Ebola: Doctors Without Borders Shows How to Manage a Plague
The more serious the emergency, the more likely he’ll hear about it late on a Friday. That, at least, is what experience has taught Hugues Robert-Nicoud, a disaster response expert for Médecins Sans Frontières, also known as Doctors Without Borders, or simply MSF. On a budget of €952 million ($1.2 billion) per year, MSF runs a volunteer collective of 30,000 physicians, nurses, logisticians, and locally recruited staff that functions as an independent ambulance corps and a kind of MASH unit for those in need. So on Friday, March 14, when his cell phone displayed a Swiss country code after 10 p.m.—he was on the road in Tokyo—Robert-Nicoud braced for the worst.
For years, MSF had been running a malaria control center in Guéckédou, a city in the West African nation of Guinea, two miles from the border with Liberia. Two days earlier, the Guéckédou clinic had received a report from the Guinea Ministry of Health detailing eight unexplained deaths in the region. At first, it sounded a lot like Lassa fever, which was bad enough, though when treated aggressively with Ribavirin, a proven antiviral, Lassa is usually not fatal.
When the MSF staff set out to investigate, they soon heard from people who knew or treated the dead that they had suffered severe headaches, muscle and joint pain, bruising, and some bleeding. The visible bleeding, in particular, was troubling: That suggested Ebola, a virus without a cure that has killed between half and 90 percent of those it has infected. It’s marked, toward a victim’s end, by bloody gums and hiccups. “That was the day my life changed,” Robert-Nicoud recalled later. “When I have two specialists at MSF telling me it doesn’t look like Lassa fever, that it looks like Marburg or Ebola, I dropped my pen and thought, This is trouble.”
Ebola is rare, and MSF has helped to keep it that way. Since 1995 it’s responded to more than a dozen outbreaks of the virus, managing to limit the number of deaths in most areas to double digits. It’s done this by responding with stunning speed, isolating patients, tracing their contacts, and making the community aware of the threat.
Robert-Nicoud and his deputy immediately looped in MSF Belgium, where it has more Ebola veterans and operates a massive warehouse that supplies many of its field operations in more than 60 countries. Hours later, MSF Belgium began getting ready to ship off “Ebola kits” to Guinea—pre-prepared boxes of disinfectant, those now familiar personal protection equipment (PPE) suits and hoods—as well as medicine to treat symptoms like nausea and joint pain. It also e-mailed its most seasoned Ebola fighters, such as Marc Poncin, a 52-year-old doctor of molecular biology and a 20-year MSF veteran. Poncin led the effort to snuff out a 2010 Ebola outbreak in Uganda. He was skiing in British Columbia when he heard about Guéckédou.
“I could tell right away it could be bad, because it was near population centers, which it hadn’t been before,” Poncin says, speaking by phone from Conakry, Guinea’s capital. “Usually it’s been in remote locations, in the forest, so it’s already isolated to some extent.” All the same, with MSF’s track record, “I had the feeling that by the time I got there, it would be mostly for closing it out.” When Ebola was confirmed a week later in a lab at the Pasteur Institute in Lyon, France, MSF already had a task force assembled and people erecting tents and fencing for its first Ebola center in Guéckédou.
MSF is able to move so swiftly, in large part, because of its decentralized structure, which is more akin to a guerrilla network than a top-down corporation. They go where things are worst, often to care for civilian casualties and refugees of war. They also confront “neglected” diseases, from malaria to HIV/AIDS to drug-resistant tuberculosis. They are truly global, privately funded, and astonishingly effective, able to treat diseases others won’t touch in places few will go—and where they’re not always welcome. In parts of Guinea, that was certainly the case. Still, several weeks into the outbreak, it seemed as if MSF might have it in hand.
“To some extent, all of us felt that it might end in May,” says Dr. Pierre Rollin, an epidemiologist with the Centers for Disease Control and Prevention (CDC). Rollin arrived in Conakry on March 31. The outbreak was serious, even “unprecedented,” as MSF declared that very day. “But for most of May, we had no new cases showing up at the treatment centers in Guinea or Liberia, and it was possible to think it might have run its course,” Rollin says. “What we didn’t know—or what we knew, but failed to appreciate—was the effect of the civil wars. Violence in these countries had taught people never to trust what people in the capital have to say. So it wasn’t just that foreigners in space suits were frightening them. Or rumors that the whites were bringing this disease, although we did hear that. It’s that the people in the rural areas didn’t trust any outsiders at all, including their political leadership.”
