C-17 aircraft became operational in early
2015, and a similar pod capability funded by the Paul G. Allen Foundation become operational
in mid-2015, the contract with the Phoenix Air Group was the only means the United States had
to transport those infected with Ebola.

Many medical lessons resulted from treating Ebola patients in advanced facilities where adequate
fluid replacement and real-time monitoring of blood chemistry were possible. Physicians
learned that Ebola caused 5-7 liters of fluid loss, even sometimes up to 12, in 24 hours, leading
to profound electrolyte imbalances severe enough to cause cardiac rhythm abnormalities.
Maintaining adequate fluid and electrolyte replacement was critical for survival. Beyond
challenges in caring for the patient in the hospital, there were associated challenges for ground
transport and—because of the copious fluid loss—hospital waste management. NSC staff
requested and received a briefing from the treating physicians and worked to disseminate this
clinical knowledge in medical channels.

CRISIS (August-December,2014)

As July turned to August, Liberia was descendinginto chaos. Caseloadswere rising rapidly in
Sierra Leone and Guinea. The WHO, along with the Presidentsof Guinea,Sierra Leone,and
Liberia,announceda responseplan with funding needs of $71million.

As the scope of the crisis became clearer, the President directed NSC Leadership to begin
making plans for the U.S. to intervene on a large scale, and to do so in a way that drew other
nations into the response. Homeland Security Advisor Lisa Monaco recalls the President giving
clear direction for the U.S. to organize and lead an international response, with particular focus
on enhancing the nascent British response in Sierra Leone and French response in Guinea. It
was the beginning of a remarkable chapter of Presidential leadership on Ebola that would
continue through the entire arc of the response.
With the President’s direction clear, NSC officials, under Monaco and Ambassador Rice’s
leadership, worked closely with CDC, USAID, and DoD to escalate the U.S. response. At a July
31, 2014 Deputies Committee meeting on Ebola, agencies were asked—at the request of the
President—to be forward leaning in their provision of leadership and assistance in the response.
Convinced that Department and Agency commitments were still not appropriately scaled, and
frustrated by working-level conversations that hit dead ends when trying to identify capabilities,
Lisa Monaco used the DC to ask DoD and others what operational capabilities they had to
deploy.

12
NSC staff started to understand CDC’s limited capacity to call forth and coordinate a
multiagency response. To help coordinate the on-the-ground response and organize a more
robust response, NSC staff asked USAID to deploy a Disaster Assistance Response Team
(DART) to the region, a trained group of technical experts specializing in assessing needs and
coordinating relief efforts. On August 1, 2014 USAID activated the Washington, D.C.-based
Response Management Team, a first step in mobilizing for the response.

Deploying a DART into a public health emergency was not an immediately evident course of
action. No DART had ever been stood up to respond to an emergency that began as a disease
outbreak. The proposition was not initially welcomed by CDC, which already had personnel on
the ground with separate funding and chain of command. But NSC staff brokered the agreement
between CDC and USAID at an IPC level meeting that a DART should be deployed, with a CDC
official designated as the DART deputy with overall leadership for public health and medical
issues. The idea, in the words of a senior CDC official, was to marry “CDC’s brains with
USAID’s brawn.” CDC would lead the strategy, but as in disaster responses, USAID would
bring the systems and personnel to assess and validate needs, establish logistics and
communications systems, and coordinate requests to other parts of the U.S. government,
including the Department of Defense.

On August 3, 2014, the NSC Deputies Committee ratified the decision to deploy the DART with
interagency participation. U.S. Ambassador Deborah Malac formally initiated the request for a
DART team, marking the beginning of the emergency phase of the U.S. response. The main
body of the DART deployed to Liberia on August 4th, with its leader arriving on August 7th.

On August 5, 2014,Chairmanof the Joint Chiefsof Staff MartinDempseyasked his senior

civilianSpecial Assistant to assessthe statusof DoDpreparednessto aid in the responseand
evaluatewhether protocolswere sufficientlydevelopedto allow active duty, reserve,and
nationalguard forces to work safely and effectivelyin support of public healthfirst respondersif
called to do so by the President. Secretaryof DefenseChuck Hagel establishedthe DoD Ebola
Task Forcethat same day.

Liberian President Sirleaf declared a national emergency on August 6th. On August 8th the WHO
declared a Public Health Emergency of International Concern, its highest level of alert. The
NSC Deputies Committee met again on August 11th, the same day the DART team expanded its
deployment into Sierra Leone.

In Liberia, it was a strange time of both fear and unexpected normality. Embassy and USAID
personnel who lived the full course of the epidemic noted that even at its height, many of
Liberia’s citizens went on with their daily lives. Reports of bodies in the street are accurate but
nevertheless overstate disruption to life in the capital, which was less than might be expected.
The density of cases, though large in aggregate, was ultimately a fraction of the population —
peaking in September at 1 per 400 in Liberia and 1 per 3,000 in Guinea. Embassy staff noted the
absence of crowds and frequency of ambulances, such that even as hospitals and clinics
collapsed one after the other, life went on with a surprising degree of normality.

13
In mid-August, President Sirleaf deployed the Liberian Armed Forces to quarantine the West
Point neighborhood, which suffered a large cluster of cases. Violent disturbances broke out.
Communities began to protest the placement of ETUs within their neighborhoods and became
alarmed by the seeming pattern of sick relatives going in for treatment only never to be seen
again. Disturbances grew so widespread that concern grew among NSC staff that the breakdown
of governance in Liberia was not out of the realm of possibility. Greater action was seen as
needed to stop the spread of the disease because of the civil disorder it was causing. CDC staff
in Monrovia warned of the impending spread of the disease across West Africa if the response
was not escalated.

Officials at USAID's Office of Foreign Disaster Assistance who put together the composition of
the responders deploying to West Africa noted the nuclear disaster at Fukushima served as the
initial template for mobilizing the DART. They presumed the WHO would play a similar
coordination role that the International Atomic Energy Agency did in Japan and that the DART
team would essentially be working in support of WHO rather than managing the entire response
itself. The need for the DART to take a leadership role in developing an overarching plan for the
entire response only became apparent several weeks after it deployed.

In retrospect, USAID officials are of the view that the DART should have rolled out one month
earlier, which would have better positioned it for the deluge of cases to come and the leadership
role it was thrust into. It was not that the threshold for deploying a DART turned out to be too
high. Rather it was that the DART was not at first seen as an obvious vehicle to manage the
public health emergency response given that WHO and CDC personnel were already on the
ground. OFDA, too, was overstretched, having already deployed in 2014 large DARTs to Syria,
Iraq, and South Sudan. Deploying a DART only became a logical course of action when there
was consensus that the response had evolved from a public health emergency to a broader
humanitarian disaster. Officials in Washington came to favor the DART’s deployment when
they realized there was no other operational platform that could orchestrate the push/pull
processes required to manage such a response and that a platform was needed for interagency
coordination. They also judged that the DART’s presence on the ground would encourage
NGOs who work with USAID to flow personnel into West Africa—a critical need.

Devising how DART staff would work with CDC teams in the region was one of the early post-
deployment challenges. The eventual integration of personnel from CDC and USAID under an
improvised chain of command, with the CDC team lead serving in effect as the DART’s deputy
officer, is one of the response’s significant organizational innovations. Yet in the early days
each agency had a mutual incomprehension of the other’s capabilities and essentially worked as
parallel entities rather than an integrated team. CDC personnel initially resisted being brought
under the DART structure, having typically operated independently when deployed
abroad. Once they assented, the nature of that integration would get re-litigated every 29 days as
CDC team leads switched out. Early leadership rotations took distinct steps backward. “We did
not have unity of command,” the head of the OFDA said of this phase. Gradually USAID and
CDC learned to work better together as they each figured out their strengths and how to combine
them. OFDA personnel noted that although they were able to “muddle through” with CDC in
the response’s early months, a more stressing outbreak scenario would not have allowed for this
kind of on-the-job learning and negotiation.

14
The difficulty that agencies and departments who focus on health had in working with those that
do not have a health mission would become a recurring theme in the domestic and international
response. Integrating the public health expertise of the CDC and other HHS components with
the response capabilities of USAID, DHS, and the Federal Emergency Management Agency
(FEMA), a component of DHS, was a central challenge. While the National Response
Framework created in the aftermath of hurricane Katrina specifies agency relationships and
mobilization plans for a domestic response in great detail, through HSPD-5, that response was
never formally activated. There is no corresponding framework for U.S. mobilization in an
international response.

USAID is well practiced at responding in conjunction with the U.S. military to hurricanes,
earthquakes, and other natural disasters, but the public health challenges presented by Ebola
were altogether different. Rather than being a point event that happens once, with disaster
management essentially a linear exercise in assessing and managing consequences, epidemics are
by their very nature non-linear. They grow, change shape and size, and can behave like a
snowball rolling downhill. They also require specialized knowledge to manage that is not a
normal part of a DART humanitarian response or DoD’s disaster response capabilities. In
addition, USAID typically works with non-governmental organizations on the ground to provide
assistance during a disaster response, but the paucity of partners in West Africa—to start with
and due to evacuations and fear of Ebola after the outbreak intensified—created the double
challenge of needing to actively recruit the very contract labor force that the DART is used to
having at its disposal. Nor could this labor force be easily adapted for the epidemic. Before fall,
2014, MSF was the only organization in the world, NGO or otherwise, with any depth of
experience in deploying to contain an Ebola outbreak—a stark reminder of the paucity of
international resources to address nations who need help responding to an outbreak of infectious
disease.

CDC also found itself in new territory. Its personnel do not typically deliver medical services or
health care, but rather work in partnership with Ministries of Health. Though CDC has a
significant international presence, with over 2,000 officials and contractors performing $2 billion
of work in 60 countries, it did not have large existing programs in the three affected countries
and the relationships they bring. Nor was CDC institutionally postured to surge staff at the scale
needed in the Ebola response. The challenge was thus to bridge USAID’s mentality of rendering
“things” and services (i.e. supplies, food, personal protective equipment) with the HHS/CDC
worldview of mobilizing experts. Both became necessary to address the crises, yet the expertise
of the two agencies was only put into meaningful conversation in August, 2014.

With the inadequacies of WHO’s fumbling leadership becoming more apparent as August, 2014
went on, the DART’s requirements assessment process became crucial to mobilizing U.S.
government and international capabilities. A fundamental role of the DART is to assess what is
needed – what “requirements” exist that need to be filled in order to mobilize an effective
response. Yet the DART found itself saddled with a situation it had never encountered before,
having not previously applied its assessment skills to a widespread epidemic. The tools it had,
its loose relationship with CDC and with DoD’s staff of military planners, and the general

15
confusion with the scene playing out before it, were not an ideal mix. “We knew then we had to
go in heavy. We didn’t know initially what tools to deploy,” the OFDA Director noted.

The DART’s ethos worked against it at this point. On August 3, 2014, the DoD official
designated by Secretary Hagel as the Department’s Ebola Coordinator recommended to the head
of OFDA that a military logistician, medical logistician, and military planner deploy with the
DART to assist in its development of requirements. USAID initially declined this offer by DoD,
reflecting the institutional preference to minimize extraneous participants and deploy with the
standard configuration honed by years of experience. OFDA did request a medical planner be
integrated with the RMT team in Washington on August 6th and on August 14th integrated into
the DART two military planners already deployed with Operation Onward Liberty, AFRICOM’s
security assistance mission to the Armed Forces of Liberia. On September 12th additional
planners from AFRICOM arrived at the DART. The missed opportunity to integrate planners in
this crucial planning period was nevertheless the first of many missteps in USAID and DoD
relationship.

In a similar episode later in the response, the DART team initially refused to accept one of
USAID’s own expert on IT and data systems, despite the obvious need to address information
flow in the response. Part of the challenge was the processes OFDA has for augmenting DART
teams. To prevent non-essential USAID personnel from using the DART as an expedient
platform from which to engage in the response, OFDA typically prefers that other USAID
officials travel in-country through the traditional TDY process, which requires approval by the
U.S. Ambassador to the country. If a non-traditional member is to be added to the DART,
position description and list of duties needs to be developed and approved by both OFDA and the
U.S. Ambassador, who in this case was not yet persuaded that more work on data and
connectivity was the best use of limited personnel slots the Embassy was able to support.
USAID’s Ebola Coordinator soon secured the data expert as a member of the DART team, but
this chain of events revealed a tendency toward adhering to standard practice that in effect
limited the DART from taking advantage of all available resources. The after action review
conducted by USAID’s Office of Foreign Disaster Assistance cited “incorporating technical
resources from USG partners” as the primary challenge to USAID’s initial ability to respond.
The view at DoD was harsher. In September, 2014 some on the Joint Staff characterized the
DART’s requirements definition process as “broken,” leaving the DoD unsure of what it actually
needed to provide to arrest the epidemic.

The situation continued to deteriorate in Monrovia and the region as the DART deployed and got
its footing in August, 2014. In Washington, leaders began to evaluate what a larger response
might look like. With few NGOs willing to send medical personnel, creating an “enabling
environment” that induced first responders to work in West Africa became a priority.
Establishing a word-class treatment facility in the region was identified as one of the most
important means of convincing health workers to join the response, who needed to know they
would be cared for if they fell ill. NSC thus asked DoD officials whether the military had a field
hospital that could be deployed to serve this purpose.

After a back and forth over what capabilities DoD had in the inventory and who should be
deployed along with them, the Deputies Committee agreed that DoD should deploy a medical

16
unit, which became the Monrovia Medical Unit (MMU), on August 26, 2014. This highly
sophisticated combat hospital was designed as a world-class trauma center and had many
capabilities beyond what was required for the situation, but was sent forward anyway because
the military had no deployable facility optimized for infectious disease isolation and treatment.
Over a series of teleconferences and meetings of clinical experts from within the government and
academia, HHS led an interagency team that defined requirements for the facility’s
reconfiguration for treating health care workers infected with Ebola.

An interagency team of medical and infectious disease experts made recommendations for exact
medical procedures that would be performed, as well as those that would not (e.g.
cardiopulmonary resuscitation, mechanical ventilation, hemodialysis). One NSC physician later
pointed out the decision at the time not to include the dialysis capability, now known to be
essential in the care of Ebola patients, but then seen as posing too much risk to health care
workers to administer safely, reflected how minimal the experience base was for treating Ebola
in advanced clinical settings.

Because the U.S. military argued it should not have to provide the clinical staff to treat patients,
despite having the quickest capability to deploy them, Secretary Burwell volunteered the Public
Health Service Corps (USPHS), a uniformed commission of experts, for this unprecedented
mission. The USPHS Commissioned Corps ultimately deployed several hundred personnel in
support of the MMU and the Ebola containment efforts across the three African countries,
drawing staff away from exiting responsibilities within the federal government and tribal
agencies.

On September 2, 2014 the President of Medicines Sans Frontier (MSF), an organization

historically averse to partnering with any military, appealed for United Nations member states to
send civilian and military assets to assist in the response. The MSF President also personally
urged the White House to intensify U.S. involvement. It was a notable commentary on the
inaction of Western governments to confront the emerging crisis.

The CDC Director and OFDA Director visited the region during the last week in August and
echoed MSF’s call for greater involvement when they returned to the United States. “Unless the
emergency actions outlined below are taken – and progress measured in hours rather than days or
weeks – there could be tens of thousands of cases of Ebola within months,” the CDC Director’s
September 2, 2014 trip report read. “The disease will likely become endemic throughout much
of Africa, become established as an ongoing global threat for many years, and cause
destabilizing economic, political, and social devastation in the West African region and beyond.”
On September 3, 2014 the CDC Director visited the DoD official in charge of Ebola and also
spoke with the President. His message was that the epidemic was taking a turn for the worse and
extraordinary measures were necessary, including possibly the deployment of the U.S. military.

On September 4, 2014, Chairman of the Joint Chiefs Martin Dempsey forwarded Secretary of
Defense Chuck Hagel an update from the AFRICOM Commander identifying the need for a
broad interagency effort to develop a comprehensive strategy to fight Ebola. Dempsey was
worried about requests to deploy DoD assets piecemeal in the absence of a mature interagency or
international plan. It was a complex time, with many in DoD—including the DoD Ebola

17
Coordinator—reluctantto deeply involve the military in the responsegiven new demands
associatedwith humanitarianand counter-ISIL operationsin Iraq and Syria and the general view
within most parts of DoD that health is a WHOor HHSresponsibility.

Despite increased focus on the possibility USAID and CDC might make a formal request for the
military to become involved, little of the specific formal planning that Dempsey called for was
underway at either the Pentagon, AFRICOM, State, USAID, CDC or elsewhere in the
interagency. USAID and CDC had managed to build by the end of August a skeletal strategy,
essentially a whitepaper and excel spreadsheet. The NSC-drafted US Government Strategy for
Reducing Transmission of the Ebola Virus Disease in West Africa was released on September 4,
2014. But both documents were a long way from the kind of detailed operational plans that
military planners align assets against. Without direction for DoD planners to conduct detailed
planning before decisions were made for DoD to ramp up its role, and with top civilianvi and
uniformed officials at DoD signaling their reluctance to involve staff in interagency planning for
fear of being drawn into the response absent senior direction, an integrated plan was not
produced. The military planners detailed to USAID and the DART were helpful at educating
USAID about DoD’s capabilities, but did not themselves evolve into a core planning team
anticipating the future needs of the responsesp.

It would be incorrect to say the NSC and interagency were asleep at the switch at this crucial
moment. The tempo of engagement was high. The NSC staff maintained a daily drumbeat of
interagency meetings, conference calls, and communication with teams in the field. National
Security Ambassador Susan Rice’s personal commitment kept Ebola front and center on the
NSC agenda and led her to press hard for a more aggressive response, a commitment shared by
USAID Administrator Raj Shah and the President himself. But the realization set in late that the
epidemic had outrun the WHO. When mobilization became necessary, there was a “mutual
incomprehension” of what capabilities among USAID, DoD and CDC could be mobilized. The
key planners from USAID, DOD, CDC, and HHS had not been directed by their leadership to
jointly brainstorm what capabilities could scale the response. As a result, the policy planning
process at the end of August had not generated the creation of mature interagency options in the
very period where it would have been ideal to have planners from agencies working closely
together.

The Department of Defense lessons learned team concluded that the military was simply not
prepared or postured for the demands that fell upon them just a few days after Dempsey’s letter
to the Secretary in early September, 2014. “DoD monitored the worsening situation but neither
planned nor postured for the level of response support eventually required,” was its conclusion.
The mathematics of Ebola had outrun the international response, with the epidemic at this point
doubling in size every three weeks. The speed of the response now mattered tremendously, but
the major organs of the U.S. government had essentially been caught flat-footed when the NSC
Principals Committee began debating whether to recommend the deployment of military forces.

