Sunday, March 29, 2015

The MSF Report: What Went Wrong – A Timeline

The Médecins Sans Frontières report, issued this week, gives us an insight in to the early stages of the Ebola outbreak. As the organisation that first flagged the scale of the Ebola health crisis, the MSF is in a strong position to critique the international and domestic response from the outset. The MSF acknowledges, “it is difficult to draw definitive conclusions whilst lacking the necessary distance for a thorough critical review. Here [they] put forward initial reflections on the past year”, however, the report does not pull any punches; it is firm and critical of those parties it perceives not to have responded quickly enough, in some cases itself included.

I have reviewed the 20 page document and summarised the findings in to the four main areas of interest in this report: what went wrong at the beginning; what must we do to eradicate Ebola; what will be the lasting impact of Ebola on West Africa; and what are the lessons learned for the future?

The report begins with an emotive reminder of the risks that healthcare staffhave faced during the fighting of the outbreak:

“The vulnerability of medical staff to Ebola is a double tragedy – the virus takes the lives of the very people meant to tackle it. Nearly 500 healthcare workers have died of Ebola in Guinea, Liberia and Sierra Leone to date.”

What mistakes were made at the beginning?

Denial of Facts by the WHO

Having investigated the ‘mysterious disease’ reported by the Ministry of Health in Guinea on the 14th March 2014, the MSF’s predictions of Ebola were confirmed by laboratory tests in Europe on the 21st of the same month. At this point the Ministry of Health in Guinea declared an Ebola outbreak in the country.

The detective work of the MSF epidemiologists revealed that contact had been made between the early victims of Ebola with family members, both within Guinea and in neighbouring Sierra Leone and Liberia. The scope of the outbreak was therefore potentially much larger, and unconfirmed cases were coming in from over the borders.

“It was dawning on us that the spread of the outbreak was something we’d never seen before. Just days after we arrived, an alert came in of suspected cases over the border in Foya, Liberia,” says Marie Christine Ferir, MSF emergency coordinator. “Then it went from bad to worse – a confirmed case showed up 650 km away from Guéckédou in Guinea’s capital, Conakry.”

On 31st March, MSF publicly declared the outbreak as ‘unprecedented’ due to the geographic spread of the cases. What now seems obvious was, at the time, considered exaggerated and alarmist by many. On 1st April, the World Health Organization (WHO), via its chief spokesperson in Geneva, was the first to call into question MSF’s declaration, objecting that the virus dynamics were not unlike those of past outbreaks, nor was the outbreak unprecedented. This was the first major mistake in the international response to the Ebola outbreak.

Undiscovered Outbreak in Sierra Leone

There was concern within MSF all along about the puzzling absence of confirmed cases over the border in Sierra Leone. From the onset of the epidemic, the US biotechnology company Metabiota and Tulane University, partners of Sierra Leone’s Kenema hospital, had the lead in supporting Sierra Leone’s Ministry of Health in investigating suspected cases. Their investigations came back Ebola negative, while their on-going surveillance activities seem to have missed the cases of Ebola that had emerged in the country.

In mid and late March, Ebola cases in Guinea were discovered that were reportedly coming from Sierra Leone. MSF immediately sent these alerts to the Ministry of Health and the WHO in Freetown to be followed up locally.

Then, on 26th May, the first confirmed case was declared in Sierra Leone and the Ministry of Health called on MSF to intervene.

Lack of Transparency and Information within Sierra Leone

After 26th May MSF’s priority became setting up an Ebola management centre in Kailahun, the epicentre at that time in Sierra Leone. With MSF’s teams already spread thin, and due to the high number of cases, MSF lacked the capacity to simultaneously manage essential outreach activities such as awareness raising and surveillance.

“When we set up operations in Kailahun, we realised we were already too late… The Ministry of Health and the partners of Kenema hospital refused to share data or lists of contacts with us, so we were working in the dark while cases just kept coming in.”

Lack of acknowledgement by the world

In late June, MSF teams counted that the virus was actively transmitting in more than 60 locations in Guinea, Liberia and Sierra Leone. Facing an exceptionally aggressive epidemic and unable to do everything, MSF teams focused on damage control and prioritised the majority of resources on running Ebola management centres. Critically, it was not possible to roll out the full range of containment activities in all locations.