For those quiet weeks, Rollin says, people hid their sick and dead, a period during which the government of Sierra Leone, neighbor to Guinea and Liberia, denied reports of an outbreak there. In late May, Ebola came roaring back, and by June it was out of control in all three countries. The hostility to health-care workers in the field peaked with the number of cases, too. By July, Poncin says, there were at least 20 Guinean villages MSF couldn’t safely enter to trace contacts.
It got harder to get anything done: Airlines refused to fly to the affected countries; cargo ships wouldn’t berth; expats—including many of the most capable professionals in these countries—fled. Health-care workers were among the first to die. Summer’s rainy season left unpaved roads impassable. In August people were dying in the street outside abandoned hospitals. As of Nov. 7, 13,241 have contracted Ebola in Guinea, Sierra Leone, and Liberia, with 4,950 dying, according to the World Health Organization. Most assume those figures are low.
MSF didn’t retreat. It continued sending its experienced members and began training more. Since April it’s sent more than 700 international aid workers to the epicenters of the disease and hired 3,000 West Africans. It’s tapped its reserve fund for major emergencies and has spent $143 million to stop the outbreak. The U.S. division, according to Executive Director Sophie Delaunay, has contributed $21 million to the fight and has sent 65 Americans to the region—among them Dr. Craig Spencer, New York’s first Ebola patient. Spencer cleared the virus and went home from the hospital on Nov. 11, but not all MSF staff have been as fortunate. Two dozen have fallen ill; 13 of them have died.
“We were reaching our breaking point, and we thought, surely there are countries that have civil protection forces, people who drill on chemical spills, who know evacuation and quarantine procedures, who’ve prepared for bioterror—some country will send them to us,” says Christopher Stokes, who’s coordinating MSF’s Ebola response from Brussels. He laughs at his optimism. “We have seen a few other small [nongovernmental organizations] here, but no one else came!”
Despite MSF’s appeals all summer long to the WHO, the United Nations, Unicef, and foreign governments, only in the last few weeks has the international community, led by the U.S., the U.K., France, and Cuba, begun to act in West Africa. For the last seven months the world’s first, best—and in Guinea, only—defense against Ebola has been a 43-year-old, idealistic, impatient, and often imperious group of doctors in midcareer, with a higher-than-average threshold for risk and a tendency to extend their middle finger.
MSF began, fittingly, as an act of rebellion. Established in Paris on Dec. 22, 1971, MSF’s 13 founders included physicians who’d worked for the International Committee of the Red Cross (ICRC) in Nigeria during its 1967-70 civil war. Incensed by the Nigerian government’s starving of the Igbo people, which the future MSF doctors considered an act of genocide, they wanted to speak out about it, but the ICRC told them no. Enraged by the gag order, they decided to create their own self-sufficient force of EMTs and drafted a charter of first principles. It commits all the members of MSF to “provide assistance to populations in distress, to victims of natural or man-made disasters, and to victims of armed conflict … irrespective of race, religion, creed, or political convictions.”
From the start, MSF reflected its founders’ dedication to those in need, a fierce independence, and, not least, wanderlust. “We were descendants of the ranks of the idealistic left,” Xavier Emmanuelli, one of MSF’s original 13, wrote in his 1990 book, Au Vent Du Monde. “We had as reference all the great antifascist struggles,” he wrote, “and the heroes of the Resistance” during World War II. “I wanted to become a son of adventure, the navigator of the tragic, and to face the blaze of revolution.”
As it grew, MSF opened offices in a number of European cities and, eventually, “sections” on every continent. Formally, it’s an association, with each new location proving itself in the field. It runs five “operational centers” in France, Belgium, the Netherlands, Switzerland, and Spain. Each has the authority to launch a mission, though that’s rarely done without consultation, and sometimes they disagree. This decentralized structure, Stokes and others say, is a key strength—it means MSF can function like true first responders. Following the 2010 earthquake in Haiti, he says, it took all of 30 minutes to decide they’d be going in; they had a clinic open the next afternoon.
