Learning about epidemic response from sub-Saharan African countries

In 2014, as one of us (A.T.D.) lay dying in an Ebola treatment center in Liberia, losing hope as the disease progressed, a hospital cleaner offered what could have been a final pep talk. “Doctors have fought for you,” he said. “Don’t let their hard work go to waste.” That, or perhaps a miracle, pulled her through.

In the past week, amid increasing calls for lessons learned to inform the U.S.’s response to Covid-19, we thought of that cleaner’s words. Many countries in sub-Saharan Africa lack critical resources, but they have a wealth of expertise in outbreak preparedness and response — from Ebola and Marburg to yellow fever — and we can learn a lot from listening to them.

As global health researchers who focus on epidemics, we were part of a team that extensively documented what was learned from the 2013-16 Ebola outbreak in West Africa by conducting in-depth interviews with more than 200 stakeholders to understand their perspectives on it.

In Liberia, the country where we lived and worked, there were at least 4,810 deaths from Ebola. In West Africa and beyond, 11,323 people died from the disease. That enormous human cost should have been a wake-up call to leaders around the world, a memento mori about how vulnerable and connected we are.

Instead, in the aftermath of that epidemic, calls for the United States to embrace the lessons of Ebola largely fell on deaf ears. A wealth of international “lessons learned” conferences were held, but few West Africans received invitations — or visas. The accents around the tables were largely American and European. There was a palpable sense that America knew best, that an epidemic the scale of Ebola could never happen on its soil. But now the death toll of Covid-19 has far exceeded that of Ebola.

Epidemics are signs that human connection is in crisis. The world is interconnected enough to share viruses across thousands of miles, yet we live in a fractured society, one in which richer countries have long sidelined the knowledge of poorer countries. In the course of our research in Liberia, one man, a pharmacist, told us, “Nobody cares to listen to poor people, and that’s why health crises happen.”

SARS-CoV-2 is not a “foreign virus.” It is our shared global responsibility. To respond to it humanely, we must move away from siloed discussions and toward cross-cultural partnerships and true global dialogues. We may have lost our chance to radically alter the course of this pandemic, but there is still a window of opportunity to listen to lessons from experts in sub-Saharan Africa promoting balanced partnerships, knowledge-sharing, and mutual support between high- and low-income countries at this time. As case numbers climb on the African continent, we will need each other — and honor our diverse expertise — more than ever.

Although not all the lessons from Ebola in West Africa translate to other contexts, we have identified five areas from our research that we think could help: designated health facilities, health systems strengthening, hygiene measures in public places, fact-based messaging, and community wellbeing.

Identify designated health facilities

When Ebola first hit Liberia in 2014, it had a case fatality rate of between 60% and 90%, and no known treatments. In a context with few ICU beds, health practitioners quickly realized that the best course of action was to identify separate structures to isolate and treat patients. The first Ebola treatment unit in Liberia was a freestanding hospital chapel, chosen because it had a separate entrance and exit. A self-contained cholera unit was then repurposed into a treatment facility, and tented facilities followed. Similar facilities are now being constructed in the U.S. to treat people with Covid-19.

During the recent Ebola outbreak in the eastern Democratic Republic of Congo, an innovative addition to patient care was the introduction of single-patient transparent cubes. These served the triple purpose of isolating patients, protecting health workers (who were able to monitor vital signs from outside the units), and permitting loved ones to visit without risking exposure.

Build health systems during an epidemic response

Strengthening health systems does not have to wait until an outbreak is over; it can be integrated into the architecture of an epidemic response. During Ebola, we interviewed cadres of health workers who received training in infection prevention and control, a skill set that is now helping prevent the spread of Covid-19 in Liberia. Networks of community health workers were bolstered, widening access to care for people in remote and rural areas. And thousands of contact tracers helped build an epidemic surveillance system that has since been reactivated during small outbreaks of meningitis and Lassa fever.

Introduce hygiene measures in public places

As they face Covid-19, many countries in sub-Saharan Africa have taken decisive measures rooted in lessons from Ebola, quickly shutting down air routes and putting hand-washing stations in public places. In Liberia, where many people do not have access to running water at home, some supermarkets have recently installed outdoor taps activated by foot pedals. Rwanda has done the same, using more modern technology.

The U.S. could follow their lead, placing hand washing devices at the entrances of grocery stores and public transit, to ensure that everyone who enters has clean hands, regardless of hygiene practices at home.

Avoid fear-based messaging

We learned that in Liberia, communication rooted in fear can cause widespread anxiety, and may even cost lives. In the earliest days of the Ebola epidemic, some humanitarian organizations used slogans including “Ebola Kills!” and “Ebola is Deadly!” on billboards. Their intention was to encourage the public to take the outbreak seriously, but instead it discouraged people from seeking medical treatment. “If we’re going to die from Ebola anyway, we’d prefer to die at home with our families,” people told us.

We learned that fear is rarely a good motivator; people generally respond better to calm, fact-based messages.

Support community well-being as well as clinical care

That might sound like a contradiction in terms, like fighting a fire and cleaning the house at the same time. But during Ebola, we learned that balancing urgent clinical care with the general well-being of the community is the best prescription for containing an outbreak. People tend to do better at complying with difficult measures such as social distancing when they are able to meet their needs for information, communication, and social support. Clinical care alone does not end an outbreak: People need to feel a sense of shared communal ownership and to see the results of their actions, no matter how small.

We still remember the poignant words of the hospital cleaner, a true frontline hero who helped one of us recover from Ebola. And we offer the same sentiment to leaders responding to this pandemic. In countries like Liberia, experts have learned expensive lessons in outbreak response. Don’t let their hard work go to waste.

Angie T. Dennis is a Liberian health researcher and Ebola survivor. Katherina Thomas is a global health researcher on epidemics and a visiting researcher at MIT and Harvard University.