The Case of Ebola Virus Disease

Background

The EVD epidemic was one of the most important public health threats this century – a crisis that challenged local governments and communities in Liberia, Sierra Leone, and Guinea, as well as governments around the world.  The epidemic spread to affect over 28,650 cases, including 11,325 deaths. The national health systems were still recovering from years of civil war, and had limited capacity to respond. This was partly due to severe shortages of health workers, health facilities, pharmaceuticals, and other necessary materials and public health systems. The response was hampered by poor road infrastructure, unreliable power and communications networks, and limited access to safe water supply. Other less visible factors were also important. People were suspicious of government intentions and responses in a post-conflict environment. Health workers generally had little confidence in the system and did not trust health authorities. Given the limited trust that people had in government, and the government’s inability to provide health services and safely handle dead bodies as the number of cases escalated, a vicious cycle of suspicion, miscommunication, mistrust, exposure to infectious dead bodies, and explosive transmission took hold. At the same time, other governments closed their borders to the three countries, stopping trade and commerce, creating yet another vicious cycle of loss of income, limited access to food, and heightened illness. The epidemic spiraled out of control, resulting in intense fear and turmoil throughout the sub-region. This fear rapidly extended to other countries around the world, and threatened the cohesiveness of communities and governments in Liberia and around the world.

There are historical and contextual issues that shape current vulnerabilities and resilience in the face of recovery from an acute crisis in West Africa. Sociopolitical tensions engendered by ethnic, class, and economic inequalities contributed to mistrust between groups, as well as violent conflict and several civil wars and lasting from the late 1980s to early 2000s in Liberia, Sierra Leone, and Guinea. The legacies of the transatlantic slave trade, inequitable trade policies, aid policies, and land reforms continue to affect the current political and economic systems in ways that may not only be unsustainable, but are harmful to the people who live in them. Understanding factors that have influenced current systems, including how they are connected to each other, helps to explain how the Ebola epidemic spiraled out of control in West Africa, as well as the types of vulnerabilities and adaptive capacities of communities and systems to respond.

Community resilience played a critical role in turning around the EVD epidemic. Although communities are a key component in the health system, they are largely neglected in the efforts to strengthen health systems, including in the post-epidemic plans.  In the case of Liberia, it is difficult to attribute any particular intervention to turning around the Ebola epidemic, yet it’s clear that communities played a leading role.  Hopkins faculty and Ministry of Health officials conducted a systematic analysis of interventions and when they occurred in the epidemic curve, showing that much of the decline in the epidemic curve was driven by critical behavior changes within communities, and happened before the international efforts were organized, while most of the building of treatment units came after the epidemic had waned (Kirsch et al 2016^).  Local leadership and community engagement helped reduce people’s exposure to Ebola, including through culturally acceptable ways of dealing with dead bodies, and a more integrated clinical and public health response, were instrumental in turning around the epidemic.  An important implication is that efforts to strengthen health systems should not only address the physical infrastructure and government health services delivery, but also build up the social infrastructure and systems to enhance community engagement in the health system. 

^  Source: Kirsch TD, Moseson H, Massaquoi M, Nyenswah TG, Goodermote R, Rodriguez-Barraquer I, Lessler J, Cumings D, Peters DH. Impact of interventions and the incidence of ebola virus disease in Liberia-implications for future epidemics. Health Policy Plan. 2016 Oct 29. pii: czw113