The international management of epidemics sometimes involves handing over control to a group of foreign experts who have a superficial understanding of a very complex region, several researchers believe.
On August 1, 2018, the 10th outbreak of Ebola Virus Disease (EVD) was declared in the Democratic Republic of Congo (DRC) in the Province of North Kivu. The international response to the outbreak has been huge with an influx of over half a billion dollars Americans for international aid. A newly approved highly protective vaccine was used and new drugs as therapeutic agents were tested and found to be effective in reducing the death rate from EVD.
However, on June 25, 2020, the day of the official declaration of the end of the 10th EVD epidemic causing 2,287 deaths over a period of 23 months, it turned out to be the most virulent outbreak to affect Congo and the second largest and longest response in the world to date.
The extensive public health system put in place to fight Ebola has generated problems, including sexual abuse and conflicts. Although officially the exact number is not known, there were probably some 200 to 300 episodes of violence directly related to the epidemic or with regard to national and international efforts known locally as the “Riposte”.
We wanted to find out why the “Friposte” had caused so much friction in the communities. To achieve this, we studied the different ways in which local communities and the Response approach the prevention, treatment and follow-up of Ebola cases.
Analyzes of humanitarian action require rigor in recommending ways and means to improve the international management of epidemics. Thus, in our series of articles we propose an entirely different approach. We argue that the international management of epidemics sometimes consists of ceding control to a group of foreign experts who possess, at best, a superficial understanding of a very complex region. And we suggest that local know-how and Congolese institutions may have the capacity to better manage an Ebola outbreak more effectively than international partners.
Rethinking epidemic management
Our research was carried out – from conception to publication – by a group of Congolese researchers from different academic and professional backgrounds. Our four recently published articles offer unique vantage points from which to visualize an otherwise heavily studied epidemic. When read in isolation, their findings may seem modest: careful analyzes of important aspects of the 10th EVD outbreak. However, taken as a whole, they call into question the very foundations of the international management of epidemics.
In the first of our four articles, we focus on Mangina, a city in North Kivu. This health zone was the starting point for the spread of the epidemic. Cases of Ebola had been documented locally three months before the epidemic was officially declared and an international response (the Riposte) was deployed. Through careful monitoring of the initial chain of transmission, we demonstrate that traditional methods to combat the transmission of infections were remarkably effective in controlling the spread of Ebola. These included isolating the sick and using plastic bags to bury the dead.
The article shows how locally developed prevention and care mechanisms slowed the spread of the epidemic, which exploded from 26 cases in the three months preceding the deployment of the Response to 250 cases in the following three months, when the people got scared and started to disperse further. The Mangina case offers valuable lessons on the importance of promoting outbreak response strategies that are inclusive, trusted and accepted.
In the second of our four articles, we describe the EVD screening and treatment system developed by La Riposte. We illustrate the perverse effects of the Response's militarized, fear-based approach to testing and treatment. This approach has prompted patients to flee the Response, which has had a negative impact on the rate of spread, morbidity and mortality of the epidemic.
We argue that if existing staff and institutional structures were used to manage Ebola instead of imposing new ones, decades of trust in the Congolese health system could have been leveraged to involve the population in surveillance measures. and control.
In the third of our four articles, we consider the challenges survivors face. Improved treatments dramatically reduced mortality during the 10th EVD outbreak in the DRC. For those who presented early in the course of their disease, Ebola was no longer a death sentence but rather a preventable and treatable disease. Thus, new measures have been introduced for survivors. They received material goods on leaving the treatment center; they were enrolled in support groups; and they had to go through a very rigorous health screening process.
In this article, we demonstrate that coercive approaches to the Response have instilled fear in survivors and reinforced their stigmatization within the local community. We also challenge the assumption that international humanitarian organizations should play a leading role in reintegrating survivors into the community.
The last of our four articlesconstitutes a conclusion to the series. It assesses the strategic and operational issues around the epidemic and the efforts undertaken by the Response to contain it. We highlight how the lack of effective communication, the indecisive provision of free health care and the turning a blind eye to the situation at the time, characterized by electoral tensions and disputed local politics, led to poor acceptance of these efforts. As a result, the Response was locally perceived by many as a vast machine of economic extraction, which further increased the mistrust of the populations.
Call the local
Based on these findings, we offer the following concrete recommendations for better outbreak management.
First, take into account the socio-cultural, political and economic context of the region of intervention.
Second, strengthen, improve or expand the existing health system instead of creating a parallel system that weakens it.
Third, listen to and integrate local actors, skills and practices, rather than marginalizing or excluding them.
Fourth, create favorable conditions that provide space for local communities to take ownership of the fight against the epidemic.
More deeply, we also propose the possibility of a different nomenclature in epidemics, a nomenclature that takes into account trust and family duty instead of "suspects of Ebola" and a nomenclature that takes into account dignity and respect and not, for example, “safe and dignified burials”.
It will take time to change all that. But it has to happen. As many Congolese pointed out during the 10th outbreak, “communities see much further than the response”.
Rachel Niehuus, Surgeon and Medical Anthropologist, Emory University; Ben Radley, Lecturer in international development, University of Bath; Welcome Mukungilwa, Researcher at the University Research Center of Kivu (CERUKI); Christopher Vogel, Research Director at the Insecure Livelihoods Project, Ghent University, and Serge Kambale Sivyavugha, Searcher, Catholic University of Bukavu
This article is republished from The Conversation under a Creative Commons license. Read theoriginal article.