In international crises, policymakers and politicians rarely have a dress rehearsal before their debut on the main stage. Yet in retrospect, the Ebola outbreak of 2013–15 amounts to exactly that—a real-life test of Washington’s ability to detect and contain an infectious disease that threatens global security. Precisely because those who fought the spread of the Ebola virus knew how close we came to global catastrophe, the National Security Council initiated a detailed study of the successes and failures of the international and domestic responses. Starting in February 2015, 26 departments and agencies across the U.S. government participated in a “lessons learned” process headed by the White House that produced a 73-page analysis with 21 findings and recommendations. I led this effort, under the stewardship of National Security Adviser Susan Rice and Ebola Czar Ron Klain, and I authored the NSC report recently made public by The New York Times.
It was clear to those who responded to the Ebola outbreak that the response system of the United States and the international response system would risk collapse if faced with a more dire scenario. It was equally clear that a more dire scenario taking place was a question of when, not if. As the NSC report concluded, “future epidemics, especially those that are airborne and transmissible before symptoms appear, are plausibly far more dangerous.” It continued: “An appropriate minimum planning benchmark . . . might be an epidemic an order of magnitude or two more difficult . . . with much more significant domestic spread.”Although the costs of the current pandemic will not be fully measurable for some time, what was done and what was left undone in the nearly four years between the end of the Ebola crisis and the first appearance of COVID-19 is now in the public domain. It is all too clear how and when the United States failed to better prepare.
THE OUTBREAK LAST TIME
The Ebola virus dominated headlines in the United States in the summer and fall of 2014, as it spread uncontrollably across West Africa; Thomas Duncan became the first infected person to die of the disease on U.S. soil. Ultimately, Ebola claimed the lives of over 11,000 people worldwide and two people in the United States. But those who participated in the response overwhelmingly came away with the view that it could have been exponentially worse.
With Ebola, we got lucky twice over: the deadly hemorrhagic pathogen, a filovirus, was not airborne, and the outbreak occurred in a remote region of the world with few linkages to population centers in Africa and no direct air routes to global cities. We also knew that we wouldn’t get lucky twice again. With urbanization and deforestation driving together species that don’t normally interact and “wet markets” selling wild animal meat across Africa and Asia, the world is developing in ways that significantly increase the likelihood that a zoonotic virus will jump from an animal host to a human. Biotech lab accidents, terrorists, and offensive bioweapons programs are also possible sources of mass infection. When a virus makes the jump for whatever reason, intercontinental air travel ensures that it spreads with spectacular speed.
Even though the Ebola virus is far harder to catch or transmit than the new coronavirus (and easier to test for, since a test had already been developed), Ebola was its own harsh teacher. With the number of people infected doubling every three weeks at the epidemic’s peak, there was a tremendous penalty for inaction. Either Ebola was contained early, while it still was an “away game,” to use the parlance of counterterrorism, or it would quickly become a “home game,” threatening the security of the U.S. population and the global economy. U.S. President Barack Obama ordered a response for which the government had no playbook: a military mobilization of 2,800 troops, who worked in support of tens of thousands of civilian health responders in Guinea, Liberia, and Sierra Leone. Together, they built thousands of beds in Ebola treatment units to isolate and care for those who were infected, supported contact tracing to limit transmission, and led community education campaigns about how Ebola is spread. The last major transmission chains were stopped in late 2015, just over a year after the U.S. military deployed.
Although Americans can be justifiably proud of the role their nation played at a moment of global peril, the response to Ebola exposed gaps in preparedness and capability in every agency in the U.S. government tasked with health and security. The same was true for the international system. Shortfalls appeared in a bewildering array of places, from the U.S. Public Health Service not having enough yellow fever vaccines on hand to deploy personnel to West Africa to the U.S. Africa Command not having an updated pandemic plan. At home, single Ebola cases swamped the public health and hazardous waste disposal systems of New York and Texas. Washington also presumed a degree of competence in the ability of the World Health Organization (WHO) to respond to a major epidemic—a degree of competence that it turned out not to have. Once the magnitude of the crisis came into full view and the United States and its partners rushed capacity to West Africa, the failure to initially field adequate testing capacity and personal protective equipment to frontline medical personnel presaged the crisis now playing out with COVID-19.
