Cover image courtesy of EU Civil Protection and Humanitarian Aid Operations. “Ebola in Guinea.” Flickr, Yahoo!, 8 Apr. 2014, www.flickr.com/photos/eu_echo/13717624625.
–by Garrett Eakers and Shanzay Ilyas–
MSF was the first international aid organization to respond to the 2013-2016 Ebola outbreak in Western Africa, caring for more than 10,000 patients over the course of the epidemic. Their seemingly deft and rapid response set an unprecedented example for their own organization and the rest of the world. Though they established their prominence at the forefront of humanitarian healthcare, their performance during the crisis was marked by assumptions about their tenuous relationships with other aid organizations and state actors. Recognizing a need for rapidly addressing the crisis, MSF engaged with the outbreak without the full support of other aid organizations that could better sustain their mission. This resulted in MSF overextending their capability to adequately address the immense scale of the outbreak. They then called on other international aid organizations to support them, assuming their readiness, funding, and competency. Though MSF promotes and observes neutrality and impartiality, they called on other governments to play active roles in addressing the outbreak, calling into question the practicality of a core principle of their charter. Overall, their ‘urge to help’ was marked by a desire to save as many people as they could, a desire that was not proportional with their actual capacity to do so.
G: From the University of Oklahoma Honors College,
S: This is the Urge to Help Podcast. I am Shanzay Ilyas
G: And I’m Garrett Eakers. We’re both third-year Microbiology undergrads, and students in Dr. Andreana Prichard’s honors class, “Africa and the Urge to Help.” Our podcast is titled “Medical Monopoly: A Critical Investigation into the Role of Médecins Sans Frontières in the 2013-2016 Ebola Crisis.”
S: I’m going to stick to MSF because I am not French nor do I know how to speak French.
G: Same here. So, in this podcast we’re critically examining the response that MSF, an international medical aid organization otherwise known as Doctors Without Borders, had to the urge to help in the Ebola epidemic that took place in West Africa from late 2013 to 2016. MSF was one of the first to respond and was a leader in the ongoing response, but encountered issues with its own capacity to respond, coordinating a broader response, and the difficulties of remaining neutral in the context of the largest Ebola outbreak ever, all of which we’ll explore later. So to begin, since you’re a microbiology student, do you want to tell us more about what Ebola is and how it works Shanzay?
S: Why of course Garrett. According to the CDC, Ebola is a disease that is caused by the Ebola virus. The source of the virus is presumed to be bats, so the bats act as a vector in infecting primates including humans. The virus was first identified in 1976 in present day Democratic Republic of the Congo. Various small outbreaks of the disease appeared from then on, but the largest Ebola outbreak occurred from March 2014 till June 2016. The virus is housed in bodily fluids, so a person can be infected when he or she makes direct contact with infected body fluids. The interesting thing about this virus is that it sticks around long after the infected person is deceased (CDC 2018).
G: Interesting. So why is this disease so deadly?
S: Minor symptoms of the disease are conspicuous soon after the virus infects the body, so an infected person can be spreading the virus before he or she is diagnosed with Ebola. Some of the symptoms, including fever, headache, diarrhea, and vomiting, mirror those of common diseases found around West Africa like cholera and malaria, so patients in the early stages of the disease can be incorrectly diagnosed. If dehydration and blood loss from hemorrhaging is not properly taken care of, the patient has a good chance of passing away (Friedan 2014). The outbreak in 2013 had a record breaking mortality rate for the Ebola virus disease. G. do you wanna go into how the outbreak came about?
G: Sure. According to the World Health Organization, the outbreak began in Meliandou, Guinea, in December of 2013 when a baby and his family fell ill with the virus (2015). By January of 2014, several family members had died and workers at a hospital in the city of Gueckedou became infected. Once the virus reached the city, it spread rapidly. By March it was in Liberia and by May it had spread to Sierra Leone. An international epidemic was unfolding, and the international aid community took notice. In March, MSF became the first aid organization to send healthcare workers to the affected countries. It already had experience with Ebola outbreaks, and used this knowledge to be the first international responder. It was fundamental to helping control the outbreak, but a critical analysis of the organization reveals some issues that reduced their efficacy.
