Compared to this time last year, news about Ebola is hugely more encouraging. Although not over, the number of new cases per week tends to be in single figures instead of the hundreds. Out of the tragedy there have been some awe-inspiring achievements, such as the recent news that a vaccine had proven 100% effective in trials in Guinea. The development process, which normally takes decades, had been condensed into months, setting a precedent both for vaccine research and emergency response.
In unchartered territory, innovation and learning have been the backbone of the Ebola response. As well as the vaccine, there have been other high-tech offerings. For example, a US$5 million mobile high containment medevac unit was hailed as a possible “game-changer” for future outbreaks.
While I do not wish to deny the importance of making sure foreign staff who risk their lives going into an epidemic context can be safely evacuated should the need arise, this is not the kind of innovation which I believe has made – or will make – the difference. Indeed, there is something amiss about the priorities and assumptions that such investments reveal.
Local efforts, local innovation
Concentrating on shipping people in and out of epidemic areas overlooks the wealth and potential of local expertise, and the need to invest in that. As Ebola is (hopefully) drawing to a close, I’d like to draw attention to the local efforts and innovation which have been central to turning the epidemic around. These are the real “game-changers”.
Nowhere is this more obvious than at the MAGic anthropology conference at the University of Sussex where I am currently – and where, exactly a year ago, the idea for ERAP was conceived. Here, there is a wealth of panels to illustrate the effectiveness of community-based and community-led Ebola response.
Presentation after presentation has revealed how learning and behaviour change was often rapid. Villages instated their own isolation techniques, households devised (heart-wrenching) strategies to deal with infected family members, people used local materials – such as plastic bags – as makeshift protection.
Crucially, much of this was in the face of confusing public health messaging, for example that no one survived Ebola, or that you caught Ebola from bushmeat. Also, as Sylvain Faye emphasised, sound infection control measures did not necessarily hinge on heterodox biomedical explanations of disease causation; often people retained their own understandings of the real causes of Ebola.
Creating new health structures
In terms of coordination, case management and surveillance, there are some striking differences across the region about the extent to which local health system capacity was used, and what that means for sustainability and preparedness in the future. In general, the tactic – at least in Sierra Leone, which I know best – has been to set up standardised systems to bypass the existing structures deemed to be ineffective in order to perform the complex logistical tasks necessary.
The Sierra Leonean response came to be organised thorough District Ebola Response Centres (DERC) reporting to a National Ebola Response Centre (NERC). This was led by the Sierra Leonean Military, with support from the British Army, and took management of the epidemic out of the hands of the District Health Management Teams.
Another example is the Ebola Community Care Centres (CCCs) in Sierra Leone. The CCCs were devised as an alternative to hospitals – which had been roundly rejected by many patients – at a time when case numbers were already outstripping the number of beds, and models predicted the situation to worsen dramatically. In Sierra Leone they became a key response strategy. However, in the end they arrived at the same time as ambulances and treatment centres were scaled up which made their original function redundant and most were empty. One of the (many) controversial aspects of the CCCs has been that they pulled nurses out of the normal health care system to staff the empty CCCs at a time when the already weak health system needed bolstering.
The Kenema case
In one district things were different, however. Kenema, in Eastern Sierra Leone, became the frontline of the country’s Ebola epidemic due to the presence of the Lassa fever ward and laboratory. From May to at least August they struggled on without the international assistance which was to come later – and Kenema Government Hospital lost over 40 staff as a result.
Kenema stands out compared to other districts as neither the DERCs or the CCCs have made a significant dent there. The DERC is a side show to the regular surveillance team meetings led by members District Health Management Team and the Lassa surveillance team. The CCCs were never built and instead staff at the Primary Health Care units stayed in their posts but were trained in infection control.
Like elsewhere, Kenema’s learning curve has been steep and painful, but at least when the epidemic is finally over they will have both the know-how and the systems integrated into the DNA of the district health system, enabling them to deal better with future epidemics.
The examples from MAGic and of Kenema shows the importance of local learning and the huge achievements that were made, under incredibly difficult circumstances and with very little monetary assistance. Investment should be made in understanding how these local responses were mounted, and how they can be supported in the future. In the face of media friendly headline-grabbing innovations, we should also recognise them for the game-changers they were.