'WHO should have been fighting the virus, not MSF'

A Médecins Sans Frontières banner hangs at an Ebola treatment center in Guinea. For months, MSF was the only organization dealing with the epidemic in West Africa. Photo by: European Union

Starting this Friday, Sierra Leone will implement another three-day lockdown across the country in efforts to curtail further spread of the Ebola virus and finally bring the cases down to zero.

While some gaps remain, there is now a sense of optimism that the country “will eventually get there,” MSF’s new Regional Communications Coordinator for West Africa Yann Libessart told Devex.

However, with the battle still being fought hard in Guinea — only about half of deaths due to Ebola on the second week of March were identified prior, and unsafe burials continue to be reported in the country — nothing is for sure. In Liberia, hopes of finally being Ebola-free were dashed when a woman tested positive Friday in Monrovia, 15 days after the last known case was discharged March 5 and halfway through the World Health Organization’s 42-day requirement of no new cases before a country can be declared free of the virus.

Authorities have yet to identify the source of Liberia’s new case. But it signals the countries’ difficult battle in getting to zero transmissions over a year into an epidemic that has killed more than 10,000 people, including at least 400 health workers, and which was fraught with a lot of tensions and finger-pointing between different players in the aid community.

A long, lonely journey

MSF’s Ebola response timeline

March 14: The Ministry of Health in Guinea sends MSF Geneva reports of a “mysterious disease” killing a high number of people, including health workers.

March 18: An MSF team from Sierra Leone with experience handling viral hemorrhagic fever arrives in Gueckedou, Guinea. This would be followed in the coming weeks by two more teams that would bring the number of experienced international workers in the country to 60.

March 21: Lab sample sent to Europe confirms the mysterious disease afflicting Guinea is Ebola.

March 22: Guinean health ministry announces Ebola outbreak.

March 31: MSF declares to the general public that an “unprecedented” Ebola epidemic has broken out in several areas in Guinea, with eight confirmed cases in the capital, Conakry. At the same time, Liberia registers its first confirmed case of Ebola, which would lead an MSF team to set up isolation wards in Monrovia and Foya. But after 21 days, and with the situation seemingly under control, the MSF team would leave Liberia for Guinea.

May 10: Guinea’s government reportedly accuses MSF of fomenting panic.

May 26: Sierra Leone confirms its first case of Ebola, leading its health ministry to ask MSF to intervene and set up a 60-bed management center facility in Kailahun. At this point, MSF no longer has the capacity to carry out in Sierra Leone other activities it did in Liberia and Guinea, such as surveillance and awareness raising.

Late June: MSF finds Ebola has been transmitted in more than 60 locations across the three countries and decides to focus the majority of its resources on running Ebola management centers. A small team of three arrives in Monrovia to help set up a 40-bed facility that would be run by Samaritan’s Purse.

June 24: MSF declares the epidemic is out of control and that the organization has reached its limit, and calls on other organizations — including WHO — to send necessary resources to curb the epidemic, medical staff in particular.

July 28: Two of Samaritan’s Purse’s staff members that were sent to help MSF in Liberia are confirmed to have contracted Ebola. The group suspends operations in the only two management centers in the country and as a result, MSF would start training coordinators and staff with no prior experience in viral hemorrhagic fevers. MSF also starts the construction of a 250-bed facility in Monrovia.

July 31: WHO announces a $100 million joint response plan to tackle Ebola, and in a news release, says the scale of the outbreak is “unprecedented.”

Aug. 8: WHO declares the outbreak a public health emergency of international concern. By this time, more than 1,000 people have died of the virus, according to MSF.

Since WHO announced the virus as a public health emergency of international concern on Aug. 8, donors have disbursed millions in funding — although recent reports show the bulk of the pledged funds have yet to arrive — and different players, local and international, have tried to work together to boost the response on the ground, from direct medical intervention to raising awareness about the disease.

That wasn’t the case over a year ago, when international medical group Médecins Sans Frontières had to deal with the disease on its own for months. In a damning report published Monday, MSF identified the many times it rang the alarm on the fast-spreading virus in the West African region, and the number of times it received a hollow response.

