REPORT Pushed to the Limit and Beyond A year into the largest ever Ebola outbreak Content This year thousands of health workers have risked their lives 5 Sounding the alarm to support patients and help control the Ebola outbreak, 8 Global coalition of while facing stigma and fear in their own communities. The inaction vulnerability of medical staff to Ebola is a double tragedy – the virus takes the lives of the very people meant to tackle it. Nearly 13 Last hope to control 500 healthcare workers have died of Ebola in Guinea, Liberia and the outbreak Sierra Leone to date. 16 Doctors without a cure… but with care This report is dedicated to them and to our 14 MSF colleagues who have lost their lives in Guinea, Sierra Leone and Liberia 20 Looking to the future during this epidemic. They are sorely missed and our deepest 22 Map of the region sympathies remain with their families and friends. 8,351 people admitted into MSF Ebola Since the start of the outbreak in West Africa, MSF has set In 2014, MSF spent €59,054,680 on its Ebola up 15 Ebola management and transit* centres management centres. response * Transit centres are short-stay centres for people to await The remaining €789,668 was spent responding in blood test results. If the test comes back negative, they Mali, Nigeria and Senegal will be discharged. If positive, they will be transferred to an Ebola management centre. COVER PICTURE An MSF health worker in protective clothing carries a child suspected of having Ebola in the MSF treatment centre in Monrovia, Liberia on 5 October 2014. © John Moore/Getty Images |2 Introduction We are now a year into the deadliest Ebola outbreak the world decline in cases, yet the country will has ever seen, with at least 24,000 people infected and more than remain at risk while Ebola lives on in 10,000 deaths. Ebola has destroyed lives and families, left deep neighbouring Guinea and Sierra Leone. scars, and ripped at the social and economic fabric of Guinea, Liberia and Sierra Leone. A significant challenge remains ahead of us. To declare an end to the out- The virus cut a vast swathe through the months were wasted and lives were break, we must identify every last case, three countries, in a cross-border geo- lost. No one knows the true number of requiring a level of meticulous preci- graphical spread never seen before. deaths the epidemic will have ultimately sion that is practically unique in med- Fear and panic set in, the sick and their caused: the resulting collapse of health ical humanitarian interventions in the families were desperate, and national services means that untreated malaria, field. There is no room for mistakes or health workers and MSF teams were complicated deliveries and car crashes complacency; the number of new cases overwhelmed and exhausted. Medical will have multiplied the direct Ebola weekly is still higher than in any pre- workers are not trained to deal with at deaths many times over. vious outbreak. Success in reducing the least 50 percent of their patients dying number of cases in one location can be from a disease for which no treatments A year later, the atmosphere of fear and swiftly ruined by an unexpected flare-up exist. Nevertheless, the world at first the level of misinformation still circu- in an unforeseen area. ignored the calls for help and then lating continue to hamper the ability belatedly decided to act. Meanwhile, to halt the virus. In Sierra Leone, hot- Many questions, few simple spots persist, while in Guinea health answers MSF Ebola management centre, Kailahun, workers come under violent attack due A year into the outbreak, many ques- Sierra Leone. A medical team gets ready to to ongoing mistrust and fear. Encour- tions abound. How did the epidemic enter the high-risk zone. agingly, Liberia has seen the sharpest spiral so spectacularly out of control? © Sylvain Cherkaoui/Cosmos Sylvain © 3| Why was the world so slow to wake up to its severity and respond? Was it due to fear, lack of political will, lack of exper- A SADLY UNIQUE YEAR tise, or a perfect storm of all three? Did While MSF has helped to control Ebola outbreaks in nine MSF make the right choices? How could MSF have done more and saved more countries over the past 20 years, the epidemic that has raged in lives? What have we learned from this west Africa proved uniquely catastrophic. In the past year, MSF outbreak and what must be done differ- has been pushed to the limits and beyond, launching a response ently in future? There are many ques- marked by many firsts for the organisation, many of them tragic tions and few simple answers. beyond words. MSF teams are still absorbed in tack- The first time we: ling the ongoing outbreak, and it is dif- ficult to draw definitive conclusions ∙ Lost so many patients to Ebola, ∙ Shipped in and set up incinerators