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New Ebola outbreaks: putting context and community first

Written by Kerrie Holloway, Marc DuBois

Hero image description: DRC: A trip to the front lines of the fight against Ebola Image credit:World Bank / Vincent Tremeau Image license:CC BY-NC-ND 2.0

Ebola has returned to Guinea and the Democratic Republic of Congo (DRC). Already the response to these outbreaks differs significantly from previous ones – both were detected early, and responses have already been mounted.

International donors and agencies will be scrambling to kick-start an international response but, to avoid the failures of the past, the response should be owned by Guinea and DRC rather than the international community, guided by community priorities and grounded in local health structures. Ignoring these priorities and failing to embed them in the response contributed to previous prolonged, destructive outbreaks in the top-down responses in West Africa and eastern DRC.

Contextualise the response

The first priority must be to make the response relevant to each context. Previous Humanitarian Policy Group (HPG) research on the 2014–2016 outbreak in West Africa and forthcoming research on the 2018–2020 outbreak in the DRC (commonly known as DRC’s 10th outbreak) demonstrates that the main challenge at the outset is to place context at the centre of understanding problems and charting a strategy forward. We know from previous responses that this cannot be reduced to an anthropological understanding of ‘traditional’ beliefs. Crucial contextual guidance should be both specific to communities and national in its scope, with previous responses failing to appreciate the impact of national politics on local intervention.

Guinea’s last outbreak occurred in 2014–2016, but large strides have since been made in the development of preventative vaccines and therapeutic treatment. Crucially, today’s response must recognise that Guinean’s past experiences may be outdated and work to counteract the lingering stigma of Ebola virus disease (EVD). By contrast, eastern DRC’s last outbreak ended last year, so communities there should have a better understanding of the disease and what it takes to defeat it. Meanwhile, the missteps that led to corruption and what became known as ‘Ebola business’ must be avoided to build communities’ trust in the response.

In both countries, the broader context of Covid-19 must also be considered – not because either country is in the midst of a large outbreak, but because many other countries are. More than ever, local health structures and community ownership will be essential as the international health response system grapples with the pandemic and has less surge capacity, financial resources and ability to travel than in previous EVD outbreaks.

Focus on whole ecosystem of needs, not just Ebola

In Guinea and eastern DRC, Ebola is just one of many health risks, and health is just one of many unmet needs. However, in both previous responses, the international community remained focused strictly on eradicating Ebola, despite other intersecting crises. Yet, when Ebola is not the main concern of the community, and their priorities are left unaddressed, the response is more likely to struggle because it remains, in the eyes of the people affected, a response for and in the self-interest of the responders.

The reappearance of Ebola in both of these areas means this is a humanitarian and health emergency, as well as a longer-term public health concern. Thus, the community’s whole ecosystem of needs should be considered in response planning. Ebola should be one focus among many, and the other priorities should be set by the community. Other diseases – such as measles, malaria and cholera, which killed more people during the 10th outbreak in DRC than Ebola – should be given adequate attention, so that the focus is appropriately on saving lives in these communities, not just stopping the spread of a single disease.

Strengthen local health structures

Local health structures in Guinea and eastern DRC will struggle to deal with another outbreak of significant size, highlighting missed opportunities in previous outbreaks to strengthen health systems. In the DRC, despite a $1 billion international response, forthcoming HPG research shows the region is no better prepared to tackle this outbreak than the previous one.

To break the cycle of large international responses being parachuted in with every new EVD outbreak, local health structures must be fortified and placed at the centre of the response. Rather than set up temporary Ebola treatment centres, money should be invested to make existing health centres fit for purpose. Local doctors should be employed and trained in combatting Ebola, alongside doctors from elsewhere, and all should be paid and treated equally. Ebola should be treated as part of a community’s overall health needs, and local health structures strengthened to the point where this is possible. This is particularly true in DRC where, arguably, Ebola can now be considered an endemic disease.

Engage with communities for ownership, not access

Placing insufficient weight on community engagement was one of the main faults in the 2014–2016 West Africa response, and was one of the nine objectives named at the start of the response in the DRC’s 10th outbreak. Yet community engagement has rarely progressed further than employing anthropologists and top-down risk communication with the aim of accessing communities and triggering behaviour change.

At the very least, information gleaned from social science experts and communication with communities must be used to design the next responses, not smooth their pre-determined trajectory. In Guinea, this will be particularly crucial as vaccines are rolled out for the first time. Community engagement in both contexts should aim to get communities on board with the preventive measures necessary for combatting Ebola and instil in them a sense of ownership over the response. This proved critical to ending DRC’s 10th outbreak, where cases only began to decrease when the response was decentralised fully to the community level, community leaders and local NGOs became involved and communities felt responsibility for their own care.

Never before have we been confronted with two simultaneous Ebola outbreaks, in two different parts of the world, while also battling a pandemic. Resources will be stretched, and it will be more important than ever to control the Ebola outbreaks in Guinea and DRC quickly. To do so, these responses must be approached in ways that make sense for the individual contexts, not just the international community.