It’spossible to read unfoldingevents during this period as failuresof foresight and the product of
capability gaps at several levels. The governmenton the whole lacked a global system to detect
the emergenceof biologicalthreats, a capability the Global HealthSecurity Agenda is trying to
build in countriesoverseas. Nor was there a standingdoctrine for how to combine the various

18
capabilities for fighting biological threats to global security resident in HHS/CDC, USAID, and
DoD. There was in essence a “failure of imagination” in the years before 2014 to plan, build,
and exercise deployable capability to contain an epidemic. The decision to deploy a DART was
fundamentally an ad hoc response. It is therefore unsurprising that the most critical failure of the
DART in the field was its inability to quickly integrate the specialized knowledge—and
associated CDC personnel and military planners—needed to properly conduct the joint
assessment of requirements that is its core function.

A second place where more specialized capacity was needed was at AFRICOM, a Combatant
Command created in part to marshal whole of government responses to hybrid security
challenges. AFRICOM planners did not aggressively build the kind of worst case plans it was
soon scrambling to complete. The DoD lessons learned team found that AFRICOM did not have
a current pandemic influenza infectious disease response plan on the books, as they were
required to—a not infrequent oversight, given the general mismatch between number of staff
planners and plans they are in theory held responsible for updating. The addition of military
planners to the RMT and DART provided some essential connectivity, but that connectivity did
not trigger the larger planning effort that came to be needed.

The third failure of foresight arguably occurred at the level of the NSC Staff, Deputies
Committee, and in the planning staff of departments and agencies, whose efforts to elicit what
operational capabilities could be mobilized from CDC, USAID, and DoD in early and mid-
August was not followed by deeply integrated planningthat could have supported the NSC
decision process. One member of the Ebola Task Force recalls the lack of a clear threshold for
when the epidemic crossed into an international emergency that the U.S. had to help solve, rather
than relying on the WHO to take the lead, as a key reasons why Deputies had not yet flipped into
full crisis mobilization mode. Another noted that the explicit preference of top DoD officials to
resist involvement until explicitly directed effectively curtailed military planners from deep
engagement with their interagency counterparts before the formal decision to deploy the military.

Diplomatic & Military Mobilization

By early September, 2014 the mushrooming epidemic led decision-makers to explore many
options for intervention. USAID Administrator Raj Shah placed a phone call to Chairman of the
Joint Chiefs General Dempsey at the beginning of the second week in September asking if the
military could build and staff a 1,300 bed Ebola treatment facility in Monrovia, the size needed
to contain infectious patients based on projected caseloads. It was a request that led to what
became the nation’s theory of civil-military epidemic response even as the request itself would
have a long tail of unintended effects on the resources the military and others deployed.

The call crystalized for Dempsey earlier cautions he and other DoD officials had expressed over
what the military could and should provide to the response and what it should at all costs
endeavor to avoid. He formulated his judgment, later shared with the Principals Committee with
the support of Secretary of Defense Chuck Hagel, in terms of “unique capabilities” and
“redlines.” What the military could and should do is leverage its unique capabilities in support
of USAID and other health responders, including logistics support, mobile laboratories, training
health care workers, setting up an intermediate staging base, opening an air bridge, and providing

19
command and control capabilities through the establishment of a Joint Task Force. What the
military should not do is provide patient care. The military, in Dempsey and Hagel’s view, did
not have large numbers of medical providers trained to care for Ebola patients, and should not
have to supplant civilians who are better positioned to serve this function. The uneasy way in
which USAID, CDC, and DoD grappled with what to do and who should do what, in the eyes of
the CDC Director, reflected a “critical mutual misunderstanding” of each other’s capabilities and
mission requirements.

The NSC Principals Committee met on September 10, 2014 to decide the contours of the U.S.
response to the escalating crisis. At that meeting, National Security Susan Rice conveyed the
President’s view that Ebola should be identified as a tier-one national security emergency,
equivalent to Iraq or Syria, and set in motion a dramatic escalation of the response. The tier-one
designation was pushed for by NSC staff who were concerned State and DoD were not yet
treating the outbreak as seriously as they should be.

Particularly persuasive in the meeting were estimates of future caseloads presented by CDC
Director Tom Frieden and the Director for National Intelligence. NSC staff came to refer to
Frieden’s chart as the “hockey stick” slide for its sharp upward curve estimating over a million
cases by January absent further intervention. The modeling made clear that the mathematics of
transmission created a tremendous penalty for delaying intervention, with case numbers at their
peak roughly tripling for every month the response was not scaled up. Speed was of the essence.
White House Chief of Staff Denis McDonough and the President’s other senior advisors were
seized with the need for action after hearing Frieden’s case. Others later noted Frieden’s
presentation of the alarming models warped policy considerations by overly focusing attention
on a perceived “bed gap” in treatment facilities. It was the beginning of a period of debate and
uncertainty over what interventions would most effect the course of the epidemic.

DoD, while acknowledging the seriousness of the situation, continued to insist that others
provide patient care. Dempsey’s stance against having uniformed personnel treat patients, given
the high cost of moving to Africa units that have current responsibilities abroad or in the
homeland, was reluctantly agreed upon by other Principals. This decision established a de facto
division of labor between military and civilian responders, with civilians treating patients and the
military providing logistical support to help them do so.

Although National Security Advisor Rice was very clear that the U.S. response should cover all
three affected countries, the U.S. diplomatic strategy began to coalesce around an international
division of labor reflecting historic colonial ties. The U.S. asked the French government to
provide military and civilian responders in Guinea and asked the British government to increase
its mobilization in Sierra Leone. This allowed the U.S. government to focus its resources on
Liberia, which by now had the overwhelming percentage of cases. Specific mobilization
timelines were briefed to and agreed upon by Principals on September 12, 2014. The military
had a scouting party in Monrovia four days later, the same day President Obama announced the
escalation of the U.S. response, and Operation United Assistance, in a nationally televised
speech at CDC.

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In three days in September, 2014, a new theory of how the U.S. government as a whole can
respond to epidemics was born. During an interview with CNN, Dempsey explained his
reasoning for deploying the military to fight a disease in the same terms he described the U.S.
approach to counterterrorism. “Ebola, to use a sports metaphor, needs to be an away game. And
that's why the United States military is involved. I can promise you that the United States
military will do its part, with civil authorities, to keep this thing from coming to our homeland.”

Diplomatic Engagement

The decision to dramatically escalate U.S. involvement in the Ebola response increased the pace
and level of interagency coordination. The NSC staff was by now in full crisis support mode. A
major focus during the rest of September, 2014 was ramping up the global response to the
epidemic. The President and National Security Advisor engaged in multiple calls per day to their
counterparts to secure international commitments of support and rally others who had resources
to deploy. On September 18, 2014, Ambassador Samantha Power addressed a special meeting of
the U.N. Security Council. On September 24, 2014, President Obama made a historic call for
action at the U.N. General Assembly, which was preceded by a pledge drive that was
spearheaded by the NSC staff.

One of the early frustrations of NSC officials was the sluggishness of the State Department to
support this coalition building effort. Secretary Kerry was not yet deeply involved. State sent an
Undersecretary to represent it at to the first Principals Committee meeting on Ebola. There was
a sense that no one on the “7th floor” where the Secretary and Deputy Secretary have offices or
in the Africa Bureau recognized how dire things had become. State, in the eyes of the NSC, was
missing how essential the diplomatic campaign was to preventing a regional crisis from
becoming a global one.

A confluence of factors in August and September, 2014 hampered State’s ability to respond.
The spilling of ISIL over the Syrian-Iraqi border, the massacre of Yazidi men on Mount Sinjar in
Iraq, and subsequent U.S. military and humanitarian mobilization consumed the Secretary at the
same time he was participating in the NATO summit and U.N. General Assembly. Iran
negotiations consumed the role of one of the Department’s Deputy Secretaries, while another
Deputy Secretary who was charged with coordinating the Ebola response went on unexpected
leave with pregnancy complications. Meanwhile, many of the staff who would later engage on
Ebola had just managed Africa Leaders Summit at the beginning of August and scheduled
personal leave during the period that turned out to be the very moment when the Ebola crisis
escalated.

Another part of the challenge for State was that the management of Ebola was distributed across
many bureaus, both regional and functional, with no obvious “heavy” under which everyone
could cohere. State also had no surge staffing mechanism to mobilize. “What is the State
Department’s equivalent of a DART team?” one NSC official asked. This classic organizational
impasse is something of a known failing of the State Department structure, National Security
Advisor Susan Rice recommended the formation of a dedicated Ebola unit and supported the
State Department’s decision to call Ambassador Nancy Powell, known for her work on avian
influenza, out of retirement to run it. The State Department Ebola Coordination Unit (ECU)

21
opened its doors two days later, on September 15, 2014, more than a month after the WHO had
declared a public health emergency of international concern and five and a half weeks after DoD
established its own Ebola Task Force. The focus of the State coordination unit was to provide a
single organizational center to support the building of a coalition of actors to work with the host
governments while also ensuring that the Embassies in each country had sufficient staffing and
financial support to perform emergency duties during the crisis.

While the establishment of the Ebola Coordination Unit significantly improved State’s internal
coordination and effectively ramped up State’s support to Embassies in the region, the State
Department’s own lessons learned team documented shortcomings that were also noted by NSC
staff. One early difference of opinion regarded who should take the lead in defining
requirements for international donor assistance. Ambassador Powell wanted to defer to the UN,
which is usually a best practice in a disaster response, and center diplomatic asks around a UN
roadmap then under development. However, at the request of the WHO, the UN had not
activated its Office for the Coordination of Humanitarian Affairs (OCHA) and was in the initial
process of standing up the United Nations Mission for Ebola Emergency Response (UNMEER),
which later was widely deemed to be ineffective and quite possibly counterproductive to the
response. NSC staff assessed that the DART was further ahead at defining requirements and did
not want to wait for the UN, UNMEER, and WHO, which by now were recognized as having
lost control of the outbreak. The difference of opinion reflected a disagreement over what the
threshold is for when an ongoing WHO response should be deemed ineffective. The ultimate
ineffectiveness of UNMEER also points to the need to rely on existing institutions when speed is
of the essence rather than to create new response entities out of whole cloth.

The second issue was the agility of State’s response to the tempo of diplomatic events and a
seeming reluctance to elevate issues to the 7th floor’s attention, which holds the offices of the
Secretary and Deputy, perhaps out of deference to the many other crises occurring
simultaneously. “If we decided at 4 pm that POTUS had to make a call,” a senior NSC official
said, “he would make it the next morning. State's ordinary processes of writing and clearing
points made it hard to kick into warp speed.” In part because the NSC moved much faster than
State processes, the White House kept its own list of partner contributions even after that
function was formally assigned to the State Department Ebola Coordination Unit. In the eyes of
NSC staff, State’s contribution tracker was always less complete. The White House effectively
led coordination of coalition building until the October timeframe, with NSC staff regularly
developing the “asks” and delivering them through calls by the President or Ambassador Rice.
Secretary Kerry did make dozens of high-levels calls in September and October and hosted an
Ebola Ministerial. State’s Ebola Coordination Unit did also eventually put in place expedited
clearance mechanisms with the Secretary’s staff and relevant bureaus. Despite these failings, the
overall diplomatic campaign to mobilize international involvement in the response was later
cited by NSC staff as one of the best examples of “a la carte internationalism” during the
Administration’s second term.

Turnover was also an impediment to smooth operationsin State’sEbola CoordinationUnit.

Though its leadershipwas consistent at the top, with two Ambassadorseach serving several
months at the helm,State’s own lessons learnedteam noted that only three staff worked on the
Ebola CoordinationUnit for more than three months. The rest were loanedfrom other bureaus

22
for short periods, sometimes for just a few days, with little of the formal “left seat, right seat”
transition process used by the Joint Staff and at OFDA. The Ebola Coordination Unit also had to
create spreadsheets used to track partner commitments that NSC officials were surprised did not
already exist. Because the functions performed by the State Department during the response
were in some ways the least novel in relation to institutional competencies, its performance
deserves greater scrutiny and internal evaluation.

While the adequate but imperfect performance by the Ebola Coordination Unit highlights the
need for State to rethink its crisis staffing mechanisms and to lay better plans for managing
global health emergencies, other parts of State turned in shining performances. The
Ambassadors and Deputy Chief of Missions in Liberia, Sierra Leone and Guinea were widely
lauded by their colleagues for effectively managing through a crisis that threatened to unravel
order in all three affected countries. Their spearheading of strategic communications campaigns
helped foster behavior change among the population, and their daily engagement to help host
governments work with the international response and pivot resources—all while overseeing an
infusion of response staff and managing the ordered departure of two posts—was an exceptional
example of heroic on-the-ground diplomacy.

In addition to the shining performance of three U.S. Ambassadors, “State medevac saved lives,”
as one NSC doctor put it, referring to State’s Office of Medical Services. The rapid negotiating
and signing of the aeromedical evacuation contract with Phoenix Air Group by State’s Under
Secretary for Management, and provision for the use of this contract on a reimbursable basis by
other nations, cemented an essential capability that helped attract more health workers to the
response. State’s legal office, “L”, also helped quickly address complex legal issues that arose in
the response, to include the difficult task of negotiating an agreement with the government of
Liberia that provided protections to U.S. health care officials who deployed to Liberia. State’s
Africa bureau also hired a temporary employee to lead the Department’s corporate outreach and
encourage U.S. companies to contribute to the response.

USAID faced similar organizational stresses and also recognized the need for a senior
coordinator to integrate the OFDA response with the rest of the building. When Nancy
Lindborg, the USAID official that had been managing the response, announced her intention to
retire in November, 2014, Administrator Raj Shah called Dirk Dijkerman out of retirement to
perform this duty. Dijkerman, like Powell, was a seasoned crisis manager with a second to none
reputation within USAID. He ended up staying for over six months, a tenure longer than
Ambassador Powell, who departed after only 90 days in part because the mechanism State used
to contract her expired at that point. Powell’s successor also departed at the same 90 day mark,
raising the question of whether State should build in greater flexibility to its surge hiring
contracts to allow events, rather than contractual limitations, to drive when emergency personnel
come and go.

The Department of Defense was also scrambling to integrate resources and expertise. A study
conducted by the Defense Threat Reduction Agency’s Threat Reduction Advisory Committee
(TRAC) noted that DoD’s health-related guidance and response capabilities are geared for either
a disaster response, a conventional mission with a force health protection component, or a
response to a biological attack. Operation United Assistance fell in between. The Office of

23
Special Operations and Low Intensity Conflict (SOLIC) was tapped by Secretary Hagel to
manage Ebola for the Department, on account of its usual role overseeing humanitarian missions
and coordinating with USAID. SOLIC provided a coordinating function within DoD and led a
regular tempo of “all-hands” meetings. However, the TRAC study noted, the initial DoD focus
on providing logistical rather than medical or health assistance had the effect of sidelining
technical experts in medical communities in the military services that could have provided better
awareness of existing capabilities. The Joint Staff Surgeon General told the DoD lessons learned
team how she kept learning more as the operation went on about capabilities she had no idea
DoD had.

The Chairman’s “redlines” against DoD personnel providing patient care moreover had the effect
of suppressing conversation about deploying certain medical, biosecurity, and biosurveillance
resources DoD did have in house, including epidemiologists, infectious disease specialists, and
research staff who support austere field trials of experimental therapeutics and vaccines. The
military’s refusal to transport people who had been in “hot zones” where active cases existed, or
to transport Ebola blood samples, even though the samples were packaged to meet commercial
air standards, required the White House to push for expanded UN air support. There was also a
huge amount of self-censorship on asking for additional military support from USAID, HHS, and
CDC once the DoD redlines were established by the Chairman and Secretary of Defense. The
sense, one NSC staff member noted, was about not wanting to “spook” DoD by asking for more
and in so doing threaten the support DoD had already pledged.

An interesting hypothetical question is whether the Chairman would have drawn up his
“redlines” at all—which in his view began as a negotiating tactic used to ensure other agencies
shared the burden of responding—had his own planners, CDC, and USAID presented an
integrated plan initially rather than USAID Administrator Raj Shah putting to Dempsey an ask in
September, 2014 that appeared to come in the absence of a detailed interagency plan. DoD, at
the same time, was under pressure from its oversight committees. Both the majority and
majority on both the House and Senate Armed Services Committee expressed concerns about the
risks Ebola posed to the health of deployed troops and the sudden use of the military to augment
health responders. Both committees imposed specific conditions on the re-programming of
funds that required DoD to provide assurances and analysis about how it would operate safely in
this new environment and the timetable on which it would transition the mission to civilian
health workers and contractors. These committees would have certainly scrutinized and likely
resisted the use of DoD personnel in direct patient care.

The TRAC study nevertheless notes that the decision by DoD to not fully engage its medical
capabilities leaves a deficit for the future because of experience not cultivated in an actual
epidemic response. TRAC urges the “redlines” be relaxed or abandoned in future responses,
where the nation may need DoD to bring all its resources to the mission. To ensure a more
coherent, all-Department response to the next epidemic crisis, TRAC recommends DoD assign a
single office responsibility for preparedness, planning, training, and exercising epidemic
response capabilities, rather than leave those responsibilities distributed, as they are now,
between OSD-Acquisition, Technology, and Logistics (AT&L)/Nuclear, Chemical, Biological
(NCB) and other offices in OSD-Policy. TRAC also urges DoD assemble a single list of
deployable capabilities to ensure Department leaders are aware what capabilities exist.

24
NSC Crisis Management

Like the rest of the government, the NSC struggled with the demands suddenly imposed on its
staff. In the eyes of key officials at departments and agencies, NSC was initially disorganized in
its management of the escalation of the U.S. response. Internally, NSC Directorates surged
staffing to support the nascent White House Ebola Task Force, which consisted of the Deputy
Homeland Security Advisor, Senior Directors, and Directors who helped manage the response,
most of whom had to continue their ordinary duties on top of their work for the Ebola Task
Force. On October 17, 2014, amidst an atmosphere of crisis triggered by the Dallas cluster, the
President tapped Ron Klain as NSC Ebola Coordinator. National Security Advisor Susan Rice
and Homeland Security Advisor Lisa Monaco deliberately placed Klain in the NSC, knowing
that the NSC had a robust organizational machinery to mobilize departments and agencies and an
established policy coordination process to quickly identify decision for Principals and the
President. Klain, like Powell and Dijkerman, was required to depart by a specific date associated
with regulations of his hire as a Special Government Employee. The NSC also temporarily
brought on board former NSC official Richard Reed, an experienced emergency manager, and
Lyle Peterson, a senior CDC official who coordinated the later phases of CDC’s response to
Thomas Duncan’s hospitalization in Dallas. Agencies report a significant increase in NSC
effectiveness once Ron Klain started as Coordinator.