WHO and the governments of some of the affected countries accused the medical group of spreading unnecessary panic when it called the situation unprecedented. When MSF tried to intervene in Sierra Leone, authorities and government partners allegedly refused to share already gathered data, forcing the aid group to start from scratch in contact tracing.

And when the medical group felt it has reached its limit and called on the international community for additional support in June, the response was limited and didn’t meet the required needs on the ground — medical practitioners who can do hands-on work and not just provide technical expertise, and investments in mobilizing and training more personnel.

Libessart said that in terms of Ebola case management, “MSF was indeed feeling very lonely.”

“WHO should have been the one leading the response and supporting the government, not MSF. There was a vacuum in leadership. For months, unequipped national health authorities and volunteers from a private aid organization bore the brunt of care — there is something profoundly wrong about that,” he argued.

The organization found help in U.S. relief group Samaritan’s Purse in late June, which agreed to run both Ebola management facilities in Monrovia and Foya in Liberia. But just a month into the partnership, two of Samaritan’s Purse’s staffers tested positive for the virus, leading the organization to immediately suspend operations. This development left Liberia’s health ministry to care for the admitted patients and MSF in a conundrum: Should it push itself over the limit and risk staff infection and project collapse?

The organization eventually decided to risk it and sent response coordinators who only had two days of intensive training and no prior experience in dealing with Ebola to Liberia.

“It [was] dangerous, but [we had] to find a way to intervene in Monrovia and Foya,” according to MSF operations director Brice de le Vingne.

The infection of the two U.S. health workers however gained the attention of the international community, and triggered a shift in response on the ground.

Late into the game

One of the biggest concerns in the Ebola response is the lack of clear leadership. WHO was expected to take on this work, but wasn’t able to do so until months after the outbreak. In October, The Associated Press obtained an internal document revealing WHO’s admission of its own shortcomings, exposing an internal web of inefficiencies, bureaucracies and communication failure across the three levels of the U.N. health agency. Its Africa office was largely blamed for the limited response.

WHO’s Ebola response timeline

March 23: WHO publishes its first report on Ebola in Guinea, a day after the country’s health ministry announced the outbreak, noting that it is mobilizing and deploying experts to help respond to the epidemic. WHO also claims that it has started mobilizing laboratories in France and West Africa to prepare for more case diagnoses.

March 28: First team of experts from WHO’s Global Outbreak Alert and Response Network arrives in Guinea.

April 16: WHO’s Regional Office for Africa issues an alert on the importance of epidemiological surveillance, public information and biosafety measures, and encourages health ministers to strengthen their respective countries’ alert systems. The following week, it would mobilize a new team of physicians to support clinicians in Guinea’s principal hospital in Conakry.

May 5: WHO claims to have deployed 112 experts to West Africa, but only one would be sent to Sierra Leone to support surveillance efforts.

May 6: A high-level meeting in Conakry identifies weaknesses in the Ebola response and the precise support implementing partners need from WHO.

Early June: WHO introduces cross-border surveillance in the forested area where the three countries converge, and sends additional epidemiologists on the ground.

June 23: Another high-level meeting takes place between Guinea’s government, WHO’s regional and country offices in Africa, and the U.S. Centers for Disease Control and Prevention. In a session with MSF, the medical group asks for a stronger leadership role from WHO.

July 2-3: WHO Director-General Margaret Chan holds a high-level ministerial meeting in Ghana — which included senior health officials, partners, Ebola survivors, airline and mining companies, and donors — to raise financial support and find new strategies to boost the response. That meeting would result in the creation of a regional coordination hub based in Conakry.

July 23: Nigeria confirms its first Ebola case, triggering concerns of an urban outbreak and plans to set up an emergency committee under WHO’s International Health Regulations to assess the Ebola situation.

July 25: The coordination center is established.

Third week of July: WHO organizes a conference with donors to raise cash and in-kind support.

Aug. 1: Chan attends a meeting in Conakry with presidents of the three countries. This would lead to a decision to isolate areas in the cross-border region and the launch of a $100 million appeal.

