One-year Ebola reviews by MSF, Oxfam cite early missteps

Now that a year has passed since the Ebola virus was identified as the cause of a mysterious disease outbreak in Guinea, Doctors without Borders (MSF) and other groups are taking their first looks back at what went wrong and what they could have done differently.

In a 22-page MSF report today, based on interviews with dozens of staffers involved in the Ebola response, the group said the World Health Organization (WHO) and other global health groups were slow to respond. However, it noted that the governments of Guinea and Sierra Leone were initially reluctant to recognize the outbreak's severity, which hampered the early response.

In a separate statement marking the 1-year anniversary, Oxfam said government and aid groups—including itself—should have spent more time on community engagement earlier in the outbreak, a move that could have saved lives.

MSF also put its own actions under the microscope, saying that its hemorrhagic fever expertise was centralized to a small group of experts and that it should have mobilized resources earlier.

Today's report comes on the heels of a Mar 20 Associated Press (AP) analysis of WHO internal documents, which suggested that political and other considerations delayed the declaration of a public health emergency, a step that might have prompted an earlier global response. In a separate report from Voice of America (VOA) on Mar 20, WHO Ebola spokeswoman Margaret Harris said assertions in the AP story are wrong, and that the spread of the virus outside the three countries to Nigeria was what triggered the emergency declaration.

Failures came from multiple groups

Joanne Liu, MD, MSF's international president, said in a statement today, "The Ebola epidemic proved to be an exceptional event that exposed the reality of how inefficient and slow health and aid systems are to respond to emergencies."

MSF's general director, Christopher Stokes, said the Ebola outbreak has often been described as a "perfect storm": an epidemic of a new disease in countries with porous borders that have weak health systems. "Yet this is too convenient an explanation," he said in the MSF statement. "For Ebola to spiral this far out of control required many institutions to fail. And they did, with tragic and avoidable consequences."

In its report, MSF said the slow global response to the outbreak could have been the result of fear, lack of political will, lack of expertise, or a combination of all three. MSF said it is still involved in addressing the outbreak and that it's difficult to draw definite conclusions without the needed distance to do a thorough review. It underscored that today's report is an initial 1-year lookback that will be followed by more in-depth reviews.

On Mar 31, about 10 days after the first virus confirmation in Guinea, MSF announced that the outbreak was unprecedented, due to its geographic spread. It said some groups, including the WHO, doubted MSF's assessment as alarmist.

As the virus smoldered undetected during April and most of May in Sierra Leone, then started actively spreading in several locations in all three countries in June, MSF said it focused on damage control and running its Ebola treatment centers and wasn't able to use containment tactics that have been used before to stop Ebola, such as contact tracing. When it sounded the alarm again in late June that the epidemic was out of control and that help was needed, MSF said it was again accused of being alarmist by members of the WHO in Guinea and Sierra Leone.

MSF said governmental reluctance to recognize the severity of the outbreak isn't unusual during outbreaks, but that it obstructed the early response to Ebola, with Sierra Leone's government initially pressuring the WHO to report only lab-confirmed deaths in June, minimizing the death toll.

Though Liberia was more transparent about the spread of cases, the country's own people accused the government of scaremongering, and few outside of Liberia responded to the country's pleas for help.

As for the WHO, the MSF said that though the agency is well poised to provide technical guidance, it lacks the human resources and emergency preparedness to make a full-fledged response to emergencies and outbreaks.

Stokes said in the report that clear direction and leadership were needed earlier in the outbreak when the virus' spread was becoming clear. "The WHO should have been fighting the virus, not MSF," he said. The group added that the WHO should have recognized much earlier that the outbreak warranted a more hands-on deployment, because elements that led to the outbreak's resurgence in June were already in place in March.

MSF said the world seemed to gain the political will to more fully battle the outbreak after foreign healthcare workers were infected and the first cases were detected outside West Africa. Liu said in the report, "When Ebola became an international security threat, and no longer a humanitarian crisis affecting a handful of poor countries in West Africa, finally the world began to wake up."

MSF scrutinizes its own actions

Unlike natural disasters that typically prompt an early and generous response from aid groups, fear of Ebola and lack of expertise in treating it paralyzed most aid groups and donors, MSF said. It added that there was some initial reluctance in some parts of MSF to respond immediately, mainly because of centralization of its Ebola expertise within an expert group.

"MSF should have been faster at mobilizing the full capacity of the organization to respond to the outbreak," it said.

In early September, MSF said, the specter of turning away patients from hospital gates pushed it into the uncomfortable position of asking for countries to send any civilian or military assets they had for containing biohazard threats. Though the support from military and other groups was helpful, the countries still lacked trained staff who could safely care for patients.

In the months ahead, MSF said it will be further examining its own response, including whether it should have adapted its strategy by, for example, doing more to address public mistrust in Guinea or pushing more forcefully in Sierra Leone at the beginning of the outbreak.

Outbreak persists

Despite recent improvements in Liberia and Sierra Leone, MSF had a sobering assessment of where things stand currently with the Ebola outbreak. It said the number of cases reported weekly from the region is still higher than in any previous outbreak and that overall case numbers haven't significantly dropped since the end of January.

It warned that Ebola cases are rising in Guinea again and that in Sierra Leone, infections are still being detected in people who aren't on known contact lists. MSF also pointed out that a new case was detected on Mar 20 in Liberia, its first in more than 2 weeks after the last case-patient's discharge.

Oxfam: Community engagement lapses hobbled response

An early emphasis on the medical approach to managing the outbreak hobbled progress against the disease in West Africa, Oxfam said in its statement today. Though beds, medical workers, and medicines are all vital, they were never going to be enough to tackle the outbreak. It added that treatment and disease prevention were equally needed and should work hand in hand.

Sue Turrell, who lead's Oxfam's outbreak response, said in the statement that progress seen in West Africa wouldn't have happened without remarkably brave medical efforts. "But what has happened in the hearts and homes of people at risk of Ebola has been equally crucial," she added.

The tide began to turn against the virus once people understood what they needed to do to stay safe and got help with things they knew would work, Turrell said. "If a greater emphasis in community engagement had happened much earlier it is more than likely that many fewer lives would have been lost."

Because of the outbreak's unprecedented scope, it's not surprising that responders learned as the situation evolved, she said, noting that early on Oxfam struggled with balancing the need to protect staff and deliver what people needed.

Ebola deeply affected the intimate aspects of everyday life in the outbreak region, from how people treat their families and neighbors to how they bury their dead, Oxfam said, adding that a compassionate approach is needed to persuade people to change how they handle intimate issues and understand the disease. It added that key tools for battling the virus—such as contact tracing and safe burials—aren't possible without community engagement and "buy in."

Case numbers keep climbing

In its latest update on the outbreak region's Ebola case totals, the WHO said today that the number of confirmed, probable, and suspected cases has risen to 24,842, with the number of deaths rising to 10,299.

The numbers include data from Guinea and Sierra Leone as of Mar 21 and Liberia as of Mar 20. They reflect an increase of 89 cases and 83 deaths since the WHO's late update on Mar 20.

See also:

Mar 23 MSF press release

Mar 23 MSF report

Mar 20 VOA report

Mar 20 CIDRAP News story "Documents shed new light on WHO's slow Ebola response"

Mar 23 Oxfam press release

Mar 23 WHO update

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