Marc Poncin • Unité de Recherche sur les Enjeux et Pratiques Humanitaires, Médecins sans Frontières/Centre opérationnel Genève
The Ebola epidemic continues to be instructive. This was indeed the conclusion of the “Focus” on this subject in our inaugural issue: the magnitude of this unprecedented crisis, its failures and successes, required that there were lessons to be learned. This is what Marc Poncin, the former coordinator for Doctors Without Borders (MSF) in Guinea-Conakry, does here as he looks back on the stormy but ultimately constructive relations with the country’s authorities.
You are going to have to face two problems: fighting the virus and the communication of MSF”. This is the warning Alpha Condé, President of Guinea, was given by one of his peers during the EU-Africa summit, just a few days after the announcement of the Ebola outbreak in Guinea in March 2014, as he would later admit to MSF. It was therefore not surprising that relations between the Head of State and MSF were marked by suspicion right from the start of the crisis, and that the public pronouncements of the organization were not well received by a leader worried about the repercussions of the epidemic on Guinean affairs.
It would take until August 2014 to rid the President of the Republic of Guinea of his suspicious attitude towards MSF. The change in the perception of the organization came about at a formal meeting in Conakry with the International President of MSF, Joanne Liu, which heralded the start of an unprecedented phase of collaboration with the Guinean authorities in the fight against Ebola. By this time, the virus had taken a significant hold in West Africa and the President had declared a state of public health emergency following the declaration by the World Health Organization (WHO) that the outbreak of Ebola in the subregion constituted a public health emergency of international concern.
As the MSF coordinator for the response to Ebola in Guinea between April and December, I propose to share my experience on the evolution of the relations established between this NGO and the government. This interaction was an important asset not only in MSF operations, but also in the long struggle to bring the epidemic under control.
A period of suspicion
In the first months following the declaration, the epidemic was largely perceived as a conventional health crisis. During this period, the authorities were encouraged in this view by the attitude and statements of the UN institutions in Guinea, failing to grasp the full scale of the crisis. The Head of State’s priority was therefore to try to reassure economic stakeholders and the public in a bid to minimise the socio-economic impact of the epidemic. It was thus the responsibility of the Ministry of Health, with the aid of its international partners, to stamp out the epidemic in the same way as they would tackle any other diseases common in the country, such as cholera, measles or meningitis.
It was inevitable that the alarming statements which came from MSF in March 2014, calling the epidemic “unprecedented”, and then announcing in June(1)Médecins Sans Frontières, Au-delà de nos limites Une année de lutte contre la plus vaste épidémie d’Ebola de l’Histoire [Stretched beyond our limits. A year-long struggle against the largest Ebola epidemic in history], MSF, March 2015, http://www.msf.fr/actualite/publications/ebola-rapport-au-dela-nos-limites that it was “out of control”, would not be well received by political leaders. These declarations, which were given wide media coverage, openly contradicted the official line.
Indeed, the first speeches by the President on the work of MSF were marked by criticism and suspicion. In May 2014, Guinea’s national press reported a declaration by the President in which he accused MSF of exaggerating the situation in order to raise more funds. He said, “Doctors Without Borders have not helped us, they have issued statements with the aim of raising enough money(2)“Ebola en Guinée : Quand Alpha Condé s’en prend à MSF, l’ONG de son ‘ami-jumeau’ Bernard Kouchner” [Ebola in Guinea: MSF attacked by Alpha Condé, his ‘twin-friend’ Bernard Kouchner’s NGO], Africaguinee.com, 12th May 2014, http://www.africaguinee.com/articles/2014/05/12/ebola-en-guinee-quand-alpha-conde-s-enprend-msf-l-ong-de-son-ami-jumeau-bernard”. Then in June, he summoned the Head of MSF to inform him that only the WHO would be authorised to communicate openly on the Ebola situation in Guinea. Not long after this, at the Health Summit, he called MSF and the other organizations “to be accountable”, saying, “their conduct has not been flawless(3)“Ebola : l’inertie des gouvernements mise en cause” [Ebola: putting the blame on government inertia], LeMonde.fr, www.lemonde.fr/afrique/article/2014/06/26/ebola-l-inertie-des-gouvernements-mise-en-cause_4446215_3212.html#0rOMzUZL4u7Q7fe9.99”.
However, probably fearing a strong reaction from MSF, several members of the government immediately distanced themselves from the President’s May 2014 criticisms, showing their support for MSF and their recognition of the work they had carried out. This was the case of Mohamed Saïd Fofana, the Prime Minister, of the Minister of International Cooperation, Koutoubou Moustapha Sanoh, and of the Minister of Social Affairs, Sanaba Kaba. For his part, the Minister of Health, Rémy Lamah, immediately went to visit the MSF Ebola Treatment Centre in Conakry to show his support for the Guinean staff, who had been demotivated by the President’s declaration.
