Ebola – Building State Capability

Public Leadership Through Crisis 14: Lessons on Crisis Communication from Liberia’s Ebola epidemic

written by Matt Andrews

Peter Harrington is an alumni of the Harvard Kennedy School, and a former fellow with the Building State Capability program (BSC). In 2014, Peter worked with the Africa Governance Initiative helping Liberia’s government deal with its Ebola epidemic. He assisted in an area called ‘Social Mobilization’; an area of the organizational response focused on engaging citizens—and fostering behavioral change in the citizenry—through communication.

In this podcast interview, Peter describes his experience and I summarize his thoughts therafter.

https://harvardbsc.simplecast.com/episodes/ltc-4-lessons-in-crisis-communications-and-response

Here are some key takeaways from the interview.

1. Liberia’s organizational structure made a huge difference

You will hear Peter speak about the Incident Management System (the IMS) at the beginning of the podcast. This was the organization created to respond to the crisis. Peter notes that it was ‘hierarchical but also remarkably flat’ like the snowflake mechanism discussed in a prior blog post.

Peter describes the IMS as being composed of many ‘teams’. Some teams focused more on ‘hard’ aspects of the crisis response (like logistics) while others focused on ‘softer’ aspects of the response (like communications, psychosocial concerns, and others). Remember prior blog posts where we discussed the importance of having clear roles and keeping in your lane — these teams were a way of ensuring both things happened at the same time (people knew what they were doing and did not interfere with what others did).

Peter notes that this structure was both flat and hierarchical. Each team had a leader and all the team leaders reported daily to Tolbert Nyenswah who was the ‘Tzar’ of the IMS. Member of the international community slotted into teams (so they too played specific roles). Each and every team was led by a Liberian. Peter notes that Tolbert Nyenswah and his close team at the center of the ‘snowflake’ was like a ‘server’ – the connection hub where all parts of the response came together. Other teams analyzed the problems, came up with ideas, implemented, monitored, produced data, etc. The central team processed the knowledge, ensured it was shared, made decisions, followed up with decisions, and orchestrated the overall coordination. Read more about this kind of structure in blog post 11. Continue reading Public Leadership Through Crisis 14: Lessons on Crisis Communication from Liberia’s Ebola epidemic

Public Leadership Through Crisis 13: Tolbert Nyenswah on leading through Liberia’s Ebola epidemic

written by Matt Andrews

Tolbert Nyenswah is a Senior Research Associate at the Johns Hopkins Bloomberg School of Public Health. In 2014 he was the head of the Liberian Incident Management System (IMS), leading the operational aspects of the government’s response to the Ebola epidemic. Following this, he led the establishment of Liberia’s First National Public Health Institute and became its First Director General and Chief Executive Officer (CEO) 2017-2019.

This is a podcast of a conversation with Tolbert on his experience (interviewed by Peter Harrington and Matt Andrews). Brief summary thoughts follow, with questions for leaders facing crises today.

https://harvardbsc.simplecast.com/episodes/ltc-3-lessons-from-leading-through-the-ebola-crisis

1. This can be terrifying

Tolbert relates to the Covid-19 challenge facing many leaders, noting that he was asked to create the Incident Management System when the crisis had already begun (not in preparation for it): “When you’re in a dire situation where people are in the streets, [you have] no best practice testing capacity … and you are setting up an incident management system at the same time … Before you really understand what the process is about, especially when information is weak …”

I am sure may leaders feel like this in the face of crisis: unprepared and with much to do. In addition, Tolbert notes, the country was in a politically fraught position: “The president was in a very, very uncomfortable position as a leader .. in fact political leadership were calling for the president’s resignation [arguing that] the government should step down.”

