Joanne Liu visiting the Ebola Management Centre ELWA3 in Monrovia, Liberia in November 2014. Pictured here with MSF physician's assistant Jackson Niamah, who addressed the UN Security Council in September 2014. ©Fernando Calero/MSF
Ebola proved to be the defining global health issue of the past year. The crisis exposed a sluggish global response and weak health systems. Among the earliest to sound the warning was Médecins Sans Frontières (MSF). Just 6 months before the initial cases were confirmed in West Africa, Joanne Liu, MDCM, started her tenure as president of MSF International. She initially thought that the conflicts in Syria, the Central African Republic, and South Sudan would dominate MSF’s agenda in 2014. But the need to fight Ebola in West Africa soon sharpened into focus, and she has not been shy about shaking the world into action—as MSF's report, Pushed to the Limits and Beyond, released March 23 to mark the 1-year anniversary from the first case, makes quite clear. In this first part of a Q&A, Liu shares the behind-the-scenes decisions that shaped MSF’s response. Next week, she will discuss some lessons learned in the concluding portion of the interview.—Dayna Kerecman Myers, associate editor.
When did you start having the sense that the 2014 Ebola outbreak would be so different than earlier outbreaks?
I found out about the first Ebola case, in Guinea, after a lab confirmed the news in March 2014. Soon after, the lab pinpointed that we were dealing with the Zaire strain, known to be one of the most virulent strains. We also noticed that the cases were regionally dispersed, coming from 4 different geographic locations spread out over about 200 km. Although we didn’t know what to make of it yet, we shared that news with the world because we felt that this had the potential to be a bit different from all the cases in the past. All of the 25 Ebola epidemics we’d seen before—from 1976 to 2014—came from a specific spot in a remote area.
MSF sounded the alarm early that Ebola was going to be a major problem in West Africa, but WHO and others downplayed the risk. What will you do different next time?
When you look back, we had some early clues that this outbreak was different. But then there was a lull of cases in May 2014. Then they picked up again, prompting us to use the phrase “out of control” in June. I think it would have been difficult to use such urgent wording before then, because we didn’t have the hard facts to back up our instincts. But in hindsight, seeing how terrible the outbreak became in August and September, it’s hard not to wonder if we should have shouted louder back in June.
What other relief efforts have suffered because of Ebola, in terms of both funding, and staff resources?
It’s difficult to measure the full impact of Ebola on MSF’s wider operational deployment. But initially, our deployments were focused on the Guinean forest region; first in Guéckédou, then we saw its mirror image in Lofa County in Liberia; then in Kenema, Sierra Leone—that was our primary triangle.
We didn’t see the effect of Ebola in terms of impact on operations in a very significant way in March. By summer, though, the impact on our operational deployments became clear. As a result, we didn’t open new projects in some countries, such as Libya, and we didn’t expend all of our activities in other countries. Any needs not rising to the level of an emergency had to be postponed.
Would you say that the challenge MSF has faced with Ebola, along with multiple conflicts—Syria, South Sudan, CAR, Ukraine—is unprecedented?
To give a sense of scale of how rapidly the crisis unfolded, when I visited West Africa in August we had 60 international staff and 500 national staff. I remember talking to the presidents of the most affected countries there, explaining that MSF is stretched because there are so many crises in the world right now, and we could not really scale up. But in the end MSF still increased its presence fivefold in terms of staffing—an unprecedented scale. We hope that 2015 will be less busy, but we thank all of our donors for putting their confidence in MSF's work. They allow us to stay in conflicts where no one else wants to go, like Syria or South Sudan.
How do you decide when it is too dangerous for MSF to stay in a conflict zone? How has MSF’s withdrawal from parts of Sudan affected the overall relief effort there?
In conflict zones, when we believe that we are being targeted directly as an aid organization or as aid workers, we do withdraw. Also, if we are not able to secure guarantee of being able to work, or we do not have the access we need and we cannot engage, we might have to withdraw.
Do you worry that MSF, because it is so strong, makes it easier for governments to avoid solving their own problems?
I find those questions kind of odd; it reminds me of how after the earthquake in Haiti (in 2010) the international community basically got blamed for saving the lives of 300,000 Haitian people after the earthquake—we were accused of creating a republic of NGOs.
Also, it’s important to remember that a lot of other international organizations are as strong as MSF. MSF became an expert on Ebola by default, because not many people wanted to work on it over the years … but we are not a university, or an organization dedicated to this one complicated disease. We also work in war zones, and provide primary health care services, etc. I think what makes us different is that we are willing to take risks and expose ourselves in difficult situations, and sometimes we fill a vacuum that is unfilled by local governments. And yet, in every country in West Africa, we worked side by side with the government. And back then, they just didn’t have the capacity to respond. What people tend to forget all the time about Ebola is that it wasn’t a known disease. West Africans knew about Lassa fever in that region, but Ebola was a new disease there, and we knew there would be a learning curve.
I’m not worried that MSF is too strong; what is key is that we need to make sure that when we fill in such a huge vacuum that we’ll be able to step back when necessary and leave the local authorities empowered to take over. Initially there were no other actors beside the national Red Cross societies, a few small NGOs, MSF, and health ministries and a few WHO officials. That small group of players had a large workload to share.
Please return next week to read Part II: Reflections and Lessons Learned