The Cipher Brief interviewed Pia Wanek, Director of Humanitarian Assistance at Global Communities, to assess how West African countries responded to, and are being affected by, the Ebola crisis. She explained why community engagement is the best avenue for strengthening West Africa’s capacity to combat diseases in the future.
The Cipher Brief: How would you assess the West African response to the Ebola crisis? What was effective, and what was ineffective?
Pia Wanek: When trying to assess the response to Ebola, it’s important to remember just how unprecedented this outbreak was. Previous outbreaks of Ebola were small, locally contained outbreaks in isolated, rural communities in East and Central Africa. They were not large epidemics rampaging through urban centers on the other side of the continent. So the Ebola crisis caught everyone by surprise, from local governments to international institutions. No one could have anticipated this.
As a result, some initial responses did not work and even backfired. The use of military and police to attempt to quarantine the West Point neighborhood in Monrovia, Liberia led to rioting and widespread international condemnation. The government’s early policy of forced cremation – while the safest option to counter further contamination – ran counter to Liberian traditions. This heightened the fears associated with strangers taking away the bodies of loved ones, leading to cases where people refused to hand over the bodies of victims of the disease, a major vector for transmission.
But we also saw incredible flexibility and innovation from a variety of institutions. Traditional tribal leadership responded to the crisis of the cremations by working with Global Communities and the government to purchase a burial site at Disco Hill, which helped reduce resistance from those families afraid to hand over the bodies of their loved ones. Community engagement, working through county level government health officials, traditional leaders, and engaged volunteers, helped promote acceptance of burial teams and other behavior changes necessary to stop the spread of the virus. The common theme here is that forced changes resulted in fear and violence, while engagement with trusted social networks showed positive results.
TCB: Before the Ebola outbreak, the economies of Sierra Leone and Liberia had been rapidly growing, and Guinea was thought to have similar potential. How have these economies been affected by the Ebola crisis? What industries have been hit the most?
PW: Any major outbreak or crisis that results in policies such as the closure of schools, markets, and other public facilities will result in economic consequences. Even those who didn’t lose family members to Ebola would have felt the impacts to their livelihoods from the restrictions on movement. Public spaces are back open. Now that the virus seems to be under control, speaking for Liberia in particular, things have been returning to normal. Public facilities have re-opened. Cross-border trade is reemerging in border communities, complete with screening stations to help prevent Ebola from spreading from neighboring countries. With continuing support at the national and local level, we know that Liberians can return to the path to prosperity.
TCB: These countries are notorious for having low public trust in government. Did the government response to the Ebola crisis change public perception? Should we expect any lasting social and/or political consequences from the Ebola crisis?
PW: There definitely were some actions that resulted in a backlash against government actions, such as the plan to quarantine West Point. But the crisis also forced the government to rise to the challenge. For instance, Liberia created an incident management system to help coordinate and organize responses to crises at all levels of government and with the multitude of stakeholders, including the UN, NGOs, donors, and regional actors.
That being said, it’s probably more important to avoid thinking of the government as one monolithic entity that people interact with in only one capacity. There is often a difference between how citizens view federal government officials and local officials. Local government, especially people like the county level health officials including environmental health technicians (EHT’s), played a vital role in fighting Ebola. That success only came about through continuous efforts to build trust with the communities they were working with. These officials would enter communities, establish a dialogue with leaders, identify key concerns, and then construct a plan to prevent infection in the community. Later, this community engagement shifted to alleviating fears associated with strangers handling the dead bodies of relatives and instituting volunteer screening centers along the border to help prevent infections. Without this level of trust, we would have seen increased resistance from people to the behavior changes necessary to prevent transmission of Ebola.
Traditional relationships are extremely important in Liberia. Traditional leaders like chiefs, elders, and religious stakeholders held sway over a large number of Liberians, especially those who were most skeptical of the government. Partnering with traditional leaders helped us reach the hardest to reach communities and tackle some of the toughest issues. It also helped improve the bonds of trust between the government, traditional leaders, and citizens.
TCB: These countries lacked facilities, equipment, and training for medical staff. How would you assess the health care industry's performance during the Ebola crisis? What does the West African healthcare industry need now to prepare for another outbreak?
PW: I just want to emphasize how incredibly brave the medical staff were in facing down something that was completely unexpected. All of them put themselves at risk to fight this disease, and many of them ended up giving their lives. Unfortunately, with so many health workers having fallen victim to Ebola, the health care system has definitely been weakened. Strengthening clinical care will definitely play a critical role in improving health outcomes.
But strengthening clinical care is an expensive, long-term process. We know that behavioral changes and community buy-in can have extremely positive health impacts at a fraction of the cost. Prior to the Ebola outbreak, Global Communities was working to improve water and sanitation in rural Liberia communities by providing them with the training and resources to become open defecation free. Of the 284 communities that were certified open defecation free, all reported not one case of Ebola, despite being in some of the hardest hit regions. Two independent public health consultants confirmed these reports, indicating a relationship between being open defecation free and being Ebola free. They also found that communities that just began the process, but were not certified, were 17 times less likely to experience Ebola. Clearly there appears to be some relationship between sanitation education and healthy behaviors and practices.
The best part is, approaches like this can be done at an extraordinarily low cost as compared to constructing, staffing, and supplying a brand new health facility. In Liberia, $130 can provide the latrines, dish racks, and hand washing facilities and incentives to help a community become open-defecation free. Such prevention can not only protect against Ebola, but can help fight against the many water, insect-borne, and diarrheal diseases that are still major public health hazards in Liberia.
TCB: One year out, how does West Africa look today? What is the outlook for their economies, governments, and society?
PW: In spite of all the challenges the region has faced over the past year, I remain optimistic about the region. From a healthcare perspective, many more people, from health care workers to your average citizen, have a vastly better understanding of disease and how it spreads. This will help in the fight against other diseases that are common in Liberia. The outbreak has led to a huge focus on the importance of strengthening health systems and supporting water, sanitation, and hygiene efforts, as evidenced by President Ellen Johnson Sirleaf’s recent op-ed. These investments will help improve public health and many key development indicators. Governments have learned many valuable lessons and hopefully will be more resilient when the next crisis strikes. And most importantly, I’ve seen so many people step up and take on hugely risky roles like dead body management out of civic pride. It’s this pride and the willingness to help one’s neighbor that makes me look forward to seeing what happens next in West Africa.