Big, charismatic figures in the early days left MSF wary of the cult of personality. It has an international president (elected by the sections), but no chief executive officer telling people what to do or say, and a relatively flat salary structure. Delaunay, the executive director in the U.S., makes $143,000. (Gail McGovern, the CEO of the American Red Cross, makes $500,000 a year.) Its managers earn at most three or four times what junior staffers do.
“What I find interesting about them is that after 40 years they still have the effervescence of a movement,” says Renée Fox, a sociologist at the University of Pennsylvania, who spent two decades studying MSF for her book Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Médecins Sans Frontières. “They have a horror of becoming bureaucratized,” she says. “It does distinguish them.” What saves MSF from becoming paralyzed by groupthink or self-criticism, she says, is an underlying pragmatism. Everything comes back to the work in the field—all its executives have field experience—and the urgent practice of medical care.
As a place to work or volunteer, MSF combines the esprit de corps of French Legionnaires (without weapons), the self-styled intellectual posturing of a graduate seminar, and the bonhomie of backpacking the developing world. “I fell under the spell of a couple of MSF doctors while studying at Tulane,” says Dr. Darin Portnoy, 52, a Bronx family physician now working in an MSF Ebola ward in Liberia. He suggests his story is common. “They were traveling to exciting places, helping out in these difficult situations, had all these amazing stories to tell—I remember thinking, I want in on that.”
“The hardship of your first missions can create a very strong bond between yourself and the organization,” says Stokes, 44, in his Brussels office, a desk in a large room with four other cluttered drafting-table desks, no cubicles, and a round table at its center. Stokes, who grew up in Britain and France, has a narrow, square face and a steady gaze. He holds two conkers, or horse chestnuts, in his clasped hands, rubbing them together gently like a rosary or hot dice.
“First, I worked in a forgotten war. The war between Azerbaijan and Armenia in the Caucasus. I was in my twenties. And it was such a strong experience of being plunged into the unknown, the collapse of the Soviet Union in the early ’90s, and the openness and generosity of the people I encountered. It creates a kind of bond with the organization, because you’re entrusted with a high level of responsibility at a very young age, so you feel as if you owe the organization and you build a fit. You want to show them back.”
The founders of MSF also committed their movement to témoignage—bearing witness to injustice—although this wasn’t formally included in its guiding principles until later. If MSF members encountered violations of human rights, they were not, as the ICRC encouraged in Nigeria in 1970, to exercise “discretion.” They were to raise hell and make sure the world knew about it.
MSF’s twin goals of “impartiality in the name of universal medical ethics” and témoignage have always created tension. This was never clearer than in 1985, when the Ethiopian government kicked MSF out of the country after it called attention to the avoidable death of 6,000 children.
Perhaps no moment captures the group’s altruistic but ambivalent character better than when it won the Nobel Peace Prize in 1999, as a sort of lifetime achievement award. MSF convened a debate to decide if they deserved the award and what it would do to them (too Establishment, “a crisis of success”). Who should receive it? Who should give the speech? What should they do with the prize money? They called the conference “Nobel or Rebel?”
At the time, the Greek chapter of MSF had ignored the MSF consensus view that it ought not to offer humanitarian support to both sides of the Kosovo War. On the eve of the Nobel acceptance, the five operational offices of MSF excommunicated MSF Athens, cutting it off financially and telling its members to cease using the MSF logo or name in its activities. (Athens ignored this, too.) This set up the odd sight of Greek MSF staffers protesting their colleagues in Oslo as they entered the Nobel ceremony in their collective honor.
In the end, an MSF fieldworker formally accepted the prize; the outfit used the occasion to protest Russia’s bombing of Chechnya; and MSF put the $960,000 winnings toward the research and development of treatments of diseases with little commercial appeal to pharmaceutical companies.
At its Brussels warehouse, MSF is learning from Ebola and adapting rapidly. Thirty feet overhead, the warehouse rafters are lined with fluorescent lights that lend everyone a slightly zombie-ish glow. Rising to the rafters are a row of massive shelves. Below them, forklifts zip back and forth, giving the overall impression of a Home Depot for medical supplies.
On a recent Thursday, Stefaan Phlips, the supply site director, leads a brief tour of the 70,000-square-foot facility, noting that he receives feedback weekly from fieldworkers so Brussels can tweak the equipment it sends. He picks up a plastic, 5-gallon bucket and points to a hole cut in one side. “We now add a second bucket and a small spigot, for washing hands, so that the whole bucket is not contaminated with every use.”
