Lessons of the Ebola epidemic(Presentation for Africa APPG, UK Parliament, 9th September 2015)

Paul RichardsEsther Yei Mokuwa

Thomas Songu

Njala UniversitySierra Leone

(correspondence: paul.richards@wur.nl, or prichards@njala.edu.sl)

EVD - it goes as it comes?

• Forests? Culture? Politics? Health facilities?– Hypothesis:

• problems posed by one or all of these factors explains spread of EVD? – An evident difficulty:

• These factors vary across Guinea, Liberia and Sierra Leone

• Regional maps tell a different story– Pattern of advance and retreat is the same across all three

countries– Hypothesis:

• rapid learning (by responders, and by communities) is the key to understanding epidemic decline?

Where Ebola has been(at May 2015)

Situation then(at 25/9/2014)

Situation now(at 21/05/2015)

Unexpected Downturn

• Occurred – across international borders– in “difficult” areas• e.g. in Kailahun and Guinea forests,

– Areas with high political opposition

– ahead of international response “surge”• Downturn in Lofa county was detected by CDC from

August 2014– Attributed to effective community engagement

Explanation of Downturn

– High levels of local social knowledge• Villagers knew who was being infected

– could thus work out why

– Rapid pooling of knowledge • by responders and communities• based on trusted links with strategic interlocutors

– e.g. long-term Lassa fever researchers

– Quarantine works• Low cost intervention

– Knowledge of quarantine is widespread in communities• Smallpox and goat plague are known models

Community responses

• Local attempts to cut off infection pathways. • Nursing of EVD patients and washing corpses, using

improvised protective gear• Local leaders and vigilantes passing bye-laws ensuring

quarantine measures were obeyed• Trusted local advocates (including survivors)

communicated need for behavior change

• Repeated but unmet local demands• Training of local “safe burial” teams• Protocols for safer “home care”

A home-care protocol

While waiting?(Africa APPG Question 4: gaps in rural and interior areas)

• The ambulance never comes– No roads, no phones

• Health care is risky and expensive– One third of villagers would wait (about 3 days) to see if patient

recovered• Money has to be borrowed, a hammock has to be chartered, feeding of

patient has to be arranged– Much persistent extreme poverty in village households can be traced to

bankrupting effect of major medical episodes

NB: symptoms of Ebola are indistinguishable from malaria in first 3 days. Rapid in-situ testing might help. But roll-out of an available rapid test has been delayed.

Strategies that might help

• Free care and feeding for patients– Build on lessons of Ebola CCCs

• These were compared favourably by villagers to PHC– (evaluation by Oosterhoff, Mokuwa and Wilkinson 2015)

• Improved phone coverage• Use drones and balloons?

• Spot improvement of rural roads• Channel funds directly to community self-help groups

• Identify and support community Ebola responders– develop effective biosafety responses at local level

Improve roads and phones

Support local respondersEbola “militia”, Jawi chiefdom

Support local innovationLiberian nurse Fatu Kekula saved family with improvised PPE

Answers(Africa APPG Questions 1, 2, 4 and 5, of seven)

• Q. 1 Lessons of the epidemic?• A. Rapid learning is key to epidemic control

– Pay attention to co-learning of responders and communities

• Q. 2 Engagement?• A. Engage communities directly, based on analysis of response

– New evidence is urgently needed, free from “claim staking”

• Q. 4 Challenges in remote area?• A. Reduce obstacles to use of distant health care facilities

– Attend to physical, mental and financial obstacles

• Q. 5 Barriers to community engagement?• A. Understand and overcome reasons for local distrust• A. Engage with key local institutions

– Beware self-appointed interlocutors or “manufactured” institutions

Dancing to a different tune?Women’s collective power beats Ebola