Community first: the key to stopping the Ebola epidemic

The tenth Ebola outbreak in eastern Democratic Republic of Congo (DRC) was declared in August 2018. Nineteen months later, it has resulted in over 3,400 confirmed and probable cases and more than 2,200 deaths. By October 2019, the head of the Ebola response, Dr. Jean-Jacques Muyembe, and the Congolese government in Kinshasa were predicting that the outbreak would come to an end before the year was out. They had good reasons for this optimism: the caseload had fallen to an average of eight a week in the first three weeks of November – a sharp decline on the 112 cases or so a week at the peak of the outbreak in May 2019. Transmission had been confined to a small set of four neighbouring health zones. An air of hope prevailed among response actors.

Serious security incidents targeting response teams in late November 2019 had an impact on the progress made over the past months. Security challenges led to epidemiological hurdles because of the reintroduction of the virus in urban centres that had previously been cleared. Additionally, a survivor who was working for the response suffered a relapse of the virus in December 2019, directly infecting over 30 people. Although relapses are rare, epidemiological experts have expressed their concerns about this and other similar cases, in terms of the increased severity of the virus in the survivor’s body. Response efforts are being reinforced to get back on track to beat the epidemic and stop transmission.

Resistance

The Ebola outbreak in DRC is the second largest the world has seen and the first in an active conflict zone. One of the main challenges from the outset of the response was the local population’s resistance to health workers, response partners (including NGOs) and the response itself. In the early months of the epidemic, the response focused mainly on medical treatment and primary care. It was essential to ensure that local health structures effectively treated patients to prevent the spread of the virus. However, a top-down structure and messaging and response activities that were not adapted to the local context and traditions meant that communities felt alienated from decision-making, leading to mistrust and increased resistance in an area where decades of conflict had already instilled mistrust in the government, its armed forces and international actors. These conditions served as a breeding ground for rumours and false information during the first part of the response.

Analysis of community feedback has revealed key issues in the response, including lack of harmonisation or consistency in messaging, which was also at times too vague or technical; mistaken or non-existent translation into local languages; and a militaristic approach involving the use of armed escorts to access Ebola-affected areas. As an example, Safe and Dignified Burials (SDB) put in place to avoid further contamination created tensions between the response and local communities in the early months. While this procedure is efficient and wellknown to health practitioners, SDB teams initially did not take into account local customs or cultural practices, such as how, in some areas, only men should carry the deceased’s body. After teams collected and analysed feedback, they recruited all-male SDB teams to address community concerns. Other procedures have also been adapted, such as using body bags with clear plastic windows instead of all-black bags so that relatives can see their loved one as they are laid to rest.

The early months of the response also coincided with a contentious period in Congolese politics. Delayed presidential elections, the suspension of voting in Ebola-affected areas and ongoing violence contributed to the politicisation of the response and increased popular skepticism as Ebola was perceived as a ‘political tool’ to interrupt the elections and prevent people from voting. In 2019, the World Health Organization (WHO) documented an estimated 390 attacks on health facilities in DRC, killing 11 health workers and injuring 83 healthcare workers and patients. T. Ghebreyesus, ‘Ebola Responders Face Deadly Attacks’, The Guardian, 10 December 2019. A third of these incidents were acts of resistance to the response.

A system-wide scale-up

Based on community feedback and the duration of the outbreak, it became evident that a health response alone was not a sustainable approach; instead, an approach that was more attuned to community needs and adapted to the local context was required. In late May 2019, a system-wide scale-up of the Ebola response was declared that adopted a more community-centred approach. Advocacy and coordination work by a group of INGOs, including Mercy Corps, played an important role in this overhaul. Several INGO meetings were held to agree on harmonising community engagement across interventions, and integrating anthropological research such as that carried out by the UNICEF Social Science Research Group (SSRG).

A community-centred approach

Under the scale-up, addressing the most pressing humanitarian and social issues facing affected communities and improving access to essential services became response priorities. However, there are still some challenges: while organisations are increasingly collecting feedback from communities, few are perceptibly adapting their activities, and more advocacy is needed within the response for different strategies that could adapt response activities to meet local concerns. To address this issue, Mercy Corps and other response actors have been implementing community engagement approaches in line with the Community Engagement Commission led by the Congolese Ministry of Health and UNICEF. Risk communication and community engagement work needs to continue even after the epidemic ends, as a means of helping communities develop their own strategies to fight the current outbreak and prevent future ones, and to help people recover from this outbreak’s social and economic impacts.

Mercy Corps has also expanded its work in Ebola response areas to address community needs around basic services, including access to water. With funding from OFDA and the UN’s DRC Humanitarian Fund, Mercy Corps is repairing existing water infrastructure and drilling new wells, helping to ensure that local communities have access to clean water – a benefit that not only supports Ebola prevention efforts, but also addresses a critical local need. Communities actively participate by identifying and expressing their needs via consultations and focus groups, and by creating community action plans. Local workers are employed on construction sites on a cash-forwork basis, and communities elect committees responsible for construction and repair work.