At 6:38 into the interview, Tolbert simply says, “It was terrifying.” If you feel you are in the same boat … read on – terrifying things can be dealt with. Continue reading Public Leadership Through Crisis 13: Tolbert Nyenswah on leading through Liberia’s Ebola epidemic

Public Leadership Through Crisis 11: Reorganizing to address the crisis

written by Matt Andrews

I was on a call two days ago with a former student who is now deeply involved in his country’s Covid-19 crisis response. He said something like the following: “Our government is not set up to respond to this; there are multiple challenges coming at us all at once, requiring multiple new ideas from multiple places, fast. We just can’t mobilize people properly.”

This is a comment I am sure many leaders would echo right now. You look at your bureaucracy and wonder if and how it will be able to handle this crisis. It’s a little like reflecting on whether a ship built for good weather can really manage a storm.

The truth is that it probably won’t.

Typical hierarchical control mechanisms seem like they give you the coordination you need in crisis (given that we often look to centralize control during such times) but we can’t control every part of the crisis through singular hierarchies, especially when crises require engagement beyond a single organization or geographic area. Also, no new crisis conforms to the pre-arranged organizational structures we have in our organizations. These structures are typically set up to deal with specific and discrete challenges—not compound problems like we face with threats like COVID-19 (where the initial threat of virus is extremely complex and has multiple knock-on effects).

This is precisely why those who have worked in crisis and disaster management suggest using new structural mechanisms to organize their response. Decentralized decision-making and coordination mechanisms are particularly advocated for use in this kind of situation (see Dutch Leonard’s video in blog post 8, the discussion of such structures in blog post 9, and the ‘part 4’ reference to such in the interview with Shruti Mehrotra in blog post 10).

What matters is that these mechanisms allow you as the leader to identify where decisions need to be made, access information (as best as possible) and ideas to make those decisions, mobilize agents to act on and implement those decisions, and constantly monitor those actions to adapt the decisions as necessary.

In blog post 9 I emphasized that there are different kinds of such mechanisms. My work on problem driven iterative adaptation (PDIA) has found Marshall Ganz’s snowflake structure as an accessible, organic mechanism to help countries think about organizing themselves to address major problems (often related to crises).

In this blog I want to reflect—very briefly, but with references for your additional reflection—on how Liberia adopted a new organizational mechanism that has elements of the snowflake (being relatively flat, fast, and flexible) to coordinate and empower decisions in response to the 2014 Ebola epidemic. I summarize the story from Liberia as well as I can in this short blog, drawing particularly on two key articles, from Princeton University’s amazing Innovations for Successful Societies case series by Leon Schreiber and Jennifer Widner (or SW), and the Journal Health Systems Reform by Tolbert Nyenswah, Cyrus Engineer and David Peters (or NEP). I am not sharing this to suggest that the Liberian Incident Management System (IMS) is the best practice for you to copy or mimic. Rather, the story shows that, Continue reading Public Leadership Through Crisis 11: Reorganizing to address the crisis

Coronavirus and behaviour: Why leaders need better ‘risk communication’

Guest blog written by Peter Harrington

Last week I wrote a post on how the Coronavirus pandemic, like Ebola, needs to be understood as a complex adaptive problem which requires mass learning to solve. In this post I want to focus in on one area of that learning – the behaviour change required to stop transmission, and the leadership and risk communication methods that are needed to make this happen. Coronavirus is both a biological and social phenomenon, and leaders neglect the social dimensions at their peril.

Let’s first establish how behaviour change relates to the epidemic. A couple of weeks ago a viral article called for radical action by authorities to replicate the Wuhan lockdown, in order to save lives and prevent the overload of the health system seen in Italy. A graphic was presented (below) which showed the effect of the lockdown on ‘true’ cases (the grey bars). It then took about two weeks for the effect of the lockdown to be visible in official cases (gold bars). As soon as a lockdown started, new cases plummeted. This is what underlies the lockdown policy in most countries – the only way to stop transmission is if people stay at home. Behaviour change, whether enforced or voluntary, directly translates into lives saved.