Over the last six months, Phlips says, the supply center has been shipping three times the average volume and twice the weight of material as it did in 2013. Each PPE costs about €60. After each use, the clothing is incinerated with other medical waste. Manufacturers include DuPont for full-body suits, Dunlop for boots, and Kanam Latex Industries for gloves. For several weeks, Phlips worked on finding better goggles. MSF staff complained the ones they’d been using fogged up too easily. He tested dozens before selecting a set from Uvex Group that look like ski goggles. To save money, cheap surgical gloves are used for a tourniquet, instead of rubber tubing, when drawing blood.
Accustomed to handling 20-bed hospitals for Ebola, MSF is running 250 beds at its ELWA3 center in a suburb of Monrovia, Liberia. “It’s a huge technical HR management, security challenge, and we’ve had to do it very, very quickly,” says Delaunay, the U.S. chief. “In other circumstances, it would take years before we were comfortable putting in such a change.”
Success of the Ebola treatment rests on gaining the trust of the local people, so MSF has, for years, used hurricane fencing—that orange netting often seen at construction sites—around the isolation areas. This allows friends and family to see patients at a safe remove and to know they’re being treated well.
One of the greatest challenges of stopping the 2014 outbreak has been arranging for safe burial of the dead. Ebola remains contagious after death for a couple of days, but the funeral rites in the afflicted countries include washing the body and the laying on of hands. Phlips’s team in Brussels designed and sourced a body bag that doesn’t leak along the zipper and opens more like an envelope, making it easier to place the body in the plastic without handling it as much.
“One of the issues we have in Monrovia, for example, you have a very high water table, so as soon as you dig in Monrovia you find water,” Stokes says. “And you have a huge amount of deaths, so there’s nowhere to put people, so we’ve been cremating, and we informed the community, but there’s a lot of hostility toward us. There may be reticence now in people coming forward, because they don’t want to be cremated or for their loved ones to be cremated—it’s not in the traditions at all.”
Where MSF locates a center often meets with resistance, too—as building a prison might. “You have to sit down with the local leaders a lot, because they fear you’re bringing in Ebola, creating a magnet for the sick,” Stokes says. “It’s quite tense in the beginning. Imagine, in the U.S., if you went to a city council and said, ‘We want to open an Ebola hospital here.’ ”
One profound adaptation—and one that’s helped with community relations—is employing survivors at Ebola centers. Survivors appear to be immune to reinfection from the same strain of the virus, according to the CDC. “We’ve had a thousand survivors so far,” Stokes says. But then there’s actually a stigma in the community. “They feel rejected when they go back home. People see them as actually being a risk for them,” he says. So MSF has invited them back to care for children or to visit homes where someone may be sick to explain why they should come to the center.
All these steps have helped contain the virus, but, Stokes says, what will stop it is a vaccine. “We’re excited. In November we’re going to test three drugs at our centers. And there’s going to be a massive scale-up of care from other actors. That will help.” He pauses. “If you look at the worst-case scientific modeling, it’s horrendous, yes. And if you do have this doubling every three to four weeks, then even the isolation capacity will come too late. But the possibility of real treatment? That’s giving us hope.”
“You really ought to come to Liberia!” says Ludovic “Ludo” Levadoux, a trainee with a pitchman’s volume and a crooked smile. “Great this time of year.” Levadoux, a French logistician in his 30s, and another, slightly shorter fellow in a T-shirt and full-zip hoodie draw coffee from a Thermos and squint as a chilling mist sweeps in under the corrugated roof where they stand. A third man, cupping a hand to light a cigarette, plays along, volunteering that he likes to take his sun in Spain, but Liberia would still be a vast improvement over rainy Brussels. “We’ll see you on the beach, then,” Levadoux replies. They all give a quick laugh.
Gallows humor is a prerequisite in their line, and all morning they’ve been getting a brief on how precious laughter might be in the days ahead. MSF is still training doctors for rotations in West Africa, and these are its latest recruits. They’ve come to Belgium to complete the all-day, two-day course MSF gives its volunteers before they head to an Ebola clinic. In a handful of tents and temporary offices, they practice putting on the PPEs and, more important, learn how to take them off without getting infected. They also get a last-minute packing tip: Bring lots of socks. Feet get sweaty fast in those wellies, and no one wants a blister in a contamination zone.
