Outsmarting an Outbreak

When Ebola strikes, what is the proper response? What measures should be taken to protect communities in a time of crisis? Should a neighborhood be quarantined? How? To help answer these questions, public health officials in Liberia turn to legal experts at the UNC School of Government.

During the 2013 Ebola outbreak in Liberia, government officials placed signs across the country to convince people the virus was a real threat. But fewer than 50 percent of Liberia's population can read.photo by Emily Rosenfield, CDC
During the 2013 Ebola outbreak in Liberia, government officials placed signs across the country to convince people the virus was a real threat. But fewer than 50 percent of Liberia's population can read.
March 8th, 2017

“I don’t want you to go — it’s too dangerous.”

Aimee Wall smiles at her nervous 11-year-old daughter. “I promise you it’s safe,” she says. “Liberia has been free of Ebola for months. You have nothing to worry about.”

An hour later, as she finishes packing her bags, Wall’s phone beeps. It’s a text from her brother with a link to a news report: “Have you seen this yet?”

Today is April 2, 2016, and a new case of Ebola has just been reported in Monrovia, Liberia — where Wall is heading tomorrow.

Connecting Carolina to Liberia

In October 2015, Wall received a phone call from Francis Kateh, the chief medical officer for the Liberian Ministry of Health. Kateh knew Wall from a decade earlier when he served as the health director in Anson County, North Carolina.

“We regularly assist counties across the state of North Carolina with confidentiality laws and protocols,” Wall says. “In the same way that we helped him in Anson County, Dr. Kateh wanted us to help him in Liberia.”

At that point, in the fall of 2015, the worst of the Ebola outbreak was over, and Kateh and his colleagues were busy looking for ways to better prevent and control future outbreaks. In order to quarantine a house, or a neighborhood, there must be a law on the books that details how and when to do that — and public officials must know it.

That was one of Kateh’s biggest frustrations during this unprecedented, widespread outbreak — Liberia did have laws on the books for Ebola response, but people didn’t understand them or know how to use them. Kateh had health officials in place, but when he went to them and said, “Do this, it’s the law,” they responded with, “Wait, what law?”

It’s a bit like having highways and state patrol officers, but no one knows the speed limit. The infrastructure is there, but the knowledge is not.

Kateh presented Wall with a technical, three-part request. First, he wanted to organize foundational training for officials in Liberia to explain how law is integral to an effective public health system. “Dr. Kateh felt that there was a gap there — people didn’t understand how important the law was to public health response. He wanted to build that foundation from the ground up.”

Next he wanted Wall and her colleagues at the School of Government to help a team of Liberian attorneys and officials rewrite old laws and draft new legislation to bring Liberia’s health codes up to date. “We help legislators draft legislation to do those exact things in North Carolina, and Dr. Kateh knew that,” Wall says.

Kateh’s third aspiration included some kind of continued training in the future. “So we take this new body of law and train people in it,” Wall says. “But we also have to help build capacity within the country to do that kind of training for public officials.”

Three ambitious and arduous goals — in a complicated country recently ravaged by a terrible virus. “There weren’t a lot of people who were willing to take that on,” Wall says.

But she told Kateh she would look into it.

Regaining lost trust

In the midst of a crisis, a solid legal code can hold a community — or a country — together. This could include a law that requires a person who has been exposed to Ebola to comply with control measures, or a law that closes down all the schools in the event of a widespread outbreak. “There has to be this legal structure already in place,” Wall says. “And government officials must have the tools to enforce those laws.”

Liberia’s history of governance is complicated at best. The last decade, while relatively peaceful, was proceeded by 20 years of bloody wars, a 10-year period of dictatorship, and over a hundred years of one-party rule, gouging a deep distrust of government and democracy in the Liberian psyche.

Since the Accra Comprehensive Peace Accords in 2003, a more calm and stable energy has settled into the country, according to Jeff Austin, a research associate at the UNC School of Government who lived and worked in Liberia in those early years of peace-keeping. “There has been a lot of collaborative work on rebuilding the country and a lot of optimism,” he says. “But the capacity challenges are just very deep, and the distrust remains.”