Aug. 8: Emergency committee meets to assess the situation, which would result in WHO announcing that the outbreak is a public health emergency of international concern.

But on Friday, AP published a new report based on another set of internal documents, which noted that the situation was made known at the highest levels of the organization. Director-General Margaret Chan was however advised against declaring the epidemic an international public health emergency to temper any angry reactions from affected governments, which were trying to downplay the enormity of the situation for fear of driving away potential investments.

Sylvie Briand, head of WHO's pandemic and epidemic diseases department, was quoted as saying: “It may be more efficient to use other diplomatic means for now.”

This latest information isn’t helping WHO, which has been pummeled with criticism. Member states, clearly concerned with the global health body’s performance in the Ebola outbreak, requested Chan to form an independent panel to assess all aspects of its response, and reiterated calls for the organization to move forward with recommendations made in 2010 by a review committed under the International Health Regulations provision to set up a global health reserve workforce and a contingency fund.

In what seems like a defense of WHO’s inaction, Bruce Aylward, the organization’s assistant director-general and appointed Ebola czar, was quoted as saying: “Had we declared it earlier, it is very, very difficult to say how perceptions would have affected the response.”

Libessart called that “nonsense,” arguing the Aug. 8 declaration clearly had an impact in controlling the outbreak.

“Had this response started earlier, [fewer] people would have died. However, local governments, notably in Sierra Leone and Guinea, have a responsibility in downplaying the Ebola situation for political reasons,” he said, emphasizing that governments of affected countries and WHO should have recognized the need for a more hands-on response early in the outbreak.

WHO has yet to respond to Devex’s request for comment.

Self-evaluations

But WHO is not entirely to blame for its slow response, as Devex has previously reported.

Pulitzer Prize-winning journalist and Council on Foreign Relations senior fellow Laurie Garett, who herself was criticized for her write-ups on the outbreak, said WHO member states should share the blame. With restrictive funding and a set up that makes it difficult to ensure competent staff are hired and retained, WHO’s subpar response should come as no surprise.

Even MSF has owned up to its own failures and shortcomings. For instance, had it mobilized more human resources early on, and trained more people from its own ranks on viral hemorrhagic fevers prior to the outbreak — there are only 40 Ebola specialists in MSF — the situation today may have been different.

It has also put into question its decision to be active in all aspects of the Ebola response, and wondered whether those actions even had a significant impact on the situation on the ground.

“At times it felt as if we were trying to do everything everywhere,” the organization noted in the report. “Difficulties in organizing efficient medical evacuation arrangements, fighting travel bans imposed without scientific evidence, helping to convince airlines such as Brussels Airlines to continue flights to the region, training other organizations, and managing fear and often hysterical public opinion in ‘home’ societies all diverted attention away from the critical needs in the field.”

Some aid groups felt MSF was managing the situation pretty well, and so didn’t intervene early on.

Libessart however said that “sounding the alarm on U.N. agencies and world leaders [was] aimed at triggering an international response in which other aid agencies, more dependent on institutional funds than MSF, would have stepped in earlier. NGOs do not have an official mandate and responsibility to respond, the U.N. [does], hence why MSF very rarely comments on other aid agencies’ decisions.”

The outbreak in addition served as a wake-up call to several donors, which are now planning to beef up support for strengthening countries’ health systems.

There is no doubt this is just the start of a long period of evaluation and self-reflection for the aid community — and rightly so. While there are signs pointing to an end of the outbreak in West Africa, the international aid community cannot be complacent: The Democratic Republic of the Congo has experienced seven Ebola outbreaks since 1976.

“Let’s hope an efficient vaccine against Ebola will soon become available, but even if it does, lessons will have to be learnt from all the failures in properly responding to this outbreak. Ebola isn’t the only deadly virus out there,” Libessart said.

What lessons can the aid community learn from the Ebola crisis and response? Let us know by leaving a comment below.

Read more international development news online, and subscribe to The Development Newswire to receive the latest from the world’s leading donors and decision-makers — emailed to you FREE every business day.

About the author

  • Ravelo jennylei

    Jenny Lei Ravelo

    Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.