MANILA — Nearly one year after an Ebola outbreak was declared in the Democratic Republic of Congo, more than 1,600 people have died and the disease has spread to a case across the border in Uganda. Aid agencies are increasingly calling for a “reset” in the response.
“I think the reason we're asking for reset is that … it will soon be one year of this response. So that clearly means that things are not working well. We have had a lot of money, a lot of funding, a lot of people on the ground, and if we are still in a response mode, we're still seeing transmission at the numbers we're seeing, then that means that something has to change in the way we're working,” Tariq Riebl, emergency response director for the International Rescue Committee in DRC told Devex.
“Medical expertise is not sufficient to end epidemics.”— Tamba Emmanuel Danmbi-saa, humanitarian program manager, Oxfam in DRC
What exactly needs to change? Different organizations involved in the response point to some common issues that need to be resolved: better coordination, clarification of roles, and concretization of community engagement. Some also called for more dialogue, among responders.
Based on Devex’s conversations with multiple international NGOs involved in the response, two international organizations, and the DRC ministry of health, it appears there is some frustration and confusion among different actors in the response. Some NGOs feel they are not being heard, while others aren’t sure where they could be falling short or feel they are being misunderstood.
DRC’s ministry of health spokeswoman Jessica Ilunga confirmed those sentiments in an interview when asked what her country needed from the international community. But she was quick to call the overall response a success, because without it, there would have been thousands more diagnosed with the disease.
"I would say what we need is ... more cohesion, more harmonization between the different interventions, more alignment with the strategic plan of the ministry of health. Because despite everything … like all the challenges or the violence and all the setbacks we've had, the public health response has been quite a success.”
Lessons from West Africa?
Representatives from NGOs Devex has spoken with were unanimous in their opinion that the goal of putting communities at the heart of the response remains a work in progress. Some of them think this is due to the response’s heavy focus on medical approaches, such as on treatment and case detection.
“Medical expertise is not sufficient to end epidemics,” said Tamba Emmanuel Danmbi-saa, humanitarian program manager at Oxfam in DRC, noting that previous Ebola outbreaks have demonstrated this. “The logic that has been used was mostly to focus on treatment, instead of equally focusing on patients and their fears and beliefs … We are calling all actors to include community authorities and nonformal leaders as decision-makers of the response.”
Social science intelligence is helping organizations build out their community engagement in the midst of Congo's Ebola response. But there are challenges in effectively using the information.
Calls for stronger community engagement date back to the 2014-2016 Ebola epidemic in West Africa, the largest in history. An important lesson from that outbreak was the need to engage communities, including recognizing the significant role community leaders such as local chiefs, traditional healers and local men and women’s groups play in the response.
There is a sense among some NGOs that those important lessons on community engagement are not being applied in the current outbreak, though others argue the complex dynamics on the ground have made community engagement a challenge.
Security is a big impediment in the response, and so are the political and social dynamics in the affected areas of North Kivu. It’s known to be an opposition stronghold, marked by decades of conflict and insecurity, leaving communities more suspicious of outsiders — even of Congolese from other parts of the country. The “level of acceptance is not as easy as one would imagine,” said Oxfam’s Danmbi-saa.
The World Health Organization realizes that community engagement is “crucially important,” but it’s one of the hardest things to do in an Ebola outbreak response, especially one with ongoing insecurity as is the case in North Kivu, said WHO spokeswoman Margaret Harris.
“The context — with insecurity and political tensions — makes all response interventions complicated, including community engagement,” Harris said in an email response to Devex. “This outbreak is unique in comparison to previous ones because of this context: A densely populated area struggling with internal displacement, ongoing conflict, and a weak health system. Much of the population is, understandably, suspicious of outsiders, and it [takes] time to create a relationship of trust.”
A report helps draw attention to what may have been a neglected part of the Ebola response in the Democratic Republic of the Congo, a country with over 200 spoken languages.