The ambiguity in the perception of MSF was perfectly summed up by the Head of the National Health Emergency Committee in charge of Guinea’s response from March to August 2014, Sidiki Diakité, when he wrote that “MSF’s involvement […] was decisive and salutary, notably through the opening of the first treatment centres and the care of the sick”, while at the same time declaring that “certain partners have been reluctant to work together, being only interested in taking over the leadership of the response and thereby increasing their influence internationally”. He then concluded that “the National Health Emergency Committee had great difficulty in controlling the statements made by NGOs on an international level, in particular those of MSF, making the task of those in government more challenging and hardly likely to reassure investors in Guinea(4)Sidiki Diakité, “Ebola en Guinée : un révélateur des forces et faiblesses” [Ebola in Guinea: strengths and weaknesses brought to the fore], Humanitarian Alternatives, inaugural issue, February 2016, p. 57-65, http://alternatives-humanitaires.org/fr/2016/01/13/ebola-en-guinee-un-revelateur-des-forces-et-faiblesses/”.
During this initial period, one of the objectives of MSF was to play a role in educating and alerting the authorities and all those involved in the response to the outbreak, on the evolution of the epidemiological situation, during the coordination meetings, and thus to guide national relief efforts. However, although they respected and encouraged their medical operations, the authorities and their institutional partners, the United Nations, did not take MSF fully into their confidence when making important decisions. At this time, the organization was not invited to attend the strategy meetings of the interdepartmental committee responsible for managing the emergency.
It is possible that the public criticism of MSF by the President played a role in their exclusion, by damaging the credibility of the organization. Fortunately, these tensions at the national level did not have a significant effect on the medical activities of MSF, but it was still necessary for them to be appeased, so they could carry out their activities in a more favourable political environment.
“The President’s friend”
There was a radical change in the level of understanding and involvement of the highest State authorities as the epidemic worsened in the subregion. In the wake of the recognition by the Presidents of Liberia and Sierra Leone and by the WHO of the gravity of the Ebola crisis, on August 13th 2014, the President proclaimed a state of national health emergency. Then on September 4th, he set up, by decree and under his direct supervision, a new National Coordination Unit to combat Ebola, strengthening its operational and budgetary prerogatives.
From then on, the President would be omnipresent in the organization of the response, ensuring the various government services were up and running and regularly convening meetings with international bodies, private stakeholders and other partners involved in the response, even going so far as to threaten with serious consequences those he judged ineffective. No one was in any doubt that he had become the “boss”, as Sakoba Keita, the national coordinator, deferentially called him.
The visit from its international president gave MSF the opportunity to allay the doubts concerning the organization, giving a clearer explanation of its role, its operations and the reasons for its alarming statements. During this meeting, the President learnt that MSF was the only international organization caring for Ebola patients in Guinea and the neighbouring countries. An unprecedented period of collaboration then started during which MSF took on the role of respected technical advisor to the National Coordination Unit, leading to regular meetings with the President and his ministers.
By overcoming the mistrust of the President, MSF also gained more operational leeway while at the same time increasing its influence over decisions on a national level. This was the case for example in choices such as the gridding of the affected areas with Ebola reference treatment centres and transit centres, or in 2014, the backing of the decision not to have recourse to containment or coercive measures against those deemed recalcitrant.
Other examples show the importance of establishing good working relations. The idea of setting up the new National Coordination Unit in September 2014 was based directly on a suggestion from MSF in an official letter to the Ministry of Health warning of increasing coordination failures when the epidemic suddenly worsened.
Another situation also arose in September 2014, at the height of the epidemic in Macenta. With a traffic jam caused by the poor state of the road blocking ambulances carrying confirmed cases to the Ebola treatment centre in Gueckedou, several patients died without having been given the appropriate care. Urgent requests from MSF, backed by an interview on Radio France Internationale(5)« Ebola en Guinée : quand les ambulances font demi-tour » [Ebola in Guinea: when ambulances turn back], Radio France Internationale, 26th September 2014, http://www.rfi.fr/sports/20140926-ebola-quand-ambulances-font-demi-tour-guinee-msf, led to the rapid involvement of the Ministry of Transport and law enforcement agencies to restore priority passage for the ambulances.
The sympathetic attitude of the President towards MSF earned the emergency coordinator that I was the name of “the President’s friend”, as used by Fode Tass Sylla, head of communications for the National Coordination Unit.
MSF and the national authorities: between pragmatism and responsibility
MSF’s independence of action requires it to establish a direct dialogue with key players in an emergency. This is systematically the case with the national medical authorities, but it is not usual to have direct contact with the highest echelons of government. In reality, during the Ebola crisis, which generated many irrational and sometimes violent reactions resulting from the frightening nature of the epidemic, MSF’s exceptional expertise on Ebola dictated this choice. The situation forced us to use our teaching skills and to be proactive, in order to influence the decisions of national authorities.
To be able to influence strategic decisions, it is not enough to set up good-quality medical services. It is also necessary to gain the confidence of the political authorities who, as we have seen, can be rather wary of MSF. This means taking time to set up a genuine dialogue with the authorities, something that often fits somewhat awkwardly with the emergency mind-set of MSF.
