The building site for a field hospital — America's first big contribution to Liberia's fight against Ebola — looks a little discouraging: a sweeping expanse of mud and puddles in swampy ground, with piles of gravel, three idle construction machines, and a single contract worker in a hard hat slouching off to lunch.
The 25-bed field hospital from the U.S. is supposed to be operational within the next week or so. But in Liberia, amid the biggest Ebola emergency in history, logistics can be chaotic and timelines tend to slide.
The U.S. response in Liberia is beset by problems as small as a broken fan belt on a construction digger and major hurdles such as finding humanitarian agencies to manage Ebola treatment units rapidly training enough people to staff them.
The U.S. field hospital for health workers who become infected with Ebola is supposed to help overcome the concern of organizations and countries reluctant to deploy medical staff. It will be the only treatment facility staffed by U.S. medical personnel.
Deborah Malac, the U.S. ambassador to Liberia, acknowledged that logistical problems and bottlenecks were making timelines slip.
"Just look around, the infrastructure challenges here are huge," she said in an interview Saturday.
Humanitarian agencies working in Liberia say the country desperately needs the 17 Ebola treatment units promised by the United States. Caring for the ill in homes spreads the infection to family members and others in the community.
Ebola has killed 3,431 people in West Africa and infected 7,470, although the reported deaths are believed to be well below the real figures.
As many as 4,000 U.S. military personnel are expected in Liberia, many of whom will be involved in logistics, notably the massive task of transporting the large quantities of protective gear, chlorine and other equipment needed to operate an Ebola treatment unit, or ETU.
Doctors Without Borders, one of the few to respond to Liberia's crisis with desperately needed Ebola treatment beds, is frustrated by the slow-footed global response to a crisis that it had warned was "unprecedented" as early as March, saying the geographical spread of the disease made it difficult to control.
"For a long time, there was an underestimation of the problem, thinking it's going to solve itself," said Laurence Gaubert, Doctors Without Borders' head of mission in Monrovia, Liberia's capital. When the crisis surged in June, the humanitarian agencies that normally sweep in to respond to any natural disaster didn't materialize in large numbers.
"We know where they are. They are in their countries, in their offices, expecting other people to do the job," Gaubert said. "I know there's a lot of fear around this disease. There's a lot of caution about sending people to work with the patients." She said the response was still too slow.
"People are saying they're going to bring a lot of things, building centers, bringing cars and a lot of other things. But bringing [treatment] centers, if there's no one to work in those centers, is not going to help," she said.
Bill Berger, head of USAID's Disaster Assistance Response Team, acknowledged that there are problems regarding who will manage and staff the 17 planned Ebola treatment units, given the complexity of training people to work in facilities where procedural errors could lead to infection. At least 216 medical workers have died of Ebola in West Africa.
"It's complex to bring all of the pieces together at the right time that you need it," Berger said in an interview Saturday. "It doesn't do any good to have ETUs out there sitting empty. We have to staff them.
"Our Department of Defense folks could easily go out and build a slew of these things all at once but it wouldn't do any good," he said. "Our military has great capacity but there are many other things that have to be in place for this to make sense."
Berger said the United States, the World Health Organization and others were scrambling to solve the management and staffing issue.
"The WHO and other partners are working on this. But I've got to say … no one country can do this. It's got to be a global effort. We need these teams from many different sources, so we're working on it, WHO is also working on it," he said.
Liberia has built up its treatment capacity in the last week, but it needs more help to scale up faster. Three weeks ago, Monrovia had three ambulances. Now there are 14, said Liberia's assistant health minister, Tolbert Nyenswah. Three weeks ago, there were fewer than 200 Ebola treatment beds. Now there are about 500. But it's still not enough, humanitarian agencies say.
Malac, the U.S. ambassador, said nongovernmental organizations were arriving in a slow trickle.
"In the early days there was a lot of concern. People were afraid, didn't really understand what they would be getting into or taking on," she said. "We didn't see the huge influx that we would have expected in a natural disaster for example, but they're coming, people are starting to come. I think it's now starting to pick up."
The U.S. plans to begin training 500 Ebola healthcare workers each week. Their 13 days of training will include working in a mock Ebola treatment unit and practical "residencies" with Ebola patients in operating treatment units.
"There is a practical bottleneck at the moment in terms of the number of ETUs that are currently open and operating, as far as locations where you can take newly trained people to do their residencies. Eventually, when we have more open and more beds available there'll be more space to be able to train people," Malac said.
One key component of the U.S. response is lab testing for Ebola. It had been taking two or three days for lab tests to be processed. The United States has provided three labs in Monrovia — the two newest ones began operating Thursday and Friday — crucial to getting people who don't have the virus moved out of treatment units to make more beds available, Berger said.
Four more labs have been requested to be deployed around the country.
A huge issue facing those dealing with the disease is that many people go into denial once symptoms develop.
"We are looking at how we can help enhance the messaging that goes on," Malac said. "We went into the real denial early on and now we're past that.
"You still have people in the country and in Monrovia who refuse to believe in it or don't want to immediately jump to the conclusion that it might be Ebola when someone is ill," she said.
"Some of that's fear, some of it's denial, but some of it is an indication that we collectively have still not managed to get the message to them in a way that they internalize and that they accept as something they need to do something about."