Even though Liberia saw its first case of Ebola in three months in early April, the danger of the epidemic that claimed around 11,000 lives in West Africa, appears to have been contained for now. On March 29, the Word Health Organization (WHO) declared that the Ebola virus was no longer a “Public Health Emergency of International Concern.” After an observation period of three months, the WHO determined that the risk of international spread was low and that afflicted countries had developed sufficient capacity to respond to new outbreaks. As NPR editor Marc Silver observes, “The world seems to have moved on from Ebola.” Although the epidemic has certainly declined in severity, the lessons learned in addressing the virus must remain in the collective conscious of public health officials worldwide, especially since some are already warning that uncontrolled outbreaks of viruses like Zika could be the “public health equivalent of Katrina.” Against the background of the Zika virus and the threat of future Ebola outbreaks, “moving on” instead of looking back and learning is both counterproductive and dangerous.
First, the medical response of the international community to Ebola reveals an effort characterized by apprehension, disorganization, and cultural discord. As the International Rescue Committee (IRC) bluntly concluded, the “weakness of global response to Ebola…hurt the credibility and confidence of the global health community.” Karin Huster, nurse and senior humanitarian adviser of Office of US Foreign Direct Assistance, similarly argues, “Slow seemed too kind a word for the world’s response. Cowardly and non-existent come closer.” In Liberia, for example, the US announced that it would establish treatment units, but took three long months to actually follow up on this declaration. In addition to this sluggish response, aggressive treatments like IV fluid therapy were forgone in favor of substantially less effective treatments like oral hydration because they were deemed “safer.” As physician Paul Farmer concludes, “We let fear dictate the quality of clinical care [and]…conventionally rationalized being ‘clinically unambitious.’” In other words, international responders allowed worry to justify slower responses and excessively restrained treatments. In the face of disease, feelings of fear are natural, but fear shouldn’t dictate our response. Nevertheless, there are strong signs that, just as with Ebola, information about Zika is primarily entering the American consciousness through a lens of fear. When even public health officials speak of the virus as “scarier than we initially thought,” it is imperative that these sentiments of apprehension not cloud the judgment and efficacy of medical responders.
Second, one of the biggest flaws in the international response was its paucity and misdistribution of resources, which often ignored local considerations. Of the eleven announced treatment units the US eventually set up in Liberia, nine never saw a single patient, while one established in the heavily-afflicted Port Loko district consistently faced resource shortages. No substantial effort was made to reorganize resources to rectify the problem. Furthermore, the international community poured so many resources into Ebola that it neglected addressing easily preventable medical risks afflicting the area: routine medical procedures, such as vaccinations and childbirth care, went “largely forgotten,” with resources and manpower focused single-mindedly on Ebola.
Not only did international responders struggle to adjust to local needs, they have also have been unsuccessful in agreeing on lessons to draw from these logistical failings. As the IRC argues, a glaring problem in ongoing dialogue over the lessons of the Ebola epidemic is the sheer “number and diversity of documents” written by different organizations. While a plurality of opinions and debate can be a constructive outlet for reflecting on the epidemic, the IRC elaborates that investigations have simply “articulated [similar recommendations] differently,” creating an environment where “consensus sounds like cacophony.” Furthermore, despite all these efforts, crucial issues are being brushed over. For example, the IRC has concluded that virtually no academic attention has been paid to the failings of “lower” ranks of international organizations, such as human resources, which struggled to mobilize enough foot soldiers in West Africa to spread information about Ebola.
Third, international medical responders failed to recognize and adapt to cultural differences, which made their interventions less effective. To be fair, certain West African traditions did contribute to the epidemic: as the WHO explains, ceremonial care and heavy communal contact with traditional healers facilitated Ebola’s spread. At the same time, the notion that it was “unorthodox” or “backwards” traditions within West Africa that hindered medical intervention is problematic. As Karin Huster argues, “The people of West Africa didn’t have strange customs. We did.” International medical responders forcibly quarantined people without a proper explanation, ignored the advice of traditional healers and local religious leaders, and went as far as jailing people with the help of local authorities for not reporting information or disobeying guidelines. Tellingly, it is medical responders who were most sensitive to cultural factors, such as Sierra Leonean customs of burying the dead in traditional cloth, who were most successful in both garnering local support and facilitating successful medical intervention. Nevertheless, the conventional wisdom supports the idea that supposed cultural backwardness undermined the international medical response. As Huster grimly explains, responders labeled people with legitimate complaints as “resistant, distrustful, non-compliant.” Such a dismissive attitude must change to address future epidemics.
Finally, international responders often were – and continue to be – painfully oblivious to the political obstacles to effective intervention in West Africa. As IRC senior health executive Emmanuel D’Harcourt argues, there has been a systemic “erasing of politics” in the international community’s reflection on the Ebola epidemic. Many reports have ignored the “political realities [within West Africa] that undercut what we were doing,” endemic factors that explain why we saw such a poor return on the billions of dollars poured into fighting Ebola. One of best examples for this was the clash between local governments and international health organizations. Although the WHO and the IRC both recommended lifting limitations on travel and trade in March because they hindered the mobility of health workers and suppliers, the Liberian government disagreed with this advice and closed its border to Guinea. Nevertheless, Ebola re-emerged days later in the country. In other cases, policy recommendations demonstrate an ignorance of more deeply-rooted problems. For example, global calls for the development of better disease response systems within West Africa will remain unheeded as long as insufficient international attention is paid to the failures of West African countries to pay health workers (the Ebola epidemic strike actually coincided with a health worker strike in Liberia over unpaid salaries).
The political reality of West Africa extends beyond technical concerns like health infrastructure: governments have the trying task of re-winning the hearts and minds of their people. One of the WHO’s Temporary Recommendations stressed the importance of keeping people updated about the situation of the epidemic and policy steps being taken. Emmanuel D’Harcourt argues that there’s a false narrative that rampant mistrust between governments and their people was something that “just happened.” Instead, he explains, it’s a “consequence of choices,” the result of generations worth of leaders not listening to the needs of their people. As the IRC elucidates, “calls for improved community engagement” often fail to delve “into why community engagement was so unsuccessful.” Early governmental responses failed simply because their constituents often didn’t trust their leaders. Troublingly, these problems of accountability and disconnect have persisted even after Ebola. The WHO has stated that that governance is one of the most “foundational of health system pillars.” While it may be too drastic to demand that public health organizations should solve underlying governance failings in a situation of acute crisis, it is critical that these groups recognize and meaningfully engage with such limiting factors.
Needless to say, Ebola has had some lasting effects on our engagement with epidemics – for instance, some argue that if it weren’t for the two-year fight against Ebola, current discussion of Zika would be limited to “page 7 of the newspaper.” However, this increased awareness is not enough. As Karin Huster concludes after observing recent responses to lingering Ebola outbreaks, “disappointingly, the crucial issues of community mistrust, resistance and lack of any semblance of surveillance system…seem to have remained, as if Ebola had never come there.” In their attempts to fully root out Ebola and address current and future epidemics, the WHO and other public health organizations must make every effort to understand their previous failings and find ways to avoid them going forward.