Ebola’s reputation is fearsome. Its horrifying symptoms, quick human-to-human transmission, and exotic locale seem ready-made for a thriller movie. Indeed, in the midst of the largest Ebola virus outbreak ever, a real-time script is emerging.
The story goes something like this: tribal habits, including archaic burial customs and a penchant for bush meat, have led to the emergence and spread of Ebola virus disease. The solution to the terrifying epidemic is to put patients in treatment centers, which are set up and staffed by foreign doctors. Despite the heroic efforts of a few outnumbered foreign aid workers, however, the epidemic has continued its spread, because too few international organizations responded to the challenge. Further, governments needed to get more directly involved, including by sending in armies, whose vast personnel and logistic capacity can help solve the problem. Also needed to prevent future such epidemics is more investment in health systems, essentially a combination of infrastructure and capacity building, such as training in disease surveillance.
This narrative serves an important function. It helps explain why the epidemic happened, who can be trusted to fight it, and who should be blamed for the things that have gone wrong.
There’s just one problem: the story is at best incomplete and at worst outright wrong. It excludes the most important truths about the Ebola virus epidemic—the very facts that could help the world stop this outbreak and prevent future ones.
Let’s start with bush meat and burial customs. These practices might explain the emergence and very early spread of the disease, but they don’t explain why Guinean villagers deliberately withheld initial Ebola virus cases from an outbreak team led by the U.S. Centers for Disease Control and Prevention (CDC), Doctors Without Borders, and their own government. Nor do they shed light on why health workers sent to inform communities about the epidemic in remote regions were ignored, threatened, or, in one tragic case, killed. Or why residents of the West Point neighborhood in Monrovia pillaged and looted an Ebola holding center. Yet those are the most important facts to understand, because they explain how a localized epidemic that was typical of past Ebola virus outbreaks became an unprecedented plague that has engulfed three countries.
These events had little to do with superstition and much to do with the deep distrust between people and the institutions charged with helping them. Villagers in Guinea had no reason to trust a government that has done little for them in the last three decades. In Liberia, health workers were viewed with suspicion because of a recent strike over pay, which led to rumors that Ebola was a ploy to get foreign donors to increase their contribution. Residents of West Point were angry that an Ebola holding center was placed in their community without any consultation. And in all three countries where there have been significant Ebola outbreaks, citizens had witnessed enough blatant corruption over the years that their suspicions that Ebola was a plot to get and steal aid money didn’t seem so far off. The heavy-handed, top-down manner with which governments communicated about Ebola, exemplified by the Liberian government’s use of the army to enforce a quarantine in West Point, didn’t help build trust.
With this diagnosis, the prescription becomes very different. Rather than shout at the population to stop its backward ways, it is important to understand the people’s concerns—and address them. In its work in Sierra Leone and Liberia, the International Rescue Committee has found that when people are treated with respect and when they trust the public health specialists working with them, they are willing to make substantial changes even to cherished spiritual rituals and are able to bring Ebola virus transmission to a halt. For example, villagers in Sierra Leone’s Kenema District were willing to forgo traditional burials as long as the sanitized burials could be witnessed and, in some cases, done by members of the community trained for this purpose.
International agencies can help the most by listening to local communities and working with them as equal partners, rather than as victims to be saved. And the governments in the region need to build trust by demonstrating that they are able to deliver on material promises and curb corruption. The media needs to focus less on condescending reporting of local customs and more on investigating corruption. Given that even in the height of an existential crisis, and with lots of funding available, some of these governments have not found a way to regularly pay workers on the frontlines of the epidemic, there is much left for everyone to do in this area.
Perhaps the most powerful notion of Ebola is that the current epidemic can be contained only by doctors in HAZMAT suits providing care in sophisticated, if vaguely creepy, facilities. These notions are reinforced by news coverage, such as the recent front-page New York Times article on intravenous rehydration of Ebola patients, which started from the flawed premise that such therapeutic choices are the key to saving lives in this epidemic. The reality is far different. The Ebola virus is a disease that is much, much easier not to get than it is to treat. Treatment helps, because it removes patients from their homes and other settings where they can infect others. But there are many other ways in which people can avoid getting infected, even when no treatment is available.