The model of White House Ebola Task Force is an obvious object of study as the NSC
contemplates finalizing its draft Domestic Incident Coordination Plan and crisis management
PPD. Both the international and domestic aspects of the Ebola response presented many novel
challenges that quickly eclipsed the ability of agencies to manage through normal processes.
Seams internal to the NSC also manifested themselves, with the need for greater integration
emerging between the Directorates who focused on the international response, such as
Democracy and Development, WMD Threat Reduction, Defense, and Multilateral Affairs, and
those Directorates like Resilience and Transborder that focused on the domestic response.
Integrating NSC activities with the wider Executive Office of the President, and especially the
press, political, and legislative advisors in West Wing, also proved challenging but necessary,
given the broader considerations that came into play once the public reaction to Ebola, and calls
for a travel ban, became a front burner issue.

The most expedient way to effectively pull together a cohesive interagency and White House
response to Ebola was to essentially “operationalize” the NSC, which was simultaneously
required to formulate policy for many previously un-encountered situations and to closely
coordinate its implementation. Under Coordinator Klain the White House Ebola Task Force at
times took great interest in overseeing tactical and operational decisions that in more ordinary
circumstances would have been addressed by departments and agencies. The degree to which
policy and actions in the response required management—and at times micromanagement— by
the White House varied based on circumstances. In many cases whole new policies had to be
drawn up. In other cases it was clear that only White House officials could make assessments
about what level of risk and political consequences the Administration was willing to tolerate.
Similarly, there were many moments when management decisions needed to be made faster than
the ordinary NSC IPC-DC-PC process could function. To speed his ability to act, the NSC

25
exempted Klain and his staff from following the usual Executive Secretary process for the
submission of information memos, coordination with other offices, and scheduling of DCs, PCs,
NSCs. The line from Klain to the NSC leadership and White House Chief of Staff was direct,
and he did not shy away from reaching deeply into departments and agencies to ensure things
were working effectively.

Given the strong dynamics for centralizing the decision making process when facing novel
circumstances, a question worth exploring further in the context of NSC crisis management is
whether the model of pushing several more senior USAID, CDC, DoD, and State representatives
to work directly on the White House Ebola Task Force would have further tightened the
integration of White House and agency decision-making. In the view of several senior officials
at State and USAID, NSC and OMB have a coordinating role that is so crucially important that
in a true crisis, a handful of senior interagency folks pushed right to the White House might have
actually made it easier for their agency to integrate itself in the response. This surge model that
includes agency staff, which is an element in the Domestic Incident Response Plan, is important
to consider in the context of the intent to downsize the NSC staff. Especially as the NSC
downsizes, more surge staffing from outside the NSC may be needed during crises to unburden
NSC Directors consumed by their “crisis jobs” and “day jobs.” Work became so intense through
the fall of 2014 that one of the NSC’s medical doctors pointed out that using a shift model would
have been far preferable to having staff operating on only a few hours of sleep for months on
end.

The NSC Ebola Task Force under Klain brought other components of the White House together
with the core NSC staff members. Congressional relations staff at the White House, who had
been closely involved since early September, worked closely with Klain on Congressional
strategy. The importance of maintaining trust with Congress was essential given the funding and
resource transfers that were immediately needed for response activities to continue for any length
of time. The decision for USAID and DoD to always brief the Congress jointly, and to do so
with officials from HHS’ ASPR and CDC, sent a signal of unity that was particularly well
received on the Hill. Interest from Hill staff was so intense that at times 600 people joined
weekly update phone calls. The trust built will Hill staffers and members helped win approval
for the reprogramming of OCO to OHDACA, which occurred before Klain’s arrival, and
provided support for the supplemental funding bill that soon became necessary, which Klain
personally saw through both Houses of Congress. Early involvement of OMB, and the rapid
maneuvering of DoD to secure operation funds, was key to ensuring the response could continue
before passage of the supplemental.

During September and October the White House Office of Science & Technology Policy (OSTP)
worked with the NSC, USAID, and its own National Science & Technology Council to mobilize
the science and engineering community though “Grand Challenges” and other events. Science
and technology officials at DTRA, HHS/ASPR, NIH, CDC, DHS’s National Biodefense
Analysis and Countermeasures Center and in other agencies and departments worked under
OSTP’s leadership to distill the government’s best expertise on many issues related to the
response, including personal protective equipment, medical countermeasures, therapeutics,
diagnostics, and vaccines.

26
The NSC legal staff and White House Counsel’s Office also convened lawyers from across the
government to address how the basic authorities of each department and agency can be used in
the context of an international health crisis and domestically absent a Stafford Act declaration,
which provides the federal government with many more authorities and funding mechanisms but
can only be declared by FEMA under specific circumstances. The legal group explored
questions around the authorities of the federal government to prevent travel of individuals
exposed to Ebola to the US; to quarantine them once they arrive; to require state and local
authorities to track individuals admitted to the US; and to implement various kinds of bans on
travel. The group helped identify areas of overlap of authorities, areas where the exercise of
authorities is dependent on the cooperation of another department or agency, and areas where our
system of federalism leaves power with state and local governments. The end product was a
summary of legal authorities that served as a useful guide to inform policy discussion on what
actions could be taken based on federal authority and what actions required the cooperation of
state and local authorities.

Military Deployment

President Obama announced Operation United Assistance in a speech at the Centers for Disease
Control on September 16, 2014, four days after Principals recommended the DoD mobilization.
Maj. Gen. Darryl Williams arrived in Monrovia that same day with an advance party of thirteen
U.S. military personnel. Within eight weeks more than two thousand U.S. military personnel
would be in Liberia, a number that peaked at just over 2,800 in December. The presence in Italy
of a large number of engineers who were returning from a training mission in early September
was fortuitous. AFRICOM immediately redeployed them to Liberia along with a Marine
aviation detachment. Within days of the President’s announcement of Operation United
Assistance, tilt-rotor Marine V-22 Ospreys, one of the loudest and most unusual looking aircraft
in the inventory, were thumping their way all over Liberia, serving as visual symbols that the
Calvary had arrived. A military and civilian air bridge was up and running quickly thanks to
emergency repairs made to the runways and taxi areas of Roberts Field in Monrovia, Liberia by a
team of Air Force Red Horse engineers and the establishment of an intermediate staging base in
Dakar, Senegal. U.S. Transportation Command gave higher priority to Ebola supplies on their
way to West Africa than material supporting the anti-ISIL campaign then underway in the
Middle East.

The military mobilization proceeded as expected at DoD, if not as fast as some at USAID and the
NSC imagined the military could move, with the rainy season proving the biggest obstacle to the
construction of basing and Ebola treatment facilities and flow of troops. The Joint Forces
Command established in Monrovia discovered the planned location for certain facilities to be
under water. A finding of AFRICOM was that longer than expected times to survey and prepare
sites selected for construction of Ebola Treatment Units occurred in part because local
communities designated parcels of land that were themselves not ideal sites and required major
remediation before vertical building could occur. Should treatment facilities need to be built
quickly in a future outbreak, it will be important to evaluate potential sites with an eye toward
speed-of-build, while keeping the trust of communities who are naturally inclined to want to
distance themselves from any treatment facility. Mobile testing laboratories deployed through
the Defense Threat Reduction Agency in September and October, 2014 substantially enhanced

27
the speed and volume of confirmatory blood testing. The deployment by DoD of these labs was
a crucial aspect of the response.

From USAID’s perspective, an inordinate amount of time in the initial weeks of Operation
United Assistance was spent defining the precise nature of the military mission, with long pauses
on operational decisions as commanders in the field sought clarification from higher
headquarters at USAFRICOM and USAFRICOM in turn engaged the Joint Staff and Office of
the Secretary of Defense. In comparison with other disaster responses, USAID personnel noted
the inability of the military commander on the ground to make unilateral judgments without
getting higher guidance on novel operational issues. The Chairman’s “redlines” about what the
military could and should provide, together with the many novel policy questions the operation
raised and a lack of understanding within DoD of what capabilities existed across the
department, triggered a significant degree of internal adjudication of each operational decision.

“It seemed to us like a big tug-of-war between various parties within the Pentagon,” OFDA’s
Director observed. The tug of war was pressurized further by insistence from the White House
and CDC and USAID leadership that the DART team make use of DoD capabilities to speed the
response. DoD in turn insisted that it only provide capabilities USAID requested through the
formal “MITAM” processes run by the DART, the way USAID has historically requested the
tactical application of military assets during a disaster response. The insistence upon using this
formal method of tasking assets became a chicken and egg problem, with DoD not wanting to
volunteer capabilities before a formal request, and USAID unsure what capabilities existed to
request. The early days of Operation United Assistance highlight a classic operational dilemma.
Those in the field often don’t know what capabilities exist across the government, or even in
their own departments, and so don't know to ask for them. The unique challenges of health
events mean that in future responses, more expertise should be pushed forward early, so that
requirements are defined with full awareness of what capabilities the Federal government has
available. Quicker adjudication of policy matters will also be needed, especially if an epidemic
is airborne and rapidly transmissible.

At a certain point, frustrated with the inability to get answers out of DoD, USAID personnel
resorted to litigating matters of policy and strategy through the MITAM processes, which
ordinarily only relays tactical requests like the need for air support to move USAID personnel to
a specific location and back. In USAID’s view, putting every question about possible support to
DoD through the MITAM was the only sure way to communicate their requests clearly and force
resolution of them amid the internal debates within DoD about what kind of support to provide.
A fruitful area for further study is how the command and control systems USAID uses to make
requests of interagency partners, especially the MITAMs process, can incorporate both tactical
and strategic requests.

The greatest difficulty mobilizing personnel in the response occurred in the agencies that do not
regularly deploy large operational teams abroad. When the U.S. Public Health Service
Commissioned Corps (USPHS) identified the 70-person contingency to staff the Monrovia
Medical Unit, they discovered not enough stock of Yellow Fever vaccines were in house and
requested assistance from the U.S. military to vaccinate their personnel before deploying.

28
Although USPHS was eventually able to contract a commercial charter flight to move their
personnel to Monrovia, they at first requested MILAIR transport.

U.S. healthcare workers intending to work in the MMU and ETUs, including those dispatched by
the USPHS, also had to be trained in infectious disease protocols on Ebola. To train them the
CDC established a three-day experiential training course for over 600 nurses, physicians, and
other healthcare providers intending to work in West Africa. The course was modeled after
curricular developed by Medicine Sans Frontier and held at the U.S. Federal Emergency
Management Agency Center for Domestic Preparedness in Anniston, Alabama.

CDC found deploying so many personnel for so long presented novel challenges. Proper travel
and evacuation insurance had to be let. Employees could earn overtime, but CDC lacked a
mechanism to offer hazard pay, as DoD and State are able to offer personnel serving in
dangerous stations overseas. CDC simply did not have the human resource systems,
compensation structures, and pre- and post-deployment support infrastructure for the scale and
speed of this response. USAID also had to deal with many novel issues related to the Ebola-
specific nature of the response, including requests for indemnification from contractors it had
never before broached.

A theme that runs throughout the response is that agencies who do not having standing
operational capabilities often find it very difficult to go operational in a hurry. The need to either
support the scaling-up of operational capabilities within agencies like CDC, or have agencies
“outsource” their operational needs in a hurry, is one of the most important findings of this study.

The international organizations that responded ran into similar complications with the health-
specific nature of the response. As it does in humanitarian emergencies as the head of the UN
logistics cluster, the World Food Program eventually became the logistical backbone of the
Ebola response in West Africa, supplanting the U.S. military as it redeployed. Yet the World
Food Program and the WHO were trying to move medical material and supplies with systems
meant for managing a non-medical humanitarian response. When it came to PPE in the early
days, no one had a very good handle on who could produce what at what volumes and where
they were in the world, or even what was needed. The Ebola Task Force asked for the assistance
of the Department of Commerce and certain contracting mechanisms at DoD to ensure PPE
supply chains for US personnel would be adequate for the scale for the response.

Data & Partner Integration

One of the most fundamental responsibilities of the response is keeping track of where the virus
is and where it is going. Identifying key indicators that would reveal the trajectory of the disease
in a timely manner was a priority of White House decision-makers. Data integration challenges
and the time-lag of data flow meant that CDC’s epidemiologic indicators often provided a
trailing rather than a leading indicator of where to direct the humanitarian and medical response.
Because medical, laboratory, and health systems in the region were overwhelmed, CDC had
difficulty generating reliable epidemiological data in October or November and was cautious
about sharing partial analysis that required conjecture or involved a proxy. For policy makers, it

29
was incredibly frustrating to not have something that gave a solid indication of whether the
response was moving in the right direction.

The difficulty in identifying reliable indicators resulted in part from systemic deficits in the data
itself and how it was aggregated. In West Africa, phone and internet connectivity is limited and
much of the population is distributed in rural villages reached by roads that are impassable in the
rainy season. A local workforce to perform data collection and basic analysis was lacking. The
data system driving the response was decidedly based upon 19th century tools. Most ETUs
recorded patient data using pen and paper. Locations of bodies of the dead were tracked with
stick pins on maps. Collating data about clusters of infection and matching patients who turned
up in Ebola treatment units with the results of testing performed on their blood samples in labs
that were often hundreds of miles away required Herculean efforts. Data reliability was so
problematic in the beginning that the U.N. had at one point to retract its announcement of
meeting safe burial and treatment targets because its own data were not verifiable.

By early October, a rough system of case reporting had emerged, centered in a statistical cell in
the Liberian Ministry of Health that was supported by WHO, CDC, and USAID staff and
partners working country wide. County health coordinators, with cell phones and phone credits
often provided by international donors, would call in with daily case tallies from local Ebola
treatment units—unconfirmed, suspected, confirmed. A small staff of Liberian health ministry
workers, augmented over time with international staff and several members of the military’s
Joint Forces Command, would collate these reports into an Excel spreadsheet and push aggregate
numbers out for reporting to the WHO, which did in turn produced detailed reporting and
analysis for West Africa as a whole.

An international statistical expert that served as a consultant in the unit later remarked to White
House staff that to fight an epidemic, “you need Microsoft Excel and confidence.” "I managed
the whiteboard,” he said, which tracked each step in processing a suspected case. The system,
however, was cumbersome and prone to miscounts. There were “three cards -- data entry upon
pick up at a sick patient’s house, upon arrival in the ETU, then when samples were taken for
labs.” Because the patient was often semi-coherent and may have been abandoned by family
members or fallen unconscious on the way to seek treatment, it was not always possible to know
their name or get the correct spelling of it. The statistical cell spent a great deal of time
reconciling data. Quality control and verification required a great deal of time. “It was very
difficult to merge in the database,” the expert said. For that reason he focused not on day-to-day
numbers of active cases, which would often jump up or down due to delayed reporting. For him,
the key number was the aggregate caseload for the two-week reporting periods. Focus on that
number, the expert said, and you knew whether we were winning or losing.

The deployment of USAID’s Chief Innovation Officer with a team of connectivity and data
specialists took place later than was ideal. When they did finally arrive in country in November,
2014, they began assembling a schematic of data flows in the response and worked to overcome
blockages where they identified them. “Just good enough” tech was their mantra, knowing that
motorbikes, cell phone cards, and paper were often the best way to move blood samples,
information about test results, and caseload data to and from rural ETUs. Facebook’s donation

30
of $20 million dollars of satellite Internet terminals also helped, as did connectivity and
computer equipment and vehicles donated by the CDC Foundation.

The mutual incomprehension of capabilities and mission that plagued early CDC-USAID
interaction extended to their use of data. CDC was oriented to collect detailed epidemiological
data on individual cases and clusters, which was not necessarily what the DART needed to scale
the response as the virus hopscotched its way from community to community. CDC’s system for
caseload data about the epidemic crashed early in the fall, having not been designed to handle the
number of cases now occurring in Liberia. USAID was left struggling to assemble a picture of
where the epidemic was, where it is was going, and where to push resources. The DART and
CDC reached greater coherency on data by late fall, but this structural mismatch reflects the
larger mismatch between biosurveillance and health data systems on the one hand and
humanitarian response data systems on the other.

In an ordinary disaster response,the UnitedNationsOffice of the Coordinationof Humanitarian

Affairs(OCHA)and the U.N.’sInformationand CommunicationsTechnology(ITC)cluster
would have been involved. But they were not mobilizedin this case becauseof the WHO’searly
insistenceof control over the response as a whole. The functionsthey would have performed
devolvedto the U.S.government’sDARTand CDC,which had not in the past had to help
support a countrywidesystemof medicalreporting.

The U.S. government has in its inventory several partially developed biosurveillance systems,
including at least three separate systems in the Department of Defense, that could have provided,
with some modification, a potentially more robust information management system for the
response. DoD briefed the USAID Chief Innovation Officer on these systems, but several
factors prevented their deployment. Part of the reluctance was that they were systems perceived
to be operated by the military. Part of the issue was that none was “just right” in terms of
functionality offered, given the operational difficulty of collecting, transmitting, and analyzing
data within the context of the Liberian health system. Part of the issue, too, was that the systems
did not easily link to and share data to each other or to systems used by CDC, USAID, or the
NGOs who worked in the response.

Recognizing the need to rationalize the USG’s investment in this area and make systems fully
interoperable, an interagency working group had begun meeting on biosurveillance systems
when the epidemic began. Its members quickly disbursed to assume crisis duties, leaving
outstanding the question of how to integrate data systems in DoD, CDC, and USAID before the
next epidemic, an issue critical to the success of the Global Health Security Agenda, which
includes a specific target on biosurveillance capacity.

Where responders on the ground saw immense challenges finding basic data, like roadmaps of
rural villages and locations of health clinics and traditional healers, the community of civil
society digital mappers and digital humanitarians saw an opportunity to help. To match the skills
of this loose community to the needs of data users on the ground, the White House Chief
Technology Office hosted twice weekly calls on data support for the epidemic. The idea was to
bring together data users and data owners in a “market” so they could find each other and work
together solving operational problems. For the first several weeks of the call and its associated

31
message board, more than 100 organizations participated. They ranged from members of the
U.S. intelligence community that were able to provide declassified imagery and maps to data
taggers who volunteered to help fuse databases into a single usable map. The White House
Chief Technology Officer calls concluded after a couple months when most organizations
working on the response migrated to a similar weekly call run by USAID.

The lessons learned report completed by two Presidential Innovation Fellows who helped
organize the data market calls lauded its overall success while flagging several barriers. The first
barrier was government officials not being allowed access to the data and collaboration tools
used by responders in the field. Most government agencies, for reasons of cybersecurity, do not
allow employees to access common platforms such as Google Docs or Skype, the voice-over-IP
calling app, on office networks. As a result, State and USAID personnel interacting directly with
NGOs and other implementing partners on the ground constantly had to rush off to coffee shops
to access these services on wifi and personal computers. Their lessons learned report suggests
easy remedies. One is for network administrators to create special enclaves to host these services
and then authorize designated response officials to use them. The other is to run Ethernet from a
commercial provider into government office space and set up stand-alone systems.