S: One key issue we found regarding their response was that MSF overextended their capability to address the immensity of the outbreak by not having the support of other organizations like WHO (the World Health Organization) and CDC (Centers for Disease Control). MSF has been handling Ebola outbreaks since the 1990’s, but they did so with no more than 40 beds and two medical centers (Vetter 2016). With the 2013 EVD outbreak having over 28,000 cases, MSF had to enlist all of its workers and resources. It wasn’t until 25 weeks after the first reported case when MSF declared that the disease was out of control. The organization had no problem recruiting staff members, since there were many local health care workers trained to deal with the disease. One complication the organization ran into was trying to control the spread of infections in triage stations both between the sick patients and to the staff workers. Patients came in when they developed certain symptoms, but it was to be determined whether the patient had Ebola Virus Disease or another local disease like malaria. However, the ebola treatment centers were running out of rooms, and MSF struggled to maintain the “low risk corridors to high risk areas” model that was established to control the outbreak. Poorly run triage and isolation facilities lead to extremely high rates of infection in healthcare workers. With only having dealt with small outbreaks, MSF had to greatly expand on its role in patient care and research with the limited resources available. The president of MSF, Dr. Joanne Liu, expressed her concern with MSF’s growing responsibilities by stating she does not want her organization to “spread [itself] out too thin” (Hayden 2015).
G: That’s one of the key issues in MSF’s response, spreading itself too thin. They needed the support of the international community, local governments, and other healthcare organizations in order to remain effective as their role expanded to match the expanding crisis. While this depends a lot on your point of view, we can say that MSF lapsed when they assumed the readiness and willingness of other agencies in the aid community to tackle this crisis. For example, Dr. Liu recognized the failure of the international community to act in a speech to the UN in September of 2014 (Liu 2014). In this same speech, she mentioned MSF’s own failures were due to a lack of supporting personnel and facilities, so at this time not only was the international community failing to act on their own accord, but MSF had also operated to their fullest capacity, and so without the extra support of other organizations, they were failing too. Like we mentioned, MSF has the most experience with delivering aid to communities affected by Ebola. However, because of the scale of this particular epidemic, they could not handle it alone.
S: By October of 2014, MSF had asserted that they were not supposed to replace the role of larger international organizations like the WHO, UN, and others, who should have been best able to tackle the crisis, but were slow or unprepared to act (Médecins Sans Frontières 2014). So, despite the fact that they were now embroiled deeply into an epidemic, they still operated with the self-concept that they were not leaders in international aid. They instead deferred, possibly out of realization of the limits of their own capacity, or perhaps because without broader support they were not ready to be the leaders. Maybe more of their rallying efforts and rhetoric should have focused on getting the international community to support their mission, since the community was slow and unprepared to act. They were at the vanguard of the response, and while we understand they are not a huge, multinational organization like the WHO, they were the de facto leaders of the aid community’s response.
G: By May of 2015, deep into the crisis and over a year after the index case, MSF’s rhetoric and criticism of the international aid community had taken on a more direct and dire tone. In a report that directly challenged WHO, they wrote that quote “Instead of limiting its role to providing advisory support to the national authorities for months, the WHO should have r ecognized much earlier that this outbreak required more hands-on deployment” unquote. (Médecins Sans Frontières 2015).
They also said in this report that, quote:
The WHO is internationally mandated to lead on global health emergencies and possesses the know-how to bring Ebola under control, as does the US Centers for Disease Control (CDC) with its laboratory and epidemiological expertise. However, both WHO in the African Region (WHO AFRO) and its Geneva headquarters did not identify early on the need for more staff to do the hands-on work, nor did it mobilize additional human resources and invest early enough in training more personnel. unquote.
