A report from the Africa All Party Parliamentary Group (APPG) and think tank Polygeia has suggested that initial awareness messaging may have exacerbated the fear felt by communities affected by Ebola and even discouraged those with symptoms from seeking medical attention.
At Westminster between October 2014 and May 2015 the Africa APPG held a series of panel discussions on the international Ebola response. Panellists who had worked in Ebola-affected communities stressed repeatedly that the response was being hindered by a fear and a lack of trust between national actors, international actors and affected communities.
Consequently, the Africa APPG together with Polygeia launched an inquiry into attempts to engage the affected communities in the response. The inquiry received 31 written submissions and held numerous evidence gathering meetings. To ensure the voices of affected communities were represented in the report, 23 key informants were interviewed. In Sierra Leone these were conducted by Restless Development and the Public Health and Development Initiative in Liberia.
An epidemic of mistrust: fear & resistance
The report finds that in the initial stages of the response, mistrust of and resistance to responders was indicative of a lack of community engagement with initial responses being impersonal and fear inducing. Like other international actors in the crisis, the UK’s initial response to the Ebola outbreak has been criticised as authoritarian. Many UK actors were not educated about traditional beliefs and practices (such as washing and dressing bodies for burial) and so in the rush to save lives foreign aid workers frequently ignored these aspects and some even tried (largely unsuccessfully) to tell Sierra Leoneans that they must “put aside tradition, culture and whatever family rites they have”.
This resulted in resistance, and at times hostility, towards the Ebola responders. The WHO recognised in April 2015 that “inadequate engagement with affected communities and families” was a “significant obstacle to an effective response”. Many NGOs responding to Ebola operated at community level but community respondents to the inquiry interviews highlighted a gap between NGO activities and the communities’ priorities.
Bottom-up and community led approaches: fostering local ownership of health systems
The report finds that community groups played crucial roles in creating successful strategies to control Ebola and build trust between responders and communities. The chief finding being that efforts to curb the outbreak were most effective when local leaders of affected communities led the demand for assistance from their governments and the international actors, and played an essential leadership role in the management of that assistance.
It advocates that although a top down approach (nationally and internationally) may always be necessary in a health crisis, it is only effective when the affected communities trust that response.
However, the report also acknowledges that the need to react rapidly in a health crisis makes it almost impossible to consult communities immediately. Therefore, the key lesson in ensuring preparedness for future health crises is that health systems should be developed horizontally, local ownership should be prioritised and investment made at community level. Such approaches foster trust and create demand for health services. Communities should be consulted about their needs and local facilities and systems developed to provide permanent services which local people trust and access and which can respond effectively during a crisis.
Co-Chair of the Africa APPG Lord Chidgey who led on the report commented:
"The UK has a rich history of supporting programmes which focus on community engagement. However, the report finds that it is essential if we are going to achieve universal health coverage under the SDGs that all donors, actors and NGOs give much higher priority to community ownership of health. Investing in earlier community consultation and working through existing community structures would strengthen local health systems and enable them to respond more effectively to a crisis. I hope the findings of this report will help guide responses to future epidemics and long term approaches to strengthen health systems."
For further information
The PDF is available to download here and hard copies have been depositied in the House of Commons and House of Lords libraries. If you would like a hard copy of the report, please contact Hetty Bailey, Coordinator of the Africa APPG at the Royal African Society- firstname.lastname@example.org or (+44)20 3073 8339