The 2014-15 ebola outbreak in the west African states of Sierra Leone, Guinea and Liberia left 11,000 dead, caused global panic, and saw the EU and member states put up nearly €2bn in financial aid.
But a new book by a British professor based in Sierra Leone during the epidemic says some simple lessons were overlooked amid the hysteria.
Paul Richards is an Emeritus Professor in Technology and Agrarian Development at Wageningen University in the Netherlands, the author of “Ebola – How A People’s Science Helped End an Epidemic”, published Zed Books as part of their “African Arguments” series, and was teaching at Njala University in Sierra Leone during the 2014-15 Ebola epidemic.
Richards spoke to euractiv.com’s development correspondent Matthew Tempest.
I’ve read the book and it seems to be arguing that the narrative that we in the West had – of ‘backward’ African burial practices undermining Western medical aid – wasn’t, in fact, the case?
They [the West African states affected] did adapt their ‘procedures’, but the point we always made during, and right at the outset, of the epidemic is that burials are non-negotiable. It is something that Africans are deeply committed to – doing the right thing by their nearest and dearest. You can have a discussion about the bio-safety hazards posed by African burial technology, but you have to fit any improvement in bio-safety within the broader meaning of African burials.
So there must be a half-way house between Western medical practices and African traditions?
The point I make in the book – and it’s borne out by the empirical evidence – is that everywhere we went people accepted there was a bio-hazard from Ebola burials.
There was an initial period of about six-eight weeks in which people, when they first encountered the disease, didn’t want to admit its existence, (and) didn’t want to take any special precautions because they didn’t believe in the reality of ebola.
And to be fair, in your book you point out the initial symptoms of Ebola are mistakable for malaria, and that it hadn’t occurred in that part of West Africa before…
Yes. But that period of opposition was quite short, in the infection chains that we’ve traced. There were other parts of the country where the epidemic was never as intense, and there were perhaps other factors in ‘ebola-denialism’.
But in the first infected areas, before there was an international response, local communities had begun to recognise that the disease was transmitted particularly by participation in funerals, and nursing the sick.
They could see the pattern, because they knew who had done what. Nursing the sick is a family responsibility. Anybody who shirks that, will be socially criticised, even stigmatised. Similarly, with funerals. And it should be stressed it wasn’t the funeral itself, it was the preparation of the body, which was the dangerous part.
And people realised the ones upholding these duties were the ones becoming infected with ebola. It didn’t take long.
Westerners don’t do their own burials anymore. It’s not a family responsibility, here we just phone the undertaker. The whole process is professionalised, and sanitised. Rural Africans have to do it all themselves.
And that was where the changes were needed, to bring in the bio-safety protocols.
But they saw what the threat was, yet saw trained ebola burial teams coming in from the cities, in ebola ambulances, and seizing the body, and basically initially dumping it on the ground, in black body bags, not even white ones [as is a traditional burial colour], there was an enormous amount of resentment. People said ‘Why not train us to do that?’ Why not train people locally? Everyone in the villages we interviewed said the same thing – it’s simple, we understand it’s ebola. Give us the equipment and train us.
So isn’t your book effectively arguing ‘go with the grain of local customs?’ Why is that so controversial?
Well, the book was launched at the start of October at the London School of Hygiene, and many of the people there had been part of the ebola response. And even there it was apparent there was a shortfall in knowledge in trying to engage in local communities. And we heard that some of the international responders were too scared to go out in the villages because they thought they would get ebola themselves, they preferred the controlled environment of supervised centres. That may be true.
It’s a nightmarish, Hollywood-scriptwriter sort of disease, but the only ebola patient who is infectious is someone in the final stages of the disease, who is vomiting or in what Medicine Sans Frontieres calls the ‘wet phase’. Then the slightest drop of infected bodily fluid can convey the virus. That is a truly terrifying situation to be in, and you can only handle with the correct protection and training and barrier-nursing.
But people discovered a lot of this for themselves, improvising with plastic bags and old raincoats and rubber boots. Some amazing stories, from when local communities had no outside supplies, yet had to bury those bodies. It could often take three, four, five days for an ebola ambulance and team to arrive.
The EU is the world’s largest aid donor, and together with member states, they put together two billion euros in aid to fight ebola. Is there anything they did wrong – or could do better next time?
I make that point very clear in the book. I don’t say there was no need for outside help or mobilisation. It was definitely necessary.
If it was being done again, what needs to be grasped firmly is that, first of all, you don’t actually need much in the way of medical support. What you need is barrier-nursing and logistics. That’s how you handle an ebola epidemic.
And secondly, you really do need to mobilise local communities as a first line of defence. And that wasn’t happening until late on in the ebola epidemic. And in some cases, it never happened.
Sometimes international outfits took over, and imposed their own routines and systems.
So next time, we need to think very carefully about what makes a ‘good fit.’ Because when I talk about local actions, I’m not just talking about intuitive actions of families and villages and so on, it includes the local professional medical, police and army. And that needs to gel before the international outfits get there. A joined-up approach, rather than the international aid to sort of ‘come down from heaven’ and imposed with no attention to what was already going on on the ground. That’s the big lesson for next time.
You keep saying ‘next time’. Will there definitely be a next time? And where?
Well, we hope not. But the virus is still there. There have been about 20 outbreaks since the original identification of the virus. They’ve only been small outbreaks, not epidemics like the West African epidemic that ran through three countries, plus international cases, and affected thousands. And the virus survives in human bodily fluid – semen, breast milk – for an extraordinary long period of time.
We don’t actually know. You can get outlier cases popping up – there have been several since the epidemic was officially contained. And they are shut down very quickly because people now know what to do. The worry is human survivors infecting people in other countries.