“People have asked for responders who are local, familiar and speak local languages. We’ve heard this feedback and have worked very hard to develop the capacity to place local workers on vaccination and disinfection teams, for example, while being aware of the risk and challenges this entails,” Harris wrote.
Carlos Navarro Colorado, principal health adviser on public health emergencies at UNICEF headquarters, told Devex that community engagement activities have been very “intense” from the beginning of the outbreak, although there were times, especially around the presidential elections late in 2018, when they had to play a “low profile” so as not to be accused of playing politics.
“The community, whether it is community leaders and traditional leaders, religious leaders, or the leader of a football club or a chess association or the students association, all of those have political views. We are working in an opposition area … and so it is not possible to speak to the community without engaging with people who are perceived to be either opposition or supporting the government,” he said.
But activities have been going well since, and successfully, in his view.
Ebola has a fatality rate of up to 93% for pregnant women but approval processes mean it has taken 10 months for the life-saving vaccine to reach them.
“I can tell when 92% of people who are eligible for vaccination do get vaccinated, where more than 90% of the burials are actually done as planned, that doesn't tell me that there's poor community engagement,” he said. “In any other kind of response that will be considered a success [although] of course in Ebola anything below 100% is not successful.”
Improving community engagement
A common understanding of what community engagement looks like could help the response, said Whitney Elmer, Mercy Corps country director in DRC.
"I would say what we need is ... more cohesion, more harmonization between the different interventions.”— Jessica Ilunga, spokeswoman, DRC ministry of health
Some actors, she said, approach community engagement by focusing on prevention messages. But community engagement needs to be seen as a cross-cutting issue. Every element of the response — from safe burials to treatment, security or infection prevention and control — needs to have a targeted community engagement approach. She said it was important to get more feedback from communities and use that to adapt the response
“The focus up until now, it's really been heavily on the medical side. So the treatments and the detection, that type of thing, and less on actually ... engaging communities to understand what are their concerns to understand what are their fears, what are the things that are blocking them from going to health centers when someone is showing symptoms, or all of the gamut,” Elmer said.
Harris said WHO is “deeply aware” that the key to ending the outbreak was effective community engagement. “For example, we and our partners are providing cutting-edge treatments and optimized care at Ebola Treatment Centres — but if people who become sick with Ebola are afraid to go to them, the response can’t succeed,” she wrote.
She added that WHO knows that “cutting and pasting [community engagement approaches] from locality to locality isn’t an option” in the current outbreak. This view was echoed by Emanuele Capobianco, director of health and care at the International Federation of Red Cross and Red Crescent Societies, who spoke of the need to “hyper contextualize” the response, understanding there is great diversity from one community to another.
Others would like to see a stronger community engagement voice at the coordination table. While UNICEF has been leading the risk communication and community engagement pillar of the response, as they did in Equatoria during the brief Ebola outbreak there in 2018, IRC’s Riebl said some UNICEF staff at the coordination table are “maybe not experts in community engagement.”
UNICEF has senior experts in the role to support the ministry of health-led Communication Commission, and has also “regularly brought up issues of community engagement” at the strategic level coordination group, according to Colorado. He said the U.N. agency “has focused as much in technical expertise as in coordination capacity and experience” when recruiting staff to help coordinate the response.
IFRC has been involving communities, particularly Ebola-affected families, in the funeral rites in an effort to respect local customs and traditions while mitigating the risk of the disease spreading, Capobianco said. They allow a family member of the deceased wear a personal protective equipment so he or she can watch over the preparation of the body for burial.
The family can also decide which items to include in the casket to accompany their deceased loved ones, and the route to the funeral site. Families are also allowed to touch the coffin where the body of their deceased loved ones has been placed.
“We and our partners are providing cutting-edge treatments and optimized care at Ebola Treatment Centres — but if people who become sick with Ebola are afraid to go to them, the response can’t succeed.”— Margaret Harris, spokeswoman, WHO
“These are examples of the negotiations that ensure that burial is safe from our perspective and dignified from the perspective of the family,” said Capobianco.
