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Ebola outbreak thrusts MSF [Doctors Without Borders] into new roles

June 3, 2015 This article courtesy of Nature News.

Relief agency sees its mission expanding after leading response to West Africa epidemic.

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Joanne Liu, president of Médecins Sans Frontières (MSF), is not overly concerned with diplomacy. Participating in a panel in Geneva, Switzerland, on 20 May with officials from the United Nations, the World Health Organization (WHO), Liberia and Sierra Leone, she propped her head on her hand, stared into space and rolled her eyes during another speaker’s remarks. When she spoke, she excoriated the world for leaving West Africa vulnerable to the largest Ebola epidemic in history. “We’re failing, guys,” she said.

Few would contest Liu’s right to make that assertion. MSF (also known as Doctors Without Borders) was the organization that alerted the world to the scale of the Ebola epidemic. Its speedy response has both reinforced its role as the world’s caregiver in health crises and catapulted it to new prominence in the international health community. In the past year, Liu has addressed the UN General Assembly and met with world leaders. Donations to her non-governmental organization (NGO) rose to €1.14 billion (US$1.24 billion) last year; in the United States, donations climbed by 50% from the previous year. “It’s a defining moment,” Liu told Nature during an interview at MSF’s headquarters in Geneva. “We have a voice that we have never had before; we need to use that very smartly.”

At a time when the WHO is lacking the funds and authority to address pressing global health needs, there is room for an organization such as MSF to take a greater role in both chronic and acute medical crises, as well as in research that enhances preparedness for those situations. But Liu insists that MSF cannot become “the world’s doctor”. “We need to be careful that we don’t spread ourselves too thin,” she says.

MSF was founded in 1971 by French doctors and journalists who decried a Red Cross edict not to speak out about the conditions they saw while treating victims of the Nigerian Civil War in the secessionist state of Biafra. Since then, the organization has provided medical services to people affected by wars, natural disasters, famines and infectious-disease outbreaks around the world. In 1999, it was awarded the Nobel Peace Prize for “pioneering humanitarian work on several continents”.

It was the first international NGO to send staff to Guinea when Ebola emerged there in March 2014, and its declaration that month that the outbreak was “unprecedented” has proved tragically correct. Since then, MSF has deployed more than 1,300 international staff and 4,000 local people to fight Ebola in Guinea, Sierra Leone and Liberia.

Wealth of experience

MSF has fought Ebola outbreaks in nine countries, but it took a leadership role in the latest epidemic in ways that it had not before. It taught staff from other organizations — including the WHO and the US Centers for Disease Control and Prevention — how to treat people with Ebola. It distributed home disinfection kits to hundreds of thousands of people in Monrovia and other communities, and delivered incinerators to dispose of bodies when Liberian burial teams could not keep pace.

Independence — one of MSF’s core principles — allows the organization to move faster than governmental and inter-governmental organizations, but it has also caused tension. In July, for instance, MSF forbade Michael Gbakie, a disease-surveillance officer at Kenema Government Hospital in Sierra Leone, from visiting four of his colleagues who were being cared for in a nearby MSF Ebola treatment centre, even though he had a decade of experience working around people with similar diseases. “They have a protocol, and they will not just allow everyone to go in there if they are not working with them,” Gbakie says. MSF eventually relented: Gbakie saw one of his colleagues, physician Sheik Humarr Khan, on the day he died.

Health officials from other countries affected by the Ebola outbreak alluded to these tensions at the MSF-organized event on 20 May: “I hope this outbreak will allow [you] to examine the way you work with your colleagues and governments,” Miatta Gbanya, coordinator of the Liberian Ebola response, told Liu.

“The ultimate goal must be functional health systems in every country.”

Liu acknowledges that the organization could have communicated better with local leaders and communities. “You need to get the community on board. This is something that we underestimated,” she says.

The organization has undergone difficult transitions in its mission before. When it began treating people with HIV in the 1990s, it had to shift its approach from emergency medicine to delivering chronic care. Much more recently, it has found itself managing diabetes and other diseases found more in middle-income nations in its treatment of refugees from Syria’s civil war.

The Ebola crisis has not only strengthened MSF’s patient-care role, but also boosted its involvement in research. The NGO used proceeds from its Nobel prize to help found the Drugs for Neglected Diseases initiative, which funds drug-development work on diseases that mainly affect poor people, and to start its Access Campaign, which pushes both to increase the availability of drugs and for the development of lower-cost medicines to treat illnesses in poor countries.

In West Africa, MSF is running clinical trials of potential Ebola treatments, pushing for more research into the disease and contemplating the creation of a biobank of patient samples along with the WHO and other organizations.

Expanded role

The temptation is for MSF to step in to fill a void left by retreating funding and authority at the WHO and other international health organizations. Although WHO member states approved some measures to strengthen the organization’s outbreak response during last month’s World Health Assembly, observers say that these measures will not address the core problems that slowed its response to Ebola in West Africa.

“The Assembly failed utterly in addressing the underlying deficiencies,” says Lawrence Gostin, director of the WHO-affiliated Centers for Law and the Public’s Health at Georgetown University in Washington DC. “There’s a great yearning on the part of WHO to be the global health coordinator, but the future of WHO’s leadership in this area is very much in doubt.”

The UN secretary-general and the World Bank are examining the WHO’s mandate in responding to health emergencies; the World Bank has outlined details for a Pandemic Emergency Facility that would fund early responses to outbreaks.

But such proposals have tended to focus on preventing the spread of outbreaks from poor to rich nations, says epidemiologist David Heymann at the London School of Hygiene and Tropical Medicine. “The paradigm is, the donors will be happy to jump up and provide funding for a rapid outbreak response, but they’re not so ready to provide funding for health-systems strengthening,” he says.

MSF finds itself increasingly enlisted to clean up the local and regional health emergencies that result from inadequate infrastructure. A whiteboard at its international office in Geneva tracks staff deployments to crises in some of the 70 or so countries where it is currently working, including Ukraine, Iraq, the Democratic Republic of the Congo and South Sudan.

To help the world to prepare for the next time that one of those local or regional situations erupts into an international crisis, Liu is convening an open discussion in Dakar, Senegal, this month to which she plans to invite all those involved in the Ebola outbreak. It is one of several post-Ebola discussions under way on the global health response; others are being organized by the US Institute of Medicine, Harvard University in Cambridge, Massachusetts, and the London School of Hygiene and Tropical Medicine, the World Bank and the UN.

Many of these discussions are focusing on matters of international law, such as deficiencies in the International Health Regulations, which are supposed to govern countries’ behaviour in health emergencies. Liu, who considers these questions less important than the practical concern of how to get treatment to people who need it, nonetheless says that she is looking forward to the upcoming MSF event.

“We’re going to get a lot of people who haven’t treated a patient who are now the world experts, and who are going to give us lessons,” Liu says. “We can only smile at this.”

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