All of it underscores another prerequisite for MSF work: a taste for adventure. “That’s certainly part of their myth, of being on the front lines,” says Peter Redfield, a professor of anthropology at the University of North Carolina, who’s written a book on MSF, A Life in Crisis. “But they are careful in who they select and who they send. It’s not risk-takers, per se, they want, but people willing to assume a risk responsibly. And they never willingly sacrifice staff in the face of death threats or abductions.”
All of the Ebola volunteers have taken seven weeks off from their jobs—four to work in the Ebola clinic, and three more paid weeks to wait out the virus’s 21-day incubation period. MSF pays—not full-time doctor money, but a few grand, plus room and board—and provides basic insurance. It also has an agreement with SOS International to use its medical evacuation services, though it’s not certain this will do much good these days: Too many pilots refuse to fly to Ebola-stricken areas.
“It’s very problematic for us,” Stokes says. “Pilots have been incredibly reticent to go to Africa for Ebola cases. You develop this kind of paranoia: If one of our volunteers were to have a car crash, or appendicitis, or complications from malaria—could we get them out?” Fortunately, “we haven’t had any of that so far—we’ve only had two Ebola evacuations, but even those have been incredibly complex. Phoenix [Air], actually, this U.S. company, has been the quickest, because Europe hasn’t been able to get its act together.”
In October, MSF let the world know it had reached its capacity. It would continue to operate the six centers and likely adapt to the changing landscape of the epidemic by opening smaller ones nearer to hot spots. But it could no longer expand overall. As such, Stokes and others look forward to the treatment centers promised by leaders in the U.S. and Europe, but those have been slow in arriving, and little has been shared about the medical personnel to staff them.
The U.S. has so far committed to sending 65 medical staff from the Department of Health and Human Services, who will provide direct patient care at a 25-bed hospital in Monrovia dedicated to treating infected health workers. At press time, the hospital was up but not yet running.
When Portnoy, the Bronx family doctor, told his wife he was thinking about volunteering, she asked him not to go. The two had long talks about the risk involved. (They have a 5-year-old.) Eventually, though, as the epidemic intensified, that it was out of control was what finally convinced him—and his wife—that he had to go.
“West Africa is where the most help is needed,” he says, “and it’s also the place it must be stopped.” Closing borders, ordering forced quarantines, and some of the other hysterical responses to Ebola, he goes on, will buy time but ultimately not safety. The way to protect the American public, he says, is to fly to Monrovia.
Two weeks into his time at ELWA3, the 250-bed Ebola center there, Portnoy confirms that the number of cases has begun to decline; at that location, there are more empty beds than patients. No one wants to say if it might be the beginning of the end—for one thing, they don’t want to jinx it. “It would be great to think so. It’s the best news,” Portnoy says, but no one’s celebrating yet. “For us, it’s more a chance to prepare, build capacity, train as many people as we can, and be ready.”
The reason it’s too soon to declare victory, he says, is that “a lot of things that should be working aren’t. Contact tracing is not working. The ambulances are not functioning. It’s hard to tell if safe burial practices are really being observed,” he says. “So we are keeping an eye on it and staying vigilant.”
On Nov. 5, President Obama asked Congress for $6.2 billion to fund the Ebola fight. For Poncin, the French molecular biologist who came to Guinea in April and never left, such developments are welcome, especially after a summer of aggravating indifference from foreign countries. But more money isn’t finally what’s needed, he says. What this outbreak exposed is that there aren’t enough qualified personnel in the global health system. The world needs rubber boots on the ground. As Stokes put it, asking the WHO to run an Ebola clinic is like “asking a consultant to build your car.” When the Australian government offered MSF $2.18 million in September, it told them to keep their money. Instead it issued a sharp rebuke for a “lethally inadequate” response and respectfully requested that the Abbott administration send trained personnel.
“I have a mixed feeling,” Poncin says of the days ahead. “The worrying part is that we have 14 out of 33 districts still reporting cases. In the east part of Guinea, we still have a lot of cases.” On the “good side,” he says, “Guinea has never given up. It was a poorly managed health system, but the authorities have taken responsibility as best they can.” In Guéckédou proper, where it all began, he says, proudly, “now, we have no more cases.”
— With assistance by Naomi Kresge