MSF's Joanne Liu, Part II: Reflections and Lessons Learned

Dr. Joanne Liu visiting an Ebola Treatment Center in Kailahun, Sierra Leone
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©P.K. Lee/MSF

This second half of a Q&A with Joanne Liu, MDCM, president of Médecins Sans Frontières (MSF), focuses on lessons learned in the 2014 Ebola crisis in West Africa. In case you missed it last week, you can read the first part here.—Dayna Kerecman Myers, associate editor.

What are the most important lessons from MSF’s self-study on the Ebola response?
MSF has not conducted a formal self-study, although we have reflected a bit. While international entities have been criticized for their response, in reality everybody, somehow, has been late in the response to Ebola. That includes MSF, because we probably should have scaled up faster.

I don’t want MSF to be portrayed as occupying a moral high ground, projecting the impression that we know better than others. I think that everybody agrees that this outbreak was unprecedented, and we’re all in uncharted waters facing the unknown.

That said, upon reflection we decided that our protocols needed to be modified and adapted to West Africa’s reality on the ground. For example, with Ebola treatment centers, we had to scale up from our typical 20-40 beds to 100-250. We realized that the drawbacks of larger centers start to outweigh the benefits at some point, though, because it is so challenging to keep up the level of medical care in such a big center.

A lot of people have pointed out that stronger health systems would have prevented the Ebola outbreak from getting out of hand. Does MSF have a role in that or only in response?
The hard reality is that by the time the epidemic is growing, and transmissions are spreading, it is way too late to stretch medical infrastructure and build health systems. And, it is not possible to fix weak health systems without an adequate number of doctors and nurses. It takes at least 5-7 years of training for doctors, 10-12 years training for specialists, and 2-3 years for nurses. There’s a lot of feel-good conversation about the importance of building health systems. But the take-home message from such grand-scale epidemics, with high case fatality rates, is that when you’re starting with weakened health infrastructure, expect the challenges to be enormous.

Also, while some have dismissed the response capacity of West African leaders, it’s important to look at what happened when cases appeared in the US and Europe. Just one case in Texas led to 2 infected nurses; in Spain one person led to another infection. If we applied those ratios in West Africa, the population probably would have been decimated. You have to deal charitably with it; you have to realize the battle is difficult and complex—and it’s not fair to blame any state for having difficulty taming the epidemic and handling the response on its own.

How has the Ebola epidemic changed the way MSF works with other aid agencies?
First, I’d like to make a comment on the past. All of a sudden, MSF found itself labeled the expert in Ebola case management. This put us in a very difficult spot. We had to make the difficult choice to train other organizations, health ministries, and military people, something he hadn’t taken on before on quite the scale that Ebola demanded. That was a hard decision for MSF directors, because it meant we had to take key experts working hands-on in the field, extract them, put them in training centers—and explain to our remaining staff in the field that they’d have to suffer for the next few weeks, because training more people was the only way to scale up.

Now, it’s completely different. We are seeing than 100 cases in the region on a weekly basis—whereas at one point we saw that number on a daily basis. We are withdrawing from Ebola treatment centers as the numbers of cases dwindle—a good sign—but we don’t want to phase out too early, either. We want to be very clear that it takes only one case to start a new epidemic. That’s the difficulty right now, because the sense of urgency is fading. It’s already hard to keep the pressure on delivering and living up to the pledges when there are so many other crises around the world.

Any last thoughts on Ebola in West Africa you’d like to share?
I want people to understand that there is a lot of rewriting history about Ebola underway, and some of it strikes a very self-promotional tone. Let’s not fool ourselves. As in any major crisis around the world, the people who act and respond to those crises are first and foremost local people. In reality, Guineans, Sierra Leoneans, and Liberians deserve most of the credit for taking care of their own people. We have to pay tribute to West Africans who have worked and put their lives in danger for their compatriots. International staff rotated through every 4-6 weeks. But we had national staff on the ground from the beginning of the epidemic in March. They endured rejection from their families, stigmatization, and despite that, they showed up at 8:00 a.m. every single day, helping to care for their colleagues, families, and neighbors. They are the real heroes.

I also think that on the research and development side, we have a responsibility to make sure that West Africans have access to any treatments or vaccines developed; the benefits should be theirs first and foremost.

Another important point is that is the fact that the international community focused heavily on the Ebola response during the peak of the outbreak; now a lot of people are turning toward the developmental phase. One of the things we need to remember from past crises, like the tsunami in 2004, or Haiti’s earthquake in 2010, is to be careful not to neglect aid to people who fall between the emergency and development phases. People are making plans to build new hospitals and strengthen health systems, but meanwhile people are without access to basic health care, such as safe maternal health care. If people don’t fall into the category of Ebola or into the development phase, they can’t access care. That gap needs to be covered and we should learn from past crises.

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