Leveraging the community of “digital humanitarians” turned out to be a smaller subset of a

larger problem. The response as a whole had challenges integrating donations of expertise and
material from other nations, the private sector, and foundations. Examples of donations gone
awry include hundreds of cots donated for Ebola treatment units that were not certified to be
safely decontaminated to hundreds of thousands of pieces of PPE donated by the Japanese
government that were not suitable for protecting healthcare workers from a hemorrhagic fever.
Many of these supplies were hauled to West Africa at great expense, only to sit unused in
warehouses, reflecting the need to overhaul the WHO’s process for managing the PPE supply
chain.

Likewise, the Paul G. Allen Foundation’s $100 million gift given at the outset of the outbreak
effectively turned the organization into an “operational foundation” that performed duties that
supported and augmented USAID and CDC teams in the field. The CDC foundation also
contributed $56 million in resources. The new concentration of foundations that work in the
health and epidemic space, who in aggregate contributed more resources than most of our
European partners, means the U.S. government needs to think about the foundation community
as it does our major allies. To harness this new source of resources, USAID Global
Development Lab’s study on private sector and philanthropic coordination recommends OFDA
hire two GS-15 “philanthropic coordination officers" whose job it would be develop
relationships and communicate with all the major foundations and private donors on a regular
basis, with appropriate coordination with agency ethics and legal officials. Their presence at
OFDA will provide a “bellybutton” for integrating private sector and philanthropic contributions
into responses. These officials could even be trained to deploy with the DART. Their presence
would help bring greater coherency than was achieved in the outbreak’s early phases, when the
activities of major donors, USAID, and the CDC were only loosely synchronized. The Global
Health Security Agenda (GHSA) will also be a useful convening framework for the integration
of foundation activities in global health.

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The Domestic Response

As the international response played out, how to prevent Ebola from spreading to the U.S. was
foremost on policymakers’ minds, especially after Thomas Duncan became the first person to be
diagnosed with Ebola on U.S. soil. Officials at the NSC were well aware of the public anxiety
about Ebola, fueled by the media, and the reactionary decision-making this sometimes drove at
local, state, and federal levels. The danger, in the NSC’s and the President’s perspective, was
that Americans could be exposed to a dangerous virus if mitigating measures were not taken.
Beyond failing to protect the nation from Ebola, a mismanagement of the domestic response
would also likely turn public opinion against U.S. participation in the international response,
making the public less willing to support the actual measures that would help bring the epidemic
to an end. This concern was not abstract. Nearly a quarter of WHO member states instituted
travel bans for the affected West African countries. Such actions not only went against the
WHO’s International Health Regulations. They also prevented many healthcare workers who
had volunteered to serve in the response from going home to their native countries, a strong
disincentive to the very labor force whose skills were most needed to stop Ebola transmission.

Aspects of the U.S. domestic response began to take shape in July as the White House prepared
for the August 2014 African Leaders Summit. The event brought hundreds of Africans to
Washington, D.C., leading the NSC to hold several interagency discussions on how to ensure the
National Capital Region was prepared to identify and properly respond to potential symptoms of
Ebola among members of the government, youth, and business delegations from Guinea, Sierra
Leone, and Liberia. These meetings identified challenges that would have to be addressed
nationwide, such as the limited number of facilities capable of testing for Ebola and the long
time required to transport a sample and receive test results.

In the weeks leading up to the summit, CDC provided Ebola awareness information to health
providers and emergency responders in and around Washington, taking the first steps of what
became a nationwide education campaign for U.S. healthcare workers and facilities. The State
Department demarched the three West African governments on the need to conduct Ebola-
related departure screening at their airports and to ensure delegation members who exhibited any
signs or symptoms of Ebola, or who had been exposed to the virus, did not travel to the United
States. CDC worked to establish departure screening at airports in the region. It was the
beginning of a system that would ultimately screen more than 450,000 travelers leaving West
Africa. DHS and CDC conducted arrival health screening on the delegations from Guinea,
Sierra Leone, and Liberia and began providing Ebola awareness flyers to arriving travelers from
the region that recommended they monitor their temperature and symptoms and inform
healthcare professionals of their recent travel.
The sudden and unexpected medical evacuations of Kent Brantly and Nancy Writebol from West
Africa to Atlanta drove home the reality that any substantial international outbreak could have
domestic implications. The NSC, in other words, must always plan for epidemics that cross
international borders. Then a chain of events starting in late September–Thomas Duncan’s
admission to Dallas Presbyterian Hospital, the subsequent infection of two Presbyterian Hospital
nurses, their medical evacuations and treatment, and the unrelated domestic case of Craig
Spencer in New York City—gave rise to public hysteria that drastically accelerated the pace of

33
the domestic response and turned Ebola into a front burner political issue with substantial
liabilities for the President.

After examining this hectic period and the months that followed, federal lessons learned teams
studying the domestic response sorted issues associated with managing Ebola in the homeland
into bins of “wins” and “more work to do.” Wins include establishing a nationwide Ebola
treatment system consisting of regional centers, treatment centers, assessment hospitals, and
frontline facilities; enhancing the nationwide lab network to quickly test patients experiencing
symptoms; standing up a system of passenger funneling and screening at U.S. ports-of-entry;
establishing an active monitoring program in partnership with local public health departments to
detect potential Ebola cases as quickly as possible; contracting aeromedical evacuation and
transport capability inside and outside of the United States; and introducing more specific
infection disease control protocols and PPE standards for Ebola. Each is an example of a
successful policy approach developed and then refined in the course of the response that reflect
great credit on the NSC Ebola Task Force, DHS, HHS, and state and local health departments
nationwide.

In the “work to do” category is improving public health risk communications; enhancing
domestic incident response policy to clarify Federal roles and responsibilities in the absence of
the declaration of a Stafford Act emergency; translating lessons learned during Ebola to future
infectious disease outbreaks, including by addressing medical, intergovernmental, and
interagency coordination gaps; improving non-Stafford Act disaster funding mechanisms;
developing a deployable infectious disease treatment capability; and strengthening hazardous
waste management.

Funneling, Screening and Monitoring

The system of passenger funneling, screening, and active monitoring implemented by FAA,
DHS, and HHS in the fall of 2014 was devised by policymakers to serve three purposes. Most
fundamental was the very existence of the system, which gave the public confidence that Ebola
would not be spread in the U.S. by a person who recently arrived from West Africa. The system
helped officials counter calls for more restrictive measures or outright bans on travel. The
second purpose was to enhance the domestic response by pairing travelers from West Africa with
the public health officials and facilities that would be responsible for caring for them should they
become symptomatic. Rather than needing every hospital in the U.S. to be prepared to handle an
Ebola case arriving in their emergency room, the active monitoring system, in partnership with
the designation of treatment and testing facilities, dramatically scaled down what the domestic
response had to focus on to be successful. Its third purpose was to provide a rich source of data
about who had entered the U.S., where they would be traveling, and whether they were
symptomatic and in need of further evaluation and possibly testing. More than 32,000 travelers
to the U.S. were ultimately monitored.

HomelandSecurity Advisor Lisa Monaconotesthat the rapid stand-up of passengerfunneling

protocolsbenefitedfrom the targeting rules developedto identify terrorists attemptingto travel
by air to the U.S. The screeningtools developedin the aftermathof 9/11was used in the case of
Ebola to identify travelerswho matcheda set of criteria that indicatedthey were travelingfrom

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an Ebola affectedcountry and neededto be screenedupon entry to the U.S. The anti-terrorism
infrastructureset up by the Department of HomelandSecurity and interagencypartnersfound a
new public health use-casethat helped protect the Americanpublic from exposure to Ebola.

While these measures went beyond what some Federal health officials thought was strictly
necessary from a medical perspective, they allowed for a more strategic and efficient way to use
resources in the face of cries from some in the public to shut down all travel between the United
States and West Africa. These practices may not be a feasible or recommended in the future, as
the funneling to a limited number of airports was only possible because the number of travelers
was small. There were also gaps in this system, particularly with travelers from Africa who
broke journey in Europe and then continued to the U.S. on a separate itinerary. But this system
of active monitoring nevertheless constitutes a significant innovation in the response to an
infectious disease that posed a credible threat to the U.S. public resulting from the President’s
personal determination to ensure decisions made were evidence based and proportionate to the
threat.

Domestic Ebola Hospital Network

HHS’s work with state and local authorities, healthcare providers, and emergency responders to
build a network of medical facilities capable of identifying, isolating, and treating Ebola patients
is also a particularly notable success. To build this system, which consists of regional centers,
Ebola treatment centers, assessment hospitals, and frontline facilities, the Federal government
funded healthcare coalitions to make investments to hospital infrastructure, update procedures,
establish reserves of PPE and other supplies, and conduct extensive training to meet defined
safety standards. CDC “Rapid Ebola Preparedness” teams, composed of expert in infection
control, occupational health, and laboratory testing, made visits to 81 facilities in 21 states and
the District of Columbia. This network is now well-positioned to serve major U.S. population
centers, as most of the United States is within a 2-hour radius of an Ebola treatment center. The
Federal government also designated three facilities, at Emory hospital in Atlanta, University of
Nebraska Medical Center, and the NIH, as the preferred location for treating Ebola cases. All
but one of the patients with Ebola treated in these centers survived.

The CDC’s Laboratory Response Network (LRN) consists of more than 130 domestic and
international laboratories whose mission is the detection of bioterrorism agents and emerging
infectious diseases, such as Ebola. Some of this lab capacity is funded by the DHS BioWatch
system. Prior to the Ebola outbreak in West Africa, Ebola could only be confirmed by the CDC
in Atlanta. As of August, 2014, thirteen LRN laboratories were qualified to test for Ebola. As of
December 1, 2014, 42 LRN laboratories are approved to test for Ebola. This increase in capacity
dramatically decreased turnaround time for Ebola results domestically. Typically, from receipt
of a specimen in the lab, a result is now available in 4-6 hours, compared with the close to 24
hours needed for some of the first domestic test results, due to delays in sample acquisition and
transportation. The decrease in time allows clinicians to make patient-care decisions in a shorter
time-frame and significantly enhances the ability of public health officials to rule out Ebola
among persons under investigation during the screening and monitoring portion of the response.

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Looking forward, lessons learned teams focused on the need for the federal government to
ensure that investments made in domestic hospital preparedness continue in the future. To
complement investments made during the Ebola response, some have suggested HHS support the
development of emerging infectious disease care systems, with standards and accreditation or
verification, to lay a foundation for the government, private, for-profit, and non-profit sectors to
build upon as a long-term national capability.

Taking the Ebola treatment network built during the Ebola epidemic as a starting point, two areas
in particular seem ripe for investment. The first is continued investment by HHS in the regional
centers and treatment centers to ensure that the capabilities established during the Ebola
epidemic are available for future infectious disease outbreaks. Particular attention should be paid
to transitioning these facilities from Ebola facilities to infectious disease facilities more
generally. The second is because the surge capacity the government can mobilize is ultimately
small compared with the possible demands of a more sustained and widespread public health
emergency, private hospital capacity and infection control is a crucial part of the preparedness
equation. It is here that the day-to-day work of infection control training and local capacity
become crucial pieces of the nation’s overall capacity to respond and be resilient in the face of a
dangerous pathogen. Should one infect large numbers of people, local hospitals and clinics,
rather than designated facilities, would become the front lines of treatment. The NSC must
ensure investments in infection control capability nationwide are sufficiently scaled to the
increased risk pandemic disease presents to the homeland.

Risk Communications

Despite risk communication being a standing field in public health, and risk communications
staff being present in Federal and state health agencies, scientists and public health experts were
largely unsuccessful in creating public confidence around how Ebola was being handled
domestically. In the view of one NSC official, images of the President hugging the nurse from
Dallas seemed to do far more to assure the public than any organized attempt at “risk
communications.” How CDC and the rest of the government can be better postured to manage
the flow of information and interaction with the media will be important going forward, to better
control both the “epidemic of fear” and the “epidemic of disease.”

An analysis of how to combine crisis and risk communications, and why the approach to
communicating largely failed in this response, is important to undertake given how much faith
has historically been placed in “risk communications science” being able to influence public
behavior. This capability is even vital given how crucial social mobilization is to controlling the
spread of disease. Who should be the face of the government is an important consideration for
leaders managing the response. It varied at differing points during August and early September,
with officials from CDC, NIH, and NSC at times playing leading on-camera roles. The NSC and
White House Chief of Staff’s office made a deliberate decision in mid-September to effectively
make the President the Administration’s spokesperson on Ebola. He spoke to the American
public on Ebola at least weekly for the next two months.

Domestic Incident Response Policy

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The most defining event in the domestic management of Ebola happened when Liberian citizen
and visitor to the U.S. Thomas Duncan tested positive for Ebola on September 29, 2014. The
circumstances surrounding Duncan’s diagnosis and treatment in Dallas, Texas revealed gaps in
the Federal government’s approach to the domestic containment of Ebola. Lessons learned
teams studying what happened in Dallas and CDC’s own after action assessment note how the
Federal government, and particularly CDC, was not well positioned to manage all aspects of the
response and that the incident was made more complex because it did not merit a Stafford Act
declaration but nonetheless requires significant Federal involvement.

Responses to public health threats like Ebola require tight coordination among Federal agencies,
state, local, and foreign governments, and private sector actors. During such incidents, clarity of
Federal roles and responsibilities and coordination across the Federal interagency are paramount.
Little of this was present in Dallas. Some had an expectation that CDC was going to help with
healthcare delivery, yet healthcare delivery is not a function of CDC. CDC’s initial forward
deployed team was built against a set of technical health requirements and was not equipped to
manage the conflicts that developed between the hospital, state, and local authorities. The Dallas
incident played out such that the “media crush” of local press attention materially interfered with
the mechanics of the incident response, a serious failure of public affairs. The CDC also was not
equipped, and did not have clear authority, to perform incident command without being
requested to do so by the state of Texas. The peculiarities of the local political environment
meant that Dallas county and the state of Texas each set up parallel incident command structures
that issued conflicting guidance, further confusing command and control.

Statements that CDC had many years of experience with Ebola, which accrued from rural
African contexts rather than managing it in U.S. hospitals, built up an expectation of competence
that suddenly unraveled, to great public alarm. The infection of two nurses caring for Duncan in
Dallas show just how quickly the premise articulated by CDC’s Director that any U.S. hospital
could successfully treat Ebola fell apart, along with CDC’s approach to working with local
authorities during a crisis. Existing CDC guidance documents for PPE that were based on
available data as of August 2014 were insufficient. It is now clear that CDC’s initial PPE
requirements were not specific enough, did not come with sufficient training and direct
observation of donning and doffing, and did not break down actions personnel must follow into
pre-event, event, and post-event stages, each of which must be managed differently.

As the chaos in Dallas unfolded, “no one hit the FEMA button,” in the words of one NSC
official. CDC’s public health expertise, combined with FEMA incident management support,
could potentially have provided the incident command structure necessary to bring better order
to the situation. A more robust Federal response may have activated the EPA to assist with the
management of hazardous waste. The EPA, which has authority under the Comprehensive
Environmental Response, Compensation, and Liability Act and the National Contingency Plan,
could have provided a Federal on-scene coordinator to Dallas to “direct and coordinate” actions
to secure, categorize, and clean up the Duncan apartment complex. Because Ebola could be
categorized as a “pollutant or contaminant,” EPA has the ability as a first Federal responder to do
this without invitation from states and localities, as happened for the 2001 anthrax attacks in
Florida and Washington, DC. Even though it is not clear that state and local officials desired or
would have deferred to incident management by FEMA, Dallas showed that FEMA/CDC

37
cooperation is underdeveloped and that protocols need to be revisited for deploying FEMA to
assist in health emergencies that fall below the Stafford Act threshold.

Discussions took place in the White House over how to better tie-in the local public health
authorities in Texas with federal authorities skilled in incident response. Though the full
National Response Framework as specified in HSPD-5 was not activated, a decision made
deliberately by NSC and DHS leadership after extensively considering the pros and cons, with
Secretary Jeh Johnson consulting directly with Homeland Security Advisor Lisa Monaco and
White House Chief of Staff Denis McDonough, Monaco instigated a call between President
Obama and the Governor of Texas, in which the President offered FEMA assistance and after
which FEMA deployed a coordinator to assist with incident management at the hospital and in
Dallas. Texas officials were also in touch with the FEMA reginal manager, but the full expertise
that federal officials could have provided was not called upon by the state of Texas officials
responding on the scene.
Taking a step back, it’s possible to see the larger challenge the Duncan case in Dallas lays bare is
how to have a sliding scale of escalation of public sector response, from local authorities acting
on their own to local authorities acting with some Federal assistance, to a declaration of a Public
Health Emergency and the full activation by DHS of the National Response Framework. The
advent of Ebola cases in the U.S. was an example of a situation that fell far short of an acute
catastrophic event, but was of such a magnitude and complexity that it necessitated a sustained
whole-of-government response. Absent an overall coordinating framework, Federal, state, and
local authorities never developed a smooth working relationship that leveraged the expertise and
authorities of each effectively. As a result, failures occurred in disinfection, the collection,
transport, and disposal of hazardous waste, the provision of social services for those placed under
quarantine, and post-event monitoring and travel restrictions for potentially exposed health
workers.

At the heart of this lack of coordination was a “confusion around constitutional limits to Federal
authorities versus state authorities,” in the words of one CDC official. In the view of one of the
lead officials sent to Dallas, CDC presumed a higher level of competence at local and state levels
than existed. Other Federal departments and agencies trusted that state and local incident
managers would follow a textbook incident response approach and call in federal support when
they needed it. Additionally, traditionally, public health issues are managed at the state and local
level and CDC defers to those officials. Going forward it is clear Federal authorities need to be
prepared to be far more hands-on and to pursue more comprehensive relationship building
among federal, state, local, and tribal incident response personnel and agencies, while of course
operating within the legal construct where certain authorities are exclusively federal where others
are exclusively state and local. CDC ultimately revealed to Federal officials a “culture of
deference” to state and local officials that profoundly affected the contours of the response.

The far more controlled and successful management of a second Ebola case in New York City
fifteen days after Duncan’s death showcased more thorough preplanning by local, state, and
federal authorities, while also illustrating more of the challenges that come with treating Ebola in
the United States. Active monitoring worked as expected, triggering safe transport of the patient
to a designated Ebola treatment facility, which within a few hours provided conformation of
Ebola via a blood test. Contact tracing quickly established who else was at risk. Yet the case

38
also surfaced the need to tighten communications, protocols, and risk classifications, and handle
large amounts of medical waste from a Category A pathogen. As an illustration of the scale of
resources involved, over 500 members of the New York City of Health played a part in this
single case, at a cost of $4,300,000.