In another speech in that month, Dr. Joanne Liu went on to link the lack of WHO response to a lack of pressure and support from UN member states, and moreover concluded that without the UN members supporting the WHO, the WHO would not in turn be able to effectively respond to the crisis (Médecins Sans Frontières 2015). So here, we see that they began to expand their rhetoric and criticism to include the broader international community, something they surely should have done earlier. If they did so from the moment they needed support, maybe that would have drawn a more immediate response from the rest of the aid community.
S: Of course, these are all faults of the international aid community, but the conclusion we need to draw here is that greater awareness of the unpreparedness of the international community could have informed MSF’s early actions. In 2015, a panel selected to review the response of the WHO to the Ebola crisis concluded that it lacked the risk-taking culture needed to conduct decisive responses to epidemics like these, and moreover found its leadership was reluctant to act even though its own operational staff recognized the necessity of decisive early action (Sifferlin 2015). If MSF had greater knowledge of the WHO’s operational tendencies at the beginning of the crisis, it could have applied pressure to the right bodies to elicit a better supporting response.
G: One of the most salient points of criticism of MSF’s Ebola response has to do with their reluctance to ask for military intervention. Militaries can provide the logistical support needed to maintain sustained health campaigns by providing transportation, hospitals, and staff. However, because MSF maintains a strictly neutral, non-politicized or militarized stance, they neglected to call on militaries from the affected countries or international bodies until September of 2014, and even then did so through less formal appeals (Hussain 2014). There are very good reasons to remain neutral, like those that author Sisonke Msimang brought up in her article titled “‘There is no Ebola here’: What Liberia teaches us about the failures of aid,” which is a very good read that deals with the issues of dependency on external aid in West African nations. Nonetheless, a well-equipped military could have helped sustain MSF’s efforts better than the inactive international aid community, and would have provided the urgent response needed in the midst of the ongoing crisis. Like we mentioned earlier, MSF lacked the material capacity to sustain a campaign large enough to effectively tackle the crisis in all its locations, so they had an obvious need for logistical support. They also called on the international community to pressure the who into action fairly late into the crisis as well, so again we see that their neutrality wasn’t really an advantage here. It would’ve been helpful to break with their tradition of neutrality earlier on.
S: MSF and the international community dealt with an EVD epidemic on a scale that was much larger than any of the previous outbreaks. With its expertise on previous smaller ebola outbreaks, MSF stepped in and took leadership in handling the local patient populations. When resources were starting to run out and the extent of the outbreak was getting out of control, MSF’s call for help to the international aid community fell short. Many organizations, including WHO and the CDC, were condemned for their inability to respond to the outbreak in an appropriate and timely manner. Despite the conflicts and issues that emerged, the outbreak was a big learning moment for the world. Local governments and international organizations have implemented new protocols and practices to prevent and prepare for future outbreaks. Liberia, the country with the most Ebola cases, created a task force that oversees Ebola-related undertakings. With help from the CDC, the country is working on constituting incident management system principles (Pillai 2014). With the local government and the CDC working together, Liberia will be more informed about the state of health in its communities. Meanwhile, the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine created the Independent Panel which set up a roadmap on how to prevent and respond to future major disease outbreaks (Moon 2015). This roadmap will be the first of its kind to deal with potential threats of epidemics of any disease that arises. At the 2015 World Health Assembly, WHO shared its goals to strengthen international organizations’ “global health security and emergency response capacities” (Kamradt-Scott 2015). WHO’s proactive and cooperative mindset will be vital to create an international coalition against any future outbreaks that threaten to arise.
G: So that concludes our podcast, “Medical Monopoly: A Critical Investigation into the Role of Médecins Sans Frontières in the 2013-2016 Ebola Crisis.” The podcast was written by us, Garrett Eakers…
S: …And Shanzay Ilyas. We also edited the podcast with the input of Dr. Prichard, and Garrett did the recording and mixing. Make sure you check out the other podcasts and articles on the website TheUrgeToHelp.com since you’re already here. Otherwise, thank you so much for listening in.
This post may have been edited by admin for clarity and length.
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