At the Ebola epidemic’s height in mid-2014, there were concerns social order in Guinea, Liberia and Sierra Leone could collapse. International mobilisation, notably after the UN Security Council declared the epidemic “a threat to peace and security” on 18 September, brought an extensive intervention and considerable progress. When explaining the dramatic increase in infections starting in March, observers mostly point to weak health systems, limited resources, population mobility, inadequate support and that the virus was largely unknown in the region, but lack of trust in the state, its institutions and leaders was also a major factor. Nor was the international community beyond reproach. It prevaricated, and mostly ignored early and clear warnings until the threat was perceived as global. Unless lessons are learned across all these issues, the next regional health crisis will be as needlessly costly and disruptive as the Ebola epidemic and pose a similar risk to international stability.
The virus initially spread unchecked not only because of the weakness of epidemiological monitoring and inadequate health system capacity and response, but also because people were sceptical of what their governments were saying or asking them to do. Lack of trust in government intentions, whether in the form of political opportunism or corruption, was based on experience. In its initial phase, many West Africans thought Ebola was a ploy to generate more aid funding or reinforce the position of ruling elites. And when Ebola proved real enough, political machinations and manipulation needlessly hindered the early response.
Initially information was not shared, and warnings were not disseminated widely enough. Countries hesitated to declare an emergency for fear of creating panic and scaring away business. Once they did so, their governments relied on the security services – their most capable, internationally supported institutions – but the early curfews and quarantines exacerbated tensions and alienated people whose cooperation was necessary to contain the epidemic. Officials in capitals also initially ignored local authorities, who were sometimes more familiar with traditional customs and accepted by their communities (with the exception of Guinée Forestière, where local authorities were no more familiar with local customs or trusted than the national government).
Despite huge investments in peacekeeping and state building in Liberia and Sierra Leone in the preceding decade and a significant UN and non-governmental organisation (NGO) presence, the region was ill prepared for a health crisis of such magnitude. Broader issues of national reconstruction, particularly in those two countries, combined with the prioritising of specific diseases, such as HIV/AIDS and malaria, contributed to produce stove-piped health sectors with abundant resources for those targeted diseases but resource-strapped health ministries overall that were particularly vulnerable to a health emergency. Aid organisations, with far better resources than the local ministries, also inadvertently undercut attempts at self-sufficiency.
It was only after the second wave of Ebola cases threatened the very stability of the affected countries that authorities took concerted action (with the help of NGOs, international agencies on the ground and donors), starting with the engagement of community leaders. Particularly in Liberia, they slowly learned what did not work and how to better communicate appropriate precautions and necessary cultural changes, eg, handling of deceased relatives, that finally helped bring the epidemic under control.
The international reaction was equally problematic and rightly criticised as dysfunctional and inadequate by many observers. Early warnings were largely ignored until cases began cropping up in the U.S. The World Health Organization (WHO), which had stalled for far too long on declaring an international health emergency, then proved incapable of mounting an effective response. The Security Council was forced to create a new body to scale up and coordinate operations – with variable results – the UN Mission for Ebola Emergency Response (UNMEER).
Lastly, the intervention may have exacerbated some risks in countries whose dysfunctional political systems not only hindered the response, but also posed serious constraints to a recovery. The arsenal of additional public health measures for use in an emergency, such as bans on public gatherings, that ruling elites acquired has potential to be misused for political gain. Although a return to open conflict in Ebola-affected countries is unlikely, a number of issues could provoke further unrest in them, from restrictions on opposition movements to simple further estrangement of civil society. This bodes poorly not only for democracy, but also for the region’s response to the next health emergency.
Divorcing political consideration from the response to public health crises should be a priority. It requires transparency from governments, opposition groups and international organisations. As a first step, West Africa’s still fragile states need to learn from and allay fears over actions taken against Ebola, as well as account for the use of Ebola-related resources. The movement toward greater regional cooperation, with regards to both transmissible disease and other transnational threats, is at least one positive development emerging from the crisis. Sustained international support is likewise necessary in the recovery process. Donors and implementers must also learn from their own failings during the Ebola response. The epidemic might not have been preventable; it certainly was controllable in the early stages. Avoiding a repetition requires addressing the errors of the past.
To definitively end the Ebola epidemic and limit the impact of the next health crisis
To the governments of Liberia, Sierra Leone and Guinea:
1. Make accountability an important component of the post-Ebola recovery strategy by increasing transparency in Ebola funding in all three countries and taking action over missing funds.
2. Build on civil society initiatives that bridge socio-political cleavages and help create a more collaborative approach to crisis response.
3. Strengthen health systems (especially for treatment of other diseases), including by investing in early warning, epidemiological capacities and adequate clinics and staff for the population.
4. Make clear distinctions between public health imperatives and actions that can be construed as giving political advantage to a particular region or party.
5. Encourage greater cross-border cooperation and information sharing on health crises and other transnational threats.
To the Economic Community of West Africa (ECOWAS):
6. Strengthen regional health surveillance, communication and coordination mechanisms.
7. Draw lessons from the Nigerian experience and establish or reinforce rapid-reaction teams to investigate and respond to possible epidemics.
To donors and the UN Security Council:
8. Pay close attention to the governance challenges that have undermined citizens’ trust in their governments and institutions.
9. Support accountability and transparency regarding Ebola-designated funds, including audits by the governments of the three affected states.
10. Remain consistently engaged in the post-epidemic recovery process, including by delivering on pledges committed at the International Ebola Recovery Conference (9 and 19 July 2015).
11. Rebuild health structures and address diseases neglected during the Ebola epidemic by sustaining support long after media and political attention has shifted.
12. Ensure necessary support for the planned African Centres for Disease Control and Prevention. Conduct an independent review of the UN response (notably that of the UN Mission for Ebola Emergency Response, UNMEER) to determine what lessons can be learned for future regional operations.
To the World Health Organization (WHO) Executive Board, Health Assembly and UN General Assembly:
13. Ensure that the WHO reform process creates an emergency unit with the capacity and ability to effectively coordinate the response to public health crises, with special attention to developing countries.
14. Insist on an independent review of the ongoing WHO reform process and hold officials at the country, regional and headquarters level accountable for fully implementing reforms.
15. Cooperate with wider humanitarian and health systems in Guinea, Liberia and Sierra Leone.
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