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Saving Lives and Learning Lessons
In 2006, Angola’s worst-ever recorded outbreak of cholera affected 15 of the 18 provinces. The crisis emerged just as MSF was withdrawing from the country after 23 years, a fact that may have restricted the initial reaction and delayed intervention. Despite treating almost 40,000 people, MSF directors requested a full evaluation of the program to determine MSF’s effectiveness and efficiency and, equally important, document any lessons learned.
Although cholera had previously been endemic in Angola, there had been no significant outbreaks in 10 years. However, the many years of civil war had seen massive population movements into towns without any significant expansion or improvements to sanitation systems.
Population density, poor sanitation and regular population movement combined with catastrophic effect in mid-February. Within six days of the first cases being detected in the capital Luana, an epidemic was declared. The disease quickly spread along the main transport routes to neighboring provinces.
As MSF was preparing its withdrawal from Angola, there was an assumption that the outbreak would be handled by the Ministry of Health, without investigating its capacity to do so. Relying on official data on the epidemic that eventually proved anything but reliable meant MSF teams also underestimated the potential scale of the crisis and took longer than usual to become functional. Even then, continual surveillance systems were weak and data recording patchy.
These factors were exacerbated by the failure to appreciate the changed context of this emergency. Whereas previous cholera outbreaks had been restricted to the capital and coastal areas, the greater freedom of movement and accessible transport systems meant there was a significantly increased risk that transmission of the disease would spread inland.
At the same time, the dramatic growth of Luanda’s population rendered the classic urban strategy, which relies on the speedy movement of ambulances to ferry patients to a single treatment center, unsuitable and ineffective. And MSF’s late reaction meant the usual balance of early prevention and curative activities became, by necessity, focused on curative activities only.
All these lessons to be learned were highlighted in the evaluation report. Yet, despite these oversights and obstacles, MSF teams still cared for nearly 80 per cent of all cases treated in the country during the crisis accounting for more than 40,000 people of which most survived (with a case fatality rate of only 2.3%). In addition MSF organized appropriate logistics, coordinated sufficient supplies to be brought into Angola, and acted when no one else did. MSF also raised awareness of this forgotten epidemic and called on other agencies to also intervene.
No intervention can ever be described as ‘perfect’. There will always be a system that might have been more effective, a process that might have been more efficient, a treatment that might have been more available. No organization can ever become truly accountable unless it accepts this reality – because it means there is always room for improvement and it is always worth striving for more.