The problem is, many many people in countries with a serious number of cases are not complying with guidance about social distancing, home-isolation and closures of business and various establishments. A public and private tug-of-war is raging between those who take this epidemic extremely seriously and are urging others to observe social distancing and stay at home, and those who see over-reaction and hysteria or don’t want to change their routines. This is going to lead directly to deaths. So what is happening here? Why are leaders’ entreaties being ignored? And should the authorities simply force everyone to stay at home?

I worked in the team that coordinated messaging and communications for the Liberian’s Ebola response. This branch of the response was known as ‘social mobilisation’, working to build citizen understanding and consent, and to change key behaviours to stem the epidemic. What we learned was later documented by Princeton, and has relevance today.

It is well documented that in the early stages of Ebola, the widespread belief that Ebola was not real perpetuated behaviours (like dressing highly contagious dead bodies for traditional funeral) which helped spread the disease. People were not reporting cases, and avoided Ebola Treatment Units (ETUs). Although the affected countries lacked beds, ETUs, burial teams, protective gear, it was people’s behaviour which was paramount in the spread. This relationship between the hard infrastructure of beds, staff, equipment, quarantine, ambulances etc., and the ‘soft’ infrastructure of social networks, messaging and norms is extremely important to remember for Coronavirus too. The hard infrastructure matters hugely: when cases mount, the number of beds, healthy medical personnel and equipment will be crucial. But it is the soft infrastructure that determines how many cases develop and therefore the burden on the hard infrastructure – i.e. the shape of the transmission curve.

Continue reading Coronavirus and behaviour: Why leaders need better ‘risk communication’

Seeing Pandemics as Complex Adaptive Problems

Guest blog written by Peter Harrington

As the world grapples with the first truly global pandemic, a crucial struggle is emerging between different ways of seeing the current coronavirus outbreak. On the one hand, it is a virus that medical science can tell us how to combat. On the other hand, it is a complex social challenge to which human behaviour and norms are the key. In truth it is both, but if we fail to understand this, and understand that it requires adaptive learning to overcome, far too many will die.

Five years ago, I worked alongside the late statistician and epidemiologist Hans Rosling in Liberia on the Ebola epidemic sweeping the country and its neighbours. I had gone back to Liberia having previously spent three years in the country with the Africa Governance Initiative, working in the office of President Sirleaf. Like many, including Rosling, I came out of a sense of duty. Looking back on that experience, it holds powerful lessons for how we respond to coronavirus today.

Rosling said something memorable in 2014, that ‘Ebola is both a biological and a social phenomenon’. In other words, beating it was as much about behaviour as beds, as much about trust as treatment. The huge spike of cases in Liberia – which at one point threatened to collapse the country – peaked around November 2014. Privately, many of the foreign epidemiological experts in Liberia admitted it is unlikely that the (belated) influx of beds, logistics, money and aid workers explains the decline in new cases around the country after that.

So what happened? It is actually really useful to look at what happened as an exercise in mass problem-driven iterative adaptation (PDIA). The headline problem was abundantly clear – an out of control epidemic with a mortality rate of over 50%. And the country lacked the capabilities to handle this epidemic. What followed was a mass learning process, encompassing many actors. Starting with the authorities: they had to learn how to set up an Incident Management System, the name for a completely new institution dedicated to the eradication of the outbreak, to avoid overloading the Health Ministry and other existing institutions. They had to learn to set up emergency response phone numbers, special burial teams, to build special Ebola treatment Units (ETUs), set up and run testing labs, mobilise mass logistics to distribute these resources, all without abandoning those in need of other healthcare.

At the same time, the stampede of outside organisations wishing to help had to learn too – to take their ‘expertise’ with public health, epidemics, logistics and communications and translate that to the local context. Some organisations – like the American CDC who came with ears and eyes open – proved very good at that. Others like the WHO proved very slow indeed. The difference was the willingness to learn. Continue reading Seeing Pandemics as Complex Adaptive Problems