The World Health Organisation (WHO) has downgraded the health risk posed by Ebola. But the threat of another epidemic will remain until we can understand what allowed the outbreak to evolve into the largest, deadliest and most widespread eruption of Ebola ever recorded. This raises the question: what have we actually learned?
The International Rescue Committee has analysed seven reports into where things went wrong and how we can do better next time. Many of the recommendations in the report overlap. That’s the good news.
But the reports concentrate on what the top levels of the WHO were doing, and undervalue some key players who carried out the bulk of the response. Above all, the voices of people in the local community who responded to the outbreak are neglected.
Historians have told us, over and over, that epidemics are political. Ebola was no exception. While it is widely recognised that the international response came late, this delay is far from the only reason Ebola evolved from an outbreak to a regional catastrophe (and global panic). In fact, governments and others began taking action and educating the public as early as April 2014. These early efforts failed because the public in all three countries involved did not do what the messengers or the messages told them. The reasons are complex, political, and largely unaddressed in the reports so far. But at heart they are about one thing: trust.
The successes achieved in the battle against Ebola – and the reason the death toll was limited to tens of thousands, rather than hundreds of thousands, as experts had feared at one point – also involved politics. The most effective responders, from epidemiologists such as Dr Mosoka Fallah in Liberia, to local government leaders like Dr Mohamed Vandi in Sierra Leone, took a wide range of actions. Their efforts ranged from tracing people to burying bodies, and they relied on cultural sensitivity and political awareness to ensure their success. Fallah worked in urban neighbourhoods, tracking Ebola contacts and engaging with communities by using existing social and political networks. This was a controversial decision at the time: what he viewed as local social networks were viewed by others as criminal gangs or opposition political groups. But this approach saved many lives. These are the efforts that the reports should have looked at in more depth.
The severity of the outbreak was partly down to the weakness of the health system in the main countries affected. They already had too few doctors and nurses, and were also grappling with underinvestment in healthcare and battling diseases such as malaria. Yet “health system strengthening” is too often treated as a technical task, to be done by experts. This ignores the politics of healthcare. For example, there is nothing in the reports on the failure to pay health workers a decent, regular wage, even at the height of the epidemic, and after abundant funding became available. Just about everyone in Liberia, Guinea and Sierra Leone knows that these problems, more than anything else, fed the epidemic. The rest of the world needs to know as well.
The reports give almost no scrutiny to those who provided the bulk of the response, other than the few who provided clinical care for Ebola patients. If the WHO isn’t doing the bulk of the work, who is? Other UN agencies, NGOs, militaries, donors and public health agencies collectively played a much larger role in the response, in terms of staff deployed, cases detected, contacts traced, bodies buried, samples tested, and money spent, among other metrics.
The reports miss the opportunity to review the data and analyse their performance. What did they do well, what could they have done better? What was the value of short-term international recruits compared with local staff? Were some donors more effective than others, and why? Were governments (and NGOs?) driven more by media coverage than public health realities? These crucial issues, many of them political, go largely unaddressed. They will recur in the next epidemic.
This isn’t the first time that our gazes are politely diverted from the messy political realities. These reports perpetuate a pattern in which international experts deal with health problems as a technical issue, leaving the real problems to fester and hinder progress.
Mixing politics with public health makes for awkward conversation. But we can’t prevent the next epidemic without having that conversation.