“We raised the alarm publicly again on 21 June, declaring that the epidemic was out of control and that we could not respond to the large number of new cases and locations alone,” recalls Dr Bart Janssens, MSF director of operations. “We called for qualified medical staff to be deployed, for trainings to be organised, and for contact tracing and awareness-raising activities to be stepped up. But effectively none of these things followed our appeal for help. It was like shouting into a desert.”

Although the writing was on the wall, again MSF was accused of alarmism. Dr Janssens recalls, “In the end, we did not know what words to use that would make the world wake up and realise how out of control the outbreak had truly become.”

Political Reluctance

The governments of Guinea and Sierra Leone were initially very reluctant to recognise the severity of the outbreak, which obstructed the early response. This is far from unusual in outbreaks of Ebola – or indeed other dangerous infectious diseases; there is often little appetite to immediately sound the alarm for fear of causing public panic, disrupting the functioning of the country and driving away visitors and investors.

On 10th May, Guinean media reported the president of Guinea complaining that MSF was spreading panic in order to raise funds. In Sierra Leone, the government instructed the WHO to report only laboratory-confirmed deaths in June, reducing the death toll count in the country by excluding probable and suspected cases.

A Vacuum of Leadership

The WHO plays a leading role in protecting international public health, and it is well known that its expertise lies in its normative work and technical advice to countries worldwide.

There was little sharing of information between countries, with officials relying on the WHO to act as liaison between them. It was not until July that new leadership was brought into the WHO country offices and a regional operations centre was established in Conakry to oversee technical and operational support to the affected countries.

“When it became clear early on that it was not simply the number of cases that was creating concern, but indeed the epidemic’s spread, clear direction was needed and leadership should have been taken,” says Christopher Stokes, MSF general director. “The WHO should have been fighting the virus, not MSF.”

Lack of expertise

Given that Ebola outbreaks in the past occurred on a much smaller scale, the number of people with experience of the disease was limited within MSF; there were simply not enough experts worldwide to stem the tide of this epidemic

Exhausted national health workers bravely and tirelessly stepped up and continued to tackle the outbreak each day, while facing stigma and fear in their own communities. Some MSF locally-hired staff were abandoned by their partners, ejected from their homes, their children ostracised by playmates. Their dedication and extraordinary hard work over the past year is parallel to none.

Lack of Leadership in WHO

“I finished my presentation at the Global Alert and Outbreak Response Network (GOARN) meeting by saying that I was receiving nearly daily phone calls from the Ministry of Health in Liberia asking for support, and that MSF had no more experienced staff I could send to them,” recalls Marie-Christine Ferir.

“I remember emphasising that we had the chance to halt the epidemic in Liberia if help was sent now. It was early in the outbreak and there was still time. The call for help was heard but no action was taken.

Meetings happened. Action didn’t,” says Ferir.

Lack of Capacity

By the end of August MSF’s treatment centre in Monrovia, ELWA 3, the biggest in the world, could only be opened for 30 minutes each morning. Only a few patients could be admitted to fill beds made empty by those who had died overnight. People were dying on the gravel outside the gates. One father brought his daughter in the boot of his car, begging MSF to take her in so as to not infect his other children at home. He was turned away.

“We had to make the horrendous decision of who we could let into the centre,” says Rosa Crestani. “We had two choices – let those in who were earlier in the disease, or take in those were who dying and the most infectious. We went for a balance. We would take in the most we safely could and the sickest. But we kept our limits too –we refused to put more than one person in each bed. We could only offer very basic palliative care and there were so many patients and so few staff that the staff had on average only one minute per patient. It was an indescribable horror.”

In Summary

Global failures have been brutally exposed in this epidemic and thousands of people have paid for it with their lives. The world is more interconnected today than ever before and world leaders cannot turn their backs on health crises in the hope that they remain confined to poor countries far away. It is to everyone’s benefit that lessons be learned from this outbreak, from the weakness of health systems in developing countries, to the paralysis and sluggishness of international aid.

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