The view from the ministry of health
DRC’s ministry of health, which has been leading the Ebola response, is aware of the calls for more community engagement by the different humanitarian agencies. But the situation is “tricky,” ministry spokesperson Ilunga said.
One issue is that humanitarian organizations — NGOs and U.N. agencies alike — employ different types of approaches but don’t coordinate in their community engagement efforts, creating confusion in the communities, she said.
“One feedback that came back quite often from the community is they said that the messages were too, how can I say? They said it was too confusing because different people will come around ... talking about Ebola but not the same way, not the same messages. And that comes actually from ... the way humanitarian actors work in the field in general because in general they don't necessarily collaborate much,” Ilunga explained.
“That's one of the reasons David Gressly was also appointed. It was to bring more cohesion and more coherence to the way humanitarian actors interact with each other, but also with the government and the community,” she said, referring to the newly appointed U.N. emergency Ebola response coordinator.
One difficulty relates to the weak traditional community structures within the communities. Normally, responders would be talking with the village chief who can advise them who to talk to and what they need to do. But in North Kivu, Ilunga said the community dynamics are completely different. A street chief or street leader they may be working with may not command as much respect or influence in a community. They’ve also had issues with hiring because of this weakened community structures.
There are about 3,000 people working on the response under the ministry’s direction, the majority of whom are hired locally, with only an estimated 100 to 150 coming from the capital Kinshasa, Ilunga said. Because traditional social structures are not in place, she said the ministry devised an incentive to get more local people to be part of the response by paying them on a daily basis, with some paid a minimum of $5 to $10 a day.
But that has created social tensions. In a region with high unemployment, the response has been seen as a huge employment opportunity, which means sometimes people will pretend to be from one area when in reality they come from a different neighborhood, Ilunga said.
“But we don't know that. We work with the fact that, OK, they were recommended by local authorities,” she said, noting that without a national ID system it is hard to verify where people are from.
Better coordination and a clarification of roles
Some NGOs said the coordination in the response has not been very inclusive, with some of them raising issues of their involvement in coordination meetings.
For example, IRC, which has been working on infection prevention and control, said they were not included in coordination forums for the first seven to eight months of the response. That changed six to seven weeks ago, when they were invited to participate in a coordination meeting in Goma. NGOs have also been invited to some coordination meetings in Butembo.
But now the meetings take place so frequently and in different locations, it strains responders’ capacity, Riebl said. For most NGOs, he said, it’s difficult for senior staff to meet in multiple locations without disrupting their operations.
In previous outbreaks, the ministry of health has only worked with specialized medical NGOs including Médecins Sans Frontières, the Alliance for International Medical Action, and International Medical Corps, given the specific expertise they bring to the table. But in the current outbreak, Ilunga said the ministry was faced with collaborating with several other NGOs, some “with no specific expertise, to be truly honest, wanting to be involved.”
“And it's not a bad thing. It's a good thing to see that people want to engage and want to help out,” she said.
“What has been tricky I think even for them, was to find a place in the response, because the way the response is organized is it's organized in different pillars with a specific expertise and they didn't actually all have this expertise. So that's how most of NGOs end up being involved in community engagement, because that's the easiest thing they can do,” she said.
She said that doesn’t mean they are not valuable to the response, and that the ministry has tried to be as “inclusive as we can.”
“We say every partner that has an expertise in one or several of [the response] pillars can be part of the working group. And so coordination meetings are open to any organization that is involved,” she said. “But like we said, the ministry of health has always been very clear about ... that Ebola was first and foremost a health issue. But then of course, considering the context, we need to take into consideration the other aspects.”
For the third time, the emergency committee advising WHO on the situation in the Democratic Republic of Congo agreed against declaring the Ebola outbreak a public health emergency of international concern.
UNICEF’s Colorado understands some of the frustration to date on the effectiveness of the coordination of the response, and that some NGOs wanted a separate coordination system similar to during a humanitarian response, but he said since the outbreak is a public health emergency, coordination is led by the government.