AFTER EBOLA
Even before the Ebola epidemic ended, the U.S. government began pursuing a three-pronged strategy to contain a more dangerous outbreak. First, it doubled down on the Global Health Security Agenda, an initiative the Obama administration launched before the Ebola crisis to expand capabilities around the world to prevent, detect, and rapidly respond to infectious disease threats. Through this initiative, the United States forged partnerships with over 60 countries around the world and used $1 billion of the Ebola Response Supplemental passed by Congress in December 2014 to establish dozens of specialty labs around the world to detect novel outbreaks and to organize country-by-country programs to deepen preparedness.
The strategy’s second prong was to further build out the network of hospitals and testing centers in the United States designated to treat Ebola and to increase the size of the national medical stockpile with more of the personal protective equipment and materials needed to fight highly lethal pathogens.
The third prong was to designate a health emergency response coordinator and create a new Directorate for Global Health Security and Biodefense within the National Security Council. It would be the job of this White House office to monitor biological threats and coordinate future responses. Crucially, this office would lead post-Ebola reforms, using its perch in the White House to ensure structural changes within agencies and departments.
Because combating a dangerous pathogen requires the close cooperation of parts of the government that don’t ordinarily work together, increasing U.S. capacity would necessitate a willingness to direct changes that might go against the culture of federal departments, agencies, and the U.S. military. It would require cajoling Congress to increase budgets, add mandates, and adjust missions. And given the magnitude of the changes, it would require the personal leadership of the president. The seriousness of the threat of an infectious disease led the outgoing Obama national security team to include an influenza pandemic scenario in a joint exercise held with the incoming Trump team. To ensure that the new Global Health Security and Biodefense Directorate’s mission would survive into the new administration intact, the outgoing White House team selected a career civil servant—a respected Pentagon biodefense expert named Elizabeth Cameron—to lead it, providing continuity from one administration to the next.
LESSONS UNLEARNED
As 2017 turned to 2018 and 2018 turned to 2019, each prong of this strategy fell away like wheels off a bus. When the money provided by the Ebola Response Supplemental ran out, the new administration continued to fund the Global Health Security Agenda. But the overall budget for the Centers for Disease Control was cut, and no robust, new investments were made in greater deployable capability in the United States or other countries. At home, the envisioned expansion of the original 35-hospital Ebola Treatment Network did not take place; the $259 million appropriated for the network in 2014 was not followed by meaningful infusions of funds, setting it on track to expire in May 2020 and leading the Department of Health and Human Services to warn in November 2017 that “the current capacity of this system is not likely to be sufficient for many types of infectious disease outbreaks (e.g., pandemic influenza and other respiratory pathogens).” Nor was the national medical stockpile significantly bolstered. Congressional leaders passed budgets that had none of the vision or scale of the $5.4 billion Ebola Response Supplemental.
The third prong of the strategy was the last to go. In his first month as National Security Adviser, John Bolton shuttered the new NSC Directorate for Global Health Security and Biodefense. Its leader departed the NSC staff just one day after the WHO declared a new outbreak of Ebola in the Democratic Republic of the Congo that to date has killed over 5,000 people.
Historians looking back at the period between the Ebola and COVID-19 outbreaks will note a haunting sequence to events. The two-year-old boy named Emile who became the first known victim of Ebola in West Africa died in the Guinean village of Meliandou in December 2013. Six years later to the month, doctors in Wuhan Central Hospital noticed clusters of severe pneumonia that was unresponsive to treatment, a clinical development that evoked the SARS outbreak of 2002–3. The NSC Ebola Lessons Learned report was completed almost exactly between these two events, in the summer of 2016.
The focus now must be looking forward, not back. Still, an accounting of the current outbreak and the U.S. response to it will be necessary, as it was after the Ebola crisis, so that lessons do not go unheeded yet again. Combating epidemics in the best of circumstances is hard, and even well-tested systems never perform as planned. It will never be known how much better prepared the nation and the world might have been for a coronavirus pandemic had the infrastructure called for by policymakers who fought Ebola been fully built. But the nation will ultimately have a sense of the cost to lives and livelihoods of its absence.
This article was originally published on ForeignAffairs.com.
