Whose priority is Ebola?
In this series of articles, medical students from across the country will discuss a range of topics from medical ethics to the NHS to public health to medical conditions to clinical governance
The unprecedented headspace flooding by Covid-19, is a familiar experience for many communities around the world. This includes regions where conflict is present or other humanitarian crises like epidemics and famine exist. In current times, mention of the number of Covid-19 related fatalities, has become almost arbitrary; the figures human dignity reducing and disconnected from the voids left in the lives of loved ones. The response to a humanitarian crisis hinges on saving lives, but also on the trust of impacted communities and education to end misinformation, stigmatisation and avoidance. This concerns acknowledging, and aiming to better the context that the crisis is established in.
Since August 2018, The DRC has been battling with the world’s second largest Ebola Virus Disease (EVD) epidemic on record, affecting Kivu and Ituri provinces. EVD is a serious viral infection with a varied and complicated clinical presentation, as well as a high mortality rate. This rate has been 60-70% throughout this outbreak. The DRC government, the World Health Organisation (WHO), national and international NGOs, the health workforce and local community leaders have driven the response against Ebola. The number of EVD cases are decreasing, teams are being pulled to other emergencies and it seems that the end of this outbreak is in sight. Now, the WHO waits for two full incubation periods (42 days) with no new cases to declare the end of this epidemic.
Is this a picture of hope and relief? In reality, this is paired with the devastating and enduring fear, disappointment, and fatigue amongst the communities affected.The prospect of navigating the unmet needs of this crisis, and informing for future missions, necessitates an investigation of the (deadly) mistakes related to this massive operation.
‘Systematic and catastrophic failure’ - Karline Kleijer (Médecins Sans Frontiers (MSF), Head of Emergencies)
The Ebola virus flourished amidst the ongoing brutal Kivu conflict, political instability, as well as inadequate access to healthcare services and safe drinking water. It seems unrealistic to assume that there weren’t going to be failures and compromises in such a complex scenario. Regardless, the response has shown this:
Obviously, this equation does belittle the storm that Ebola virus found in the DRC. However, it also places pivotal focus on dealing with communities at the core of crises very sensitively. It sheds light on the need to focus on building a foundation of trust and confidence for future collaboration, if it becomes necessary.
Initially in the response, a lack of community engagement alienated people, further instilling the deep lack of trust in the authorities. Forced isolation of patients and burials carried out in the absence of respected customs, underlined a contradiction of traditional family based caring practices as well as rejection of Ebola treatment by the communities. A lack of communication fostered suspicion and exacerbated a scepticism of the success of modern health interventions- a mistrust linked back to colonial medical campaigns. Many were suspicious of the epidemic being a political ploy; in the December 2018 DRC presidential election the virus was thought to be used to control the electoral power of those who were likely to be opposition-voting. Some believed that EVD was caused by witchcraft. The use of coercion in involvement of the police and armed forces for complying with anti-Ebola health measures only contributed to an increase in people dying from Ebola in communities. This, disastrous and counterproductive, compromised the tracing of contacts and determination of Ebola virus transmission patterns.
The existence of Ebola treatment centres started becoming ironic; people were reluctant to use them and they alongside health workers suffered over 300 attacks. In a Journal of Infectious Diseases analysis, it emerged that ‘Ebola-targeted violence had the largest impact on EVD transmission, and this effect is primarily driven by civilian-involved violence’. Devastatingly, ‘sixteen events over a 21-day interval increased EVD transmission by 60%.’ Periods of intensified violence compromised vaccine programmes, disrupted the provision of vital care by Ebola responders, and discouraged engagement in EVD treatment.
It seems impossible to consider a scenario where a highly infectious virus, that kills the majority of those infected, isn’t the main priority of groups involved. In the eyes of the communities at the core of this outbreak, Ebola is just one of the doors through which death comes. For them, a massive Ebola-centred deployment of financial resources neglects concerns of malaria, measles and pneumonia, all which have been long-standing health concerns. It ignores the catastrophic scale of poverty and hunger. For them, it has done nothing to address the insecurity that has destabilised most of their lives. For them, they witness a large sum of money directed at ebola reaping nothing but corpses.
The vicious and volatile cycle of the community feeling ignored, neglected, and violated, forced response coordinators and emergency teams to review the situation. Determined, they turned focus to the priorities of the communities affected. MSF provided access to free healthcare for illnesses affecting the population, built wells to give access to clean water, and began caring for suspected Ebola cases in the community. The Red Cross ‘persists in addressing community fears, investing in a locally-led response’. Education via community health workers became evident to be just as important as the parallel treatment of EVD. In actively contributing to the building of new Ebola isolation units, communities started to claim them as their own. The number of deaths from Ebola in the community dwindled.
Trish Newport (Project coordinator, MSF) claims that one of the lessons learned from the West Africa Ebola outbreak of 2014-2015 was that ‘community engagement was essential to stop an outbreak early’. It is disappointing, first that this lesson was essentially forgotten. In August 2018, Oxfam reported that only 3.6% of the DRC outbreak response budget was dedicated to community engagement, and only 1.6% to supporting survivors and victims’ families. Secondly, it’s a huge injustice that it took treatment centres being burned down, and health workers coming under gunfire, for the response to initiate positive changes that would be meaningful even past the end of the outbreak.
We can accept that the conflict and insecurity faced by the DRC made response efforts in this epidemic extremely difficult. But, should we celebrate that the outbreak was contained despite the difficulties? Would this normalise poor communication, ignorance and the use of coercion as frontline in the response to a humanitarian crisis? From the community perspective, the initial management of the Ebola virus, reaffirmed a pre-existing trust deficit. This negated the Ebola virus as anyone’s priority. The powerful impact of following the direction of the community in decisions that are related to their health, can’t be forgotten in the management of future outbreaks to come. This, and also the fact that ‘Patients must be treated as patients not some kind of biothreat’ (Dr Joanne Liu, as MSF international President March 2019.)
Oxford Medical Student