[intro]Hot on the heels of the Ebola outbreak that gripped Guinea, Liberia and Sierra Leone in 2014 and 2015, experts are now reflecting on the experience of the battle with Ebola to inform the Zika virus fight. The lesson? Keeping it local pays off.[/intro]
The biggest lesson after the Ebola outbreak, certainly in Sierra Leone, was the centrality of community participation, ownership, mobilisation, and engagement in ending the epidemic; however a recent Harvard Business Review article highlighted four lessons from the Ebola crisis with relevance to the recent spreading of the Zika virus: pinpoint hotspots with widespread testing; implement targeted control measures; prevent widespread transmission; and integrate research with immediate action.
It isn’t that the four conclusions the experts draw in their HBR article are necessarily wrong, the problem is that they tend to overstate technical solutions that rely upon foreign expertise at the expense of locally adapted, people-centred solutions that, when applied early enough, are less costly and disruptive.
I worked for nearly a year on the Sierra Leonean Ebola response and found that there were many lessons at the end of the outbreak. For instance, upon visiting one northern district in Sierra Leone, which was at the epicentre of the outbreak, the research team was intrigued to learn that one Member of Parliament, Isata Kabia, had organised awareness raising activities as early as April 2014, a month before the first confirmed case in the region.
Kabia was an MP in the Port Loko district of Sierra Leone. A cosmetic chemist by profession, Kabia is one authority figure who knew she had a massive role to play in mobilising her constituents. “I told them, I’m a scientist,” Kabia recalled reflecting on those early days, “I’m more scared of Ebola than you are.”
Kabia proved to be an unstoppable force during the first few months of the spread of Ebola. Using $600 of her own money, a matching sum from donors, and six phones donated by a local telecoms company, she set up a communications network linking health authorities with some of the most remote settlements that she had identified when elected in 2012, through a citizens’ parliament she had initiated.
“In 2013, right after elections, we did a citizens’ parliament and this was my way of making sure the people were involved and owned their own development track,” recalled Kabia. “We sat down, we highlighted the issues, agriculture, business opportunities, jobs, the mines, the health and education issues in the constituency. We prioritised. We decided among ourselves, what is a priority? Which area should we focus on?”
This hands-on approach helped in mounting an effective Ebola response in the constituency. “What we wanted to do was to make sure that within the interior where the burials are going on that you don’t know about, where the sick don’t have any hospitals so they’re going to be cared for at home, had a way to reach the CHO [Community Health Officer] in Lunsar,” Kabia explained. “The CHO had the command phone, and then the phones within the interior are to call him in case of any suspected case or any suspected symptoms so somebody could go and verify instead of them trying to move the person.”
Kabia explained that many of the areas were inaccessible by even the motorbikes (known as Okadas) commonly used for transportation, let alone cars. “You can’t imagine somebody sick and trying to get out to a main hospital because there’s no hospital within their own area,”said Kabia.
Significantly, this early engagement with the local community signaled a warning which, had it been heeded, may have averted huge loss of life and economic disruption later. Kabia recalled how young people from the area put on a play “using the first messages we got from the Ministry of Health about not touching sick people, not touching the dead and certain foods. So the message right there on that day in Marampa was zero touch. Zero touch for bat foods, zero touch for sick people, zero touch for dead people,” she said.
At the time, Kabia had alerted health authorities, however, due to the levels of resistance around burials and the touching of dead bodies, which is the prime cause of infection, the warning wasn’t sufficiently heeded. “When we said zero touch for dead bodies, there was such a ruckus around the room, we just knew it was going to be a big issue,” she said.
Prior to the Ebola outbreak, Kabia had championed women’s causes and concerns in her parliamentary work. “Most of my focus is on women, they need the most assistance and assisting them has greater impact for the whole society,” she said; further noting that ‘women’s concerns are everybody’s concerns’.
The distribution of power in a patriarchal society such as Sierra Leone’s typically disempowers women and Kabia notes that this is an important social point in the fight against any infection. “With Ebola and what happened we reaffirmed, with any disease, it’s the women who are the caregivers at home,” Kabia argued. “Usually, when the women themselves are sick at home, they don’t even have the power of choice. As a woman, you can’t decide when/if you go to a hospital. Somebody has to allow you, by giving you money to go to a hospital. That extends all the way through to maternal care. Somebody’s deciding for you when you go to a hospital when you’re sick. When sick at home, you are the doctor, you are the nurse. Women have the potential to be much much more affected by this disease just because of that culture,” she said.
For these reasons, Kabia had a hunch that women would play a key role in the response as informers and first responders. In the end, she worked with older women as well as young men and women. Kabia believes this mobilisation effort paid dividends: “I think, because immediately they felt included. Immediately, they felt maybe saving lives could be their responsibility. You give people that kind of power, they respond,” she said.
And respond they did. The former MP recalls how her constituents approached her and said “Honourable, how can we help?” Young people became the de facto surveillance officers, the contact tracers, the first responders. “I think that community ownership helped tremendously in my constituency and I’m sure in other areas as well. I couldn’t be everywhere so the natural thing was to set up teams where we’d have people in the local areas. We didn’t import anybody to say you go and manage that particular area,” Kabia said.
Her approach paid off. Local leadership in other districts, such as Koinadugu in the North and Pujehun in the Southeast, helped to either stave off the worst effects of the Ebola outbreak or to end it. And a lot of this happened before the massive international mobilisation joined government efforts to tackle what eventually became its peak in November 2014, with an outbreak producing a staggering 500 cases a week.
Yet we hear so little of the efforts by the MP Kabia and other local leaders whose tireless efforts undoubtedly made a decisive difference at significant points in the 18-month outbreak. It is partly understandable that the international media pays disproportionate attention to foreign medical workers who risk their lives (as frontline Ebola response workers undeniably did) to help out in a faraway land. But unless we pay greater attention to local agency, we may inevitably arrive at flawed conclusions that poor countries like Sierra Leone are totally dependent on overseas assistance; lack resilience to handle crises (even if they need additional support); and that their entire leadership is inept, ineffectual, or corrupt.
Worse, if citizens of Sierra Leone and other developing countries internalise such faulty insights, they will miss vital opportunities to build on all the positive things they achieved under extremely challenging conditions. There’s something there for Brazilians and Latin Americans to take away too.