Ebola: MSF should not replace governmental responsibilities

First published in Le Temps on 31 October 2014

MEP Charles Goerens, rapporteur on Ebola to the European Parliament’s Committee on Development, recently declared that this epidemic is "the first major international crisis in which the lead should be given to an NGO - in this case, Médecins Sans Frontières".

Given that we have repeatedly called for greater leadership from the international community, including the European Union, this proposal took us by surprise. We have interpreted this appeal, coming from an MEP who has also publicly criticised the inadequate reactions of European states in the face of the epidemic, as a symptom of the failure of existing public response mechanisms and even more so, of the huge collective difficulty in taking action.

When a disaster occurs - whether an epidemic, a natural disaster or any other event with similar effects – the primary responsibility for helping the victims as quickly as possible and minimising the impact on society falls on the affected states. Because public authorities are in the front line for initiating and managing the emergency response, the legitimacy to act can only lie with governments and their collective institutions, as embodied by the United Nations. Not addressing a critical health crisis and therefore abstaining from coordinating  healthcare for entire populations would represent utter failure on behalf of States and international institutions whose mandate it is. Such a vacuum would be as worrying as it would be politically unacceptable.

In the fight against a virus as dangerous as Ebola, which is affecting several countries and hundreds of thousands of people, governments have to step outside their traditional comfort zones. Their response cannot be merely a "damage control" exercise. The role of the United Nations is to protect the populations concerned - humanity - against a deadly collective danger through effective international cooperation.

In West Africa, in recent months, we have been witness to the non-existence of instruments and mechanisms capable of developing a rapid, effective and proportional response able to deal with the scale of an international health crisis. Despite multiple warnings and the declaration (albeit belatedly) of a state of emergency by the affected countries and the WHO, the international community is only just starting to put together a suitable operational response. The creation of the UN Mission for Ebola Emergency Response (UNMEER), the UN's very first emergency health mission, had to be improvised all the way. Only time will tell whether it will fulfil the expectations of millions of West Africans, but the human cost of the initial lack of collective responsibility will have been, and will continue to be, considerable.

MSF - a private medical and humanitarian organization - can certainly make a significant contribution to medical and operational leadership by continuing its work on the ground, sharing its expertise and experience, taking part in the development of strategies to contain the epidemic more effectively and encouraging other actors to increase their level of assistance. However, we cannot, and simply should not replace governments in assuming their responsibilities on public health.

Ironically, until last week's European Council meeting, even the most basic demands made by MSF to the European Union and other countries - such as the organization of medical evacuations for infected humanitarian workers - had gone unanswered for many long months. Consequently, hundreds of committed doctors and nurses went out into the field without knowing for certain whether they would be able to return home if they became contaminated. If it takes months to reach decisions on simple requests, how can we expect the thousands of hospital beds, the hundreds of ambulances needed, and all the other numerous medical and non-medical services to be quickly mobilized across three countries? Decisions about the deployment of additional resources might not start to have a lasting impact on the situation in West Africa until next year. A lack of preparation, a lack of responsiveness, an initial lack of political will... The system failed!

Yet there are also some truly encouraging signs: although we should remain cautious, initial efforts are starting to produce positive results in Monrovia, the capital of Liberia, as well as in Sierra Leone. This progress should allow more attention to be focused on decentralizing medical care given to Ebola patients, on interventions in rural areas and on getting an effective health system up and running again for the treatment of all other illnesses.

Meanwhile, the rapid deployment of an effective vaccine could, in theory, completely change the picture within a matter of months. Millions of people could be protected, probably making it possible to curb the epidemic. The normal stages of developing a vaccine are long and complex, but given this unprecedented health crisis, major efforts have been made to speed up the process. This development can be further hastened by avoiding any unnecessary delay between proving the efficacy of the vaccine and its massive deployment in West Africa.

To achieve this objective, an affordable vaccine must be produced. It must be available in sufficient quantity and its characteristics must permit the organization of mass vaccination campaigns. The same applies to drug treatments, which can considerably reduce the mortality rate if they prove effective. The research and development of these substances must not follow the usual, market-driven cycle, but must only be determined by the needs of the affected population. In the face of an exceptional situation, exceptional procedures must be set up to ensure that medical innovation is first and foremost of benefit to the most vulnerable. Here too, the international community can play a crucial role, although it requires strong and decisive leadership and political will.

And where does MSF fit in to all this? Our organization has neither the legitimacy nor the skills nor the desire to take on the political leadership of the Ebola crisis in West Africa. We will continue to care for patients, as that is our core role and the challenge remains huge. But we refuse to be used as an alibi for the lack of political will to assist the suffering population in West Africa, nor should we help to conceal the lack of preparedness and reactivity of the international community. In view of the disengagement that has occurred in recent years, we will fight to obtain a radical improvement in the public response mechanisms that exist to address this kind of health crisis. But our place is - and will remain - at the patients' bedside.


Thomas Nierle, MD

Bruno Jochum