Screen Shot 2019-09-01 at 14.18.54.pngBelow are the citation and selected extracts of an article in this week’s print BMJ (24 August)

CITATION: Ebola in Sierra Leone and DRC: lessons learnt
BMJ 2019; 366 doi: (Published 05 August 2019)
Cite this as: BMJ 2019;366:l5012
Mara Kardas-Nelson, journalist

MKN: In West Africa many ill people stayed in the community, and many did not seek treatment at all. Do you see the same in DRC?

Eugene Richardson: In Sierra Leone patients didn’t go to health facilities in part because there wasn’t enough staff to treat them. That’s not necessarily the case in DRC, which has four times the number of doctors per capita. But patients are still showing up to treatment units late and sometimes dying two or three days later. Or they’re not coming at all.

A Lancet Infectious Disease paper said this was due to mistrust, claiming that only 25% of people in the DRC believe that Ebola is real.4 The paper suggests that “conspiracy theories” are driving the epidemic, but that discounts a very real history of colonial exploitation: the brutal rule of Leopold II of Belgium in the 19th century, the fact that the country’s first democratically elected president was killed with the support of the US CIA in 1961.5

There’s a theme of people coming in a way that doesn’t benefit people in the Congo. So of course they don’t want to comply with outside forces. Rejecting intervention—it’s almost like a habitual reaction now.

People have been dying from malaria, measles, and armed conflicts for years, and there’s a sense that no one’s come to help. And then all of a sudden they see people from abroad with SUVs and money. They feel like all of this is being foisted on them. They feel like we’re the ones spreading Ebola…

MKN: The DRC outbreak has continued for a year. Why isn’t there an end in sight?

ER: I worry that a vertical, hypertechnical approach, with a focus on vaccinations and new drugs, is backfiring. It may be causing a lot of people to recoil. To access these new interventions people have to go through an ordeal of consent and paperwork. That does not normally accompany medical interventions, raising suspicion of ulterior motives.

I’ve been surprised to see how much refusal there is. In one village I visited, of a couple of hundred people, only eight people took the vaccine. I think this has to do with a habitual rejection that communities have as a reaction to depredation from Kinshasa and foreign entities over many decades.

Maybe we have to approach things differently. For example, we could consider paying people cash to get the vaccine, rather than assuming they’ll trust an outside force. We also need to provide high quality care across the board, not just for Ebola but for malaria, obstetrics, surgical services—things that people need every day.

Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare information – