Ending the Ebola Crisis: The View From Inside Doctors Without Borders

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May 5, 2015

In the summer of 2014, when it seemed the world was responding too slowly to the Ebola outbreak in West Africa, Dr. Joanne Liu tried to sound the alarm.

As international president of Doctors Without Borders — known by its French acronym MSF — Liu had helped mobilize aid workers to the three nations at the center of the outbreak: Guinea, Liberia and Sierra Leone. But as a non-governmental organization, MSF could only help so much, Liu says. Hundreds were already dead. Many more were infected and the crisis showed no signs of slowing down. The world needed to do more.

In the below interview with FRONTLINE filmmaker Dan Edge, Liu talks about her efforts to add urgency to the international response, particularly inside the World Health Organization. She began by discussing a summer of 2014 meeting with the WHO’s director-general, Dr. Margaret Chan, during which she urged the WHO to “step up to the plate” and declare the crisis an international health emergency.

This is the edited transcript of an interview conducted on Jan. 29, 2015.

What was the situation in July that precipitated you getting involved directly?

The situation in July was clearly not under control in terms of the Ebola epidemic, and we really were facing the difficult situation of knowing there were a lot of cases of Ebola-infected patients and not being able to respond to it. And the only way to attend to this specific problem was to have a massive increase of aid coming into the affected countries, and this was, shall we say, the key motivation to go and meet the head of the WHO.

… So tell me about the meeting with Dr. Chan.

“I just said, ‘I’ve been telling the world for the last few months that it’s an unprecedented, out-of-control Ebola epidemic. … People don’t listen to me, but you, as the head of the WHO, you need to step up to the plate and declare it because you have the authority and you have the legitimacy.'”

The meeting was really something interesting, in the sense that when we called for a meeting, we promptly got a positive answer to meet with Dr. Chan. I think for us it was a signal to say “Oh, that meeting belongs to our priority list.” And then when we met her, it was a bit of a tense meeting, but a cordial meeting. But it was to push the WHO — and I think they were getting there to a certain extent — to just tell them, listen, an immense, out-of-control Ebola epidemic is happening. …

And so when we met her, I just said: “I’ve been telling the world for the last few months that it’s an unprecedented, out-of-control Ebola epidemic. I don’t have the authority, and I don’t have the legitimacy to call it like this to an extent. People don’t listen to me, but you, as the head of the WHO, you need to step up to the plate and declare it because you have the authority and you have the legitimacy.”

You needed more from them than just an acknowledgement that this was out of control though, didn’t you? I mean, the countries needed help.

Yes. So what happened then is a few days after we met, she decided to go to the meeting with the three presidents — and this was covered by the media — and then on Aug. 8, she declared a public health emergency of international concern. And first it was good. It’s an acknowledgement by WHO that it is a priority, a worldwide public emergency.

On the other hand, we know that statesmen don’t save lives, so it needed to translate into action, and that’s what we were waiting for afterwards.

When you put it to Dr. Chan that the WHO needed to step up to the plate, what did she say in that meeting?

Well Dr. Chan — I remember her words and I remember vividly the exchange — because I said, “Dr. Chan, this is an epidemic out of control.” And she looked at me and she said: “Dr. Liu, I don’t want to be as pessimistic as you. It is not out of control. I wouldn’t word it this way.” I just said: “Dr. Chan, I’m not pessimistic. I’m just realistic.” That was our conversation.

And did she talk about the limitations of what the WHO could do? Because we found time and time again, prior to the declaration of a public health emergency, that local WHO officials were telling [people] in the field: “Look, we’re here to give advice to local governments. That’s what we do. We’re an advisory thing. We don’t have doctors. We don’t have an army of health workers who can come out and save lives. That’s not what WHO is.”

Yes, absolutely. … She told me, “Joanne, we are a normative organization and we bring technical support to the states.” And this is where I replied to her: “I may understand that, but regardless, you are today the only person who has the authority and the legitimacy to tell the rest of the world that it’s not business as usual, there is a public health emergency of international concern. I don’t.”

… Two or three weeks after your meeting with Dr. Chan, you’ve been to the region, you’ve seen it getting worse, and still towards the end of August there is nothing new actually happening from the WHO. So what do you do?

When I came back in mid-August from my visit, we went into what I call a “world tour” to tell the world what was going on in West Africa. We briefed many states, basically all the states that I thought would have capacity to intervene, either because they have experience with biological threats or disaster; because they have some of the logistic assets; because they in the past have dealt themselves with highly contagious disease like hemorrhagic fever. So we appealed to some of the big nations like the United States, Russia and Cuba, because we knew of their response in the cholera outbreak in Haiti in the past, but others as well. States from the European Union, the African Union and all the U.N. agencies. So that’s what we did for two weeks, intensively, and anyone who wanted to interview us, we gave an interview.

Did you feel at the time that people were starting to listen? Because it was still a race against time.

“All of a sudden, this deadly disease in a remote country in Africa was knocking at our doors in the Western world and we just couldn’t ignore it.”

I think people started to listen. … But I think what we have to remember is what happened back [when] the first infected Western humanitarian worker [was] repatriated in the states. As far as I’m concerned, he was contributing as a wake-up call, because all of a sudden, this deadly disease in a remote country in Africa was knocking at our doors in the Western world and we just couldn’t ignore it.

