Anton Crone
27 March 2015

Sunday marked a year into the largest Ebola outbreak in history. It has been, and continues to be, a cruel lesson in bureaucratic ineptitude and “First World” disregard for Africans, yet it has also been a year when Africans and Westerners alike have shown fidelity by staring real horror in the face. As Medecins Sans Frontieres (Doctors Without Borders) international president, Dr Joanne Liu, said in an appeal to UN member states in September: ‘To put out this fire, we must run into the burning building.’

©Julien Rey/MSF
The African suffering was only significant when the virus crossed the ocean

On the evening of 22 March 2014, shortly after a series of deaths caused by a “mysterious disease” in Guinea, lab results confirmed it and Guinean health authorities declared an Ebola outbreak – the first ever in West Africa. But poor local health systems, reluctant governments wary of fomenting panic, and an achingly slow response from world governments and aid organisations, including the World Health Organisation, made it impossible to contain the disease. Despite MSF raising multiple alarms and pleas, it took an infection in the USA, and another in Spain, for Western organisations to wake up to the threat. That the virus could cross the ocean suddenly made disadvantaged African countries significant. But that was August, four months too late.
By then the disease had spread with unprecedented ferocity, reaching far beyond Guinea’s borders into neighbouring countries, the worst affected being Sierra Leone and Liberia. Entire families were extinguished and nearly 500 health workers succumbed to the disease. To date over 10,200 people have died and the disease still holds Sierra Leone, Liberia and Guinea in its grip.

©Fernando Calero/MSF

‘The number of new cases weekly is still
higher than in any previous Ebola outbreak’

With reports of a decline in the number of Ebola cases towards the end of 2014 the general impression has been that the disease is finally under control, but more recent news and a report by MSF about their year fighting the disease gives a sobering perspective.
‘A significant challenge remains ahead of us,’ reads the MSF report titled Pushed to the Limit and Beyond. ‘To declare an end to the outbreak, we must identify every last case. There is no room for mistakes or complacency; the number of new cases weekly is still higher than in any previous outbreak. Success in reducing the number of cases in one location can be swiftly ruined by an unexpected flare-up in an unforeseen area.’


As the report was being released on Monday, in a cruel irony Liberian health officials had just announced the country’s first Ebola case in 28 days, and the Guinean health ministry revealed that the number of suspected cases in the country had more than doubled from the previous month.
The WHO’s Guinea representative, Jean-Marie Dangou, explained that the uptick in cases could be explained by previously hostile communities opening up to Ebola teams. ‘Unfortunately this has led to the discovery, not unexpected, of a large number of hidden cases and community deaths,’ Dangou told the Thomson Reuters Foundation.

Why finding hidden cases is so challenging

©Julien Rey/MSF
©Fernando Calero/MSF
Some communities see the arrival of medical teams as a death sentence

One of the greatest challenges for aid workers has been tracing people who have had contact with Ebola carriers. At the beginning of February, the WHO reported that only about 15% of new cases in Guinea were from known Ebola contacts, and in Sierra Leone about 21%. Liberian health workers are still trying to find the contacts of their latest case.
Contact tracing is a vital strategy in containing the spread of Ebola, but as vigilant as tracing teams are they are short of resources, and it is particularly difficult to follow up in the region where road access is notoriously poor, populations move around considerably and contact addresses are often missing or unclear.
Some communities have been hostile towards medical teams, seeing them as a death sentence. This mistrust was exacerbated during the early stage of the outbreak when government hospitals were not practicing proper infection control and people admitted for other ailments contracted the deadly virus. Ebola treatment facilities were so overwhelmed that people had to be turned away to face the dreaded disease on their own. The MSF report highlights just such a situation in their analysis of what made this outbreak so cruelly unique.

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The biggest Ebola treatment centre
in history wasn’t enough

In late July, already overstretched and understaffed in Guinea and Sierra Leone, MSF had to make a crucial decision with regard to taking over two Ebola management centres in Liberia. Two Samaritan’s Purse staff from the US had been infected and the organisation suspended its operations in Monrovia and Foya. No organisation stepped forward to take their place in supporting local health workers, and as Ebola cases in Liberia spiralled MSF was compelled to step in. ‘In a way the decision was made for us – we couldn’t let Monrovia sink further into hell,’ said MSF regional co-ordinator Brice de le Vingne. ‘We would have to push beyond our threshold of risk, and we would have to send coordinators without experience in Ebola, with only two days of intensive training. It would be dangerous, but we’d have to find a way to intervene in Monrovia and Foya.’

