Ebola: 10 years later, 5 things to remember
Ten years ago, on 23 March 2014, Guinea declared an outbreak of Ebola. Ebola outbreaks were known to be dangerous but also 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 biggest Ebola outbreak and answers five key questions.
What happened ten years ago?
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 felt that the symptoms of the patients were suspiciously similar to Ebola. 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 few organisations that had 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 deadly. Secondly, this outbreak had been slumbering for months (since the 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. However, it is very close to the border between 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 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 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.
Why was this outbreak different?
This outbreak was 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 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 the reporting system didn’t work well in many
places. Before this epidemic, the largest Ebola outbreak had 425 infected people! Everybody, including MSF, was utterly overwhelmed by this outbreak.
Was the response to the outbreak different, too?
For almost six months, the world tried to ignore this outbreak while it was getting increasingly 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 to an Ebola clinic, where they would receive supportive treatment, but the doctors had no curative treatment. The primary purpose of their admission was to isolate and prevent them from infecting other people. In earlier, smaller outbreaks, this was done very humanly. 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 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. Massive structures had to be built to admit the significant number of patients. And they were managed by people who had never worked in Ebola outbreaks. 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 crucial in containing previous outbreaks, had to be abandoned. There was no other option, given the enormous number of infected people. However, this large-scale approach also scared patients and their families. And scaring patients away is counterproductive in an Ebola outbreak.
MSF was used to working alone and closely with the Ministry of Health and other technical partners, like specialised laboratories. However, by the end of 2014, dozens of aid organisations, most inexperienced with Ebola, were now involved in different aspects of the response. That was needed to manage the vast numbers. But it came again with downsides: the work was divided, and organisations focused only on their specific tasks. Coordinating all those organisations in multiple places in multiple countries was highly challenging. Some governments used authoritarian tactics to force patients and their families 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 utterly 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 epidemic didn’t leave anyone much choice.
4. Did we learn anything from it?
Many things that we consider ‘lessons learned’ from the past ten years are things we knew before 2014 but were forgotten during the West African outbreak. The next significant 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 complex; 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 to take a simple oral swab of dead people to test whether they had died of Ebola. Technically, that was already possible before 2014, but it was never done. The oral swabs could test more bodies faster, allowing us to understand the epidemic's dynamics better.
We also organised clinical studies to find treatments and vaccines for Ebola. The treatment studies didn’t yield any results, but we saw a promising vaccine against the Zaire strain of Ebola, which was very encouraging. We learned from organising the clinical studies to organise new clinical studies for other drugs during the 2018 outbreak in the DRC. These led to two suitable treatments with antibodies for the Zaire strain of Ebola.
We have learned quite a few things from the massive outbreak in 2014-2016 and from the outbreaks that happened later. We must combine those lessons and develop a new and improved way of delivering medical care to Ebola patients.
5. What needs to happen in the future?
We need to adapt our intervention models to use the new tools best. We need to return to the patients instead of bringing them to us, but this time, we can bring our new tools with us: a vaccine and treatments. We can take concrete steps 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; 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 imperfect and can fail to detect the virus in people who aren’t so sick. However, they will detect the virus in very ill patients, so 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 an ambulance on the way to an Ebola clinic. Antibodies work fast and can be absolute 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 is 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 the virus can linger in the brain, eyes, and testes. Another type of drug is antiviral. They are less helpful in helping very sick patients survive, but they can clean up the virus from these places. There are positive developments to make antiviral drugs in the form of an oral pill. 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 made errors when responding to Ebola outbreaks. Some errors were forced, and some were unforced. But in general, we 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.
MSF Southern Africa 
About Doctors Without Borders (MSF)
Doctors Without Borders (MSF) is a global network of principled medical and other professionals who specialise in medical humanitarian work, driven by our common humanity and guided by medical ethics. We strive to bring emergency medical care to people caught in conflicts, crises, and disasters in more than 70 countries worldwide.
In South Africa, we run a non-communicable diseases (NCDs) project in Butterworth, Eastern Cape province, to improve care for patients with diabetes and hypertension. The project focuses on improving screening, diagnosis, management and prevention through advocacy, research, health promotion, training and mentorship of Community Healthcare Workers (CHWs).
At the end of 2023, we handed over our Tshwane Migrant Project to authorities and a local Community-Based Organisation after building the capacity to work with undocumented populations. The project provided access to medical care for undocumented people and migrants and actively advocated for continued access.
After 12 years of operations, we closed our HIV/TB project in Eshowe, KwaZulu-Natal province. The project’s community-oriented approach helped to increase the integrated management of HIV, TB, diabetes and hypertension through nine community-based ‘Luyanda’ sites, which were successfully handed over to the DoH. Many achievements were made in the task-shifting of TB health promotion activities to teachers in schools, and we shared valuable feedback with the DoH on the decentralisation of Drug-Resistant Tuberculosis (DRTB) services to the primary healthcare level.
After 22 years of activities and campaigning, we closed our HIV and TB project in Khayelitsha, Western Cape, in 2020.