Ebola in West Africa: 10 years on, five things to remember

21 Mar 2024

Ten years ago, on 23 March 2014, Guinea declared an outbreak of Ebola. Ebola outbreaks were known to be dangerous but small. But not this time: it would take two years, and more than eleven thousand deaths, before the epidemic was over. 

Dr Michel Van Herp, a renowned Ebola expert even before 2014, looks back at the largest ever Ebola outbreak, and answers five key questions.

Ebola

MSF staff members carry a deceased Ebola patient to the morgue in Kailahun, Sierra Leone. Death was always very present in Ebola Treatment Centers. More than 11,000 people died during this outbreak and at several moments, the morgues where overwhelmed. © MSF

2014 was the beginning of the largest ever Ebola outbreak. What did this look like on the ground? 

Early in 2014, there were reports of people dying of an unknown disease in Guinea. Nobody thought it could be Ebola, because that was considered a disease of Central Africa, not West Africa. But at MSF, we thought that the symptoms of the patients were suspiciously similar to Ebola. And in fact, there had been one case of Ebola in West-Africa: in Ivory Coast, in 1994, a person had been infected with a very rare strain of Ebola, Taï Forest. This was not very well known: it was only one case, and the patient had survived the infection. But when we read the reports from Guinea, we thought this was probably an outbreak of Taï Forest Ebola. We sent our Ebola teams on the ground. At that time, MSF was one of the very few organisations with experience in Ebola outbreaks.

Once on the ground, two things became clear. Firstly, this was not the rare Taï Forest strain, but the infamous Zaïre strain, which we knew was very deadly. Secondly, this outbreak had been slumbering for months (since end of 2013) and it was already present in many more places than MSF – or anybody else – was used to deal with. It had started in the Southeast of Guinea, an area that was poor and mostly ignored by the national government. But it is very close to the border with Sierra Leone and Liberia, and people from all three countries regularly move across those borders. The bordering regions in Sierra Leone (Kailahun) and Liberia (Lofa) were similarly forgotten by their governments. This way, the virus could spread and cross the borders, for months, before authorities started acting upon it.

The outbreak happened in a place in the world where no one expected Ebola, in an area that didn’t interest the authorities, and no one was ready to deal with it. It also looked like no one wanted to deal with it. It took governments, UN agencies and aid organisations a very, very long time to take the outbreak seriously. MSF felt very alone in those early months. We frantically rang the alarm bell, multiple times, but nobody seemed to listen. Everybody was in denial.

What made this outbreak so different?

This outbreak was so gigantic – the world had never seen an Ebola epidemic like this. There had been Ebola outbreaks that touched towns before, but these were small, rural towns, nothing like Conakry, the capital of Guinea, where about two million people live. Never had Ebola outbreaks happened in so many countries at the same time. The virus spread in Guinea, Sierra Leone and Liberia, but there were also cases in Senegal, Mali and Nigeria. It was also the first time that Western countries, like Italy, Spain, the UK, and the USA, had cases of Ebola.

The scale of this epidemic was absolutely unheard of. When it was finally over, in March 2016, more than 28,000 people had been reported to be infected, of which 11,000 died – but there have probably been many, many more. We know that the reporting system didn’t work very well in many places. Before this epidemic, the largest Ebola outbreak had 425 infected people! Everybody, including MSF, was completely overwhelmed by this outbreak. 

MSF felt very alone in those early months. We frantically rang the alarm bell, multiple times, but nobody seemed to listen.

Dr Michel Van Herp
Ebola expert

How did MSF's approach change with this outbreak?

For almost six months, the world tried to ignore this outbreak, while it was getting more and more out of control. By the end of the summer of 2014, other governments finally started to help, and when they made money available, other aid organisations also stepped in. But we paid a heavy price for being so late.

At the time, there were no treatments for Ebola. Patients would be admitted in an Ebola clinic, where they would receive supportive treatment, but the doctors had no curative treatment. The main purpose of their admission was to isolate them, to avoid they would infect other people. In earlier, smaller outbreaks, this was done in a very human way. A family member would even accompany the patient in the hospital. Our staff was experienced and knew how to make that possible in a safe way. There weren’t so many patients and accompanying family members anyway, so there was more time and less pressure.

But in 2014, even our most experienced staff was overwhelmed. To admit the huge number of patients, very big structures had to be built. And they were managed by people who had never worked in Ebola outbreaks before. It was impossible to allow family members inside the Ebola clinics. The safety procedures had to be extremely strict. The personal approach of patients and their families, which had been so key in containing previous outbreaks, had to be abandoned. There was no other option, given the enormous number of infected people. But this large-scale approach also scared patients and their families. And scaring patients away is of absolutely counterproductive in an Ebola outbreak.

