Responding to the 2018–2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches

Figures & data

Figure 1 Conceptualizing health systems responses to outbreaks.

Box 1 Perspectives from North Kivu

Unpublished interview data collected from Beni, North Kivu, in December 2019 by a co-author (PMK), noted that there was considerable hostility at first, when the response was led by outsiders with expensive cars. People were suspicious of their motives, believing the outsiders wanted to kill them. This was because they saw the external responders as linked to recent massacres they had suffered, which had been ignored by the Congolese government and its army. A respondent described how since 2014, when killings started in the Beni area, up to the present day no international organization had intervened to assist family members who were victims of massacres (like orphans, host house members) but suddenly for Ebola more than 50 international agencies arrived in the area. Food aid was thought to be poisoned as part of the plot to kill them and was rejected; there were numerous locally backed attacks on health facilities. After these attacks on health centers, efforts were made to integrate local people into the response teams. Local armed Mai Mai groups (who sought to protect local communities from other militias) promoted work with local doctors, nurses, religious leaders and members of women’s and youth associations. Nevertheless, many suspicions remained. When asked how Ebola survivors were regarded a respondent noted that when the survivors talked about the need to trust the medical responders they were dismissed as having been paid to say that.

The Mai Mai reportedly hold a variety of beliefs about Ebola, including that it was a plot by the ADF and other armed groups involved in previous massacres, to complete the destruction of the local Nande people. Local chiefs (who derive from locally recognized lineages but also have formal political legitimacy conferred by government) generally carry respect and authority, as do local churches, though they also reportedly contributed to local suspicions by denying the existence of the disease or misappropriating response-resources. This issue of misappropriation of emergency response funds and resources which came flooding in fueling widespread resentment, was a phenomenon in the West Africa outbreak too where it was known as “Ebola money”.^Citation60

Table 1 Recommended Actions and Approaches for Trust-Building and Community-Engagement in Emergencies

Authors	Date, Location, Data/Description	Actions
Dada et al 2019^Citation70	2014–2017, Sierra Leone. Qualitative work with community members, officers from the Community Liaison Team (CLT) and members of the Social Science Team (SST) involved in the EboVac-Salone and PREVAC trials.	Identified “four R’s” as core principles for community engagement: Reciprocity The CLT and SST ensured reciprocal communication between the trial team and the community. The CLT delivered key messages from the trial, whilst the SST completed ethnographic research in the field to uncover rumors and perceptions of the trial in the community. Relatability SST’s ethnographic findings were shared with the CLT and addressed in targeted messaging to the community. Both the CLT and SST approached the communities in an egalitarian manner, by dressing modestly, speaking local dialects, and using relatable examples. Relationships Respect Appreciation and understanding of the importance of interpersonal relationships and respect for the people, their customs, and traditions.
Enria et al 2016^Citation60	2014–2016, Sierra Leone. Study on use of social science within the EBOVAC-Salone trial in Sierra Leone. Analysis of data from: ethnographic observation, interviews with trial participants and key stakeholder interviews.	Analyses identify two important considerations that are relevant for engagement in emergency settings: Power: communities must not be considered homogeneous; community engagement requires an understanding of intra-community power dynamics; Trust: historically rooted rumours can be effectively addressed through active dialogue rather than through an approach focused on correcting misinformation.
Gillespie et al 2016^Citation69	2013–2016, West Africa outbreak countries Analysis of UNICEF’s response in the West Africa region, which, for the first time in an emergency setting, incorporated communication for development (C4D) into each country’s national response, alongside more typical components such as supplies and logistics, surveillance, and clinical care. The authors analyze a variety of data and distil seven key lessons.	(1) Strategy and decentralization: develop a comprehensive C4D strategy with communities at the center and decentralized programming to facilitate flexibility and adaptation to the local context; (2) coordination: establish C4D leadership with the necessary authority to coordinate between partners and enforce use of standard operating procedures as a central coordination and quality assurance tool; (3) entering and engaging communities: invest in key communication channels (such as radio) and trusted local community members; (4) messaging: adapt messages and strategies continually as patterns of the epidemic change over time; (5) partnerships: invest in strategic partnerships with community, religious leaders, journalists, radio stations, and partner organizations; (6) capacity building: support a network of local and international professionals with capacity for C4D who can be deployed rapidly; (7) data and performance monitoring: establish clear C4D process and impact indicators and strive for real-time data analysis and rapid feedback to communities and authorities to inform decision making.
Kasali 2019^Citation46	Sept-Oct 2018, Beni – DR Congo NGO report based on qualitative rapid data collection among community members in resistance hotspots, Beni, DRC	Principles of operation to develop activities to embed trust in every activity: Recognize priorities and ensure political neutrality of responders; Clear and consistent explanation of response strategies; Transparency in decisions and actions; Psychosocial approach; Mechanisms for tracing and responding to ongoing community feedback.
Ryan et al 2019^Citation71	May 2015-June 2016, West Africa Social scientists affiliated with the Ebola 100-Institut Pasteur interviewed 160 responders (local, national and international) Responders’ included on-the-ground social mobilisers, health workers and clinicians, government officials, ambulance drivers, contact tracers and many more. To identify and examine “social techniques for effective emergency response”	“Technologies of trust” identified from responders’ experiences, that can be used to promote actively legitimate trustworthy relationships: Openness: a willingness and genuine effort to incorporate multiple perspectives; Reflexivity: flexibly responsive to context and ongoing dialogue; Accountability: taking responsibility for local contexts and consequences, to facilitate relations of trust. By practicing these “technologies”, trust was fostered through open, transparent and reflexive communication that was adaptive and accountable to community-led response efforts and to real-time priorities. These improved the acceptance and effectiveness of emergency response strategies.
Tsai et al 2020^Citation72	2014–2015, Liberia Representative survey in 78 communities in Monrovia on the government’s awareness campaign in 2014. Then 80 key informant interviews in early 2015 in 40 randomly sampled communities, to uncover pathways through which messaging was most effective.	Quantitative evidence suggests that mediated outreach by volunteer intermediaries was remarkably effective at persuading citizens to trust health authorities and comply with contentious control policies. Qualitative data identified why: Local intermediaries were more familiar to community members and thus more trusted than government officials. They were trusted because: that intermediaries’ embeddedness in their communities enabled other community members to monitor, and if necessary, sanction them. This vulnerability and accountability made them more credible. To enable this, intermediaries revealed their workplaces or affiliations with organisations working locally. They also associated themselves with well-known community actors (eg schoolteachers) and places that residents could find and hold accountable in their stead. Once intermediaries had won the trust of their fellow residents, they were able to communicate information about Ebola without encountering resistance. However, our interview data suggest that they also began to serve as “opinion leaders,” or trustworthy sources of information about the government, and used this position to begin transferring the trust they had won to the government. One way was to pass on myths/misinformation and meet with Ebola-response representatives to discuss counter-arguments. Another was to pass on information about government expenditure on resources and about medical personnel dying – neither of which were regarded as taking place if the government’s motives were harmful.

