The Ebola outbreak started in rural areas, but by June it had reached Liberia's capital, Monrovia.
By August, the number of people contracting the Ebola virus in the country was doubling every week. The Liberian government and aid workers begged for help.
Enter the U.S. military, who along with other U.S. agencies had a clear plan in mid-September to build more Ebola treatment units, or ETUs. At least one would be built in the major town of each of Liberia's 15 counties. That way, sick patients in those counties wouldn't bring more Ebola to the capital.
But it's taken a long time to build these ETUs; most won't be done until the end of the year. And now the spread of Ebola changing — clusters are popping up in remote rural areas. So building a huge treatment center in each county's main town may no longer make sense.
Two hours outside the capital, the Army's 36th Engineer Brigade just finished erecting an ETU last week. Lt. Abraham Richardson shows me around, first giving me a tour of the triage building where all patients will arrive. Then he leads me to four giant white tents inside what health workers call the "hot zone."
"That's where all the confirmed cases will be," Richardson says. Each tent will house about 25 patients.
This is what the military is good at: landing in a place they've never been and building stuff. But some say the size of the ETUs is a problem.
Because it's taken so long to build the centers, their relatively large size is no longer useful, says Dr. Darin Portnoy, who's with Doctors Without Borders. He's just finished caring for two sick children at one of the organization's original ETUs back in Monrovia.
"ETUs are not needed right now at the same level," he says. "Right now the construction should be scaled down — fewer beds."
"Take the amazing capacity that has been brought to bear and direct [it] elsewhere," he adds.
By elsewhere, Portnoy means remote rural areas, where, sometimes, the only way to reach people is by walking for hours or taking a canoe. He says big international donors should support so-called rapid response teams that go out, find those hard-to-reach people and set up small treatment centers where they actually live.
"Just because you have a plan ... doesn't mean you have to continue on that plan," he says.
The U.S. has started to scale down its plan, building only 15 ETUs instead of the 17 originally planned. Some ETUs will now have 50 beds instead of 100. And instead of sending 4,000 troops to West Africa to build facilities and train health workers, the military says that number will now be closer to 3,000.
The military is also helping to locate Ebola cases in remote areas. Just last week, says Maj. Gen. Gary Volesky, who commands the U.S. forces in Liberia, the military gave a team of epidemiologists a ride in a helicopter to a remote village north of the capital to find Ebola victims.
But Volesky says he wants to know the military has an exit plan, and that someone else will take over the jobs that the U.S. troops have been doing.
A few hours north of the capital, at one of the busiest ETUs in Liberia, custodian John Jameson shows us the burial ground full of fresh mounds of dirt. "Three, four, five burials a day," he says.
The ones buried here were those who could make it to the ETU. Health officials say many more people are getting sick and dying in remote rural areas, which means Ebola will keep spreading.
ARI SHAPIRO, HOST:
In Liberia, the total number of Ebola cases is down, but there are still flare-ups across the country. The original plan for the U.S. response was to send in thousands of troops to help build Ebola treatment units. Now, as the spread of the disease is changing, critics are pushing the U.S. to change its plan, too. NPR's Kelly McEvers reports from Liberia.
KELLY MCEVERS, BYLINE: This Ebola outbreak started in rural areas. But by June, it had reached Liberia's capital, Monrovia. By August, the number of people getting Ebola was doubling every week. The Liberian government and aid workers here begged for help. Enter the U.S. military. By mid-September, the plan was clear - build more Ebola treatment units, or ETUs - at least one in each of Liberia's 15 counties, one in each major town so sick people in the counties wouldn't bring more Ebola to the capital. Thing is, it's taken a long time to build these ETUs. Most of them won't be done 'til the end of the year.
LIEUTENANT ABRAHAM RICHARDSON: So right now we're leaving the triage building. This will be where all the patients initially arrive.
MCEVERS: Construction on this ETU, about two hours outside the capital, was finished last week by the Army's 36th engineer brigade out of Fort Hood, Texas. Lieutenant Abraham Richardson leads the tour.
RICHARDSON: On my right side - driven to the southern entrance and taken directly to the two rub halls - these two giant white tents down there. That's where all the confirmed cases will be.
MCEVERS: This is what the military is good at - landing in a place where they've never been and building stuff.
RICHARDSON: Our current plan is to house about 25 patients in each of these. So there's four of these large tents. That's a total capacity of a hundred patients for this particular ETU site.
MCEVERS: But some say this is a problem. Now that the spread of Ebola is changing, a huge treatment center in each county's main town might not make the most sense. Dr. Darin Portnoy is with Doctors Without Borders. It runs one of the original ETUs back in the capital. He just finished a shift caring for two very sick children. He says building all these ETUs across the country is a new solution to an old problem.
DARIN PORTNOY: ETUs were needed at one time. ETUs are not needed right now at the same level. Right now, the construction should scale down - fewer beds - and take the amazing capacities that have been brought to bear here and direct them elsewhere.
MCEVERS: Elsewhere meaning out to the remote rural areas where many of the new Ebola cases are popping up, where sometimes the only way to reach people is by walking for hours or taking a canoe. Portnoy says big international donors should support so-called rapid response teams that go out, find these people and set up treatment centers where they live, not big ETUs where they don't live.
PORTNOY: Just because you have a plan that you were going to do these things, doesn't mean that you have to continue on that plan because you have the awareness of what's taking place around you.
MCEVERS: The U.S. has started to scale down its plan. Some of the ETUs will now have 50 beds instead of 100. Major General Gary Volesky commands U.S. forces in Liberia. He says just last week one of his helicopters did give a team of epidemiologists a ride into a very remote village where people had Ebola. But he says he wants to know that the military has an exit plan - that someone else will take over jobs like this when he's gone.
MAJOR GENERAL GARY VOLESKY: You know, we've had experiences in other countries where we've built a capacity, and then we've left, and the local host station couldn't sustain it, and it just fell apart.
MCEVERS: Four Navy Medical Researchers built this lab a few hours north of the capital. Lieutenant Commander Vishwesh Mokashi shows us the results of an Ebola test on a laptop.
LIEUTENANT COMMANDER VISHWESH MOKASHI: So that's what you essentially see when you see a positive case.
MCEVERS: The lab is attached to one of the busiest ETUs in Liberia. Since it opened in September, it's admitted Ebola patients every day.
MCEVERS: How long have you guys been working here?
JOHN JAMESON: From September 16.
MCEVERS: Outside the ETU, John Jameson shows us the burial ground full of fresh mounds of dirt.
JAMESON: Every day is another three, four, five burials a day.
MCEVERS: Three, four, five burials a day. Thing is, these are the ones who could make it to the ETU. Health officials say there are many more people getting sick and dying in remote rural areas, and that means the disease will keep spreading. Kelly McEvers, NPR News, Monrovia. Transcript provided by NPR, Copyright NPR.