MSF was used to working alone, in a close relationship with the Ministry of Health and some other technical partners, like specialised laboratories. But by the end of 2014, dozens of aid organisations, most of them unexperienced with Ebola, were now involved in different aspects of the response. That was needed to manage the huge numbers. But it came again with downsides: the work was divided, and organisations focused only on their specific tasks. The coordination of all those organisations, in multiple places in multiple countries, was extremely challenging. Some governments turned to authoritarian tactics to force patients and their family into compliance. That scared them even more.

All in all, the response was far from ideal. The focus on the patients and their families was completely lost in the enormous machine that the Ebola response had become. Many of the lessons from previous outbreaks were ignored or forgotten, but the scale of the outbreak didn’t leave anyone much choice.

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Even if big hospitals became the symbols of the Ebola outbreak in West-Africa, outreach activities to the affected communities remained very important. Teams would not work in the controlled environment of the hospital, but had to be flexible and adapt to the situation, when picking up patients, supporting families and disinfecting houses. © MSF

What are some of the key learnings we took away from this outbreak and response?

Many of the things that we consider ‘lessons learned’ from the past ten years, are actually things we knew before 2014, but that were forgotten during the West African outbreak. The next big Ebola outbreak was in 2018 in the east of the DRC. The international aid community went in with the approach of West Africa four years before. For most aid organisations, that was the only approach they knew. Once again, aid actors had limited, specific tasks; coordination was difficult; there were big Ebola clinics; authorities were sometimes very authoritarian. And once again, this didn’t work very well. We think, or we hope, that most governments and aid organisations now understand that. The key to containing Ebola outbreaks is focusing genuinely on the needs of patients and their families.

Fortunately, we have also learned other things. We learned how we could take a simple, oral swab of dead people, to test whether they had died of Ebola. Technically speaking, that was already possible before 2014, but it was never done. With the oral swabs, we could test more bodies, and faster. This allowed us to better understand the dynamics of the epidemic.

We also organised clinical studies to find treatments, and later also vaccines, for Ebola. The treatment studies didn’t yield any results, but we did find a good vaccine against the Zaire strain of Ebola, which was very encouraging. And we learned from organising the clinical studies, so we could organise new clinical studies for other drugs during the 2018 outbreak in the DRC. These led to two good treatments with antibodies for the Zaire strain of Ebola.

We have learned a quite a few things, from the huge outbreak in 2014-2016, but also from the outbreaks that happened later. We now have to combine those lessons and develop a new and improved way of delivering medical care to Ebola patients.

Ebola

Even when people are fully recovered, Ebola virus can linger in some specific spots in the body, such as the eyes. This can cause eye problems. MSF pleads for using specific antiviral treatments, which are known to be able to remove the last virus from the body, including from the eyes. © MSF

What needs to happen for the future?

We need adapt our intervention models to make the best use of the new tools. We need to go back to the patients, instead of bringing the patients to us, but this time we can bring our new tools with us: a vaccine and treatments. There are very specific, concrete steps we can take to improve our approach.

We should again allow a family member to accompany a patient in the Ebola clinic. This was possible before, so it must be possible now. We can protect them even better, with vaccination and drugs for pre-exposure prophylaxis. This will inspire more trust, and the more people trust the aid teams, the more lives will be saved.

Very sick patients should be tested with a rapid test. These tests are not perfect, and they can fail to detect the virus in people that aren’t so sick. But they will detect the virus in very sick patients and that way, we can give them an antibody treatment much faster. It is a one-dose treatment, a perfusion of about one hour, that can be done in a local health centre, or even in an ambulance on the way to an Ebola clinic. Antibodies work fast and can be real lifesavers. The sooner a patient receives them, the better they work. We must adapt our models to make the best use of this option.

We also need to continue looking for other components for the treatment. The Ebola virus can provoke an inflammatory response that much too strong, so strong that it can kill the patient. If we had a drug to calm down that inflammatory response, we would save more Ebola patients.

We should also improve the follow-up of patients after their recovery. The antibody treatments help patients survive, but even then, the virus can linger in the brain, the eyes, and the testes. There is another type of drug—antivirals—that is less useful to help very sick patients survive, but can clean up the virus from these places. There are positive developments to make antiviral drugs in the form of an oral pill, and six months after their full recovery, Ebola survivors should get a shot of the vaccine to give their immune system another boost.

In the last ten years, we have certainly made errors when we responded to Ebola outbreaks. Some errors were forced, some were unforced. But in general, we clearly have made progress, and there are good options for even more progress. The odds for a patient with Ebola in the next outbreak will be much better than they were ten years ago.

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