UPPSALA, Sweden (Thomson Reuters Foundation) - Unsung local heroes who helped defeat the Ebola outbreak in West Africa may hold the key to thwarting deadly epidemics in the future, experts say.
Alongside targeted assistance from abroad, local know-how is also vital in dealing with endemic killer diseases such as malaria, a recent conference in Sweden heard.
And yet the contributions made by communities have been largely overlooked, Sierra Leone-based British anthropologist Paul Richards told the Uppsala Health Summit on tackling infectious diseases this month.
Ex-civil war combatants who had reinvented themselves as motorcycle-taxi drivers in Sierra Leone and Liberia’s rural areas, for example, were among the first responders in the early stages of the 2014-2016 Ebola outbreak, which killed more than 11,300 people in West Africa.
They were helping “long before there was an international response and ambulances”, said Richards, a professor at Sierra Leone’s Njala University, whose book “Ebola: How a People’s Science Helped End an Epidemic” was published in September 2016.
Even after international agencies ferried in hundreds of ambulances, the large vehicles could not get to the most remote areas where the virus was ravaging the local population.
The motorcycle-taxi drivers, working as volunteers with international agencies sometimes buying their fuel, provided the “last mile” access to villages, rescuing patients, carrying blood samples and returning with the results, Richards said.
Yet while community efforts were vital in tackling Ebola, they often clashed with the emergency measures put in place by international organizations, said Richards.
The Ebola treatment centers set up by Doctors Without Borders and other aid groups, exemplary in their medical and hygiene standards, were initially the object of deep suspicion among local people.
This was partly because many clinics were located far from villages, making them hard for family members to access.
“Ebola attacked the very part of the community that held it together – it prevented people from caring for their sick and burying them,” said Richards. “Many told me: ‘This will destroy our community’.”
At the beginning of the crisis, conspiracy theories about the origins of Ebola were rife, and people distrusted and even attacked some health workers.
The high mortality rate, meaning more than 50 percent of patients in treatment centers would not survive, did not help.
“People didn’t want to go to ‘the place where you will die’,” said Anders Nordström, ambassador for global health at Sweden’s Ministry for Foreign Affairs, who was head of the World Health Organization (WHO) in Sierra Leone in 2014-2015.
To encourage people to seek treatment, the WHO filmed patients with smartphones, and showed the videos to villagers to reassure them.
Relatives were often not allowed to take care of patients inside the centers, in a culture where giving a sick person home-cooked food is seen as essential for recovery, said Richards.
Family members would stand outside the clinics and shout encouragement – “We’ve come with pepper soup!” - and the patient would feel better just knowing the family had cooked the food they were eating, said Richards.
Trust was a major factor in eventually ending the Ebola outbreak – but it wasn’t easy to establish, said Nordström.
“I think we all got it wrong in some way at the beginning - there were a lot of top-down messages, social mobilization, radio communications, big pamphlets etc. It didn’t work - people did not listen because we were not listening to them,” he said.
Lack of trust led to a reluctance to declare who had been in contact with an infected person, preventing other cases from being found.
“So we worked through local leaders, chiefs, mama queens, youth groups and civil society and NGOs,” he said. “It wasn’t enough to send an epidemiologist there – you needed to have access, and you needed to establish this relationship.”
Often the mistrust extended all the way up to the top, said Nordström. When in January 2016 - after the outbreak had been declared over in Sierra Leone - another case tested positive for Ebola, members of the government including the vice president and education minister refused to believe it, he added.
Today, the Ebola response holds many lessons for tackling the malaria epidemic in West Africa and beyond, said Richards.
At a recent workshop in Sierra Leone, he and his team met with local doctors, nurses and health practitioners.
Everyone knew the symptoms of malaria and the location of mosquito breeding grounds, and had great ideas about how to get rid of them, but none knew what a malarial mosquito looked like and how it could be distinguished from others, he said.
Identifying and filling in these knowledge gaps, rather than coming in with new solutions to problems, will lead to a more effective response to future health crises, said Richards.
“Malaria is a very difficult challenge; you’re dealing with a parasite, a mosquito and complex environmental issues,” he said. In those circumstances, devising a strategy from Washington or Geneva won’t work, he added.
Instead the international community should pay close attention to what local people need, he said.
Community expertise is being developed in Sierra Leone where almost every village now has a volunteer health worker who is being trained to recognize ten major diseases, he explained.
Meanwhile, as it was the most inaccessible villages that incubated the Ebola virus, Liberia is now putting in motorbike bridges, which are much cheaper to build than those for four-wheeled vehicles, enabling people to get medical help faster.
And in parts of rural Sierra Leone, local biker associations are training women as drivers, to safely transport female patients to health centers and hospitals.
All of these measures place local communities at the center.
“One of the lessons of Ebola is that civic volunteering is still very important,” Richards said. “If the need is grave enough, then people will rally together and they will do things on their own.”
Reporting by Inna Lazareva, editing by Megan Rowling.