The U.S. government has substantial efforts under way in West Africa to provide humanitarian assistance to combat the outbreak of the Ebola virus disease and thereby also help prevent the spread of Ebola elsewhere. U.S. government civilians under the direction of the U.S. ambassador, and U.S. military personnel under the Commander of the Joint Force Command (JFC), work with West African governments, international organizations, and nongovernmental organizations to deal with the outbreak. The U.S. government has disclosed its detailed plans for assistance in West Africa. The planning to date has at least one major shortcoming: The U.S. military commander on the ground in West Africa revealed on October 16, 2014, that he did not yet have a detailed, ready-to-execute plan for where to send for medical treatment any U.S. military personnel who contract the Ebola virus disease. When every minute counts in trying to save the life of an Ebola-infected soldier, U.S. military commanders in West Africa must know ahead of time exactly what life-saving plan to execute.

Ebola Has Killed Many in West Africa and May Spread Further if Not Stopped. The U.S. government assesses that Ebola transmission is widespread in the West African countries of Liberia, Guinea, and Sierra Leone.[1] The World Health Organization (WHO) reports that the West Africa outbreak of the viral hemorrhagic fever Ebola continues to spread geographically and had killed 4,447 people as of October 14, 2014.[2] The WHO expressed concern that national, international, and private organizations providing humanitarian assistance lack sufficient commonality in their plans, coordination of their activities, medical staffing, and geographic reach in light of the geographic spread of the disease.[3] The U.S. humanitarian effort should assist in addressing that concern.

USAID Has the Lead Role for U.S. Humanitarian Assistance in West Africa. The U.S. Agency for International Development (USAID) has the lead role for the U.S. government in providing humanitarian support in West Africa.[4] The USAID has established a Disaster Assistance Response Team (DART) in Monrovia, Liberia, and Conakry, Guinea, in which personnel from the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services participate, to coordinate plans, operations, administration and other issues among the U.S. agencies involved and with host country governments and international and nongovernmental organizations.[5] The USAID has spent approximately $207,000,000 in U.S. taxpayer funds through October 15, 2014, for humanitarian assistance to fight Ebola in West Africa.[6] Although the personnel of U.S. civilian agencies abroad receive guidance and support from their respective agency headquarters in Washington, D.C., civilian agency personnel in a foreign country are subject to the direction of the U.S. ambassador to that country, by direction of the President and consistent with U.S. law.[7]

The U.S. Military Has a Substantial Role Supporting USAID in the Provision of Humanitarian Assistance in West Africa. At the direction of the President, the Secretary of Defense directed the Commander of the U.S. Africa Command (AFRICOM) to execute humanitarian support to USAID in West Africa, denominated Operation United Assistance, through a Joint Force Command.[8] On October 16, 2014, the Joint Force Commander described his function as “to facilitate the coordination of all U.S. military forces’ support to USAID and other U.S. and international agencies in stopping the Ebola outbreak.”[9]

The Commander described the tasks approved to date for the U.S. military in West Africa as establishment of the JFC headquarters in Monrovia, Liberia; establishment of an intermediate staging base (in military parlance, an aerial port of debarkation or APOD) in Dakar, Senegal; establishment of logistics nodes; deploying in Monrovia a 25-bed expeditionary hospital; identification of sites for and construction of 17 Ebola treatment units; training health care providers (up to 500 per week); and operation of up to six mobile laboratories to test specimens for the presence of Ebola virus. The Commander noted that the 25-bed hospital will serve health care providers who contract Ebola and that officers of the U.S. Public Health Service, and not members of the U.S. armed forces, will staff the hospital. Further, the Commander noted that the JFC will include naval construction battalion (CBs or “Seabees”) personnel, a Special Purpose U.S. Marine Air Ground Task Force (MAGTF) to provide the command with the capability to move personnel and cargo by air, and, soon, headquarters and medical elements of the 101st Airborne Division, whose commander will then take command of the JFC. Finally, the Commander emphasized that U.S. military personnel must follow established protocols for protection against contracting Ebola and will have no assignment to care for patients or handle their body fluids, except for the three-person U.S. naval teams operating each of the mobile labs, who will handle specimens.[10]

