Improved Ebola Response: Inclusive learning & the DRC – by Joshua Moon
Dr. Joshua Moon (Hutton) updates his earlier blog in light of the developing urgent situation in the DRC.
In response to the 2014 west African Ebola outbreak, a plethora of reports, publications, and institutional changes tried to both identify and act upon lessons from the outbreak. These lessons ranged from a need to make medical technologies faster to a need to involve communities in response. The current outbreak of Ebola Virus Disease (EVD) in the Democratic Republic of Congo (DRC) is the second largest outbreak of EVD in modern history. This will form a test-case for how well these lessons have improved response. What has been learned, however, will be shaped and filtered by who is learning and how.
A systematic reading of the documents produced after the 2014 Ebola Crisis demonstrated the breadth and depth of knowledge produced. These lessons, however, also significantly overlapped. Abramowitz et al. [1] found that 407 epidemiology and social/behavioural science papers could be summarised in just 29 composite lessons. In addition, Mackey [2] and Moon et al. [3] both find significant overlaps in many of the `major’ analyses of the west African Ebola crisis.
These lessons, despite them being so common, have not necessarily been transformed into action. Both Mackey and Moon et al. find that this significant overlap has not converted into a change in how we prepare and respond to outbreaks now. Furthermore, Ravi, Snyder, and Rivers [4] find that most initiatives following the Ebola outbreak have failed to meet their financial and operational goals. This shows a lack of action upon the lessons from west Africa.
Looking at the current situation in DRC we can see that some learning has taken place. For example, the quick use of an experimental vaccine in North Kivu [5] represents action upon the lesson for increased development and use of medical technologies.
On the other hand, one of the main lessons from responding to the west African Ebola crisis recommends being aware of the community and political context of the outbreak. As we see from the coverage of the DRC Ebola outbreak, awareness of the political and community context is yet again lacking: “Unfortunately Tedros’s [sic] advisors … have already shown how little they know about the region’s devastating carnage and warfare” [6].
This is particularly salient given the violence that has befallen Ebola responders recently. As noted by the UN emergency Ebola coordinator David Gressly “it’s not just a simple matter of [local people] not understanding the importance of the [Ebola] response. It goes much deeper and may have political or economic reasons behind it” [7]. Detailed attention to the social and political context of an epidemic is crucial to response, this was a lesson from west Africa and one we cannot afford to keep ignoring.
Another lesson from west Africa that has been overlooked is the role (both technical and political) that the declaration of a Public Health Emergency of International Concern (PHEIC) plays in global responses. Supposedly functioning as a global ‘clarion call’ [8], the PHEIC declaration by WHO’s Director-General should be used to signal to the world that an epidemic requires a co-ordinated global response. In west Africa, the delay in PHEIC declaration was heavily criticised because political considerations overcame technical factors, but the political decision was framed as technical in nature. In DRC we see the same phenomenon – a delay in a PHEIC declaration for political, not technical reasons, but framed as technical in nature [8].
What shapes which lessons are learned, and which aren’t? This was the topic of my recently completed PhD Thesis. The findings of the thesis came from a historical review of past outbreak responses, more than 250 different reports and publications reporting lessons from Ebola, and interviews with 36 report authors, Ebola responders, health policymakers, and academics.
The findings of the thesis demonstrate that users of lessons want recommendations that are based in evidence, that are relevant to them, and that they can find easily. One of the main drivers of how these factors are interpreted by authors, however, is a pre-formed understanding of what an ideal response looks like. This ideal response sets the standards for what is evidence, who should participate, and how the findings should be dispersed.
More specifically, the current ideal response to a disease outbreak was found to be embedded in what is known as the `Global Health Security’ framing. This framing sets the standard for what is evidence (usually statistics or official views from governments/ international organizations), who has valuable expertise (usually `experts’ narrowly defined), and how the findings should be disseminated (high-level political meetings and the publication of a 40-page report).
These definitions shape the lessons themselves. The lessons are shaped into those which fit within this dominant paradigm and filters out views of those outside of it. Specifically, this can exclude affected communities, survivor advocacy groups, on-the-ground responders (both local and international), and anthropologists/social scientists.
Whilst the inclusion of these groups in evaluations of outbreak responses are increasing (the report of the Ebola Interim Assessment Panel does quote some local responders), the lessons from the 2014 Ebola crisis demonstrate that this is by no means complete. As the DRC Ebola outbreak continues to grow, actively learning from what is happening on the ground is required. Ensuring that these efforts are evidenced (multiple sources, qualitative narratives, and story-telling), participatory (including representatives of those who will be using and affected by recommendations), and disseminated (not just reports but social media, in-person representatives, direct communication, workshops, attendance at local meetings, etc.) will ensure useful knowledge is produced and used to continuously improve the response to this and future outbreaks.
References & Footnotes
[1] Abramowitz, S. A., Hipgrave, D. B., Witchard, A., & Heymann, D. L. (2018). Lessons From the West Africa Ebola Epidemic: A Systematic Review of Epidemiological and Social and Behavioral Science Research Priorities. The Journal of Infectious Diseases, 218(11), 1730–1738.
[2] Mackey, T. K. (2016). The Ebola Outbreak: Catalyzing a “Shift” in Global Health Governance? BMC Infectious Diseases, 16(1), 699.
[3] Moon, S., Leigh, J. A., Woskie, L. R., Checchi, F., Dzau, V., Fallah, M. P., … Jha, A. K. (2017). Post-Ebola reforms: ample analysis, inadequate action. Bmj, 356(j280).
[4] Ravi, S. J., Snyder, M. R., & Rivers, C. (2019). Review of international efforts to strengthen the global outbreak response system since the 2014–16 West Africa Ebola Epidemic. Health Policy and Planning, 1–8.
[5] Approximately 58,300 people have been vaccinated in the region at time of writing (Garrett, 2019)
Garrett, L. (2019). Ebola has gotten so bad, it’s normal. Foreign Policy.
[6] Garrett, L. (2018, October). Welcome toi the First War Zone Ebola Crisis. Foreign Policy.
[7] Aizenman, Nurith (Jun 4, 2019) An Urgent Mystery: Who’s attacking Eobla responders in Congo – and Why?. NPR [https://www.npr.org/sections/goatsandsoda/2019/06/04/726139304/an-urgent-mystery-whos-attacking-ebola-responders-in-congo-and-why?t=1559809343550] Date accessed: June 14th 2019
[8] Gostin, L et al. (2019) Ebola in the Democratic Republic of the Congo: time to sound a global alert?. The Lancet 393(10172), p.617-620.
Joshua Moon (Hutton) is a Research Fellow in Learning, Knowledge, and Global Health at the Science Policy Research Unit (SPRU), University of Sussex. His research interests include the funding and evaluation of research, global health governance, global health emergency response, and transdisciplinary research. You can contact him via LinkedIn, Twitter (@DrJRMoon), or email: J.R.Hutton@sussex.ac.uk.
Image by lukaszdylka on pixabay.