Ebola is back but still not being recognised by global powers for the health emergency that it is. APCO Worldwide Executive Director Simon McGee, who served at the UK Department for International Development and Foreign Office during the 2014-16 epidemic of Ebola, reflects on why this latest outbreak is more perilous than the last.
I REMEMBER LOOKING at the CRIP (Common Recognised Information Picture) in a Whitehall meeting room and feeling ill. A stomach-churning slide covered UN and World Health Organisation (WHO) projections on future incidences of Ebola if left unchecked, and the line on the graph looked like the left side of the London Shard, rising almost vertically and stopping only because of the right-hand margin of the page.
It was 2014: there had been an outbreak of Ebola in west Africa and it had only gradually dawned on the world – not helped by an initially sluggish response from the WHO nor the fact that the world’s media paid scant attention until two USmissionaries caught the disease – that it was serious. The virus was deadly, there was no proven effective vaccine to guard against it, it spread relatively easily from human contact, and there was no cure, although medical care could increase the luckless’ chances of survival. What had begun as a trickle of cases at the start of the year had, by the summer of 2014, spread across Sierra Leone, Guineaand Liberia. The clock was ticking louder by the day.
Fast forward five years and, at the end of another summer, governments, NGOs and multilateral institutions returned to the office to find the latest Ebola outbreak in the Democratic Republic of Congo (DRC) looked worse than it did a couple of months earlier. At the end of August, the WHO confirmed that 2,006 people had died from Ebola, making it the second deadliest outbreak ever, after 2014-16 when 11,300 people died out of a total 28,600 infected. But while the world in 2014 leapt into gear at that stage – with the UK, US and Francestepping in to take charge of international efforts in Sierra Leone, Liberia and Guinea respectively – such a reaction is yet to materialise this time round, creating a real risk that this outbreak will eclipse even that previous shocking toll, despite the recent development of a promising experimental vaccine.
Geography, conflict and human behaviours are, of course, very significant determinants in the spread of disease and on all three, today’s outbreak is by far worse than five years ago. Sierra Leone, Guinea and Liberia sit on the Atlantic coast, with topography that makes it difficult to travel long distances. A major challenge of the British relief effort in Sierra Leone was the difficulty in getting around the country due to the many rivers and poor roads, prompting the need to deploy numerous Royal Navy Merlin and UN helicopters to the country. But this problem was of course a help too, limiting the spread of people and therefore disease. Sadly, the same cannot be said for DRC. A cursory glance at the map shows that the country, at the very heart of sub-Saharan Africa, could not be more central and connected to the rest of the continent. Most of the latest victims and cases are in the provinces of Nord Kivu and Ituri in eastern DRC bordering Uganda, Rwandaand South Sudan, and at least one case has already been reported in Uganda, although Ugandan authorities detected this one case at the border suggesting that their screening (which tends to be a body temperature check) is having some effect. But of greater concern is the security situation in the country and the way this is preventing potential carriers in coming forward and seeking help and treatment.
All three countries affected by the 2014-16 outbreak had suffered tragically from civil conflict and mass killings in the 1990s and early 2000s. But by 2014, the fact that they all had relatively stable governments and security situations meant they could focus 100 per cent on the epidemic at hand, with populations more likely to cast suspicions aside and follow their governments’ public health instructions. Most people came forward for help and many communities, as I witnessed on the ground in Sierra Leone with some surprise, had very calmly and rationally divided themselves into those volunteering to quarantine themselves in a portion of a village or neighbourhood, delineated by nothing more than a piece of string and a few metres of exclusion, and the rest who were deemed safe.
DRC, meanwhile, continues to suffer not only from rampant militias and interethnic violence but from attacks by armed groups on Ebola treatment centres themselves, as well as the specific targeting of doctors and nurses working in them. Violence and disease have created a toxic mix of displacement and fear that is preventing health workers from detecting cases and potential victims from coming forward for help, with a disease that requires every last case to be tracked down and dealt with to stand any chance of being beaten. Instead, potential victims are hiding, and in many cases, only presenting themselves to medics when it may be too late. So, in light of that grim forecast, what next? The only answer is diplomacy.
Any solution will require genuine international collaboration on the ground. There were many breakthrough moments in the UK’s efforts in Sierra Leone in 2014 – such as the completion of the first British Army-built Ebola treatment centre – but the real game changers were the agreements between the UK and other countries that committed help. Encouraged by Sierra Leone’s long-standing relations with Cubaand despite long-running tensions with Western powers, the Cuban government deployed more than 250 medics to Sierra Leone, agreeing for them to be distributed and coordinated by the UK. They played a critical role in providing the manpower for British treatment centres, alongside local health workers, NGOs, and NHS volunteers, supplemented by medics and volunteers from other countries includingCanada.
Also needed is seamless partnerships and coordination between international and local actors, as we saw in 2014 with the UK and the national government of Sierra Leone. A historic friendship, and continued good relations, meant that British military and humanitarian planners were trusted from the outset to find the right land for treatment centres and burial grounds, set up local coordination centres, and establish Ebola worker training programmes at Freetown’s National Football Stadium. But critically, it also meant that we could work closely on some of the most challenging aspects of the relief effort: local social practices that we realised quickly were making the outbreak far worse, with funerals a critical breeding ground of contagion. The traditions of family members washing the bodies of the dead before a funeral, mourners paying their respects by touching and kissing the bodies of the dead, and bodies often lying in open caskets for days, were bad news. Even worse, we realised that Sierra Leone is riddled with hundreds of secret societies meaning it is not unusual for families to find countless strangers attending the funerals of their loved ones, making tracing people who may have attended high-risk funerals almost impossible. The UK made the Sierra Leone government realise that it had to suspend these social norms to minimise transmission, but only the Sierra Leone government and people themselves could change such ingrained behaviour.
Crucially and finally, 2014 showed that the fight cannot be left only to the UN system, humanitarian and medical NGOs, and the national authorities concerned. Arguably, given the civil and security situation in DRC, it should not have taken the WHO a year to declare this epidemic an ‘International Public Health Emergency,’ as they finally did in July. And while UN Secretary General Antonio Guterres was passionate, eloquent and convincing during a visit to DRC at the end of August about the need for a much greater donor response to Ebola, the UN has so many priorities – including many medium- and long-term, such as the SDGs and climate change – that it seems to find it difficult to respond with sufficient speed and scale to the here and now.
What are needed, are high-level, political discussions on what leading UN member states can do to take responsibility and defeat a disease with no cure that once more threatens the world. The solution last time was asking the leaders of P5 nations with historic connections with each of Sierra Leone, Guinea and Liberia to partner up with each government; I do not know what the exact formula is this time round but clearly it must have substantial UN/African Union security and negotiation elements, backed by the heft of international powers, to provide some semblance of temporary security for the health response to operate unimpeded.
Time will be set aside to talk about Ebola during the upcoming UN General Assembly. It must be at the highest level and with the greatest urgency if we are to avoid the doomsday projections once more.