More of the same won't solve Congo's Ebola crisis – let locals lead

Susannah Mayhew, Samuel Boland, Dan Cohen, Gillian McKay, Esther Mokuwa, Paul Richards and Ahmed Vandi
Photograph: Olivia Acland/Reuters

The Ebola crisis in the Democratic Republic of the Congo is already the second deadliest outbreak in history. More than 2,500 cases have been confirmed in DRC and 1,600 deaths have been recorded. The situation is escalating rapidly, with a new case in the transit hub of Goma reported on Sunday.

On Wednesday, the World Health Organization (WHO) declared the crisis a public health emergency of international concern. This raises the stakes and must lead to fundamental changes in the response. The WHO wants more funding to extend and reinforce outbreak control measures, but simply expanding the current approach is unlikely to result in a more effective response.

We believe it is time for the WHO to step back and allow local leaders and frontline responders to lead the response.

The majority of deaths in DRC are occurring in homes, or at health centres not equipped to deal with the outbreak. The Ebola response must go to where the cases are, which means embedding it into local communities.

Research on the 2014-16 Sierra Leone Ebola crisis has shown that learning from local responders is critical for effective response. Yet, international and Congolese frontline workers have urged a rethink on the emergency response, with community-led interventions tailored to local context given priority, their calls have gone unheeded.

Armed violence is widespread in DRC, and there are very high levels of hostility to foreign intervention. In North Kivu, one of the areas affected, “foreign” doesn’t even have to mean international. Often, simply being from outside the local area is enough to be considered an outsider.

Lack of trust in outside interventions can mean that people in urban and rural communities are reluctant to seek care or be treated at Ebola healthcare facilities, which are surrounded with orange tape and run by staff in hazmat suits. Those who do seek treatment are at risk of being perceived as sympathetic to – or even complicit in – a response widely and violently condemned by some members of their communities.

Even when conducting surveillance work in villages to identify and trace cases, responders – many of whom need the services of a translator to communicate in local languages – arrive in convoys of four-by-four vehicles. This is consistently raised as a point of contention by affected communities.

Less emphasis must be put on the international responseand more on local staff and community leaders. District authorities, traditional leaders, women’s groups and even militia groups must be allowed to take the lead in shaping a culturally acceptable response to reduce hostility and improve access and outcomes.

The severe breakdown of trust in the Ebola response demands a different approach to care provision. There are more than 1,000 public and private non-Ebola clinics in the affected areas, which have highly limited screening and isolation capabilities, despite being the first point of contact for most suspected cases. Increased resources, training and equipment provision for these clinics should be prioritised. This would help to normalise and de-stigmatise Ebola, and improve healthcare generally at such facilities.

Some families and individuals are too remote fromhealth facilities, or too fearful of them, to seek care at all. In such cases, it is too much to expect a parent to give up a child or other family member to strangers. Extended family ties are very strong, with obligations to a wide set of relatives. The reality is that some people will care for their loved ones at home regardless of medical advice.

Some responders want home care to be made safer, strictly as an interim measure. This would include widespread distribution of personal protective equipment including gloves, boots and chlorine, together with sensible instructions on minimising infection risk to the carer and maximising the survival chances of the sick, as well as information and resources that encourage facility-based care. Towards the end of the Sierra Leone epidemic, the US Centers for Disease Control and Preventiondeveloped guidelines on what to do while waiting for an ambulance to arrive, which could be adapted.

Allowing local people to lead the response does not mean there is no role for the international humanitarian community. On the contrary, technical advice, response coordination and an emphasis on human rights remain important contributions the international response can offer. But in DRC, as in Sierra Leone, a “top-down” approach is often seen as threatening, and needs to be avoided.

Experience from Sierra Leone suggests panic and undue haste undermine Ebola control. The affected population has to be patiently supported to find its own way. It also needs to be assigned a constructive role. Mobilising families to help fetch water and prepare food at Ebola care centres, or working with local communities to develop their own prevention plans (which are then funded), could go a long way to mitigating local hostility, where that hostility is based on feelings of helplessness and despair.

Above all, there is a need to trust in local common sense, once the nature of the epidemic and the infection risks it poses have been made clear. As Albert Camus remarked in his novel The Plague: “What we learn in the time of pestilence is that there is more to admire in people than there is to despise.”

  • Susannah Mayhew is a professor of health policy and systems at the London School of Hygiene & Tropical Medicine.

  • Samuel Boland is a social science researcher at the London School of Hygiene & Tropical Medicine.

  • Dan Cohen is a consulting biological scientist from Davis, California.

  • Gillian McKay is a researcher at the London School of Hygiene & Tropical Medicine.

  • Esther Mokuwa is an applied social scientist working in west Africa.

  • Paul Richards is an anthropologist, and emeritus professor at Wageningen University, NL.

  • Ahmed Vandi is a community health specialist researcher and trainer at Njala University, Sierra Leone.

All the authors, except Mayhew, have on-the-ground Ebola response experience. Mayhew headed the Ebola Gbalo research programme in Sierra Leone.