Funding

The domesticEbolaresponsealso highlightedshortfallswith Federaldisaster funding

mechanisms. Evenat the height of the Ebolaresponsein Octoberand Novemberof 2014,HHS
had trouble movingfunds,hiringspecializedpersonnel,and deployingexpertsto the field. In the
absenceof Congressprovidingan emergencysupplementalappropriation,HHSwould have
seriouslystruggledto managethe incidentunder its own authoritiesand funding.

Beyond HHS, many agencies struggle to find the funds necessary to respond to emergencies in
the absence of a Stafford Act declaration. FEMA’s Disaster Relief Fund is the primary source
available to finance the Federal government’s response to domestic incidents, but in practice the
expenditure of funds is limited without a Stafford Act declaration. Other agencies may or may
not have their own emergency funding accounts. To respond to urgent situations under their own
authorities, most agencies rely on reprogramming existing funds from standing accounts,
reimbursing other agencies for the provision of services, or requesting a supplemental emergency
appropriation from Congress. These options require significant amounts of time and
administrative resources. None move as quickly as epidemics.

NSC and OMB should work with departments and agencies to conduct a comprehensive review
of Federal disaster/emergency funding authorities to determine which agencies require additional
funding mechanisms and/or transfer authorities to respond effectively to emergencies.

Deployable Infectious Disease Treatment Capability

In October 2014, national policymakers were faced with the prospect of a widespread Ebola
outbreak in the United States after two Dallas nurses contracted the disease while treating
Thomas Duncan. Worst-case scenarios based on the number of those potentially exposed caring
for Duncan and their contacts suggested authorities might have to treat over 100 cases of Ebola
simultaneously. This led the White House to ask DoD to be prepared to deploy mobile medical
facilities to an airport hanger in Dallas and to train enough military personnel to provide
treatment should local health authorities refuse to admit Ebola patients to healthcare facilities.
DoD eventually trained two “Mobile Medical Teams” of 30 people. Thankfully, the disease did
not spread further within the United States during the treatment of other Ebola positive patients.
However, had the situation ended differently, it may have been necessary for the federal
government to play a larger role in the treatment of Ebola patients.

Policymakers should examine whether and how the Federal government should develop a
deployable infectious disease treatment capability to respond to future infectious disease cases in
the United States and under what circumstances such a capability can and should be deployed.
There are multiple pathways to building deployable capabilities for domestic response that
policymakers should consider. First, HHS’s National Disaster Medical System (NDMS) could in

39
theory yield 6,000 deployable medical experts. Second, strengthening the ability of the U.S.
Public Health Service to deploy more rapidly to treat infectious diseases in the U.S. and abroad is
another avenue. Third, the Department of Defense has important infectious disease capabilities
and has already considered whether to maintain trained DoD teams in each FEMA region and
whether to keep active the two mobile medical teams originally trained for Dallas. Finally, the
Veterans Administration has a potential role to play in emergencies, but the circumstances in
which it can turn on its “fifth mission” of emergency health response are unclear. Which of
these avenues to pursue is an open policy question.

Hazardous Waste

Hazardous waste is another area identified by the NSC and by lessons learned teams in which
significant work remains. Among the warning signs from the Ebola response: had New York
City had to treat a second Ebola case concurrently, it would not have had the capacity to dispose
of the waste. The reticence of state and local officials to permit transit and uncertainties about
appropriate standards meant one state put itself in a procedural position of not being able to
accept the hazardous waste it generated. The decision by elected officials to ban transport of
Ebola waste across their municipalities based on political calculations placed a premium on
ensuring that the Federal government publicized the science behind safe waste disposal. The
NSC is working with Federal agencies as well as state and industry officials to forge a way
ahead. The current approach is to develop industry guidance for best practices in order to
provide state officials a standard on which to base action. Follow through will be essential to
ensure the system can respond more agilely, and responsibly, in the future.

It is important to note that, while we have learned a lot over the course of the response, many of
the adaptations that worked for Ebola will not be applicable in the future. Certain measures, like
the revised PPE guidance, may not apply to infectious disease outbreaks with other modes of
transmission (e.g. aerosol transmission). Rapidly being able to develop PPE guidance, with
quicker coordinated action between communities of experts, including the National Institute for
Occupational Safety and Health and the Occupational Health and Safety Administration, will be
important. Likewise, while the domestic response in most respects was a policy success, it’s also
true that the overall number of Ebola cases treated in the U.S. was small. The system was not
tested in the way the international response was. It is easy to see places where a more
widespread outbreak would have significantly stressed parts of the domestic health system and
potentially caused parts of it to collapse. In addition, the more transmissible the disease, the less
our approaches to Ebola are appropriate. Transmissibility and clinical severity are the axes that
will drive the nature of any future response. The challenge is to be ready to act across the full
spectrum.

Is the Strategy Working?

November, 2014 was a month of uncertainty and reassessment in the international response. In
September, 2014 the CDC’s Modeling Task Force, a component of the CDC Ebola Incident
Command, publically issued alarming predications that the eventual caseload might grow as high
as 1.4 million by the end of the year, absent additional intervention. Though CDC Director
Frieden was careful to caveat the model’s assumptions, “the CDC models really drove policy,”

40
one USAID official said. “They made us focus only on ETU beds,” something the media later
seized on as a perceived example of mismanagement in the response. White House policy
makers, against the advice of some staff on the Ebola Task Force, placed an intense focus on
treatment beds, among many other output metrics such as delivery of PPE, number of burial
teams, number of health care providers, and time required to collect and test a blood sample. Yet
come late October caseload data in Liberia appeared against all odds to be dropping precipitously
before a single ETU constructed by the U.S. military was open for treatment. While some ETUs
built by USAID funded NGOs had opened, the epidemic was not unfolding as expected. The
new data forced planners to examine their assumptions. If we don’t understand the factors
behind the caseload drop, how do we know our strategy is optimal, officials asked?

The strategy of the response was based in large measure on the standard medical narrative for
Ebola. From the first documented outbreak in 1976, epidemiologists successfully broke the
infection chain by placing the sick in isolation, tracing their contacts, and safely burying the
dead. The theory of the U.S. response was to use this approach on a grand scale, with some
modification. The logic of the response was largely built around a single number–70%.
Characterizing the predominant thinking at the time, modelers generated a scenario that indicated
successfully removing 70 percent of patients from the transmission chain, through patient
treatment in ETUs and safe burials, would cause the epidemic to abate. Together, the
predominant thinking about response methodology and the CDC model created an operational
goal for the response. Many early U.S. government metrics tracked our progress towards
reaching 70%.

The unexpected drop in the Liberian infection rate showcases how community behavior changes
and safe burial practices, in addition to patient isolation and contract tracing, appears to be a
more potent causal factor in breaking the chains of transmission than appreciated initially. It was
the Liberian people, by taking matters into their own hands and changing how they interacted
with each other and with people who fell sick in their own communities, who appear to have
broken the back of the epidemic. Taking a step beyond even Sierra Leone and Guinea, Liberia
instituted a mandatory policy of cremation in early August, 2014 as a means of body disposal for
Ebola victims, upsetting traditional burial practices but in so doing forcing social compliance
with safe burial. Though the policy was later rescinded after community resistance and fear, a
significant number of Ebola victims in Monrovia were ultimately cremated at a government run
facility. USAID’s fast mobilization of partners to support safe burial practices was a significant
success.
The impact of community behavior changes, such as safe burials and social distancing, indicates
the need to develop data collection strategies, metrics, and analytical approaches that will assess
the status and changes of these important components of transmission in the future. This will
require investment in basic and applied research to assess appropriate data collection strategies,
metrics, and analytical approaches.

As one noted Ebola expert told White House officials, “this one changed all the rules.” The

estimated transmission potential of Ebola, as estimated by R 0 , or ‘R naught’, began declining in

Liberia the week of the U.S. announced intervention. In the words of one expert, “fear stopped

Ebola.” A statistician working in the response, in hindsight, saw the same phenomena in the

data. “It was very clear by the end of October that the epidemic would never explode. This was

41
very hard to communicate to international policy makers,” he said. NSC staff were aware of the
new data showing the pronounced decline in transmission in Liberia, but were uncertain they
could trust it. They also knew the trends were different in Sierra Leone and Guinea, and were
concerned a resurgence was possible as had happened just a few months before. The consensus
position was to continue with a modified build out of the original response plan given the lack of
confidence in epi data. As one NSC Ebola Task Force member noted, “We were managing risk.
Even if you put a 90% confidence interval around the data, we needed to plan for the 10% risk.”

The observation that community behavior change is crucially important alongside patient
isolation, treatment, and safe burial is an insight that has important implications for future
outbreaks. It is much easier to scale social mobilization interventions than treatment
interventions, provided social drivers of change can be identified and leveraged. It therefore will
be important to widely deploy social mobilization campaigns alongside the provision of clinical
care in order to breed confidence between communities and responders going forward. Social
mobilization will be even more essential in an epidemic in which we are not prepared to rapidly
field therapeutics and vaccines. DHS officials have noted the importance of social mobilization
was also highlighted by after-action reviews of the U.S. government responses to H1N1 and
pandemic flu.

It is interesting to note that what happened in some communities during the Ebola outbreak
replicated itself in South Korea during the June, 2015 MERS outbreak. When it became clear
the South Korean government had not effectively contained MERS, some officials in local
municipalities unilaterally deployed security forces with heat-detecting cameras at train stations
to stop those with fever from entering their communities. This is the kind of powerful behavior
change that future epidemic responses will have to anticipate and harness. Medical and cultural
anthropologists and communication experts should thus always be among the very first to be
pushed forward into the field.

The consequence of behavior change so quickly reducing transmission is that ETU capacity was
overbuilt in some communities in Liberia. It is unfair to equate this fortuitous development with
mismanagement or lack of strategy. Mobilization in any crisis is inevitably untidy and
incremental, especially in epidemics, which themselves are notoriously unruly to manage.
Policymakers on the NSC staff could not predict and be sure how Ebola was spreading based on
early indicators and did not have full confidence in the data that was being reported up. It was
also entirely plausible to estimate that for every reported case, there were a substantial number of
cases that went unreported, making it difficult to determine whether the initial decline in cases
was real.

The decision to go on building out ETU capacity in an adapted modular format was rooted in
part on the need for “insurance” in case the data showing caseload drops did not reflect the actual
state of the epidemic and in part because nearly 80% of the spend on ETU construction had
already occurred. Construction could be completed for a very modest remainder of the overall
investment, essentially making completing the build-out of ETUs an inexpensive form of
insurance. Furthermore, policymakers were hearing reports about the building of ETUs
generating hope in communities, a much less quantifiable but still critical indicator. Without an
option for quality treatment, community behavior change could have also taken a darker turn –

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leaving peopled shunned and isolated, left to die alone, thereby further fueling transmission.
Stopping ETU construction would have sent the wrong signal to the population.

Even though ETU build out in Liberia was not as decisive as at first imagined as a causal factor
stopping transmission, many other effects of the U.S. mobilization were centrally supportive of
the efforts that do appear to have done the most to lower infection rates. The rapid expeditionary
basing, logistics bridge, transportation capabilities, lab deployment, and command and control
and synchronization functionality brought by the military helped usher in a far more robust
response and bring more international health workers into ETUs and onto social mobilization
teams. Survey of responders done by USAID showed anecdotally that the stand-up of the
Monrovia Medical Unit (MMU) bolstered confidence, drawing more international and local
heath workers than would have otherwise come. Finally, the very fact of the large-scale
deployment instilled confidence in the Liberian population. “If we did anything,” one DoD
official said, “we brought hope to the country and infrastructure so Liberia and others could
come in and do their work.”

Models and DecisionSupport

By December, the original 1.4 million case prediction of the CDC modeling group, which many
did not realize had been predicated upon the response not being scaled up, was seen as so off the
mark that news media began dissecting the modeling approach used by CDC and its
assumptions. Several major newspapers ran features on the state of disease propagation
modeling, and modelers themselves discussed their struggle with the over-aggregation of data
and lags in case confirmation. The discrepancy between early predictions and the ongoing
outbreak led many policymakers to essentially discard the relevance of the modeling community
to inform operational decisions during the response. Among U.S. government departments and
agencies, the CDC modeling controversy also triggered a debate about the sharing of caseload
data. In the very early phases of the response, CDC representatives negotiated a data sharing
arrangement with the Liberian Ministry of Health that gave CDC access to detailed case data of
Liberian citizens. As part of the terms of this agreement, CDC consented to not further share this
data with other parts of the U.S. government. This effectively cut off communities of disease
modelers in the Defense Threat Reduction Agency and other parts of HHS, which in many
respects have more substantial analytical capabilities, from data available to CDC. In what
remains a point of contention to this day, other parts of the interagency maintain that CDC did
not have the authority to negotiate an agreement with the government of Liberia that shut them
out of access to data.

A related issue is the need for models to be more predictive and for policymakers to better
understand their limitations. Input from the CDC Modeling Task Force, in the opinion of some,
drove bad decisions in the early formation of U.S. strategy for the response, even as their dire
forecasts played a catalytic role motivating action. As such, there is a need for models to be
predictive, but also to characterize uncertainties and limitations for policymakers. OSTP is now
examining how infectious disease forecasting and analytics can be more systematically
developed, generated, communicated, and iterated during an outbreak response. A working
group within the National Science & Technology Council is drafting a strategy for improving the
national capabilities for epidemic analytics and forecasting. A modeling group at the
Department of Health and Human Services in the Biomedical Advanced Research and

43
Development Authority (BARDA) may provide a useful interagency touch point to integrate
community wide assessment during future health events. In a future outbreak the policy
aspiration should be to combine coordinated modeling in human health with modeling from
environmental, animal health, and commerce flows.

Therapeutics & Vaccines

Throughout the response, there was always the hope that therapies and vaccines would arrive in
time to help treat patients and speed the end of the epidemic. Despite over twenty years of work
on filoviruses, there were no licensed vaccines or approved therapeutics to treat individuals
infected with Ebola at the outset of the epidemic. Many factors have impeded the development
of medical countermeasures for Ebola, including: a lack of understanding of the natural reservoir
and its mechanism of transmission to humans; the use of different viral strains in different
laboratory studies and different species of non-human primates in non-clinical studies; the
necessity to perform non-clinical evaluation of potential medical counter-measures in biosafety
containment level four (BSL-4) labs; and the need to evaluate candidate products in non-human
primates. Most experimental vaccines or drugs, including ZMapp, had been produced only in
extremely small quantities for use in animal testing. Their safety and efficacy in Ebola patients
was unknown, and was administered only with a “compassionate use” wavier granted by the
Food & Drug Administration.

HHS’ Public Health Emergency Medical Countermeasure Enterprise (PHEMCE) became the
interagency body to coordinate government efforts. By late November 2014, the US had
multiple Ebola vaccine and therapeutic candidates in early stage development and being
manufactured at pilot scale for evaluation in non-clinical and clinical studies. By early January
2015, with cases of Ebola declining in West Africa, it became important for the U.S. government
as a whole to look at the research questions that remain to be addressed and determine a priority
order and a strategy for addressing the clinical trials aimed at Ebola prevention or treatment.

NIH proposed randomized clinical trials with ZMapp as the primary candidate and potentially
move to TKM or favipiravir as secondary and tertiary candidates. On February 27, 2015, in
partnership with the Liberian government, the National Institute of Allergy and Infectious
Diseases (NIAID) launched a clinical trial to obtain safety and efficacy data on the
investigational drug ZMapp as a treatment for Ebola. The study continues to be conducted in
Liberia and the United States, is a randomized controlled trial enrolling adults and children with
known Ebola virus infection. The United States government also expedited the safety and
efficacy trials of several Ebola vaccine candidates in humans and made two vaccine candidates
available under compassionate care exemption. Altogether, it supported the development of five
Ebola vaccine candidates in various stages of development. Two vaccine candidates - cAd3 and
rVSV- have completed Phase I human clinical trials. On February 2, 2015, the USG announced
the Phase II/III Ebola vaccine study in Liberia known as PREVAIL opened at Redemption
Hospital in Monrovia evaluating a single injection of either of two candidate Ebola vaccines—
ChAd3-EBO-Z, made by GlaxoSmithKline, or VSV-ZEBOV, made by NewLink
Genetics/Merck—versus a saltwater placebo injection.

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On March 26, 2015, the USG announced the Phase II/III Ebola vaccine study in Liberia known
as PREVAIL (Partnership for Research on Ebola Vaccines in Liberia) achieved and exceeded its
initial goal of enrolling 600 people into its Phase IIcomponent. The next (Phase III) component
of the study planned to enroll about 27,000 Liberians at risk of Ebola virus infection. However,
as a result of Liberia’s successful infection control and prevention strategy targeting Ebola, there
has been only a handful of new case in the country since February. Together with the DSMB,
the PREVAIL leaders, the Liberian co-principal investigators, and the NIH—decided that it was
not scientifically appropriate to complete the 27,000 person phase III component of the trial. To
secure data on safety, they extended the phase IIcomponent to 900 additional volunteers to give
a total of 1500. The Center for Disease Control also organized combined phase IIand III trial of
VSV-ZEBOV in Sierra Leone, known as STRIVE, that has enrolled over 7,500 participants.

Vaccine Indemnificationand Liability Issues

Medical countermeasure manufacturers have at times found that, under ordinary tort law and
liability models, developing, manufacturing, and deploying a product presents substantially
greater economic risk than the potential economic gain from the sale of the product. Therefore,
in cases where the national security and public health interests are sufficiently high, liability
protections have been considered to reduce risk for manufacturers, as was the case for the
worldwide deployment of the H1N1 Influenza vaccine. In the US and several countries around
the world, this liability protection is sometimes accompanied by a “no fault” mechanism to
compensate those are determined to have been injured as result of the administration or use of
medical countermeasures. The Ebola outbreak raised similar issues as manufacturers worked to
develop Ebola vaccine candidates on an expedited basis.

In response to global commitments to contain the epidemic in Africa, manufacturers accelerated

the development of candidate Ebola vaccines. Compared to other traditional vaccines that may
have years of safety data based on the administration of tens or hundreds of thousands of doses,
the Ebola vaccine candidates are novel products for which manufacturers will have limited
information, even after the clinical trials are completed. Based on these perceived increased
risks, at least two major manufacturers of vaccine candidates against Ebola communicated to the
US, UK, and multiple international organizations, their significant concern as to liability
associated with the accelerated development, regulatory approval, and potential subsequent
deployment and use of their Ebola vaccine candidates in West Africa. While the manufactures
sought global indemnification, the focus of U.S. policy was on limiting liability and attempting
to develop a corresponding compensation plan for those suffering adverse effects.

