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The Guardian’s Editorial declares “The second largest outbreak of the disease has already sickened thousands. WHO’s declaration of an emergency of international concern should prompt more and better support”.

In addition to urging more supppot for the critical WHO response The Guardian also points to the Ebola Gbalo Research Group’s findings on the need for locl leadership to the response “community leaders and local staff must take the lead in the response, and that supporting home care as an interim, if far from ideal, measure may be necessary.”

By Paul Richards, Njala University, Mokonde, Sierra Leone

The unexpected outbreak of Ebola Virus Disease in Guinea, Liberia and Sierra Leone in 2014–15 constituted the world’s first epidemic. A more recent outbreak in eastern Democratic Republic of Congo (North Kivu and Ituri Provinces) in 2018–19 has also begun to assume epidemic proportions. Medical responses in both countries have been met by local resistance. 

The arguments are worryingly similar. Ebola, it is asserted, is not real. It is a money-making or political scam, by unpopular governments or distant international agencies. The alleged intent is to make money by harvesting blood or body parts, or to reduce populations for political or religious ends. Ebola is a plot. 

This results in non-reporting of cases and attempts to nurse family members at home, often using treatments associated with African traditional medicine. Without biosafety protection for home carers, infection is clustered within specific families or villages. The resulting situation pits ‘the people’ (family or community more broadly) against the political and medical authorities (conceived as remote elites with bad intentions).

Ebola, in other words, generates a populist politics.

There are many definitions of political populism, but all share a basic idea of opposition between ‘the people’ (good, moral) and an ‘elite’ (bad, immoral). Populism mandates ‘the people’ to take action into their own hands, regardless of existing norms or laws. 

Populism appears to flourish in market economies in which a majority of small, independent producers see themselves pitted against distant and manipulative elites.  Family farmers directed much of their populist ire against banks and financiers in a locally influential populist political movement in the US Mid-West at the end of the 19^th century. 

If populism is a direct challenge to established forms of public authority it also feeds on rumour. Research suggests that people scoring high on measures of populist affinity are more likely to believe in unsubstantiated plots and conspiracies, such as the idea that Ebola is germ warfare gone wrong. 

That Ebola should develop a populist politics is an unexpected finding, since it is confined to Africa, and Africa has been deemed the continent least affected by populist political tendencies, perhaps because market forces are relatively under-developed.  This may be beginning to change.  In Sierra Leone, market integration through better road and rural transportation has been a feature of the post-civil war economic landscape

A rare exception to the notion that populism is uncommon in sub-Saharan Africa is the foreign policy of the late Libyan leader Colonel Gaddafi, who sought to promote populist uprisings in several West African countries, including Sierra Leone, based on the philosophy of his Green Book, which advocated for direct political action based on citizen assemblies. In the 1990s this was a powerful influence among the youth of the region, alienated both from distant diaspora elites and from their own tradition-bound rural communities.

Gaddafi’s project motivated a number of sub-Saharan insurgencies but failed to strike lasting roots.  So why does Ebola generate a widespread populist political response, where the oil money of the Libyan leader could not?   

Populism grows through the strong opposition of community and elite values.  

Post-war market integration in Sierra Leone has generated a wider awareness of differences in wealth and life chances between political elites and the ordinary people.  The civil war drove many people temporarily out of the countryside and into refugee camps, where they became aware (often for the first time) of huge differences in life chances between the urban elite and rural poor. 

Some went back to the villages after the war, but many have continued a betwixt-and-between existence in large rural towns such as Lumpa and Waterloo, hoping to tap better educational opportunities for their children living in the shadow of the rich. It was in these districts that Ebola spread like wildfire, based on a veritable storm of denial sustained by charismatic religious figures, such as an Imam in Waterloo who stirred up great excitement by promising a cure for the disease until he, himself became infected and died.

Political scientists advise that to counter the growth of populist politics directly by categorising those who advance this agenda as wrong-headed, deluded or ill-informed only serves to strengthen populist support. ‘We know better than you’, or ‘trust me, I am a doctor’ feeds basic suspicions that the truth is being hidden. 

The populist prefers self-reliance. In Sierra Leone, fevers (mostly caused by malaria) respond to family tender loving care. In Sierra Leone, pepper soup is the great pick-me-up. Home cooking strengthens the will to live. So, it is the line of first defence when Ebola strikes – a disease in which the initial symptoms are malaria-like. 

The international response to Ebola (by contrast) sends an ambulance with a siren screaming to the sick person’s door. The patient is then forcibly removed, with a moon-suited hygienist spraying great gusts of pungent chlorine on their departing footsteps. The tearful family follows at a distance, carrying a bowl of food to offer the patient hope of life, only to be turned away by security guards at the treatment centre gatehouse. 

Bombarded by international media messages that 90 per cent of Ebola victims are doomed to die, the over-wrought family can only conclude that this is indeed nothing like a hospital.  Rumours of blood and organ harvesting, and death camps, quickly find a home. 