That distrust played a major role in the chaos and devastating loss of life caused by Ebola.

West Point is a slum on the peninsula of Monrovia and home to roughly 75,000 of the city’s most impoverished residents. With no access to running water and only four communal toilets, it is exactly the kind of place that breeds disease. When officials started reporting cases of Ebola in West Point, the government reacted impulsively. “They were asking questions about public health and emergency powers, and what tools they had available, but no one knew what to do,” Wall says.

With no good protocol in place, President Ellen Johnson Sirleaf ordered the army to quarantine the slum on August 20, 2014. When armed soldiers rolled into the neighborhoods and began erecting barricades, they were met by hundreds of angry and terrified people. Soldiers fired shots into the air in an attempt to disperse the swelling crowd. In the chaos and confusion that ensued, four people were injured and a 15-year-old boy was fatally shot.

Ten days later, amid building international criticism, President Sirleaf lifted the quarantine. Many government leaders expressed regret over how the situation was handled, according to Wall.  “Talk about mistrust — it must have been terrifying for those people.”

Trapping them in an area where a highly contagious virus has been reported created a huge rift between government officials and their citizens. Another major point of contention revolved around the traditional practice of carrying a dead body and keeping it in the home for a few days. “These are things their communities have always done. But public health practice and law says you should not do that in some situations,” Wall says. “There was so much confusion about forbidding customary practices, and huge trust issues. People kept asking, Is the government trying to trick us? Why is the government stealing our dead bodies?”

Jeff Austin and other members of the team from UNC and the CDC walk across a makeshift bridge in a neighborhood outside Monrovia.

[/media-credit] Jeff Austin and other members of the team from UNC and the CDC walk across a makeshift bridge in a neighborhood outside Monrovia.

Reaching the people

Liberia is home to a tropical climate where the air hangs heavy with heat and humidity year-round. During the rainy season (May through October) water pours from the sky, saturating the earth for days on end. The intense rain often washes out bridges and roads, making travel and communication to remote villages nearly impossible.

This presents yet another major challenge for public health officials to cope with when Ebola hits. “We heard that this area was experiencing an outbreak and the people living there didn’t understand it,” Wall says, pointing to a county outside of Monrovia on a map. “The public health officials and volunteers had to park their cars and walk for two days to explain the proper protocol to the tribal leaders there.” In remote areas, people have almost no contact or connection with government officials — their trust lies solely in the tribal leaders.

Jeff Austin and other members of the team from UNC and the CDC walk across a makeshift bridge in a neighborhood outside Monrovia. Photo by Emily Rosenfield, courtesy of the CDC.

Across the country, officials erected huge billboards declaring “Ebola is real” in an attempt to convince people that the virus is indeed a real threat, and not some sort of government conspiracy.

But fewer than 50 percent of Liberia’s population can read. “They talked about adding things to the law that didn’t make sense practically for their population,” Wall says. “How important is signage when people can’t read it? You can’t impose a literacy requirement.”

Seemingly every facet of public health protocol was met with misunderstanding at best and animosity at worst. In Liberia, burning a dead body is a massive taboo. More than a year has passed since Ebola swept across the country, but the men who helped end the epidemic — the “body burners” — are still shunned by their communities.

Mapping new laws  

Taking all these unique challenges into consideration, Wall knew that transplanting public health laws from North Carolina wouldn’t do any good. She needed to examine public health laws that work well in places similar to Liberia.  Fortunately, the U.S. Centers for Disease Control (CDC) had already initiated a project that involved mapping out public health laws from many vulnerable countries including Liberia. The lead researcher on that team is from the UNC Department of Public Policy — Ben Meier. “My research doesn’t go into the politics of reforming laws,” he says. “It deals with comparing the existing laws of some 20 sub-Saharan African countries.”