whilst lacking the necessary distance 2,547 of our patients have died, a to cremate bodies, as happened for a thorough critical review. Here we catastrophically high number that in Monrovia when the national put forward initial reflections on the shocked MSF teams – even in most burial teams could not cope with the past year, describing key moments and warzones, losing so many patients number of dead. challenges from the perspective of MSF in such a short time is unheard of. staff. More in-depth reviews will cer- ∙ Distributed approximately 70,000 tainly follow. ∙ Had MSF colleagues fall sick with home protection and disinfection Ebola, 28 of whom became infected kits for 600,000 people in Monrovia. This paper is based on interviews with and 14 tragically passed away. dozens of our staff who give a snap- ∙ Distributed antimalarial drugs shot of the reality for MSF over the past ∙ Turned Ebola patients away, as to more than 650,000 people in year, both on the ground and in head- happened at our overwhelmed facil- Monrovia and 1.8 million people in quarters. We have been tested, pushed ity in Monrovia. Freetown. beyond our limits, and made our share of mistakes. ∙ Responded to viral haemorrhagic ∙ Constructed a specialised materni- fever on such a large scale in ty unit to care for pregnant women What also clearly emerges is that no multiple countries simultaneously with Ebola. one was prepared for the nightmarish – Ebola in Guinea, Sierra Leone, spread and magnitude of this epi- Liberia, Nigeria, Mali, Senegal, in ∙ Embarked on MSF’s largest knowl- demic. The Ebola outbreak proved to addition to an unrelated Ebola edge transfer effort, with more be an exceptional event that exposed outbreak in Democratic Republic of than 800 MSF staff trained on safe the reality of how inefficient and slow Congo and Marburg in Uganda. Ebola management in headquarters, health and aid systems are to respond as well as 250 people from other to emergencies. ‘Business as usual’ ∙ Mobilised against an Ebola organisations such as the World was exposed on the world stage, with epidemic spread over such a vast Health Organization, the US Center the loss of thousands of lives. What will geographic area, and in densely for Disease Control, International we have learned from these mistakes? populated urban centres. Medical Corps, GOAL, Save the Chil- dren, French Red Cross and others. ∙ Diverted human resources from Hundreds more were trained on-site other MSF emergency projects on in the affected countries. such a scale. International and national staff reassigned from ∙ Began clinical trials of experimen- headquarters and other MSF tal treatments and vaccines in the projects worldwide account for 213 midst of an outbreak. departures of the more than 1,300 international staff deployed to ∙ Addressed UN member states at respond to Ebola. the UN General Assembly, as we did in September 2014, declaring ∙ Opened an Ebola management that we collectively were losing the centre with 250 beds. Prior to this battle against Ebola. epidemic, a 40-bed centre was the largest we had built to respond to a large-scale epidemic. |4 Sounding the alarm Unprecedented, out of control: a war of words ‘Mysterious disease’ even if never seen in this region before.’” virus’s spread so as to contain it. On 21 On 14 March 2014, Dr Esther Sterk in Three MSF emergency teams were March, laboratory confirmation of sam- MSF’s Geneva office was informed of deployed at once, one from Geneva, the ples sent to Europe came through late a ‘mysterious disease’ reported by the second from Brussels, both with rein- in the evening and on 22 March, the Ministry of Health in Guinea. Several forcements and supplies. The third, an Guinean Ministry of Health officially health staff taking care of the sick had MSF team based in Sierra Leone with declared the outbreak as Ebola. died and mortality was very high. Suspi- viral haemorrhagic fever experience, cious of Lassa viral haemorrhagic fever, was redirected over the border with Unprecedented spread she forwarded the report describing the some protection materials and was the The detective work of the epidemi- symptoms of the cases to Dr Michel Van first to arrive in Guéckédou, Guinea, on ologists revealed some unconnected Herp, MSF’s senior viral haemorrhagic 18 March. chains of transmission in different loca- fever epidemiologist in Brussels. tions in the Guinée forestière region, Acting on their suspicions, the team many of whom had family in neigh- “What jumped out at me from the med- immediately set up the priority activities bouring Liberia and Sierra Leone. ical report was the hiccups, a typical for an Ebola outbreak: caring for the sick symptom associated with Ebola,” recalls in Guéckédou hospital, training local “It was dawning on us that the spread of Dr Van Herp.