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Looking for leadership in the Ebola epidemic

A conversation with Dr. Joanne Liu, president of Doctors Without Borders, about the challenge Ebola presents the global health community.

Medecins Sans Frontieres International President Dr. Joanne Liu visiting the Ebola treatment center in Kailahun, Sierra Leone. (Photo: P.K. Lee/MSF)

As the Ebola epidemic spreads in West Africa, the international president of Médecins Sans Frontières (MSF) — or Doctors Without Borders — is calling for greater resources on the ground and better leadership in response to the outbreak. Cases are now confirmed in Nigeria, the fourth country in the region.

Dr. Joanne Liu, a physician who leads the organization’s International Board and International General Assembly, has worked on MSF’s responses to the tsunami in Indonesia, the earthquake and cholera epidemic in Haiti, and Somali refugees in Kenya. She has called the Ebola outbreak “unprecedented” and says it needs an equally extraordinary response.

We spoke with her by telephone on Thursday from Geneva, a week after she returned from 10 days in West Africa, about MSF’s response to the epidemic and the leadership in the region. The below excerpts from our conversation have been lightly edited for space and clarity.

Q. You have said there is a “vacuum” of leadership in the outbreak response. Can you describe what you mean?

A. The magnitude of the Ebola epidemic is unprecedented. We’ve never had an Ebola outbreak with this many people contaminated in so many different sites, in such high numbers. The other particular thing about this epidemic is it has reached urban areas, whereas in the past it’s always been in isolated, remote, rural areas. This is what makes it different, and this is what makes it much more concerning as well.

What has been lacking since the beginning is an entity or body that will somehow portray themselves as seeking the leadership and the coordination of the response to the Ebola epidemic. The current governments are trying to do their best, but the reality is they don’t have the capacity. They don’t have the experience.

Q. In a global health crisis like this, what does good leadership look like? What kinds of structures, processes and coordination need to be put in place that haven’t?

A. The thing is, you need people who are operational in the field. You don't just need people sitting in meetings discussing things. You need to come out with a plan with clear priorities and capacity to implement it. This is not happening yet.

We have some hope [with the visit of two U.N. officials who were in the region at the time of our interview, Dr. David Nabarro and Dr. Keiji Fukuda] that we are going to have a plan of action afterwards. But saying all that, we're five months into the epidemic.

Governments in place need to take more leadership. They need to reassure the population. They need to explain what is going on. But those governments need some support, and the best body to do that is the WHO — the United Nations' World Health Organization. They need to step up to the plate now.

Note: Later in our conversation, Dr. Liu reiterated her hope that the visit serve as a "turnaround point" for the WHO to take a "more assertive leadership role." Then on Friday, the day after we spoke with Liu, Nabarro announced that more health workers would be brought in and said “the United Nations is looking at ways to radically scale up support to fight Ebola." And on Tuesday, Bloomberg reported that the WHO is developing a plan outlining the funds that will be required and its goal for reversing the trend of new Ebola cases. E-mail and phone messages to WHO representatives asking for a response to Dr. Liu’s comments were not immediately returned. 

Q. Should there be more of a response from international leaders?

A. Absolutely. I think that today it’s part of the solution. I know that the U.S. is quite involved. They really are trying to scale up. But other countries like the U.K., France, Germany and Canada need to provide more help as well.

Everybody is scared of Ebola. People are scared in Liberia and Sierra Leone and Guinea, but people are also scared in Canada and the U.S. The reality is the only way to contain the epidemic is if we increase the response capacity in the countries where we have patients infected. It’s not by barricading ourselves in our home country, or by stopping flights or just giving money. We need to have people sent to the ground to do the legwork. We need more people to do health promotion. We need more people to do the data collection, the contact tracing, the safe burials. We need more people to care for patients who are infected.