We’ve told the world. Chan said it as well, because she’s labeled Ebola as a public health emergency of international concern, but that was not enough. It was enough when it came in your doorstep and just said, by the way, that’s your neighbor who got it today.

There’s a certain irony in that — and also it cut both ways because there was a lot of hysterical debate in the U.K. where I’m from and in the U.S. which said, we need to basically shut these countries off, you know, close off Liberia and Sierra Leone and Guinea in order to stop the virus coming to the Western world. Did you ever have to make the case that rather than quarantining these countries, we needed to flood them with people, flood them with aid, with help, with medical work?

Surely. I think one of our key messages when I did my U.N. address on Sept. 2 … was we just cannot shut down those countries from the rest of the world. That the only way to control and contain this epidemic is to fight it at its origin. Basically the fire will not extinguish itself on its own, but I was saying we need to run into the burning building. That was my remark. And so I always tell people that it’s not by barricading yourself in your country from hypothetical cases that can come in your country that will make a difference. But where we contain the epidemic is by increasing massively the aid in affected countries. …

Shortly after your speech, at the U.N. at the beginning of September, the United States pledged some pretty small help actually, I think it was a 25-bed treatment center. What was your response to that?

Well, it was actually a huge disappointment back then, and we voiced our disappointment. But in addition we continued talking to Washington, saying you have to pledge much more than that and you need to take leadership. …

… So do you have a sense of what changed between what they initially offered — 25 beds — and what they later offered — 3,000 people and a lot more beds? …

Well there was different things, absolutely. It’s not only us, but as well some from [the Centers for Disease Control and Prevention] went to West Africa only a few days after me and as well made a press conference. … At that time the chain of transmission was exponentially increasing and every three weeks the number of cases were doubling — and these were conservative figures.

…It was in the interests of the [U.N.] states, not particularly United States, but states in general, to contribute to the response.

… At this early stage, there’s a probably a limited amount of collective learning we can do, but what are the big lessons for you? What are the big lessons and what needs to change before this happens again?

I think we’ve said it on several occasions. If we look at the macro level is the fact that with a public health emergency of that magnitude occurring in countries where they have weak medical infrastructure, we are going to need to develop international mechanisms to bring support to them, but not in terms only of technical [expertise], but hands-on operational support, and so that we have to learn from.

… Are you optimistic about the international community’s ability to learn from events like this?

I think we learn with difficulty. Especially in those kind of environments, because when it’s a world emergency, everybody is responsible and nobody’s responsible. … What might be the difference with Ebola is people were really scared, and when you think of human nature, fear somehow sticks and holds. So people might remember, and that might be the difference for wanting to build the capacity to respond.

“I think we learn with difficulty. Especially in those kind of environments because when it’s a world emergency, everybody is responsible and nobody’s responsible.”

I was listening to Jim Yong Kim, the person in charge of the World Bank, who just made a statement yesterday or a few days ago and said, “Well Ebola has been a big emergency and what we need now is a lot of smoke detectors for the next time around.” And I thought it was interesting that he said that, that we need a lot of smoke detectors. And I’m like well, you may need a lot of smoke detectors, but we’re going to need the firemen who will want to go and run into the fire. That’s what it means in terms of needs. It’s not only having the tools to detect, and the surveillance, but the courage to go and run into the burning building. And this is something that you cannot build ahead of time. You don’t build courage ahead of time. … And this why I think it’s very difficult to find out if next time around we’re going to do better.

… You can’t build that specific courage in advance, but you can build the capacity and the organization in advance. Are you saying there needs to be a sort of internationally mandated organization which is ready to respond? Because that sounds a bit like MSF.

No, I don’t think you just can put people on the starting block and then wait … for the next Ebola-like epidemic. I think that you need somehow a small-capacity response who’s going to run the first few kilometers of the marathon. But after that you need to build somehow mechanisms that you will not have to argue what will happen, who’s going to go and step up to the plate. And then you need to have this game plan ahead of time, and say, well the state will not need to somehow have the feeling that you are stalking money from people to go and respond to it, but they will have easily releasable amount of money and releasable workforce and knowhow into the field.

And this is the kind of commitment we need but I think somehow it would be a bit ridiculous to build something that we don’t know when it’s going to come around, if it’s in two months, six years, 10 years. But our feeling is it’s going come around again.

… You had the desire to pull out at one point.

At one point we almost wondered should we come with the threat to the rest of the world that if you don’t step in, we are going to pull out. Because what our teams were facing in the field, and I know you’ve talked to many of our colleagues, was humanely unacceptable for national and international staff. I had people coming in tears telling me: “I’ve never thought that there would be a morgue that was not big enough for all the bodies, and I’m piling up the bodies outside the morgue. I never thought that somehow I will have to turn back patients from my center.” …

I’d been in so many field assignments throughout my lifetime with MSF, in the worst war zones, and I’ve never seen so many death that I’ve seen when I was in West Africa. And that will leave a mark. …


Jason M. Breslow

Jason M. Breslow, Digital Editor

Twitter:

@jbrezlow

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