Information is critical

Effective community engagement and mobilisation also means that information about Ebola comes not only from medical staff, international organisations or the government, but also from community leaders and individuals recognised and trusted by their community. By taking into account community dynamics, we lay the groundwork for a more decentralised response and better communication flows. Mercy Corps has used evidence from the West Africa Ebola response in 2014–2016 to demonstrate how critical a role community mobilisation plays in curbing an outbreak. Community Mobilization: Essential for Stopping the Spread of Ebola, Mercy Corps, 29 May 2019.

As part of Mercy Corps’ response to Ebola, the ECHO-funded programme ‘Pamoja’ (‘together’ in Swahili) established 40 information centres in Ebola-affected areas. The centres are managed by local organisations trained and supported by Mercy Corps, with key information on the disease, good sanitation and hygiene practices and prevention measures and how to react should symptoms appear. The sooner a case is detected and addressed, the shorter the chain of contamination. As the local population receives the information directly from local and community-recognised organisations, a domino effect helps spread good practices in the community, and fight disinformation.

These centres not only provide information to the community, but also gather feedback about response actions and teams. By analysing this feedback, Mercy Corps and Ebola response teams intend to adapt and adjust their activities to address rumours and disinformation, improve programmes and provide useful information to the broader humanitarian community. Some of the most common rumours the centres have received and clarified are the belief that Ebola was invented by the government as a way of annulling the presidential elections, or was created so that foreigners could make money from it. Misinformation on possible side-effects of the two vaccines is also common: in early January 2020, one centre picked up a rumour about one of the Ebola vaccines affecting women’s fertility. In response, thanks to a cascaded sensitisation campaign, 67 people in Butembo were persuaded to get the vaccine.

Coordination is key

A coordinated response and clear information-sharing among NGOs, UN agencies and government institutions is essential in any response, but particularly so in an Ebola crisis, where a fast and effective response is necessary to stop transmission. Conversely, a lack of coordination between responding actors can lead to the duplication of structures and activities.

Thanks to adjustments within the response plan, important reforms in the government coordination structure In the second half of 2019, the government of DRC appointed Dr. Muyembe, a well known researcher who specialises in Ebola, as the head of the Multisectoral Committee for Ebola response reporting directly to the National President Tshisekedi. and a strengthened coordination and support mechanism following the declaration of the system-wide scale-up in May, coordination has improved. NGOs were given a voice in strategic coordination forums, the Ebola Emergency Response Coordinator (EERC) appointed by the UN Secretary-General began to call meetings exclusively with NGOs and the Social Sciences Research Group reinforced its direct support to technical commissions with an emphasis on anthropological findings.

Building resilience to future outbreaks

Community resilience to future outbreaks can only be built by reinforcing existing structures such as local organisations and traditional community leadership, and Mercy Corps ensures that traditional and/or religious leaders are included in the engagement process (via local organisations, community structures such as Community Action Cells (CACs) or voluntary Care Groups). Mercy Corps has used community feedback to shape future programming, and will continue to give a central role to pre-existing community structures.

Due to high population mobility, not least in response to conflict, efforts to address Ebola must remain consistent, and response capacities should be maintained in high- risk areas until the epidemic is over, even where Ebola seems to be under control. In late 2019, the government began holding high-level discussions on the post-Ebola transition, and the most recent Strategic Response Plan has integrated priorities to support the health response, including the response to needs beyond Ebola, such as access to essential services in health, education and water and sanitation. The post-Ebola transition plan is centred around three key areas: strengthening health systems for this and any future epidemics; a multi-sectoral approach to address other basic needs; and contributing to local stabilisation, social cohesion and governance to link emergency and development phases.

As the post-Ebola phase approaches, we must also consider the survivors and their families. More needs to be done to support the 1,000-plus survivors to overcome stigma, as well as help with their social reintegration. Mercy Corps is designing a post-Ebola strategy that includes early recovery, such as providing livelihood support to families affected by Ebola and capacity-building of local organisations. Mercy Corps’ current and future programming puts a particular focus on three main intervention areas (Butembo, Beni and Katwa), which have been most affected by the outbreak, and which account for 72% of survivors. The post-Ebola strategy currently being drafted in Kinshasa should be realistic and respond to the main concerns identified via community feedback. Mercy Corps, together with other INGOs, is currently advocating for two additional seats for INGOs in national exit strategy discussions. As this crisis has demonstrated, community engagement that goes hand-inhand with coordination is a fundamental factor in successfully fighting this disease.

Marcela Ascuntar is Mercy Corps’ Strategic Coordination Specialist for the Ebola Response in DRC.