The AFRICOM Commander has stated that he has received approval to send up to almost 4,000 members of the U.S. armed forces to West Africa as part of Operation United Assistance. He estimated that the first six months of the Operation would cost an estimated $750,000,000 and emphasized that the estimate may require adjustment.[11] The chain of command for Operation United Assistance runs from the President, to the Secretary of Defense, to the Commander of AFRICOM, and then to the Commander of the JFC in Monrovia.[12]

Despite the Stated “Top Priority” for Health of Military Personnel, Commander in West Africa Lacks Ready-to-Execute Plan for Treatment of Military Personnel Who Contract Ebola. In implementation of the presidential order for Operation United Assistance, the Under Secretary of Defense for Personnel and Readiness on October 10, 2014, directed that “[p]rotecting the health of our personnel and their families is our first priority” and issued extensive instructions on pre-deployment, deployment, and post-deployment training, screening, and monitoring for DOD personnel deployed to Ebola outbreak areas.[13] The Joint Force Commander expressed confidence in his ability to protect the forces under his command, expressed satisfaction with the rules of engagement under which those forces operate, and emphasized that the military personnel under his command will receive the training needed to ensure that they minimize their risk of contracting Ebola. At the same time, he acknowledged the possibility that a member of the U.S. armed forces might contract Ebola.[14]

On October 8, 2014, at a press conference, a reporter asked the four-star general commanding AFRICOM what happens if a member of the armed forces in West Africa contracts Ebola. He replied that, “if somebody does contract Ebola and becomes symptomatic, they will be handled in—just like you’ve seen on the recent ones who came back on an aircraft that was specially designed to bring them back, and they’ll go back to one of the centers that is specially designed to handle the Ebola patients right now.” However, the AFRICOM Commander’s two-star subordinate on the ground in Monrovia, the Joint Force Commander, answered differently and uncertainly a week later. Asked by a reporter at a press conference on October 16, 2014, what military or civilian medical facility would receive a member of the armed forces who contracted Ebola, the Joint Force Commander responded:

Well, I would start with that [sic] the ambassador just mentioned, there are non-government organizations, AID, CDC. I fell in—we fell in on a host of folks that have been living here for some time, and operating in this complex environment. And so, if, god [sic] forbid, one of the soldiers, sailors, airmen, or marine contracted this disease, as I mention [sic], they would be stabilized, they would be quarantined, we would go through the appropriate protocols. People would be attending to them in the appropriate PPE [personal protective equipment]. As of today, no one has shown those symptoms that I’ve had since I’ve been here [sic]. I’ve been here 30 days as of today. And so they would be quarantined and then we would synchronize and work those actions so they would go back to the appropriate medical facility.[15]

The reporter asked as a follow-up question: “And has any U.S. military medical facility been identified as the one that would accept potential Ebola-exposed patients?” The Joint Force Commander responded:

Not to my knowledge, ma’am. I’d have to get back to you on that. I know that the joint surgeon, we’re in constant contact with not only the joint surgeon, but our own Army surgeon about the appropriate protocols. I would envision that the—I’ve got a lot of time in Europe that [sic] Landstuhl [U.S. Army Medical Center, Germany] would probably be activated, but I cannot comment on that fact. I know that here on the ground, I’m at the tactical level, my concerns would be about stabilizing the soldier, sailor, airman, or marine, making sure we use the appropriate PPE, and then we would work with the coordination and synchronization to get them to the appropriate medical facility, where they could get the treatment they needed.[16]

Conclusion: DOD Planned Carefully for Assistance to West Africa and Needs to Plan Equally Carefully for Assistance to U.S. Military Personnel if Ebola Strikes Them. The AFRICOM Commander and the Joint Force Commander have a duty to members of the U.S. armed forces in West Africa to know exactly what medical actions their commands must take immediately to have a chance of saving the lives of those members if they contract Ebola. The Joint Force Command, working with the necessary officials at higher headquarters and the CDC, must determine promptly a planned destination medical facility for any Ebola-infected member of the armed forces. The commanders should plan in advance exactly where and how to send Ebola-infected soldiers to a pre-selected, prepared medical facility where they have a chance at life-saving treatment. When an individual exhibits the symptoms of Ebola, time is of the essence in getting the individual to treatment. The Department of Defense owes it to members of the U.S. armed forces to plan ahead in detail, so that DOD can execute the life-saving plan immediately if a member of the U.S. armed forces contracts Ebola in West Africa.