9th September 2015 This meeting was taken as oral evidence for the Africa APPG Ebola inquiry which resulted in the report- Lessons from Ebola affected communities: being prepared for future health crises. Available here-http://bit.ly/1U4rsef Follow the Africa APPG on Twitter @AfricaAPPG For more information on the Africa APPG visit- http://bit.ly/1SSrIcR and to sign up to the APPG public mailing list register here- http://bit.ly/1oF83Cp The Africa APPG is supported by the Royal African Society.

1. Lessons of the Ebola epidemic
(Presentation for Africa APPG, UK Parliament, 9th September 2015)
Paul Richards
Esther Yei Mokuwa
Thomas Songu
Njala University
Sierra Leone
(correspondence: paul.richards@wur.nl, or
prichards@njala.edu.sl)

2. EVD - it goes as it comes?
• Forests? Culture? Politics? Health facilities?
– Hypothesis:
• problems posed by one or all of these factors explains
spread of EVD?
– An evident difficulty:
• These factors vary across Guinea, Liberia and Sierra Leone
• Regional maps tell a different story
– Pattern of advance and retreat is the same across all
three countries
– Hypothesis:
• rapid learning (by responders, and by communities) is the
key to understanding epidemic decline?

3. Where Ebola has been
(at May 2015)

4. Situation then
(at 25/9/2014)

5. Situation now
(at 21/05/2015)

6. Unexpected Downturn
• Occurred
– across international borders
– in “difficult” areas
• e.g. in Kailahun and Guinea forests,
– Areas with high political opposition
– ahead of international response “surge”
• Downturn in Lofa county was detected by CDC from
August 2014
– Attributed to effective community engagement

7. Explanation of Downturn
– High levels of local social knowledge
• Villagers knew who was being infected
– could thus work out why
– Rapid pooling of knowledge
• by responders and communities
• based on trusted links with strategic interlocutors
– e.g. long-term Lassa fever researchers
– Quarantine works
• Low cost intervention
– Knowledge of quarantine is widespread in communities
• Smallpox and goat plague are known models

8. Community responses
• Local attempts to cut off infection pathways.
• Nursing of EVD patients and washing corpses, using
improvised protective gear
• Local leaders and vigilantes passing bye-laws ensuring
quarantine measures were obeyed
• Trusted local advocates (including survivors)
communicated need for behavior change
• Repeated but unmet local demands
• Training of local “safe burial” teams
• Protocols for safer “home care”

9. A home-care protocol

10. While waiting?
(Africa APPG Question 4: gaps in rural and interior areas)
• The ambulance never comes
– No roads, no phones
• Health care is risky and expensive
– One third of villagers would wait (about 3 days) to see
if patient recovered
• Money has to be borrowed, a hammock has to be chartered,
feeding of patient has to be arranged
– Much persistent extreme poverty in village households can be
traced to bankrupting effect of major medical episodes
NB: symptoms of Ebola are indistinguishable from malaria in first
3 days. Rapid in-situ testing might help. But roll-out of an
available rapid test has been delayed.

11. Strategies that might help
• Free care and feeding for patients
– Build on lessons of Ebola CCCs
• These were compared favourably by villagers to PHC
– (evaluation by Oosterhoff, Mokuwa and Wilkinson 2015)
• Improved phone coverage
• Use drones and balloons?
• Spot improvement of rural roads
• Channel funds directly to community self-help groups
• Identify and support community Ebola
responders
– develop effective biosafety responses at local level

12. Improve roads and phones

13. Support local responders
Ebola “militia”, Jawi chiefdom

14. Support local innovation
Liberian nurse Fatu Kekula saved family with improvised PPE

15. Answers
(Africa APPG Questions 1, 2, 4 and 5, of seven)
• Q. 1 Lessons of the epidemic?
• A. Rapid learning is key to epidemic control
– Pay attention to co-learning of responders and communities
• Q. 2 Engagement?
• A. Engage communities directly, based on analysis of response
– New evidence is urgently needed, free from “claim staking”
• Q. 4 Challenges in remote area?
• A. Reduce obstacles to use of distant health care facilities
– Attend to physical, mental and financial obstacles
• Q. 5 Barriers to community engagement?
• A. Understand and overcome reasons for local distrust
• A. Engage with key local institutions
– Beware self-appointed interlocutors or “manufactured” institutions

16. Dancing to a different tune?
Women’s collective power beats Ebola