National and international stakeholders are racing to assess the scale of the Ebola outbreak in the Democratic Republic of Congo (DRC) and determine how to respond. While DRC has a history of containing Ebola – this latest outbreak is its ninth since Ebola was first identified in 1976– the identification of a confirmed case in Mbandaka, a city of a million people, has caused alarm. As the current outbreak and response unfold, it is important to take stock of lessons identified during the 2014–16 Ebola outbreak in West Africa, which infected 28,600 people and killed more than 11,325. It prompted major public health, humanitarian and military interventions, and the knock-on effects in Sierra Leone, Liberia and Guinea – to economies, agricultural production, financial stability and the social fabric – were wide-ranging and substantial. Drawing on our research on the Ebola response in West Africa, here are four things for practitioners to consider.
The importance of staying ahead of the curve
The best time to mount an effective response to an Ebola outbreak is yesterday, because the incubation period (of up to 21 days) between contracting the disease and becoming symptomatic can make it difficult to quantify and contain an outbreak. The importance of mounting an effective response before the outbreak spirals out of control cannot be underestimated. In West Africa early opportunities were missed, and the response consistently lagged behind the outbreak. Early recognition must be followed by timely and effective action.
Vaccines are important, but community engagement remains essential
Doses of Merck’s experimental Ebola vaccine rVSV-ZEBOV, which has been shown to offer effective protection against Ebola, have reached DRC. The vaccine – which is being offered to responders and will be dispensed to people who have had contact with confirmed cases – marks a significant development in Ebola response. While it is not a proven silver bullet, and implementation will mean overcoming significant logistical challenges (such as maintaining the vaccine ‘cold chain’ in DRC’s remote terrain), the vaccine should comprise one part of an effective response.
Another critical component must be listening to and working with affected communities. Issues around communication, community engagement and trust marred the early phases of the West Africa response. Top-down communication sidelined the communities whose engagement was essential in enabling people to protect themselves and others from infection. Effective community engagement can reduce mistrust of and resistance to health authorities and stigmatisation; prevent transmission of the disease; identify safe, supportive practices of care; and develop safe and supportive burial practices. The early stages of the West Africa surge did not prioritise such engagement or capitalise on affected communities as a resource, but treated them more as a problem to be overcome or as a security risk, and as hidebound by culture and unscientific reactions.
The impact of fear should not be underestimated
Most Ebola reports and lessons learned written through the rational lens of hindsight fail to explain, or at the very least acknowledge, the complex role fear plays in Ebola epidemics and responses. The effects of fear can be seen everywhere: in the behaviour of individuals in affected communities, the recruitment of staff at national and international NGOs, the policies of critical industries such as airlines and insurance, media reporting and the responses by governments, in affected states, regionally and globally. Efforts to acknowledge and mitigate fear and fear-driven responses should be prioritised from the outset. This includes listening to communities, addressing issues surrounding staff recruitment and duty of care and providing effective training for national and international responders.
The intersection of domestic, international, health and humanitarian agendas
Unlike the Ebola outbreak in West Africa, this outbreak has hit a country suffering from ‘one of the most complex and longest-lasting humanitarian crises in the world.’ In West Africa, the decision to avoid the ‘humanitarian’ label meant that the surge capacity, emergency funding and coordination structures typical of a large-scale disaster response were not triggered, and the formal cluster system was not activated. While this had the positive effect of compelling national authorities to take the lead in the response, it also left many non-health NGOs unsure of how or where to engage. Treating Ebola predominantly as a public health crisis, especially in the early stages, also meant that its wider implications, for instance for education, livelihoods, protection and political stability, were downplayed or ignored. Both humanitarian and public health responses stand to play a critical role in addressing this outbreak in DRC – systemic issues surrounding incentives, institutional mandates and funding must not be allowed to undermine a cohesive and effective response.
Applying and implementing the lessons of the West Africa Ebola outbreak response can help save lives and ensure this outbreak remains small and contained. Everyone involved – national government, NGOs, the international community – must ensure that the same mistakes aren’t made again, for the sake of the affected communities that must be at the heart of the response.