This is an edited-down version of a post by Paul Richards that first appeared yesterday on African Arguments, launching its promising new ‘Debating Ideas’ series.
Covid-19 is a flu-like illness (symptoms include fever, cough, and breathing problems) caused by a corona virus (SARS CoV-2). Like Ebola, the virus causing Covid-19 circulates within populations of bats and crossed over to humans via the bush meat trade.
Currently, attention is focused on reducing the rate at which Covid-19 spreads. Predictably, some politicians have demanded border closures against immigrants and refugees, but in a globally connected and inter-dependent world blaming and stigmatising helps no one. It is better to share ideas about what can be done to protect.
This is where Africa’s experience of Ebola has something to offer. Communities experiencing Ebola in West Africa in 2014-15 rapidly learnt from scratch how to cope with a deadly new infection, and this provides the rest of the world with important information on strategies to address novel disease threats more generally.
Like Ebola, Covid-19 is a family disease, in the sense that many infections occur in the home.
The name for Ebola in Mende, one of the main languages of Sierra Leone, the worst affected country in 2014-15, was bonda wote, literally ‘family turn round’. In other words, it was clearly recognised that this was a disease requiring families to change behaviour in major ways, especially in how they cared for the sick.
Covid-19 will require similar changes at the family level, especially in terms of how the elderly are protected. The buzz words for epidemic responders include self-isolation and social distancing, but the details of how to implement these vague concepts have been left to local social imagination.
Answers are required for both the uninfected elderly, and for others who are sick.
Should grandpa be packed off to a shed in the garden away from the family for his own protection? What happens when grandma gets lonely and wants to see the grandchildren? Who does the shopping? How does the daily-paid worker ‘self-isolate’ when there is no sick pay? Who collects the children from school when a single mum is sick?
Much depends on actual family arrangements and housing stock. So African solutions for Ebola will not work directly in other parts of the world. But it is important to know that under the challenge of Ebola, local people showed much inventiveness in devising solutions to such problems.
Evidence shows that ways can be found to reduce family risks of infection, even with a disease 30 times more deadly than Covid-19. For Ebola, these ranged from the elbow knock that replaced shaking of hands as a public greeting, to the appointment of a single carer in the household to look after the sick while waiting for help, to the carefully choreographed ‘safe and respectful’ funerals that allowed some element of local ritual back into the burial process, a major source of infection.
Every encouragement should be given to this local adaptive creativity, and the authorities should listen carefully to information from below about what would help to make a difference.
Ebola taught that epidemics cause deaths from other diseases through their impact on health systems. In all there were about 12,000 Ebola deaths in Upper West Africa (Guinea, Liberia, Sierra Leone) in 2014-15 but many additional fatalities resulted from, for example, closure of facilities such as maternity clinics.
So contingency planning is required. A key challenge for Covid-19 is how health system care should best be organized, without severely disrupting other forms of health provision.
For Ebola, the first response was to build large field hospitals (Ebola Treatment Centres). These were seen as the safest option. But they were shunned by families, because so few patients came out alive. They were also often in the wrong place (built behind, not ahead, of the epidemic).
Information started to filter through that some communities were taking their own steps to reduce infection and bury the dead. This raised the question whether there was more scope for community care.
Family do-it-yourself responses proved controversial. International responders were adamant that there should be nothing resembling home care; it was too dangerous. Local communities were equally adamant that there would have to be some form of home care; they could not stand by and watch family members die, when an ambulance to take a patient to an ETC might take days to arrive over bad or non-existent roads.
Families saw it as their duty to be involved in care of the sick. So, they repeatedly asked what to do while waiting for help to arrive. Could they not prepare food for the sick? Could they not be trained to safely bury the dead?
No, they were told. Ebola required specialist management.
Communities answered back. They pointed to areas at the outset of the epidemic, where the epidemic was rolled back with only local resources. In Sierra Leone’s Kailahun District, for example, an intense initial outbreak was reduced to a trickle of cases by local responders organizing quarantine and burial with improvised resources. That cases then declined without outside help implied either that the disease burnt out more readily than anticipated, or that local improvisation worked better than expected. There is evidence to support both interpretations.
Experts knew that Ebola control required prompt diagnosis, before the ‘wet’ symptoms of the disease became apparent. Something had to be done to speed up the presentation of cases. The answer was to build much smaller community care centres (CCC) close to where active transmission was taking place. This also changed the relationship between families and Ebola responders from fear to active cooperation.
Staff of CCC were for the most part local volunteers – trained nurses who had not been absorbed on to the payroll of the Ministry of Health, or villagers willing to take on high-risk chores for a decent wage. The fact that staffing was local meant patients saw familiar faces, and this built trust. CCC also normalized Ebola by bringing treatment within a framework of general medical assistance.
As a result, patients were presented more promptly than was the case with the distant ETC. Ebola (indistinguishable from malaria or typhoid in its early phase) was more rapidly identified and isolated. One study estimates that CCC contributed up to one third of the infection control ending the epidemic in Sierra Leone.
This example of responders modifying their approach to infection control better to accommodate family requirements may hold lessons for Covid-19.
Families need to think like epidemiologists, but equally epidemiologists need to think like families
Specifically, cases may have to be kept out of main hospitals as much as possible, Thus, there may be a need for field treatment facilities not dissimilar to CCC, as a half-way house between home isolation and intensive care. In effect these facilities would isolate and triage the most vulnerable cases, as was the case with Ebola CCC.
There is also a possibility that any such facilities might be run up by military personnel and staffed by medically trained ‘volunteers’ (retired doctors and nurses), as in Sierra Leone.
Interesting to note, the chief medical advisor for England was previously one of the proponents of the introduction of CCC in Sierra Leone, and we may be about to see some lessons directly transferred.
Quarantine for Ebola in Sierra Leone is also an issue from which Covid-19 responders might wish to draw lessons. Much of it was organised and imposed by the state, and was at times heavy-handed. But communities also organised their own quarantine. They understood that self-isolation was in their own interest, and this sometimes worked surprisingly effectively.
Use was made of an approach used during the civil war of 1991-2002 of mobilising community youth to identify infiltrators. Visitors who might have been carrying the virus were turned away. But in other cases the approach was more focused on sequestering those who were well. Rural families sometimes decamped from villages with outbreaks to settle down for a few weeks in their farms, where sleeping quarters were sometimes built for the purpose.
In this respect, Sierra Leonean rural communities showed a clear appreciation of the fact that there were two distinct kinds of quarantine – self-isolation and protective sequestration. Both kinds are being used as part of the response to Covid-19, but at times without adequate discussion of how the two types differ and have different social motivations – self-protection and altruism towards neighbours. It is not wise to talk about self-isolation for the sick and the elderly in the same breath. The different motivations need to be more clearly explained.
The main lesson for both Africa and other parts of the world from Ebola for Covid-19 is that shared learning between communities and medical professionals is a key aspect of human adaptive response to emergent diseases. In any disease in which community mobilization is an important aspect that families need to think like epidemiologists, but equally epidemiologists need to think like families.