A review and critique of current dynamics by Prof. Paul Richards, Ebola Gbalo Research Group
The Ebola outbreak in north-eastern Democratic Republic of Congo is dramatically worsening. It began in August 2018, and there was a prompt and forceful international response, based on lessons learnt from the West African epidemic of 2013-15. Treatment centres were rapidly put in place. Vehicles and equipment are available. An effective vaccine to protect front-line health workers has been deployed. And yet things are going from bad to worse.
The major voices in the international community explain this reverse by reference to the complex and chaotic war raging in the region. Ebola centres are attacked. Convoys are at risk. Health workers have been killed.
Voices on the ground, however, talk about another issue. People are dying in their communities, meaning that they either do not understand the disease, or they have not been mobilized to play a key role in the response.
The Guardian (May 15th 2019) reports one of these on-the-ground commentators as saying “the agencies needed to have the local people actively working against Ebola. Anything else is a band-aid solution.”
The West African epidemic was considered a wake-up call and the international agencies heeded the warning. Could it be, however, that the wrong lessons were learnt?
The vigorous, top-down, part militarized response in place at the end of the West African epidemic is not the best model for Ebola control in an active war-zone such as North Kivu. Maybe it would be better to look at the early days of the epidemic in West Africa, when the international responders were few, and resources – from vehicles to rubber gloves – were in short supply.
What happened in the rural districts first infected, such as Kailahun District in Sierra Leone and Lofa County in Liberia?
Quite surprisingly, the epidemic ended promptly in these areas. In fact, in some of the worst affected parts of Kailahun District the epidemic ended before the international response was deployed.
New terminology had to be invented. Those areas where Ebola peaked and then quickly disappeared were classified as “silent districts”.
It transpired that the “silent” areas were where local people had been most active in working to halt infection chains. Community members quickly saw that the disease spread from person to person through touching patients. Carers improvised protection from plastic bags and coats worn back-to-front. Chiefs and elders passed bye-laws restricting movement from village to village and quarantined affected households. Hand-shaking was abolished!
One chief, who lost his wife in the first stages of the epidemic, organized and instructed volunteer burial and case finding teams through his open bedroom window, while serving a forty-two-day quarantine, and daily tapping advice from an infection control specialist in a near-by town via his cell phone.
These local examples convey a different lesson about Ebola response; and most importantly, it is one that can be applied under conditions of low-level armed insurgency.
Explanations of how the disease works and what to do to protect against it can be conveyed by phone or radio broadcasting, without trainers needing to be present on the ground. Key supplies (rubber gloves, boots, chlorine, vaccines) can be airlifted by drones if roads become impassable due to risk of ambush. Local volunteers finding cases or contacts on foot attract little notice, whereas well equipped treatment centres with brand new ambulances stir the interest of belligerents, whether to loot or make a political statement.
Posters or leaflets can advise what families or burial teams can do to minimize infection risks. When communities are cut off from sources of outside help these can be air-dropped. A suitable graphic was prepared for use in Sierra Leone covering what to do while waiting at home with an Ebola patient, and its impact was increased by radio discussion.
If insecurity halts inter-village movement this is an advantage; reduced movement helped limit infection chains in the West African epidemic.
Of course, it would be better if a cease-fire could be arranged in north-eastern Congo, to allow specialist Ebola care centres to operate, but while conflict persists the pressing need is to help local communities develop their own capacity to respond to the disease. A key lesson of the West African epidemic is that local solutions were often surprisingly effective when given a chance.
Paul Richards is a British anthropologist who contributed to the Ebola Gbalo project, an assessment of local and national responses to Ebola in Sierra Leone. His book, Ebola: how a people’s science helped end an epidemic was published by Zed Books in 2016.