africa appg- dr richards on the role of community in the ebola response
TRANSCRIPT
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Lessons of the Ebola epidemic(Presentation for Africa APPG, UK Parliament, 9th September 2015)
Paul RichardsEsther Yei Mokuwa
Thomas Songu
Njala UniversitySierra Leone
(correspondence: [email protected], or [email protected])
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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?
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Where Ebola has been(at May 2015)
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Situation then(at 25/9/2014)
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Situation now(at 21/05/2015)
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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
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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
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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”
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A home-care protocol
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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.
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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
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Improve roads and phones
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Support local respondersEbola “militia”, Jawi chiefdom
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Support local innovationLiberian nurse Fatu Kekula saved family with improvised PPE
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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
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