In Sierra Leone rumour spreads mainly by word of mouth. The other great medium for propagation of rumour – the internet – has only limited reach in Sierra Leone. According to the 2015 census 87 per cent of Sierra Leoneans over 10 years-old lack internet access. This figure is even higher in districts where Ebola first emerged and for people over 40. So, whether Ebola was judged real or not mainly depended on how people reacted to government warnings conveyed over the radio, versus the interpretations of friends and neighbours on the street. 

What can be done to overcome this populist reaction, now dogging the steps of Ebola response in North Kivu? 

Medical treatment has to change. A large and distant centre devoted to only one disease, which most people have never before encountered, is a recipe for potential misunderstanding. Ebola response has to embrace family concerns. 

A big step forward in Sierra Leone was the opening of community care centres (CCCs).  Smaller and more quickly built than Ebola Treatment Centres, these were located in places where cases were on the rise. Their function was to test the sick, in order to isolate Ebola patients, sometimes by referral, sometimes within the CCC itself. Families could more easily accompany patients to a small, local CCC, and visit repeatedly to track progress. Even home-prepared food could be readily supplied. 

A further but equally important function of the CCC was once a patient was admitted all kinds of sicknesses were treated, and not just Ebola. Those testing negative for Ebola were treated free of charge for malaria, typhoid and other complaints. This encouraged rapid reporting, and thus rapid disruption of infection chains.

The manner in which public authority was exercised, and by whom, was also important.  Increased military involvement was often counter-productive, since it seemed to confirm rumours about political bias or germ warfare. Community-based leaders, including traditional chiefs, were more effective than politicians or technocrats. Ebola is a family disease (it spreads among those who provide intimate care) and chiefs and elders are frequently consulted to help deal directly with family matters.

The current problem in North Kivu is even more perplexing than in Sierra Leone since lack of trust is compounded by armed conflict; a cease-fire is an agreed urgent need.

But halting armed conflict will not be enough, by itself, to address the populist challenge unless Ebola response itself changes.  As in Sierra Leone, it is beginning to be recognised in eastern Congo that a tunnel-visioned focus on Ebola is a recipe for failure. A better approach is to address other major local health challenges while simultaneously mobilising communities to play a more active role in disease control, through (for example) taking responsibility for case finding and safe burial.  This way, trust emerges from the wider engagement between responders and communities.  Unhelpful rumours then have less fertile soil in which to grow.       

Members of the Ebola Gbalo Research Group Prof Susannah Mayhew and Esther Mokuwa reported on their findings and engaged senior WHO and IFRC health and emergency response leaders on lessons to be learnt for the DRC outbreak at an event hosted by Dr Michaela Told at the Graduate Institute Geneva / Global Health Centre on 13 May 2019.

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The Ebola Virus Disease outbreak in West Africa in 2014 shook the world and dramatically highlighted the need for new approaches in responses to disease outbreaks, including strengthening resilient health systems. While much has been learnt from the 2014 crisis, the current outbreak in DRC has underlined again the challenges of operating in a fragile context.

The event discussed the lessons learnt from the West Africa outbreak and their relevance for the current crisis in DRC. It was be informed by findings of a three-year ethnographic study entitled “Ebola Gbalo” undertaken by the LSHTM and Njala University and aimed to  define pathways on how we can better support communities in responding to an Ebola outbreak in a challenged context & the role of policy-making in this.

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• Programme
• Biographies of Speakers
• Pictures of the Event
• Responding to the Ebola virus disease outbreak in DR Congo, The Lancet

Ahmed Vandi and Lawrence Babawo of Njala University presented research of the Ebola Gbalo Research Group on the role of the Districts in responding to the Ebola crisis at the 2018 Liverpool Global Health System Research Symposium.

Against widespread assumptions about rapid and early collapse of the health system, the authors find that before the arrival of international actors, local involvements at district and community levels can be of great help in initial epidemic interventions.

However, overall many District health systems are fragile and benefit from continued central support including for training of middle level health workers to recognise and investigate eminent disease outbreaks at the lower levels of the health system.

The Ebola outbreak in the DRC is escalating. The Ebola Research Group reflects in a new article on lessons from Sierra Leone and how frontline workers and communities can be brought in more centrally into the design and implementation of the response.

https://respondingtoebolaorg.files.wordpress.com/2019/05/lancet_ebolagbalo-sierraleone-lessons-for-drc_pre-print-for-posting.pdf

It is unclear how public authorities shaped responses to Ebola in Sierra Leone. Focusing on one village, we analyze what happened when “staff, stuff, space, and systems” were absent. Mutuality between neighbors, linked to secret societies, necessitated collective care for infected loved ones, irrespective of the risks. Practical learning was quick. Numbers recovering were reported to be higher among people treated in hidden locations, compared to those taken to Ebola Treatment Centres. Our findings challenge positive post-Ebola narratives about international aid and military deployment. A morally appropriate people’s science emerged under the radar of external scrutiny, including that of a paramount chief.

https://www.tandfonline.com/doi/full/10.1080/01459740.2019.1609472?scroll=top&needAccess=true

We have posted key project presentations from Antwerp, Liverpool, Bo/Freetown and London https://responding-to-ebola.org/presentations/

Please view the summary of the research protocol