“At the end of the day, the outbreak is coordinated by ministry colleagues. So I understand that that may create a frustration, but [we don't want to] supplant the government on those key positions. We are there supporting the government,” he said.
WHO Director-General Tedros Adhanom Ghebreyesus meets regularly with NGOs in DRC, said Harris. A number of them have his phone number or chat with him on WhatsApp. But she said WHO and other response partners are aware that some NGOs wanted to be further involved in coordination.
“We welcome this and continue to strive to ensure that all who wish to contribute practically to ending this outbreak can do so,” she said.
The activation of the system-wide scale-up of the protocol of the control of infectious diseases at the end of May helped improve coordination, appearing to clarify the roles and responsibilities of the different actors responding on the ground, NGO representatives said.
Mercy Corps’ Elmer told Devex in mid-June that “there has been a lot of confusion and a lot of inefficiencies around how things have been coordinated,” but more recently said they are seeing “positive steps on changes to the overall coordination of the response.”
Much of the improvements have been attributed to Gressly’s appointment in May as the U.N. Ebola response coordinator. He has created two new forums that are welcomed by humanitarian organizations. One is an Ebola emergency response team, which met for the first time June 28 and is open for all humanitarian groups involved in the response. The second is the partners coordination forum, which is also open for NGOs to participate in, even via conference call, Riebl said.
“It's something that we think is healthy because it's once a week. So we can actually plan our calendar,” he said.
Now the U.N. has appointed a coordinator for the Ebola response, the U.S. government hopes to see a new strategic plan.
He also said there is a need to “reset leadership and coordination” in the Ebola response and “take it out of the hands of the WHO,” which some believe to have been stretched thin in the response, having taken various roles in the response besides providing technical expertise.
Asked whether there will be changes in WHO’s role with Gressly on board, Harris said “WHO will continue to play a strong technical and operational role,” and will continue to be the lead agency for the public health response.
“We welcome the UN coordinated strengthening of the response — indeed, it is something we asked for. This will allow WHO to focus on the health response while others focus on their areas of expertise, and allow the response to go to the scale required whilst playing to the strengths of partners,” she wrote.
Security as a dilemma
Security remains a top concern for many of the responders on the ground. In the last week of June, WHO was again forced to temporarily suspend its operations in Beni after sustaining attacks on health workers there.
WHO has made strides in the five years since the Ebola virus outbreak in West Africa, but that doesn't mean it has the capability to respond to conflict situations.
The repeated attacks on health workers and Ebola treatment facilities has led the Ministry of Health to deploy police and military forces in the response, but some of the NGOs feel that it’s only fueling further community suspicion and mistrust in the response, noting that there’s already mistrust between the communities in the affected areas and security forces.
But not being able to access communities due to insecurity could have deadly consequences, especially if health workers are not able to access a certain area and follow certain contacts any given day.
“It's such a nightmare. If you talk to the ministry [of health] they will tell you, ‘what do we do in a situation like this?’ But we, as NGOs, we don't believe securing the response with armed or uniformed men will promote community acceptance, but rather translate to the opposite, given the proximity between the response team and uniformed men ... that the community doesn’t trust already. That's a dilemma we have now,” Oxfam’s Danmbi-saa said.
Ilunga said the ministry of health understands the concerns of NGOs, and said when they can, they don’t include police force or the army. But the issues in the communities are twofold.
“When you have a community problem, because the community is reluctant or refuses an intervention, or a community that is just violent in the sense that they just ask people to leave or might threaten them, these are issues that can be solved by community engagement. Obviously,” she said.
But next to the community issues is the problem with armed rebels and armed militias, she said.
“And that's something that we have been telling the humanitarian actors: that their community engagement and [the] violence by armed groups are two different things. We can solve the first part with traditional community engagement activity. But the second part is not the responsibility of the Ministry of Health. That's another issue that ... must be dealt [with] by the interior and the defense ministry,” she said.