On December 5, 2014, the NSC Deputies Committee agreed to support and explore options for
limiting liability for Ebola vaccine makers and establishing vaccine injury compensation
schemes that might be used in connection with a possible vaccination program for a successful
Ebola vaccine candidate. The elements of this three-fold policy included the: (1) encouragement
of enactment of Public Readiness and Emergency Preparedness (PREP) Act-like regimes in other
countries; (2) liability limiting arrangements or contracts for delivering/administering the
vaccine; and (3) creation of a vaccine injury compensation fund.

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NSC and HHS staff pushed all three elements of the strategy with the United Kingdom, WHO,
and Gavi, the vaccine alliance. Upon further examination, it became clear that creating a vaccine
injury compensation fund on behalf of the three affected countries posed logistical and legal
challenges that could not easily be surmounted in the near term. Furthermore, WHO, Gavi’s,
and the United Kingdom’s interested in pursuing a long term solution to the challenge of vaccine
liability waned as the epidemic wound down. The U.S. policy for vaccine and therapeutic
indemnification remains incomplete, but is nevertheless deserving of further policy exploration
on account of its criticality to future outbreaks.

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THE DRIVE TOWARD ZERO (January-June,2015)

By January, 2015 it was apparent that the epidemic was subsiding in all three affected counties.
Tens of thousands would contract Ebola across West Africa and more than half of those infected
would die, but following the massive U.S. and global response, nowhere near the worse-case of
1.4 million would fall victim. This late phase of the response was characterized by a lessening of
intensity of transmission but a greater comparative difficulty in stopping transmission altogether.
Beating Ebola grew harder with each day. As people let their guard down, it became easier to
imagine a fever as being caused by malaria, not Ebola.

By March, 2015 Liberia verged on reaching zero. With this heroic turnabout, DART and CDC
began placing additional attention on health recovery and building health sector capacity to
prevent future outbreaks from becoming epidemics. The donor community also began to focus
on restoring economic growth. The big worry was that donors were writing checks to provide
health services that cannot be sustained by government revenue alone. The calculus of
sustainability thus became paramount, with growth of the Liberian economy needing to “catch”
the costs of health sector improvements as Ebola funding sunsets.

By May, 2015, the distribution of the virus and number of transmission chains in Guinea and
Sierra Leone, while still unprecedented by the standards of earlier Ebola outbreaks, became more
amenable to classic means of contact tracing and isolation than the urban clusters that
predominated earlier in capital cities. Social mobilization in affected communities proved
critical but difficult. The virus had largely retreated into rural communities that harbored the
greatest levels of distrust of central authorities. “Getting to zero” in the words of the U.S.
Ambassador to Guinea came down to “anthropology, anthropology, anthropology.”

The response to Ebola in West Africa began without a playbook for how to win the trust of
affected communities. Over time, principles for how to communicate with local populations
emerged: identify trusted intermediaries to serve as communicators, tailor information to local
context, and, most importantly, facilitate two-way communications. The “flying Imams
program,” which transported trusted religious leaders by helicopter to speak with communities
all over Guinea, is a shining success story of a finely tuned education effort. The way to think
about social mobilization, in the words of one communications expert, is "building out the value
chain of different networks: education, religious, health, media, elder/clan, business." "Think
good development practice. Recruit from within. Demilitarize clothing. The messenger more
important than the message." The most successful campaigns were often run by experienced
implementing partners with a long history and large local staff in country.

One of the most sophisticated social mobilization and contact tracing campaigns of the response
took place in the Forecariah prefecture of Guinea in May, 2015. The goal of the campaign was
to visit villages with recent clusters of Ebola until each member of all households is confirmed to
be non-febrile. Unlike earlier informational campaigns in Forecariah, the goal of the 95 door-
knocking teams armed with thermoflash “thermometer guns” was to refer anyone with fever to
one of 30 doctors who after further triage can transport suspected cases to an ETU for evaluation.
The entire prefecture of 240,000 was placed under soft quarantine for the 21-day campaign,
necessitating food aid for residents. The WHO, CDC, DART, WPF, and other partners hired and

47
trained local door-knocking teams and arranged food and cash payment for households who
complied with the household survey. Cash and food eased the intrusiveness of the campaign.

Beating Ebola grew more difficult at this stage because the low density of cases incentivized
behaviors that work against the response. The rarer the virus became, the less people and
communities were willing to radically change their behavior, leading to the continued spread of
the virus. Triage at local health care facilities became important as people failed to adhere to
rigorous entry procedures. Small tents set outside health care facilities became vital places for
screening patients who might have Ebola from those who do not. One of the last known cases of
Ebola in Liberia was caught during triage at the very same place in Monrovia where so many
health providers died the summer before. Redemption hospital redeemed itself when a CDC-
trained triage nurse identified and safely isolated a female patient who turned out to be Ebola
positive.

By now implementing partners and NGOs had grown expert at training healthcare workers to
safety work in ETUs. Sierra Leone’s National Ebola Training Center, run by the International
Organization for Migration, and housed in the national stadium in Freetown, saw 7,000 Sierra
Leonian healthcare workers pass through its gates. Practical training was now emphasized,
including simulations in a mock ETU where students in full PPE treat “patient trainers” who
themselves are actual Ebola survivors. No longer do trainees experience an ETU setting the first
day they work at an ETU.

This last phase also surfaced inherent difficulties in maintaining a high tempo response for so
long. More than 3,000 CDC employees supported the response over its course, including 1,200
who deployed to West Africa. CDC and USAID continued to strengthen their expeditionary
capability and grow ever more sophisticated in their approach, but it became harder to generate
the number of experts with the right expertise to spend extended periods of time in country. In
Guinea, where the infection seemed destined to simmer at a low level for months after the
caseload dropped from peak levels, French-speaking epidemiologists were hard to recruit.
Though CDC personnel earn overtime, post-differential does not kick in until 42 days. Since
most rotations are only a month to six weeks, personnel are not eligible for the 30% increase or
hazard pay. Supervisors and spouses in Atlanta grew reluctant to assent to third and fourth
rotations.

Despite high-level White House intervention by the NSC Ebola Coordinator, the Office of
Personnel Management proved unable to respond to CDC management requests for greater
flexibility and augmented hiring capability—a failure worth studying further. The CDC
continued to adjust internal policies to help support those deploying to West Africa. It developed
pre- and post- deployment programs, began to set a two-month target for the duration of
deployment, and recruited a safety officer to help mitigate responders’ exposure to violence and
social unrest. But the limitations on hiring and compensation were far from ideal. One question
lurking in the back of the minds of CDC personnel was whether and under what conditions it
would be necessary to move from asking for volunteers to assigning personnel during an
emergency who had not explicitly volunteered for duty. “If someone had said we would have
that many people out there for this long, I wouldn’t have believed them,” one CDC official said.
“And we’ve done it safely.”

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To strengthen its ability to deploy personnel, CDC has created a Global Rapid Response Team
(GRRT) made up of Atlanta-based staff and five geographically dispersed units that function
interchangeably as a single international team. The goal is for the teams to be deployable within
24-48 hours after a request and for the teams to scale to provide over 50 staff within seven days
of activation. The teams are designed to function in an integrated manner with the DART.

USAID experienced the same personnel stresses. More than half of its deployable staff activated
on the Ebola response at a time when several other crises requiring DART deployments were
unfolding simultaneously. Capacity was so stretched that at certain points in 2014 and 2015
OFDA’s standing and reserve capacity were essentially maxed out. Had another disaster or
disease outbreak occurred, there would have been no one left to deploy. OFDA is relooking at
staffing models, moving from the assumption that it will deploy three to five DARTs per year to
a multiple response strategy that assumes three simultaneous deployments with one team held in
reserve. To accomplish this OFDA is growing its reserve roster and also differentiating team
models for fast onset natural disaster that typically require intense engagement for a two month
period and longer complex technical responses like Ebola or Syria that could well run a year or
more.

Meanwhile, at the White House, NSC Ebola Coordinator Ron Klain returned to the private sector
in mid-February, 2015, handing duties to Amy Pope, who also became the President’s Deputy
Homeland Security Advisor. The State Department’s Ebola Coordination Unit (ECU) shut down
shortly thereafter. Though the State Department based its shut down decision on an analysis of
the epidemiology of the outbreak and the ability of bureaus to resume the residual workload,
NSC staff noted an increase in coordinating challenges almost immediately after the ECU shut
its doors. Though they had assented to its closing, NSC staff soon seconded guessed their
decision, wishing the ECU had remained active for at least one additional month. The utility of
having experienced crisis managers at State and USAID called back into action is a clear model
for how to effectively run an emergency command and control structure. But each agency ran
into their own challenges with the mechanism used to bring those managers in, raising the
question of how best to augment staff during crises.

Glimpses of the Future

In this last phase of the response, glimpses of the tools of future interventions could be seen. A
customized ETU data management system emerged from a partnership between Google.org and
MSF. In “Project Buendia,” rechargeable tablets and a battery powered wifi network allowed an
ETU to go paperless and automatically transmit all patient data electronically. The tablets
themselves are encased in plastic that can be immersed in bleach to be completely
disinfected. Inductive pads allow for charging without removing the case. Data entry is done
with large buttons that are easy to use while in PPE. All data is synced to all tablets in the
system so those outside the hot zone can track new patient observations instantly.

Becausethe tablet buttons are far easier to press and see than the paper charts typically used to
log patient vitals and administeredmedicines,the field trials of Project Buendiaat an MSF ETU
in Sierra Leone revealeddoctorsand nurseswere able to record more data each time they check

49
on a patient. They could therefore see diagnostic clues emerge more quickly. These same
doctors and nurses were able to work faster and see more patients each round in the hotzone.
The tablets and wifi network are engineered to run for a week before needing to be
charged. Patient data can be uploaded via satellite phone to a central database. NSC medical
staff note such a system will help connect treatment units to each other to quickly share
experience, knowledge, and best practices gained from clinical treatment, an aspect of the Ebola
response that did not develop as quickly as hoped.

Apps for contact tracing and for active monitoring of contacts also came into use. Because
smartphones and tablets make it easy for contact tracers to capture more information about those
they are interviewing, digital devices can help collect a broader array of data that in turn allows
trends to be spotted earlier than paper forms. The paper forms most Ebola case investigators
used do not collect the breadth of social data that reveal all routes of disease propaganda or
differential diagnosis. There are other benefits of moving to digital platforms. CommCare, one
of the Fighting Ebola Grand Challenge Winners, fielded an app in Guinea that geo-tags all data
entered by contract-tracers. Supervisors can now see whether contact-tracers actually went to the
contacts' neighborhoods or falsified the information by filling it out without going to meet the
contacts. Geo-tagging the data enabled partners to define target locations for behavior change
and education campaigns and allowed district managers to see trends in what makes contact
tracing most effective.

The states of Marylandand Texas,amongothers,similarlyexperimentedwith smartphoneapps

that allowedpeopleunder active monitoringfor Ebola to report whether they were experiencing
symptoms. Reportingon smart phonesprovedfar less laboriousthan public healthworkers
contactingpeopleby phone twice daily,pointingto an approachthat could scale in a future
epidemicwhere the numbersof people under active monitoringor quarantineare larger.

The OSTP-USAID grand challenge on PPE also catalyzed many important innovations that are
already impacting the effectiveness and usability of PPE in the West African response and in
modern clinical settings. Work on building better data systems also got underway. A data
summit cohosted by USAID & WHO in Accra, Ghana, in May, 2015 included participants from
15 governments, as well as representatives from NGOs and the private sector. The idea is to
build national health data systems that are more able to spot and contain an epidemic and better
able to share data when an outbreak does occur. CDC, likewise, learned a great deal about the
virus and its routes of transmission through virus persistence studies and a household
transmission study. CDC also made significant strides developing rapid diagnostic technology.

U.S. government agencies were also trying to develop better approaches and capacities
themselves. The difficulty in negotiating the early data picture has led USAID to explore what
role there may be in a future response for two distinct types of expertise. The first is a “data
logistician.” The idea is to deploy select DARTs going forward with such data logisticians, who
can figure out early what information will be critical to guide decision-making and how to distill
that information from the various information systems in play. A second potential role that
would selectively deploy is a “connectivity engineer.” This engineer would plot information
flows and figure out how to free up bottlenecks and otherwise improve data flow. In June 2015
FEMA signed agreements with a handful of tech companies to provide volunteers to serve in a

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'Tech Corps' that could be deployed when disaster strikes. Google, Microsoft, and Intel are all
participating.

###

51
 FINDINGSAND RECOMMENDATIONS

The Ebola epidemic showcased substantial gaps of global preparedness and capacity in
infectious disease response. The failure of the WHO to coordinate an effective response
was belatedly recognized in the U.S. government, which then rapidly mobilized. Built into
the U.S. government approach to the containment of infectious diseases abroad was the
assumption of a level of capability and competence in the World Health Organization that turned
out not to exist. U.S. policymakers at first assumed the WHO would lead the response in West
Africa, then tried to reinforce the WHO as its leadership faltered, and only belatedly recognized
that the WHO was incapable of mounting an effective operational response and that forceful U.S.
leadership was needed to prevent a global catastrophe. Strengthening the WHO’s ability to
perform the coordinating role it aspires to during global health emergencies must be a U.S.
priority in the years ahead. The U.S. should also consider advocating that UN-OCHA be able to
be mobilized under Chapter 6 of the U.N. Security Council, which would augment its ability to
mobilize in a future epidemic.

When the U.S. mobilized after the WHO failed to contain the epidemic, gaps in
preparedness and capacity surfaced in every major agency tasked with health and security
in the U.S. government. With no model for how the U.S. government should respond to an
international health emergency and no obvious lead agency to coordinate the response, the
concept of operations was worked out on the fly. It took time for USAID, CDC, and DoD to
devise a civil-military theory of pandemic response and command and control structure to
integrate their operations. Standing response doctrine did not contain well-defined strategies to
build trust with local populations or rapidly assist civilian outreach to change behavioral
practices. The Department of Defense lacked the capacity to medevac its own personnel if
infected, did not have a deployable medical unit optimized for infectious disease treatment, and
had no set protocols for operating in an environment with filovirus. Failures on the domestic
front were even more apparent, and included fundamental misjudgments in the capacity of
hospitals to treat Ebola and the steps local authorities would need to take in conjunction with
Federal authorities in the event of an Ebola case in the U.S. While the response was ultimately
able to arrest the epidemic abroad and keep the American population safe at home, it is easy to
imagine a more stressful scenario would be far more disruptive.

The very dynamics of globalization and population growth will lead to more pandemics,
which must appropriately be considered among the most serious national security threats
to our homeland. As noted in the National Security Strategy 2015, population growth,
urbanization, deforestation, the expansion of agriculture, the bunching of species together in
island ecosystems, global commerce flows, and an unsurpassed level of intercontinental air travel
are creating the very conditions for the next dangerous pathogen to emerge. A strong scientific
consensus exists that we will see more zoonotic pandemics and infectious disease outbreaks
going forward. Given that a highly contagious virus has the potential to kill millions of
Americans, and that even small outbreaks have significant consequences, our level of
preparedness, and investment in the Global Health Security Agenda, should be substantially

52
increased. We are in effect underinvesting in pandemic preparedness as a national security
threat.

Merely maintaining the current scale of response activities as a standing capability is likely
not sufficient. Ebola was in effect a test of the international response system. It is hard to catch
and easy to test for. It cannot be transmitted from person to person until symptoms are present.
It occurred in a region of the world with few mega-cities and minimal connectivity by air travel.
Future epidemics, especially those that are airborne and transmissible before symptoms appear,
are plausibly far more dangerous. The U.S. Government should inventory key “enabling
capabilities”—to include PPE procurement and supply chain, medical logistics, critical reagents,
and hazardous waste management—and ensure it is prepared to confront a wide range of
emergency scenarios. An appropriate minimum planning benchmark might be an epidemic an
order of magnitude or two more difficult than that presented by the outbreak of Ebola in West
Africa, with much more significant domestic spread.

To organize U.S. deployable capability, the NSC should establish an inventory of existing
response capabilities in the interagency and consider creating a create a “lighter touch”
international equivalent of the National Response Framework. Until biosurveillance
capability is established in all countries and international response mechanisms are in place,
countries with robust public health systems must maintain the capacity to assist less capable
countries. While reform at the WHO and in other multilateral institutions is vital, the United
States cannot afford to wait until deployable international capability comes online. The United
States and willing partner nations should maintain an interim global response capability as a
bridge to whatever investments are ultimately made at the international level. To organize our
ability to response, the NSC should create an international framework for disaster response.

A key part of the international framework will be codifying the “civil-military” doctrine
for epidemic response developed for Ebola, but without DoD’s “redlines” and with a view
towards different scenarios. The interagency division of labor in the Ebola response was
effective and should be codified into a doctrine for epidemics with properties similar to Ebola,
with the DART serving as the operational lead, CDC nested under the DART, and the U.S.
military providing unique capabilities in support. The rapid expeditionary basing, logistics
bridge, transportation capabilities, lab deployment, and command and control and
synchronization functionality provided by the U.S. military helped dramatically accelerate the
response. However, DoD’s redlines need to be re-evaluated, as they impose limitations on
deploying relevant capabilities that may be necessary. At the same time, CDC must be better
understood as a technical agency that provides advice and epidemiological assessment versus an
operational agency that can itself coordinate a humanitarian response without substantial
interagency support.

A single person accountable to the President for response efforts is a model that works in
extremis cases. Because epidemic responses draw from so many parts of the government and
raise so many novel policy issues, naming a White House coordinator with clear lines of
authority designated by the President proved an effective way to provide overall leadership for a
response. It is clearly preferable for departments and agencies to provide leadership under the
usual processes established in PPD-1. But as a last resort, if departments and agencies prove

53
unable to manage evolving circumstances or novel and unprecedented events, the White House
Coordinator model, situated in the NSC framework, is one worth employing in the future.

Funding mechanisms and triggers for mobilization short of a Stafford Act declaration need
to be established. While we have made legislative and organizational advances in the Federal
government to designate the HHS Assistant Secretary of Preparedness and Response (ASPR) a
national leader for domestic preparedness, the Ebola outbreak demonstrated gaps in the Federal
government’s ability to prepare both for international and domestic responses to infectious
disease outbreaks. Greater preplanning is needed, especially since the resources that combat
epidemics are widely distributed across the government. Similarly, funding mechanisms and
clear triggers for involvement short of the declaration of a Stafford Act need to be established so
resources can be mobilized short of a catastrophic event

Global vaccine and therapeutic liability, medevac capability, and domestic hazardous waste
disposal are issues that were raised but not solved by the Ebola response. Further policy
work is needed to address each of them. The President should consider hosting an international
conference on vaccine and therapeutic liability. Allies should be encouraged to establish their
own medevac capability. Further work is needed at the state level on hazardous waste disposal.