Most of those ways, in fact, are best found not by foreign experts but by people living in their own communities. One woman in Liberia who treated many of her sick neighbors was able to protect herself using plastic bags and other household items. Villagers and urban slum dwellers have found ingenious ways to enforce self-quarantines. In one village, guests were warmly welcomed—and then instructed to sit in a chair near the road, while the friend or relative they came to see sat on another chair a few feet away. In another village, the women’s group agreed to stop traveling to trade in surrounding areas, and the young people’s group agreed to stop attending parties in nearby villages. Since these quarantines were designed by the people subjected to them, they are much more likely to be successful. Such resourceful community members, supported by public health workers and community organizers such as Mosoka Fallah in Monrovia, have arguably had far more impact on this epidemic than any foreign medical team. A recent CDC publication made this point, but it garnered little attention in the face of omnipresent images of clinicians in Ebola suits.
Unfortunately, the narrative of foreign rescue through treatment has proven influential in dictating resources to date. Doctors Without Borders called for a huge investment in treatment, and the involvement of foreign armies, and was successful. U.S. President Barack Obama and British Prime Minister David Cameron went along, as did other donors, such as the World Bank. Transparent data are hard to come by, but a $52 million World Bank investment is instructive: more than half of those funds were allocated to Ebola virus treatment units, while less than two percent were allocated to health promotion.
This is not to say there is no place for treatment and that Ebola virus treatment, which is expensive, should not be funded. But clearly, many of the people who are getting the best results, such as Fallah and locals like him, need to get a much larger share of the attention, support, and funding than they are now.
Another popular story, common to the point of consensus within the aid community, is that it is possible to prevent future Ebola virus epidemics by investing in health systems. Liberian President Ellen Johnson Sirleaf shared this view in an October 2014 Washington Post editorial. The editorial summarizes the prevailing narrative, starting with the assertion that “Liberia had made significant progress in building up its public health systems” until Ebola undermined this work by slipping “through the cracks” of the fragile new system. The remedy is more of the previous health systems work, including getting the “training and means to recognize symptoms and isolate patients immediately.”
As with the other narratives, there is some element of truth. Had the government been able to follow all the initial Ebola virus victims, and the people who came in contact with them, the epidemic most likely could have been contained. In New York City, for example, the health department was able to deploy hundreds of people to trace and monitor all the contacts of the one New Yorker who contracted Ebola virus disease.
But, once again, inconvenient facts get in the way. Liberia has already seen a significant investment in its health systems, engineered by one of the best-managed assistance programs in Africa (full disclosure: the International Rescue Committee was one of the implementing partners in this effort). So why wasn’t there more evidence of strong health systems after a decade of capacity building? One answer is that the Liberian government was not regularly paying its health workers. Low morale turned out to be an important cause of mistrust and therefore a driver of the Ebola virus epidemic. The problem was not a lack of investment in health systems, but an excessive focus on technical fixes, combined with a failure to address head-on the most challenging, politically sensitive governance issues of the health systems.
It’s easy to see why this didn’t happen. Training is more comfortable for everyone involved than following the money from the Ministry of Finance to the monthly salaries of frontline health workers, identifying leaks, and plugging them. The Ebola virus epidemic has made it clear that such plumbing work, however sensitive, has to be part of any future health systems approaches. Those working on rebuilding West Africa’s health systems also need to regularly measure trust in government—a metric that is tracked all over the world—and invest in activities that build trust.
THE NEXT EPIDEMIC
The West Africa Ebola virus epidemic is complex, confusing, and concerning. We can end it only by understanding, and acting on, the real story. The real story isn’t one of a foreign doctor in a HAZMAT suit rescuing a superstitious population and training a few people before he leaves. The real story is that only local communities can end the Ebola virus epidemic in collaboration with public health workers. Both communities and frontline health workers need the dependable support of a government they trust.
Knowing that, the world needs a different international response to the crisis. It needs to prioritize prevention, which in the case of Ebola is much more desirable, from every standpoint, than treatment. In doing so, the world needs to focus as much, if not more, on the behavior of governments and other actors as on that of communities. And last and probably least comfortably, aid organizations need to question the ways in which they’ve been building health systems, making sure that they focus on the difficult but foundational issues of finance and governance. These won’t be easy changes. But anything less will be a betrayal of the international community’s duty to help West Africa—and protect itself.