The comparative legal data Meier provided filled a crucial gap for Wall as she and Austin sat down with Liberian officials and CDC attorneys, Emily Rosenfeld and Akshara Menon, to evaluate the best ways to reform various pieces of Liberia’s public health code. She spread out copies of laws and supporting documentation from countries across Africa. “It was this incredible road map,” she says. “We said, ‘Okay, they want to do this differently in Liberia. Well, here is how they do it in Tanzania, and here’s how they do it in South Africa.’ The research Ben brought in made it so much easier to supplement and modify their laws.”

The marriage of the two projects highlights the benefit of different approaches to the same area of research, according to Meier. “My work on its own is not enough,” he says. “And Aimee’s project requires the work that we’re doing as a setup for it. So they are very complementary approaches — one can’t reform national legislation without going to the country, and one can’t go to the country without understanding what all other countries are doing.”

Supporting Liberia’s legal system

When Wall received that telephone call from Kateh in October 2015, she told him that she and her colleagues were not the right people to help him. “We don’t do global health law,” she said. “We do North Carolina public health law. But let me see if I can find someone who can help you.”

As she began contacting people, she realized Kateh may have reached out to the right person after all.

“There are lots of people that could teach him about the foundations of public health law and the public health system, but there weren’t too many people who were willing to go in and actually help rewrite the laws,” Wall says. A pro bono group of attorneys provided assistance several years ago through the International Senior Lawyers’ Project and the new team was able to build on much of their good work. But legal resources are scarce and attorneys trained in public policy, public health, and legislative drafting are even scarcer.

Wall’s ability to help is, in part, due to the close similarities of the United States constitution and Liberia’s constitution. Liberia was founded by free black Americans from the United States so their legislative system has strong American influences. The country uses American law as precedent in its courts, teaches American case law in their law schools, and passes statutes that look a lot like U.S. laws. Liberia’s current constitution, drafted in 1985, looks very similar to ours. “In the absence of that, our utility is minimal,” Wall says. “But they have a constitution — it’s funny how close it is to ours. A lot of the same concepts are in there — many of them improved.”

Liberia is currently considering a bill that would change the structure of their government by devolving a lot of functions from the national level down to local governments. “That bill would direct an organization called the Liberian Institute for Public Administration to provide support to the country’s counties and towns,” Wall says. “They would be providing technical assistance that is very similar to what we do here at the School of Government.”

If that law passes, the UNC School of Government’s role in Liberia could go beyond the realm of public health. “How do we help them train local officials about finance? About purchasing and contracting? And how do we help them back up that training with technical assistance?” Wall asks. “We do that kind of stuff here on a daily basis. I think that’s what makes the School of Government so good — we get these phone calls and questions, and that feeds our training, writing, and research.”

Wall sees an opportunity to help her new friends and colleagues in Liberia build their internal capacity to do the kind of work that the school does in North Carolina. She has been working especially closely with Tomik Vobah, the General Counsel for the Ministry of Health in Liberia. Vobah visited Chapel Hill this past fall to learn more about our public health and legal systems. He also spent time with Gene Matthews, the former General Counsel for the CDC and Senior Fellow at the Gillings School of Global Public Health, who introduced Vobah to national and international experts in order to help him build out his own public health law network. Wall hopes that these relationships — with UNC, the CDC, and many others — will help give Vobah the support he needs to become a leader in this field for his country and region.

Both Wall and Austin are quick to point out that their role is to provide guidance and support —not to come in and write their laws for them. “They wanted our help, but they made it clear the final product will be drafted by Liberians,” Wall says. “And that’s important. They need to own it and have pride in their product as Liberian-born.”

“Today, more than ever before, they know the wars are over and they are an independent country that is about to experience a transfer of power — from one peacefully elected government to the next,” Austin says. “There is a lot of pride in that.”

Aimee Wall is the Thomas Willis Lambeth Distinguished Chair in Public Policy at the UNC School of Government.

Benjamin Mason Meier is the Zachary Taylor Smith Distinguished Professor of Public Policy and an Associate Professor of Global Health Policy in the Department of Public Policy in the UNC College of Arts & Sciences.

Jeff Austin is a research associate at the UNC School of Government, and has worked in Liberia through the Carter Center.