Consultant, Centre on Global Health Security
Associate Fellow, Africa Programme
Philip AngelidesFormer Research Assistant, Centre on Global Health Security, Chatham House

Drawing on interviews with key Sierra Leonean and international responders, this paper helps shed light on the challenges that affected Sierra Leone's response to the Ebola outbreak.

A soldier during inspections for signs of fever, one of the symptoms of Ebola, at a checkpoint in Nikabo, a village in Kenema, Sierra Leone, on 27 August 2014. Photo: Mohammed Elshamy/Anadolu Agency/Getty Images.A soldier during inspections for signs of fever, one of the symptoms of Ebola, at a checkpoint in Nikabo, a village in Kenema, Sierra Leone, on 27 August 2014. Photo: Getty Images.

Summary

  • The 2014–16 West African Ebola epidemic was unprecedented in both scale and duration. By March 2016, when the World Health Organization (WHO) announced an end to the Public Health Emergency of International Concern declared in August 2014, some 28,616 confirmed, probable and suspected cases, with 11,310 deaths, had been reported in Guinea, Liberia and Sierra Leone – the three worst-affected countries.
  • The exceptional magnitude and duration of the emergency meant that the response was honed over time, presenting a rare opportunity to study the management of the response as it matured. This paper focuses on Sierra Leone, which experienced the highest number of cases, with 14,124 infections, including 3,956 deaths, reported to WHO, and where the operational architecture of the Ebola response went through three main iterations over a 22-month period.
  • The initial response to the outbreak was characterized by confusion, chaos and denial. While a country can be overwhelmed by a serious outbreak, a situation in which WHO fails to mobilize the assistance needed to help a national government take control of an epidemic is unusual. The rest of the international community was, meanwhile, slow to rally. The window of opportunity to contain the outbreak through conventional control approaches closed, and the outbreak became a humanitarian crisis.
  • A number of international actors poured resources and expertise into the response, including through a specially created UN Mission for Ebola Emergency Response (UNMEER). The UK, through a joint civilian–military operation, took a leading role among Sierra Leone’s international partners, including in overwhelmingly funding and supporting the National Ebola Response Centre (NERC) and a network of District Ebola Response Centres (DERCs).
  • The paper draws on a set of interviews with key Sierra Leonean and international responders who were embedded in the various command-and-control structures during the emergency. These shed light on the challenges that, to varying degrees and at various times, affected the response. Among issues highlighted were political manoeuvring and probity, inadequate financial agility, lack of coordination, partner ambivalence towards response structures, and tensions in the key relationships.
  • The NERC, chaired by Sierra Leone’s president and under the operational control of the defence minister, was judged a qualified success, considering the varied agendas, operational cultures and complexity of the problems encountered. Decentralization of the response appeared to be important for the level of agility and tailoring necessary. As in most humanitarian operations, personalities and personal relationships appeared to be key to the functioning of the response.
  • The establishment of a civilian-led, military-supported operation appeared to work well. However, what took shape in Sierra Leone in response to the Ebola outbreak reflected a rare convergence of factors that is unlikely to be replicated, and care should be taken not to generalize the applicability of the approach taken in this instance to future health crises.