Both images ©Anna Surinyach/MSF
‘There were so many patients and so few staff. It was indescribable horror’

Training of an unprecedented 1,000 people began in the field and at MSF’s headquarters in Belgium, and while a team deployed to Foya, construction began on a treatment centre in Monrovia. With 250 beds ELWA 3 would become the biggest treatment centre in history. But it was not enough.
‘We were desperate because we knew that we couldn’t do more, and we knew exactly what those limitations meant,’ says MSF Ebola task force coordinator Rosa Crestini. ‘It meant there would be dead bodies in homes and lying in the street. It meant sick people unable to get a bed, spreading the virus to their loved ones.’


By the end of August the gates to the facility could only be opened for 30 minutes each morning. ‘We had to make the horrendous decision of who we could let into the centre,’ says Crestani. ‘We had two choices – let those in who were earlier in the disease, or take in those who were dying and the most infectious. We went for a balance. We would take in the most we safely could, and the sickest. But we kept our limits too – we refused to put more than one person in each bed. We could only offer very basic palliative care and there were so many patients and so few staff that the staff had on average only one minute per patient. It was an indescribable horror.’
By then world attention had finally been redirected to the crisis by the first diagnosis of Ebola outside of West Africa in the US, and the first case of human-to-human transmission in Spain. On 8 August the WHO finally declared the outbreak a “public health emergency of international concern,” and the wheels of funding and aid began turning faster. By then 1,000 had died; the disease was so well entrenched that more than 9,000 would follow. The certainty is that if more had been done sooner, many of those people would have been saved.

©Gabriele François Casini/MSF

Hope for the future

It’s difficult to find a positive side to such a prolonged and deadly event, yet out of it come lessons and hope for the future. One such hope is for pregnant women who were previously thought unable to survive the disease. ‘As the number of people infected in other outbreaks was low – too low to gain an understanding of how Ebola impacted pregnancy – little research had been done,’ says midwife Ruth Kauffman who is pioneering MSF’s work with pregnant Ebola patients. ‘All we really knew about pregnancy and Ebola was that usually the women die either while pregnant or else during the birth. As Ebola is a haemorrhagic fever, once a woman goes into labour, she will most likely bleed to death. We also knew that unborn babies don’t survive, as the virus appears to concentrate itself in the placenta and in the amniotic fluid which surrounds the fetus.’ But news of a few women who had survived after giving birth reached Kauffman and her research with these and other women has been critical to saving the lives of others.Tanzani wild frontiers

©Anna Surinyach/MSF
©Sylvain Cherkaoui/MSF
Prior vaccine research went into combatting bioterrorist use
of Ebola

While medical workers have been dealing with Ebola, they have taken the opportunity to distribute upwards of 1,8 million antimalerial treatments to people in the affected areas -the largest distribution of antimalerial treatments ever.
The scale of the epedemic has also sped up vaccine trials for Ebola. According to the MSF report, ‘there was no vaccine, drug or rapid diagnostic test on the market proven to be safe and effective against Ebola in humans.’ Big pharmaceutical companies did not consider short-lived outbreaks affecting a few economically disadvantaged people in Africa a priority. Most of the research and development had been conducted by small firms and public institutes supported by public defense funding for combating bioterrorist use of Ebola or stockpiling products for Western markets.
‘Research and development finally accelerated in early August, when the WHO confirmed that using Ebola products not yet tested on humans was ethical and even encouraged, given the exceptional nature of the outbreak,’ says Julien Potet, policy advisor for MSF Access Campaign. ‘Public and private research sectors fast-forwarded the process to start clinical trials from what usually takes years to mere months.’
Another positive outcome has been that thousands of medical workers in Africa and the West have received crucial training and experience in handling such a crisis.