Because the military, humanitarian, and health first responders do not meet up frequently,
exercising, table-tops, training, liaison officers, regular detailing of personnel, and senior
management exchanges are needed, both within governments and at the international
level. Health and non-health agencies had the most learning to do about each other and their
respective capabilities during the Ebola response. More needs to be done to regularly bring them
together. Regular exercising will also help prepare everyone for “black swan” events where no
template for how to respond exists. The level of integration USAID, CDC, and DoD have now
reached should be perpetuated and mechanisms should be established to facilitate joint planning,
preparedness, and exercise programs. Setting who is in charge for planning and preparedness
during the interludes between crises is imperative.

Health and non-health agencies need a common language for situational awareness, a
defined set of triggers for when to mobilize, the ability to deploy “light touch” interagency
assessment teams to monitor events long before they become crises, and a single system of
situational reports. The NSC should establish criteria to categorize the potential seriousness of
a health event as a tool to facilitate situational awareness between personnel in health and non-
health agencies. Important variables in this system of categorization include clinical severity
and transmissibility, risk of global spread, threat to the homeland, and local institutional
capacity. Likewise, health and non-health agencies should partner more frequently to deploy
“mini-DART”-like assessment teams that report out to the relevant departments and agencies, so
all Federal agencies potentially involved in a response have situational awareness of evolving
events long before a major mobilization is required. Situational reporting should be integrated
below the level of the White House to provide a unified view of developments.

Greater study of populationbehavior change and social mobilizationis needed. Some

communitiesproved remarkably adept at lowering Ebola transmission rates before treatment
beds became available or home health kits were distributed. Others reacted poorly to messaging

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campaigns. Understanding the dynamics of social mobilization—what worked, what did not,
and how campaigns can be made more effective going forward in difficult cultural contexts—is a
crucial matter for the research community to explore. To that end, OSTP should work with NSF,
NIH, and CDC to fund interdisciplinary research that would add to the existing literature on
behavior change and better characterize and understand how to impact social behavior in health
responses. The capability building analysis in the review of planning efforts for the 2005
pandemic flu and 2009 incidence of H1N1 are relevant to understanding how the U.S.
government should enhance its ability to effect behavior change.

The management of public perception and community behavior, both at home and abroad,
together with anthropological expertise, is a fundamental part of any response. How and
why “risk communications” failed in the US needs to be examined. The future role of cultural
and medical anthropologists, and how to integrate them into the response from the get-go, needs
to be further developed, with DART teams potentially considering how to develop a “social
mobilization module” that could be deployed in a future response, not unlike USAID’s emerging
notion of deploying “connectivity engineers” and “data logicians” as part of DARTs when
needed.

Establish mechanisms to harness better the potential contributions of the private sector,
foundations, and the digital humanitarian community. The resources contributed by the Paul
G. Allen, CDC, and Bill and Melinda Gates Foundations to the Ebola response are far larger in
aggregate than those given by many traditional allies and partners. The foundation community
has essentially “gone operational.” Large communities of “digital humanitarians”—coders,
mappers, data scientists—stand ready to assist first responders. These are each resources the US
government must better integrate into future responses by maturing its liaison activities with the
private sector and foundations. Similarly, multi-donor coordination was a challenge at the
international level, leading to the need for more work in this area by the WHO and UN.

Critical care and evacuation capability for health care workers is essential. Creating an
“enabling environment” for first responders is critical. Giving those who volunteer to care for
others the certainty that they will be provided the highest level of care if they fall ill, and will
have health and travel insurance as part of their contracts, and appropriate indemnification for
contractors, is essential to attracting the labor force in any future response. Investments made in
air evacuation capability must continue so this vital mission can be restarted at a moment’s
notice. Similarly, we must maintain the ability to quickly deploy and staff advanced field
hospitals dedicated to treating health care workers. In a domestic outbreak capacity for
transporting infected members of the general public may also be needed, raising the question of
whether private air medical vendors, who elected not to build out Ebola transport capability,
would be willing to provide services in a domestic response.

Lessons in “Response Science” need to be further distilled. Capturing and sharing lessons in
clinical care and long term survivor care will be important when dealing with any novel
pathogen whose properties are not well understood. Just as the electrolyte disruptions caused by
Ebola and its persistence in immunologically privileged parts of the body were a surprise to
medical researchers, so too will there be other clinical surprises in future epidemics that will
need to be identified and mitigated.

55
Technology is a key part of enhancing effectiveness in the response, but epidemics move too
fast to try out good ideas in the field. Spurred on by “grand challenges” sponsored by USAID
and OSTP, significant advances occurred in PPE, diagnostics, patient monitoring, contact tracing
data collection, and analysis. However, very few of these significant advances progressed
beyond the field trial stage before the epidemic subsided, suggesting that the identification of
needs and the research and development to address them must occur well before the onset of
crisis and then be very rapidly trialed across outbreaks and emergencies. CDC, in partnership
with OSTP, should review strategies and objectives to maximize future deployable innovations
based on the incredible outpouring of innovation during the Ebola epidemic.

Management of the risk of exportation and importation of a disease by international

travelers is essential. The combination of exit screening at the point of origin and arrival
screening with active monitoring in the United States helped manage the risk of Ebola spread
without disrupting the international travel system. However this may not be scalable for other
pathogens, or in other locations. In future international public health emergencies, policymakers
will need to consider how best to manage the risks associated with travel and be prepared to
counter the politically expedient call for travel plans.

Better data systems and indicators are one of the biggest ways to improve pandemic
responses. Current barriers to data collection, reporting, and information sharing, along with
the inherent difficulty of modeling trends in population behavior, limit the use of predictive tools
and data systems as decision aids for policymakers. Nevertheless, it is entirely within the realm
of possibility to design national health data and biosurveillence systems that can in emergencies
share relevant data with all responding organizations and agencies. Digital systems should be
designed to high, low, and no-tech areas, and, if properly designed and implemented, will help
responders more quickly establish a feedback loop between information collection and assistance
delivery. Workforce development and capacity building are crucial to strengthening data
systems.

Global humanitarian response capabilities are stretched to their limits and need additional
capacity to handle the “new norm” of multiple crises. 2014 became the first year in which
international humanitarian responders faced four of the most serious “level 3” events
simultaneously -- Syria, Iraq, South Sudan, and Yemen -- while also dealing with the Nepal
earthquake and Ebola. OFDA at one point had four DART teams in the field, some of which had
multiple country teams, which made it difficult to consistently staff them and the Washington-
based RMT. The same stress on government assets trickled down to the contractors who support
them. Experienced field managers working for implementing partners mounting Ebola
eradication campaigns in Guinea were suddenly redirected to Nepal to manage the earthquake
response. Aggregate humanitarian response capability needs to be right-sized for the “new
normal” of humanitarian emergencies, with OFDA re-examining its footprint and number of
trained staff ready for deployment.

Stopping an outbreak at the source before it becomesan epidemic is crucial. Even during
the push to zero in West Africa, the United States was pressing forward with the Global Health
Security Agenda, which aims to build strong, sustainable systems for preventing, detecting, and

56
rapidly responding to outbreaks of infectious disease. The move to develop common global
targets by which to measure capacity to prevent epidemics like Ebola is imperative. The
countries of the GHSA have now developed such a global assessment tool and common targets.
These should be rapidly used and adopted by the WHO and other global entities focused on
preventing epidemic threats to develop baselines, 5-year plans, and to synchronize investment.

57
 AGENCY REFORMSUNDERWAY

&

REFORMS SUGGESTEDBY LESSONSLEARNED STUDIES

Reforms and activities underway un-italicized

Issues for Principals and Deputy Consideration in italics.

National Security Council

.
• NSC is working on a draft Domestic Incident Response PPD, which will provide for the
designation of a lead Federal agency during incidents that are not covered under the
Stafford Act, require the designation of a senior response official to lead the Federal
government’s response efforts, and provide a mechanism for DHS/FEMA to provide
incident management support to the lead Federal agency
• NSC is developing clearer internal procedures and interagency crisis management
mechanisms
• Ongoing work streams on GHSA, WHO reform, Ebola recovery, hazardous waste, and
decontamination standards and regulations.
• NSC is developing an international response rubric to tier and categorize options across
epidemiology, political, and humanitarian risk factors and will stand up an epidemic
threat cell in the interagency to advise on these matters before and during crises and to
regularly conduct exercises to prepare for future response. The rubric will include a
common categorization of health event severity and triggers for mobilization.
• Clarify (perhaps through a PPD) agency and department roles in pandemic response
plans beyond that specified in the Biological Incident Annex of the National Response
Framework.
• Develop PPD requiring implementation of an international response framework that
mirrors the National Response Framework including identification of ESFs and ESF lead
agencies.
• Work with agencies to develop a national-level, contagious biological outbreak plan for
domestic and international response that identifies expected levels of performance and
capability requirements and provides standards for assessing needed capabilities.

USAID
• OFDA is developing an operational response framework that streamlines and codifies
how OFDA will engage, coordinate, and support other interagency capabilities in major
responses.
• OFDA is expanding existing staffing capabilities and the pool of trained responders
through a Multiple Response Strategy. The MRS staffing pattern will ensure OFDA has
adequate depth to fully manage multiple simultaneous L3 responses around the world.

58
 • OFDA is expanding collaboration and engagement with CDC into a broader partnership,
enhancing its infectious disease response capacity, and evaluating the triggers for when
an epidemic response overseas rises to the level of a disaster declaration.
• OFDA is hiring a “Private Sector and Diaspora Advisor” to preplan coordination with
foundations and private sector donors.
• The Global Development Lab and OFDA commit to work together to establish greater
understanding and collaboration on applying data and technology support to future
humanitarian operations.
• The USAID Global Health Bureau and OFDA are developing a joint pandemic
preparedness effort to build local capacity and develop standing implementing
mechanisms that can be rolled out quickly in the event of a health related emergency.
• Funding bush meat and animal vector studies and mitigation programs.
• Consider initiating senior Management exchanges with CDC
• Consider institutional changes within the UN, similar to the WHO reform efforts
underway.
• Clearly communicate the successes and failures of the UN Mission for Ebola Emergency
Response (UNMEER) and the Ebola field coordination model and the failure to use the
existing international humanitarian architecture model.

Department of Defense
• DoD is in the process of drafting a DoD Instruction on Global Health Engagement to
provide policy guidance to the Department.
• DoD is establishing a DoD Global Health Engagement Council which will be used to
coordinate the Department’s Global Health Engagement activities and increase visibility
of DoD assets and capabilities.
• DoD is conducting a capabilities based assessment of requirements to operate in
environments impacted by Pandemic Influenza or Infectious Disease including
movement policies.
• DoD is conducting all-hazards disaster preparedness training in West Africa to bolster
national emergency preparedness systems.
• Joint Staff Surgeon General elevated to become a direct report to the Chairman of the
Joint Chiefs of Staff as of July 1, 2015.
• Develop language for DoD’s Guidance for the Employment of the Force that highlight
phase zero health engagement by COCOMS.
• DoD is evaluating long-term overseas laboratory support programs in order to balance
ongoing support to West African Ebola countries and enduring Cooperative Threat
Reduction mission priorities.
• Evaluate biosurveillance capabilities and programs within DoD and explore how best to
leverage capabilities in support of USG biosurveillance efforts.

Department of State
• Formalize pandemic crisis management mechanisms and the criteria and decision
process Department leadership would use to determine what mechanism was appropriate
for a particular threat level.

59
 • State is studying how to ensure medevac capability persists in the future from all regions.
• MED has assessed all posts with an Infectious Disease Threat Readiness Survey and
established a tiered system. In the event of a novel infectious threat at a post this
provides immediate information to MED about local ability to care for Americans at post
or need for Medevac.
• MED is in the process of upgrading the Personal Protective Equipment for handling of
infectious threats in Health Units and providing training on its use to HUstaff worldwide.
• Consular Affairs is incorporating lessons learned into the FAM for the Consular
Information Program, Pandemic Medical Evacuation, Visa Screening, and Consular crisis
staffing standard operating procedures.
• The International Security Advisory Board (ISAB) is undertaking a study of the
international security and foreign policy implications of significant overseas disease
outbreaks.
• Designate a senior official to coordinate State’s pandemic preparedness (including
institutionalizing lessons learned from the Ebola and other recent pandemics) and State’s
participation in the Global Health Security Agenda.
• Conduct after-action reviews at each affected post and regionally (to examine lessons
for, e.g., interagency coordination in country, the ICASS management platform, policy
decisions affecting the safety and security of embassy personnel, including LES staff) and
with each bureau in HQ with one or more core functions during the crisis
• Clarify State Department authorities and responsibilities (internally and vis-à-vis other
USG actors) to coordinate with the private sector in advance of and during a pandemic.
• Develop technology solutions to facilitate State’s role as resource mobilization and
outreach coordinator.

Health & Human Services//Centersfor Disease Control

• Examining approaches to developing and maintaining an appropriately sized emergency
response fund
• Clarifying and codifying internal HHS crisis management processesfor coordination of
emergency responses that originate outside of the United States, but which have either
domestic implications or necessitate the international mobilization of HHS resources to
an exceptional degree.
• With NSC and FEMA, codifying concepts of Lead Federal Agency for responsesthat fall
below the threshold of a Stafford Act response, declaration by the Secretary of a public
health emergency, or Presidential declaration of a national emergency, and for requesting
infrastructure or other support from FEMA as needed
• CDC is reviewing its approach to incident command, and has implemented plans to train
a cadre of subject matter experts in incident command
• Working with GSA to ensure federal facilities are always available to isolate and
quarantine individualsas needed
• Completing end-to-end planning for movement of highly infectious patients, both from
overseas and within the US

60
• Ensuring there is a coordinated mechanism for prioritized, coordinated purchase of PPE
or other materiel in short supply, both across USG and HHS
• CDC is broadly reviewing its modeling to better inform management, understanding and
communication of the impact of operational decisions on the outcome of the response
• Strengthening approaches to risk communication
• Strengthening administrative preparedness for emergency deployments, including hiring
actions, procurement capabilities, how to transition administrative and fiscal systems to
emergency states, and the safety health, and security of deployed personnel.
• CDC has largely established but is refining pre- and post- deployment procedures to
streamline overall, better match deployer skills and abilities with dynamic mission
requirements, and ensure that a comprehensive health and medical framework exists for
large, international deployments where Embassy capacity is limited.
• Facilitating the work of HHS health attaches as well as OGA Washington staff to
communicate with international counterparts in partner ministries of health as well as
across sectors and agencies (within USG and with partner nations), to support an
international response at the diplomatic and strategic level
• Developing requirements and strengthening processes for more rapid deployment of staff
internationally, including determining how many staff are needed for what types of future
deployments, pre-identifying personnel, and ensuring they have required passports and
immunizations.
• Stood up a tiered system of hospitals to assess and care for Ebola patients, including one
hospital in each of ten HHS regions that will care for Ebola and other high pathogen
diseases in the future. Operationalized a National Ebola Training and Education Center
to further develop and train participants in this network as well as in 45 other state
designated Ebola assessment or treatment centers.
• Continuing support for development of vaccines and therapies for Ebola, including a
planned trial comparing immunogenicity of vaccines furthest along in the development
pipeline. This new trial will be being conducted in collaboration with researchers and
governments in the 3 affected countries. Further developing warm-based capability for
use of platform technologies for rapid development of countermeasures for the next
disease, e.g. monoclonal antibodies
• Conducting a comprehensive study of the health of Ebola survivors in West Africa and
supporting service provision to Ebola survivors in West Africa.
• Global Health Security Agenda (GHSA) Implementation: GHSA plans are complete and
implementation is underway in almost all of the 17 Phase 1 countries. The U.S.
Government recently announced the final 13 Phase 2 countries toward our 30-country
commitment. CDC has made progress in distribution of GHSA resources to host
countries and partners; placement of CDC staff in the field for day-to-day support of
implementation; and initiation of GHSA activities across all GHSA objectives and
targets. Five countries (Peru, Portugal, Georgia, Uganda, and the United Kingdom)

61
 completed the GHSA independent assessments; additional countries, including the United
States, are committed to completing the assessment in 2016.
• As part of CDC’s efforts to support Global Health Security priorities, CDC is increasing
the agency’s international emergency response capacity by establishing a Global Rapid
Response Team (Global RRT) to ensure that CDC can immediately respond in global
health security threats with a trained, connected and sustainable workforce. The Global
RRT will provide dedicated personnel and resources to CIOs to support international
emergency response, including outbreak response.
• Expansion of CDC global staff: CDC has hired staff in 11of the 17 GHSA Phase 1
countries to support GHSA implementation. 6 staff (Bangladesh, Burkina Faso, Guinea,
Indonesia, Liberia, and Sierra Leone) were hired as CDC Country Directors and will
serve a dual role as the GHSA program lead. 5 staff (Cameroon, Cote d’Ivoire, Ethiopia,
Senegal/Guinea Bissau, and Tanzania were hired as GHSA program leads.
• CDC is employing 11recently selected temporary (2-year) epidemiology field assignees
(TEFAs) to enhance nationwide preparedness activities for Ebola and similar disease
risks. TEFAs are assigned to state or local health departments but can work regionally,
nationally, or internationally based on need.

Department of Homeland Security

• DHS is drafting a comprehensive Ebola after action review that will document lessons
learned that should be integrated into future emerging infectious disease planning.
• The DHS Office of Health Affairs is reviewing its Decision Support Cell (DSC) and
other operational activities to determine necessary improvements and additional
resources required for improved response and coordination in future emerging infectious
disease events.
• The United States Coast Guard (USCG) is revising its CBRN training and exercise
requirements for the use of PPE.
• Customs and Border Protection (CBP) and CDC are working to conclude a MOU on
information sharing regarding travelers suspected of exposure to infectious disease.
• CBP has implemented data collection review practices to improve enhanced Ebola
screening reporting thoroughness and oversight.
• FEMA is working with interagency partners to update the Biological Incident Annex to
the Response and Recovery Federal Interagency Operational Plans (FIOPs).
• NBIC established a liaison at CBP to access travel data and assess travel patterns. In
addition, NBIC has recently evaluated and acquired commercial private sector travel
data. Both data sources will assist NBIC in understanding translocation risk of emerging
infectious diseases.
• NBIC is supporting an Office of Science & Technology Policy effort to improve
infectious disease forecasting capabilities to provide decision-makers with better
anticipatory analysis.
• NBIC is currently working with Department of Veterans Affairs on a proof of concept to
demonstrate interagency data sharing and integration to support biosurveillance
information needs. If successful, NBIC plans to leverage its efforts with VA, as a model
for integrating data from other agencies.

62
 APPENDIX A

Timeline

December 2013

December 6 A boy dies of Ebola in Meliandou, Guinea, now suspected as the index case.

February 2014

February 13 Unrelated to the epidemic, which was then unknown, President Obama launches
the Global Health Security Agenda.