In return, this involvement results in a de facto proximity between MSF and the authorities, and it is here that the organization must take care not be be “hijacked”. MSF must know how to refuse certain requests tactfully when they are not within the organization’s operational objectives. This was the case for example with requests to contact private companies, mining firms and airlines, or even the Saudi Arabian authorities in the case of the pilgrimage to Mecca, to reassure them regarding the epidemic.
In certain cases, the risk of being manipulated is even greater, such as during press conferences bringing together government representatives and the organizations most involved in the response, MSF, the WHO and the Center for Disease Control and Prevention (CDC). One way of reducing this risk has been to set up a validation process in order, for example, to avoid certain ministers asking editors to make last minute changes to reports, as happened at first.
The organization also found itself unwittingly embroiled in power games which could have had serious consequences. A memorandum on the management of the response to the Ebola outbreak dated September 23rd 2014, written by a senior official from the Ministry of Health and addressed to the President, did indeed accuse MSF of having influenced “the French government, via the French Ambassador and the Minister Ms Girardin, with the consequent risk that the French Red Cross would not find the funding necessary to run its operations”. This is ironic when we think that MSF was in the process of signing an agreement with that very organization to facilitate their intervention in Macenta. In this same memorandum, the official asked the President to replace the Emergency Coordinator, i.e. myself, with someone else. Fortunately, relations with the President had eased by the time the note was circulated.
Finally, these constraints remain manageable if MSF adheres to clear operational objectives and an area of intervention of which the authorities have been informed, and executes its activities reliably. When working in such close collaboration with the authorities, it is nevertheless important to ensure that the relationship continues to serve MSF’s purposes. An effective safeguard to guarantee MSF’s independence is to keep responsibility for communication with Head Office, while informing the mission of future communications. This system makes it possible to continue to raise awareness and to keep the key players in the emergency informed as and when the situation requires.
For MSF, developing this kind of interaction with the authorities is an exception, just as was the health and humanitarian crisis caused by the Ebola epidemic. For this close collaboration to be set up, it was necessary to establish a proper process of consultation and for the various partners involved to show a certain openness of spirit. This enabled MSF to contribute significantly to the definition and choice of the national strategies used in the response, while greatly facilitating the deployment of its operations to care for the people affected. It is remarkable that during all this period of intense socio-political tension, MSF did not experience any constraints when carrying out its numerous activities.
This situation was to a large extent dictated by the nature of the epidemic and by the expertise in treating Ebola acquired by the organization over the last ten years: MSF went beyond the purely medical sphere and care of patients, to respond to public health needs relating to control of the epidemic. This situation is also linked, unfortunately, to the failure of global health and humanitarian systems to come to the aid of the victims of the epidemic, and to the lack of experience and ability of the national authorities to contain the outbreak during the first few months.
Translated from the French by Faye Guerry
The end of the Ebola outbreak in Guinea was first declared on December 29th 2015, followed by a second declaration on June 1st 2016, after a resurgence of the disease. According to the WHO, the total number of cases recorded was 3,814 with 2,544 deaths (67%). In the five treatment centres run by MSF in Guinea, of the 1,939 confirmed cases admitted 916 patients survived, that is 72% of the total number of patients cured in Guinea (1,270).
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|1.||￪||Médecins Sans Frontières, Au-delà de nos limites Une année de lutte contre la plus vaste épidémie d’Ebola de l’Histoire [Stretched beyond our limits. A year-long struggle against the largest Ebola epidemic in history], MSF, March 2015, http://www.msf.fr/actualite/publications/ebola-rapport-au-dela-nos-limites|
|2.||￪||“Ebola en Guinée : Quand Alpha Condé s’en prend à MSF, l’ONG de son ‘ami-jumeau’ Bernard Kouchner” [Ebola in Guinea: MSF attacked by Alpha Condé, his ‘twin-friend’ Bernard Kouchner’s NGO], Africaguinee.com, 12th May 2014, http://www.africaguinee.com/articles/2014/05/12/ebola-en-guinee-quand-alpha-conde-s-enprend-msf-l-ong-de-son-ami-jumeau-bernard|
|3.||￪||“Ebola : l’inertie des gouvernements mise en cause” [Ebola: putting the blame on government inertia], LeMonde.fr, www.lemonde.fr/afrique/article/2014/06/26/ebola-l-inertie-des-gouvernements-mise-en-cause_4446215_3212.html#0rOMzUZL4u7Q7fe9.99|
|4.||￪||Sidiki Diakité, “Ebola en Guinée : un révélateur des forces et faiblesses” [Ebola in Guinea: strengths and weaknesses brought to the fore], Humanitarian Alternatives, inaugural issue, February 2016, p. 57-65, http://alternatives-humanitaires.org/fr/2016/01/13/ebola-en-guinee-un-revelateur-des-forces-et-faiblesses/|
|5.||￪||« Ebola en Guinée : quand les ambulances font demi-tour » [Ebola in Guinea: when ambulances turn back], Radio France Internationale, 26th September 2014, http://www.rfi.fr/sports/20140926-ebola-quand-ambulances-font-demi-tour-guinee-msf|