As global health researchers focused on epidemics in sub-Saharan Africa, we teach the principles of multisectorial, community-centered outbreak response to health journalists, practitioners, and communicators — from cholera to Ebola, and now, COVID-19. When we teach, there’s a metaphor we like to use; one inspired by the human body.
Every day, about 30 trillion blood cells complete a lap of the circulatory system. There are two kinds of blood cells, and they don’t do the same job or move at the same speed. White blood cells are the health workers of the human body, protecting us from infection. Like our frontline responders, they are good at rushing to the site of problems.
Red blood cells inhabit the same arteries but play a very different role. Their priority is to carry oxygen from the lungs to the organs. While white blood cells tackle emergencies, red blood cells nourish the organs, supporting the long-term well-being of different parts of the body. Although their jobs are different, both types of blood cells work together, coordinating and collaborating in their response.
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Anatomical metaphors like this one go back centuries and have been applied to everything from health to architecture. In his 15th century drawings, Leonardo da Vinci imagined the world as the human body, its different parts functioning in concert for the greater good of the overall system: the skeleton, the supports of the earth; the lungs, the natural world; the heart, the human spirit.
As we tackle seemingly conflicting priorities in this coronavirus pandemic, human-centered analogies like this one seem more needed than ever. Policymakers and public health leaders face divisive questions, such as, how do we fight a deadly virus and heal a deeply fractured society at the same time? How do we maintain self-isolation while also preventing crises of mental illness, chronic disease, social exclusion, and economic injury?
A multisectorial, community-centered approach is a prescription for tackling seemingly conflicting objectives: saving patients on the frontlines, while also supporting the essential and secondary needs of communities, building better systems to support them through this crisis — and the next.
Partner coordination is essential to the approach, which should include not only the most visible stakeholders, but also those from historically disadvantaged groups, such as immigrant and low-income populations. After all, pandemics are not only public health crises but crises of our social fabric, fed by common denominators like health inequity, income disparity, and structural discrimination.
The community-centered approach has been used, to varying degrees of success, in recent outbreaks of Ebola in West Africa and the Democratic Republic of the Congo. Some gains were made in preventing, preparing for, and responding to the general needs of affected communities, even while difficult measures such as quarantining were in place.
We learned that emergency medical care alone does not end an epidemic; communities need to feel heard and supported for an outbreak response to succeed. We know that fostering a sense of shared ownership and trust helps to repair broken connective tissue in times of crisis.
The recent 2018-20 Ebola outbreak response ecosystem in eastern DRC is an example. It consisted of 10 separate but complementary pillars — including patient care, contact tracing, psycho-social care, point-of-entry screening, and community engagement — overseen by a multisectorial committee. Weekly community feedback meetings were held, so that members of the different pillars could understand the rapidly changing needs of communities. A safe burial and cremation pillar, such as that used during Ebola, could bring together expertise in best practices on approaches to funerals during epidemics.
A social sciences task force made up of medical anthropologists and social and behavior change specialists supported the overall ecosystem, collaborating with epidemiologists to map and address the priorities of the most vulnerable populations. The apparent success of containing that outbreak was due to the efforts of all involved, particularly local communities. Their role in outbreak response is indisputable; at times when community trust faltered, so did the response.
A pillar approach could work for the COVID-19 response, based on the mapping of community needs in different countries and regions. For example, under an infection prevention and control pillar, centrally-coordinated task forces could be set up to donate soap to prisons and detention centers — as was accomplished under the multipartner response to the Ebola outbreak in Liberia.
Under a nutrition and agriculture pillar, we could see rapid assessments of food-insecure households, like those conducted during the Ebola outbreak in Sierra Leone — creating channels for aid to reach impacted small-scale farmers in the U.S., for example.
A mental health pillar could create virtual support systems for those vulnerable to mental illness, deploying mental health officers trained to respond to COVID-19, just like those trained by WHO to manage Ebola-related trauma during the West Africa outbreak.
A noncommunicable diseases pillar could see diagonal funding channeled into the prevention of obesity and hypertension — which are not only risk factors for chronic illness, but also for critical cases of COVID-19. A safe burial and cremation pillar, such as that used during Ebola, could bring together expertise in best practices on approaches to funerals during epidemics.
Such approaches to COVID-19 will surely differ across countries but should honor the needs, concerns, and voices of all communities, particularly the most disadvantaged populations. Some efforts have already begun.
In January, the Nigeria Centre for Disease Control launched a multisectorial COVID-19 preparedness group, when the Wuhan outbreak was barely on the radar of high-income countries like the U.S. and U.K. It includes experts on themes such as communicating with communities. The Inter-Agency Standing Committee, co-led by the World Health Organization, has released multisectorial guidance for the COVID-19 response in humanitarian settings, including recommendations for community engagement and income support.
Communities are the building blocks of health systems, and when we honor their voices, needs, and opinions, we can replace rupture with resilience — even in the midst of a devastating public health crisis. By mapping the needs of communities and integrating the voices of historically sidelined populations into the very architecture of this approach, we can build interconnected systems that will last long after the end of this pandemic.
Like the metaphor of the circulatory system, a multisectorial community-centered approach allows us to tackle seemingly diametric needs at the same time, building connective tissue as we go. Outbreak response does not have to be a zero-sum game. While frontline workers save lives, we can nourish our broken systems.
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