March 2014

March 21 Pasteur Institute confirms Ebola in blood sample collected in Guinea by MSF
March 23 WHO announces Ebola Outbreak
March 24 National Security Advisor and President notified of Ebola outbreak in Guinea.
March 27 WHO makes an initial funding appeal for $4.8 million
March 31 First cases are confirmed in Liberia. The CDC sends a five-person team to Guinea
to assist the Ministry of Health and the WHO.

April 2014

Early April NSC Staff sends the Presidenta memo on the outbreak
DoD dispatchesstaff from US AMRIID to assist LIBR in performingEbola tests.
April 30 WHO reportsa total of 239 cases and 106 deathsin Guinea and Liberia.

May 2014

May 10 Ministryof Healthof Guinea reports 233 suspect and confirmedcases of Ebola,
Mid-May CDC anticipatespullingteam out within a month
May 17 Presidentasks G-7 countriesto join the Global HealthSecurity Agenda
May 25 WHO notifiedthat Ebola was found in Sierra Leone.

June 2014

June 14 CDC deploys five person team to Conakry and focuses on reestablishing
systematic reporting in all three counties.
June 20 [confirm] The first US interagency meeting concerning Ebola occurs on June 20.
June 21 MSF publicly states “epidemic out of control”
June 23 NSC consults with CDC and USAID about state of outbreak
June 27 NSC hosts interagency call to assess current status of outbreak, address support to
response, and identify further capabilities. US contributions exceed $3 million.

63
June 30 NSC staff speaks for the first time directly with MSF
June 30 Memo on Ebola and MERS sent to POTUS
Late June MSF determines virus spreading in over 60 locations in Guinea, Sierra Leone, and
Liberia.

July 2014

July 2-3 WHO Regional Office for Africa convenes emergency ministerial in Accra.
779 cases reported to date across region.
July 9 Ebola Strategy interagency meetings (sub-IPCs), coordinating by NSC, begin
bringing together USAID, State, CDC, and HHS to discuss U.S. support in light
of recommendation emerging from Accra WHO meeting. HHS leads process to
coordinate support for WHO appeal.
CDC stands up its Emergency Operations Center for Ebola
July 10 NSC staff flag for NSC leadership the lack of a macro picture of USG is going for
the response.
July 11 NSC asks CDC with its EOC to propose a framework for the interagency
response
July 15 CDC director Tom Frieden proposes expanding CDC/HHS leadership, but State
and USAID resist proposal
July 17 WHO reports total cases have exceeded 1,000.
July 22 NSC hosts IPC to finalize framework for interagency coordination and division of
labor.
CDC representative in Sierra Leone files situation report documenting a severe
crisis on the ground,
July 23 Kent Bradley confirmed as Ebola positive.
Late July NSC begins holding near daily IPC meetings led by Gayle Smith
July 25 First case from Ebola in Nigeria
July 28 Liberia declares emergency, shuts borders and schools.
White House Ebola Task Force beings daily internal meetings & IPC-level calls
July 29 USAID approaches NSC with idea of deploying DART Team
July 30 High level CDC-NSC consultation on direction of epidemic
20 CDC staff in region.
NSC recalls CDC Director Tom Freidan from personal leave to help manage
response
WHO declared “Level 3” emergency
July 31 NSC Deputies Committee meets, recommends CDC to surge and focuses on
domestic preparedness. Agencies asked to “lean forward.”
Staff call following explores DART deployment.

August 2014

August 1 The WHO along with the presidentsof Guinea,Sierra Leone,and Liberia
announcea response plan with funding needsof $71million.
August 2 NSC Senior DirectorGayle Smith meetswith DoD’s MichaelLumpkin,CDC’s
Tom Frieden,and USAID’sNancy Lindborgto determine way ahead

64
August 3 The first American patient with Ebola arrives in the United States.
NSC Deputies Small Group meets and agrees USAID should deploy an
interagency DART
August 4 Ambassador to Liberia Deborah Malac declares a disaster in Liberia
USAID activates a Disaster Assistance Response Team (DART) and has
personnel in Liberia that same day
NSC sends memo to President on CDC surge and domestic preparedness
NSC and OMB discuss budget for response
August 5 Secretary of Defense Chuck Hagel creates DoD Ebola Task Force
August 6 Liberian President Ellen Johnson Sirleaf declares a State of Emergency
August 7 DART leader arrives in country
August 8 WHO declares a Public Health Emergency of International Concern
August 11 NSC Deputies Committee meets to discuss how to build a more robust UN
response to the crises
Second DART team deploys to Sierra Leone
August 14 USAID publishes its first fact sheet on Ebola, the government of Guinea declares
a public health emergency.
August 18 The State Department awards a contract to Phoenix Air for the exclusive use of
its bio-containment plane
August 21 Kent Brantly discharged from Emory Medical Center
August 26 NSC Deputies Committee meets and agrees that DoD should deploy a 25-bed
DoD mobile medical unit to care for Ebola health care workers
August 29 Senegal confirms its first case of Ebola.
President makes Ebola Public Service Announcement
Late August WHO releases roadmap estimating that $490 million in humanitarian assistance
will be required. WHO director general Margaret Chan and UN leaders revise
this estimate to $600 million one week later

September 2014

September 2 MSF President Dr. Joanne Lui appeals for UN member states to send civilian and
military assets to assist the response.
More than 100 CDC staff deployed
September 10 Meeting of the NSC Principals Committee informed by CDC Director Frieden
that cases could reach 1 million. Principals agree that Ebola should be
designated a tier-one national security threat.
September 12 NSC Principals Committee agrees with DoD plans for mobilization of the U.S.
military to West Africa.
September 14 EXORD signed by DoD establishing “Operation United Assistance”
September 15 State Department’s Ebola Coordination Unit begins operation
September 16 President Barack Obama announces a dramatic increase in the US response in a
speech at CDC, including increased involvement of the Department of Defense
(DoD). Maj. Gen. Darryl Williams arrives in Monrovia with an advance party of
13 U.S. military personnel.
DoD submits requests to make additional fiscal year 2014 Overseas Contingency
Operation (OCO) funds available for this effort, and Congress authorizes $750

65
 million of the $1 billion reprogrammed from OCO funding to DoD’s Overseas
Humanitarian, Disaster, and Civic Aid Program.
The UN Office for the Coordination of Humanitarian Affairs (UN OCHA)
publishes a report estimating funding needs at $1 billion.
September 18 United Nations Security Council hosts Special Session on Ebola
September 19 United Nations Security Council creates the first ever UN emergency public
health mission, the United Nations Mission for Ebola Emergency Response
(UNMEER).
NSC Deputies Committee meets
September 22 NSC Principals Committee meets
September 24 Obama calls for a global mobilization on Ebola at the UN General Assembly
September 25 25-bed MMU arrives in Monrovia
September 26 President Obama hosts previously planned Global Health Security Summit
September 28 Liberian outbreak at its peak
September 29 Thomas Eric Duncan confirmed as Ebola positive in Dallas Hospital

October 2014

October 8 Thomas Eric Duncan dies

October 10 Funneling of passangers into 5 U.S. airports begins
NSC Principals Committee meets
October 11 Program of “funneling” travelers from Ebola outbreak countries to 5 U.S. airports
for arrival screening and active monitoring by public health officials launches at
John F. Kennedy International Airport in New York.
October 13 Nina Pham confirmed as Ebola positive, admitted to NIH 10/15
October 15 Amber Vincent confirmed as Ebola positive, admitted to Emory 10/19
October 17 President Obama appoints Ron Klain as White House Ebola Response
Coordinator
The WHO confirms that Senegal is Ebola-free after receiving its first and only
Ebola patient in August.
October 19 NSC Deputies Committee meets
October 20 Nigeria is confirmed Ebola-free after having 20 cases and eight deaths
October 21 NSC Principals Committee meets. Agree to ask for $6.2B supplemental.
October 23 Craig Spencer confirmed as Ebola positive admitted to Bellevue Hospital, NYC
October 24 President welcomes Nina Pham to the White House
NSC Deputies Committee meets
October 25 NSC Principals Committee meets
October 28 Amber Vincent released from Emory Medical Center
NSC Deputies Committee meets
October 29 NSC meeting on Ebola w/ President Obama

November 2014

November 4 Chairman of the Joint Chiefs Martin Dempsey requests a DoD “red cell” evaluate
strategy for combating the Ebola epidemic.

66
November 5 The Administration submits a fiscal year 2015 “Emergency Appropriations”
request for $6.18 billion to respond to the Ebola outbreak.
November 7 NSC Deputies Committee meeting on funneling and screening
November 10 WHO states Mali received its first Ebola case through Guinea
November 13 Monrovia Medical Unit accepts first Ebola patient
November 14 NSC Deputies Committee meets
November 15 Official request for funding for UNMEER rises to $1.5 billion
November 18 Homeland Security Council meets with president Obama
November 21 NSC Deputies Committee meets
November 26 WHO Ebola Situation Report shows 15,935 total cases and 5,689 deaths.
November 30 Last day that Ambassadors Powell leads the ECU

December 2014

December 1 Former Ambassador Steven Browning takes over the ECU with Andy Weber as
his Deputy Coordinator.
December 5 NSC Deputies Committee meets to discuss vaccine liability
December 7 The number of new Ebola patients per week started a mostly consistent decline in
Sierra Leone.
December 10 Congress appropriates $5.4 billion for emergency funding for Ebola.
DoD Red Cell reports findings that social mobilization is epidemic’s “center of
gravity”
December 12 State stops tracking donations to the Ebola Crisis.
NSC meeting w/ President Obama. Approves sure in Sierra Leone.
December 18 U.S. military personnel peak at just over 2,800
December 18 NSC Deputies Committee meeting

January 2015

January 9 NSC Deputies Committee meeting on transition

January 14 NSC Principals Committee meeting on transition
January 16 NSC Deputies Committee meeting
January 21 Mali is declared Ebola-free after eight cases and six deaths
January 23 NSC Deputies Committee meeting on transition
January 29 NSC meeting w/ President Obama on transition

February 2015

February 5 NSC Deputies Committee meeting on transition

February 11 President Obama announces transition of Ebola mission, wind-down of Operation
United Assistance
February 12 White House convenes first of three Ebola Lessons Learned Summits
February 28 Total of 23,969 cases and 9,807 deaths.
19 medevac options to repatriate potentially exposed Partners in Health workers

March 2015

67
March 6 NSC Deputies Committee meets to discuss medical evacuation CONOPS and
MMU transition
March 8 Number of deaths due to Ebola in this crisis surpasses 10,000 people.
March 25 Number of Ebola cases passes 25,000.
March 27 Last reported Ebola patient in Liberia dies before initial Ebola free declaration
NSC Deputies Committee meets to recommend accelerated efforts in Guinea
March 31 State Department’s Ebola Coordination Unit officially disbands.

April 2015

April 1 Africa Bureau,OES, and IOat State take former ECUtasks.

April 30 Monrovia MedicalUnit is turned over to the Governmentof Liberia:PHS
concludesmissionat MMU

May 2015

May 9 Liberia declaredEbola free after 42-days without a new case.

May 13 NSC DeputiesCommittee meets to endorse end of OperationUnitedAssistance
May 21 NSC PrincipalsCommitteemeets to endorse end of OperationUnitedAssistance
May 27 Presidentapprovesend of end of OperationUnitedAssistance

June 2015

June 30 Operation United Assistance ended

A 17 year-old Liberian boy is discovered during safe burial testing to be Ebola
positive, 52 days after Liberia was declared Ebola free.

September 2015

September 3 Liberia declared Ebola free a second time.

November 2015

November 7 Sierra Leone declared Ebola free

November 20 New cluster in Liberia discovered

January 2016

January 4 RMT and DART de-activated

January 15 New cluster in Sierra Leone discovered

68

List of Federal Lessons Learned Studies and Official Histories
USAID
Larissa Fast (Global Development
Lab)
Stephanie Sauvolaine (OFDA)
Mette Karlsen/Kat Echeverria (FFP)
Caroline Andresen (OFDA)
Mia Beers/Stephanie Savolaine
(OFDA)
Kama Garrison (GH)
Eric King (Global Development
Lab)
Sarah Glass (Global Development
Lab) & OFDA
APPENDIX B
Subject Complete
LessonsLearnedregardingthe use of
data and digital systemsin the Ebola 2016
Response
Overallreview of OFDA's Ebola
Response(2-phasedapproach:1. 2016
Bendingthe curve; 2. Gettingto zero)
Internal after action review on FFP’s
response. Ongoing lessons learned
exercises on cash-based programming, 2016
including through external NGO the
Cash Learning Partnership (CaLP)
Independentexternal evaluationof
technical/programmaticinterventions&
2016
their relative contributionsto "bending
the curve"
Convene Interagency Forum for a
facilitated after action session to capture
experiences and lessons learned related 2015
to interagency coordination (1st forum
will be on Phase 1: bending the curve)
Assessment to improve timeliness for
data on social mobilization investments
to improve programs in real time given 2016
the constraints emergency response.
timelines
Rapid assessments of information
management and digital systems for
July 2015
response coordination in Liberia &
Guinea
Brief lessons-learned assessment of
USAID’s ability to integrate and leverage
February
private sector partnerships in
2015
humanitarian response with the objective
to increase internal capacity and improve
69

Department of Defense
CDR Ray A. Glenn (J-
7/AFRICOM)/COL Eric Allely
(Joint Staff J-7/NGB-JSB)
John Trigilio (OSD(P)-SOLIC/SHA)
Barbara Gossage (NORTHCOM J7)
Gigi Kwik Gronvall (DoD Threat
Reduction Advisory Committee)
Dr Steven L. Rearden (Joint Staff
Historian's Office)
internal processes to capitalize on
valuable resources in times of crisis.
Subject Complete
Briefing and
Joint Staff J7 JCOALessons Learned executive
Team performed a study commissioned summary
by AFRICOM. Focused on operational released
performance of DoD response, including July, 2015.
civ-mil integration, what lines of effort Final report
added the most value, and DoD's released
performance in the eyes of those agencies December,
it supported. Report will be public. 2015
Office of the Secretary of Defense
Review will focus on DoD's internal
processes and the structures that
supported USAID, including the chain of
command within DoD, funding and its
constraints, DoD's internal battle rhythm,
and the template for dividing up
responsibility within DoD. OSD-
Homeland Defense is separately using
Ebola to update pandemic and infection November,
disease strategy, a two year process 2105
Northcom's study focuses on the training
of the medical responder teams,
emergency procurement of PPE, and
Northcom's linkage with the Defense
Logistics Agency to maintain a medical
response force. Spring, 2015
DoD's future strategic role in global
health security, defining the network
responsible for health security concerns
within DoD, and potential technology
gaps that DoD should prioritize
addressing May, 2015
Official history, written at the Secret
level, of the evolution of thinking and
decision making of the Chairman and
other key Joint Staff personnel involved
in the Ebola Response May 2105
70

DHS
Aaron Firoved (DHS Health Affairs)
Bradley Dickerson (CBRN PLCY)
Department of State
C. Tony Pfaff (S/P)
Uzma Javed (CA/OCS)
InternationalSecurity Advisory
Board (ISAB) (POC: Rebecca Katz,
ISN)
Charles Rosenfarb (M/MED)
Subject Complete
DHS is preparing an after action report
on DHS’s role in the Ebola response. 2016
Subject Complete
Focus on bilateral and multilateral
partnerships, State's interface with
governments of the affected countries,
the performance of State's Ebola
Coordination Unit, and how the Consular
offices adjusted to their new disease
detection role. Study undertaken in
cooperation with three GWU graduate
students. Internal report. July, 2015
CA/OCS has reviewed its existing FAM
guidance and OCS Duty Officer
guidance regarding pandemics. In
coordination with our consular Global
Health and Consular Information
Program Working Groups, CA/OCS has
drafted a revision to 7 FAM 050
Consular Information Program, including
a new Appendix devoted to the subject of End of
Consular Information and Pandemics. CY15
The U/S for Arms Control and
International Security Affairs has
requested that the ISAB undertake a
study of the international security and
foreign policy implications of significant By January
overseas disease outbreaks. 2016
Medevac lessons learned and SOPs July 2015
71

Anne Healy (D-MR)
Health & HumanServices
Centersfor DiseaseControland
Prevention:DavidMaples,
EvaluationTeam Lead,
CDC/Divisionof Emergency
Operations:
Serena Vinter,PolicyUnit Lead,
EbolaResponse,LaurenHoffman,
Lead,CDC/Officeof Director
LiaisonTeam to EbolaResponse
Officeof Global Affairs:AMB
Jimmy Kolker.POC - CAPT Mitch
Wolfe
Office of the AssistantSecretary
for Health(OASH):Dr Karen
DeSalvo
OASH/Office of the Surgeon
General (OSG) / Commissioned
Corps of the USPHS: RADM Scott
Giberson and CAPT Beck
Office of the Assistant Secretary
for Preparednessand Response
Focus on internal coordinationand
staffing mechanismsto support an
internationalresponseeffort. 2016
Subject Complete
CDC is basingits lessonslearnedeffort
in its EbolaEvaluationTeam,which
under DavidMaplesis responsiblefor
coordinatingamongCDCs officesto
producean interimprogressreport and
then lessonslearnedreport. He intends
to focus on a broadswath of issues,
includingdata consistencyand disease
propagationmodeling;CDC's
internationaldeploymentprocessand the
healthand safety of its personnelwhile
abroad;how CDC partnerswith states
and localitieson active monitoring;the
synchronizationof risk communication
strategies;and administrative
preparednessto transitionto emergency
states in hiringactionsand procurement
capabilities. 2015
Lessonslearnedstudy. 2016
Lessonslearnedstudy. 2016
Overall command/coordinationof the
Commissioned Corps
activation/deployment.Lessons learned
during interagency,interdepartmental
and international partner response,
inclusive of primary mission - MMU
development and operations. 2015
HHS has elected to pursue a full lessons
learned process conducted by an outside 2015
72

White House Chief Technology
Officer/PresidentialInnovation
Fellows
Julia Kim (GSA) & Mikel Maron
(State)
White House Office of Science &
Technology Policy
Jayne Morrow
Director of National Intelligence
Michael F. Danowski
ODNI Strategic Evaluation
entity and is in the process of designing
and contracting the external review.
HHS is also looking extensively at issues
of funding, legislation, and policy around
its own capability to mobilize in a health
emergency under a variety of different
authorizes, up to and including the
declaration of a public health emergency
or Stafford Act emergency
Complete
Subject
Data sharing betweenUSG and
respondersin response'sinitial phase;
effectivenessof White House CTO-GSA
data sharing teleconferences. March,2014
Subject Complete
Internal memorandumcataloguing
experienceof the NationalScience &
TechnologyCouncil’smobilizationon
Ebola. June, 2015
Subject Complete
Review of Ebola intelligence analysis January,
and collection. 2016
73