Q. You’ve spoken before about what you’ve called an “Ebola psychosis.” What do you mean by that?

A. People are absolutely scared of it. It’s understandable, but in the Western world I think maybe it’s a bit out of proportion. The chance that you are going to be exposed in the Western world to Ebola is very, very unlikely. But when people don’t completely understand the disease and the chain of transmission, and they know it has a deadly outcome, it’s scary. That’s normal. It was the same thing when we started to have HIV patients in the past. We were scared. It’s normal.

Q. A doctor on the ground in West Africa told The Guardian newspaper “it's not rocket science” to trace people who’ve been in contact with the disease, “but it needs an organizational structure and good leadership.” I’d imagine the need to manage the multiple organizations involved is one of the biggest leadership challenges.

A. Just to be clear and give a reality check, the number of organizations that are acting in the field right now can be counted on the fingers of my hands. So there’s not that many. It’s not like Haiti after the earthquake, where you had 12,000 NGOs trying to bustle around and find a way to justify their presence. The reality is there are very few organizations that are deploying right now.

We want to change the narrative to some extent. A lot of people think the only way to make a difference in terms of responding to the Ebola crisis today is by coming with a space suit and treating people in an isolated care facility. There are other ways. Like the doctor said, the contact tracing is not rocket science. You just need to get the name of a patient, then find out where they are and follow them up. This type of organization needs to happen.

Q. If there aren’t that many organizations on the ground there, why is it still so important to have an entity in charge?

A. You always need a coordinating body. You need someone who’s going to centralize the information, and centralize what is going on. That’s always necessary, even if you have five or 10 people, and not 400 or 12,000 like we saw in Haiti. That’s part of the basic management.

Q. This fear you’ve spoken about, how does your own organization prepare its health workers to deal with that and live with that?

A. We have a special training for it. We have experienced people who have been in other Ebola epidemics before and they’re matched with the new people. When you start to work — and I’m going to take the example of working in an isolation center — you’re not on your own. You’re paired for at least 10 days just to make sure you really are integrating the whole routine about personal protection.

This is not something that we take lightly. We are absolutely rigid about our protection for our staff. This is one of the reasons why we haven’t been able to scale up in terms of capacity. When you think of other types of emergencies, like cholera, it was easy to scale up because the contamination was not as difficult to control. But for Ebola it’s another set of rules, another game.

Inside the Ebola protective clothes, it's more than [104 degrees Fahrenheit]. It's like being in a sauna. So you can’t last more than an hour at a time inside the center. You have to do turnover between people who are going to go inside. It’s not the same thing. We’re not talking about the same kind of care.

Q. How much worse  have things become since MSF first started engaging in the outbreak?

A. When it started in Guinea, our Ebola center was the size of 30 beds. Back then — and I’m just talking in March, only five months ago — we were like, ‘Oh my God, this is such a huge center. This is really something new.’ We were all wide-eyed, concerned.

Today, we are in Monrovia [the capital of Liberia] with a center of 100 beds and we’re contemplating the idea of doubling the size of it because of the demand. It’s not enough places to care for patients who are infected. Every day we are breaking new ground in terms of the case management.

Note: MSF called the Ebola outbreak in West Africa “unprecedented” as early as March of this year, noting that Guinean health officials had recorded 122 suspected patients and 78 deaths. Today, MSF has six centers and more than 1,000 staff on the ground.

An update from the WHO on Friday said the epidemic had spread to four countries and claimed at least 1,427 lives. In a news release, the organization also said the number of Ebola cases has been underestimated.

I later wrote Dr. Liu to ask her a few follow-up questions. One of them — asking about her greatest challenge in leading MSF’s response to the Ebola outbreak — did not elicit a response. But she did answer the following question in an email.

Q. What has been the biggest thing you've learned about leadership in the process of leading MSF's response to Ebola?

A. I don't have much to say on this except that in extraordinary circumstances, one needs to take extraordinary measures. MSF, as an organization, has tried to adapt and went beyond its comfort zone. The epidemic is unprecedented.

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