Box 2 Local Perspectives on Local Intellectual and Scientific Involvement and Communication

Experiences of co-authors (PK, KKB, CK) in DRC show that there were serious communication deficiencies alongside a lack of space for local scientific or academic debate on Ebola outbreak responses. For example, Public Health and Medicine Faculties at universities including the Université Libre des Pays des Grands Lacs (ULPGL, in Goma, North Kivu) and Institut Supérieur des Techniques Médicales de Bukavu (ISTM-Bukavu, Eastern Congo), would have been appropriate institutions to engage to help to identify and shape critical solutions. They were not involved, although some individual faculty members did provide input and help to collect data. Local frontline health workers were not consulted (despite being expected to implement many of the response actions) and frequently felt bypassed and undermined (e.g. when they were unable to explain the reasoning behind certain response actions that local people did not like or understand). There were no scientific presentations by humanitarian agencies or the national public health program that could have enabled locally appropriate debate about the response and more informed solution-building.

Communications were frequently unclear and inadequate. Local radio programs presented preventive messages without any scientific evidence; there was huge confusion about the vaccine as it was rolled out; and the quality of debate was poor. These deficiencies could all have been improved with the participation of local researchers, health workers and institutions.

Box 3 Local Perspectives on Transforming Crisis-Response in DRC

Local intellectuals, including those co-authoring this paper (PK, KKB, CK), are clear about the way in which the response interventions could and should have been adapted and transformed.

Lessons from previous outbreaks in DRC do not appear to have been well learned.

Local academic institutions should have been involved in discussions about how to shape the response and its communication in local languages. The connection between local suspicions of the Ebola response and previous massacres which neither UN peace keeping forces nor the Congolese Government have been able to prevent, needed to be recognized in messages as well as actions. To combat suspicion of the motives of government and international responders, other health needs should have been addressed alongside Ebola and local people (i.e. from Beni, from Butembo etc.) should have been more systematically integrated into local response teams. The knowledge of local frontline health workers should have been incorporated and acted on.

Strong partnerships should have been developed with a wide range of local authorities and “leaders of opinion” - through meetings/dialogues as well as active mobilizing, training and hiring them for the response. These local stakeholders include local chiefs (i.e. locally recognized leaders at different levels of local government organization: chiefdom chiefs, groupement chiefs, locality chiefs), local churches (Christian and Muslim), health community workers (liaison health agents at health center), traditional healers (whose coordination office shares a compound with the Office of Health Inspection in North-Kivu), women’s associations, youth associations, local civil society and administrative authorities (territory administration) and leaders of armed groups operating locally.

Proper processes for local accountability needed to be put in place for transparency and to prevent misappropriation of protective items and supplies that were entrusted to them to distribute. Where armed conflict and breakdown of government authority continues, treatment centers may need to be secured, but not without mobile teams using local languages to raise awareness about Ebola and help to build trust in the response.

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