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Medical experience and transfer of skills

Zimbabwean doctor and HIV specialist, Innocent Muleya, approached MSF about volunteering in July last year. He chose to run into the burning building.
‘A lot of my friends still think I’m crazy,’ he says. ‘But I try to encourage them to go; that they can benefit from the experience.’ Innocent did a lot of research to be sure he knew what he would be dealing with. When he was deployed to Sierra Leone’s Bo district in late August, an intense week of briefing followed before Innocent was put to work. ‘What gave me real confidence was the five other doctors who had been there since the beginning.’ That they were still at it, dealing with such horrific circumstances made Innocent realise that this could actually be done.

©Sylvain Cherkaoui/MSF
‘It felt good to be needed. Even a smile was needed’

Other ailments and illnesses were neglected as Ebola threatened local health systems. ‘In the hospitals there were many sick children and pregnant women who needed help,’ says Innocent. It became too dangerous and many hospitals were evacuated and closed.
‘We became like an island dealing with everything,’ Innocent says, recalling the case of a mother who had walked into the Ebola treatment centre after giving birth in the government hospital. ‘She had had a c-section at the hospital but she walked out straight after because no one was looking after them. With fresh stitches, and carrying her newborn child, she climbed aboard a motorcycle taxi. ‘The government hospital was 10, 12 kilometers away from here. When she arrived her child had a fever and she was barely walking.’
Much of his work involved caring for such people, as well as those with Ebola. ‘But it felt good to be needed. Even a smile was needed,’ Innocent adds, flashing a confidant grin that only a doctor with such a name can muster. His smile hardens when I ask him if there is truth in the sense that Ebola is under control.
‘I’m skeptical about what’s under control. A definition of an Ebola outbreak is one case,’ he stresses. ‘This all started with one case. It’s unpredictable. There’s no single week that’s the same. You can go days thinking it’s quiet, and then all of a sudden – Panic! A cohort of patients is found. Now is not the time to relax. Yes, the numbers are coming down, we are doing something correct, but we need to intensify it and continue. It’s like fighting fire. You don’t go to where the fire has already been, you go where it’s not to stop it spreading.’

Quelling the flames

Aminata Sankoh (left) went from critical to caretaker when she survived the disease, helped her son through it and as his condition improved, expanded her focus to on other children in his ward, keeping parents appraised of their loved one’s conditions via regular cellphone calls. Her actions saved children’s lives. She is one of many heroes of the Ebola crisis. ©David Conteh/MSF
Unaffected regions shouldn’t have to suffer from a lack of tourism

The lessons have been incredibly hard for international aid organisations and African health workers alike. Regional health care systems have been destroyed by this epidemic. There have been many casualties from other ailments as all efforts have been put into combating Ebola, and there will be many more such casualties unless basic health services are restored immediately. ‘Children have missed vaccinations, HIV patients have had their treatment interrupted and pregnant women need a safe place to deliver their babies,’ says the MSF report. As a result of resources diverted to Ebola, currently there is a threat of a measles outbreak in the region.
Among the secondary effects are a severe economic downturn in an already struggling region, as well as other African regions unaffected by Ebola. Despite Eastern and Southern African countries putting stringent preventative measures in place, and remaining completely free of the disease, the tourism industry suffered drastically as safari goers spurned travelling there. It’s ironic that there were cases of Ebola in the United States and Europe while East and Southern Africa had none.
Finally the panic amongst tourists has settled and tourism is picking up. But the Ebola crisis in West Africa is not over, and already the world seems to be looking away. International regard for the continent remains dark. But perhaps if people were to read beyond the devastating headlines, if visitors were to step off the wildlife safari circuit and spend time with the people, they might feel the true warmth of this continent and help quell the flames. africa-geographic-logo


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  • ReginaHart

    Excellent reporting – thank you.

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  • Really good article – thank you! One of the nicest in-depth pieces of writing I’ve seen on Ebola in recent months – and I have been keeping an eye on the epidemic via Virology News, to which I’ve posted this article to help spread the news.

  • Really good article. Too bad that it ignores the effort to get viable alternatives to use in easing the illness, reducing mortality, and helping to stop the spread. What western influence ( medicine ) wanted and still wants is highly profitable treatments and vaccines. There are alternatives that could have saved many lives.

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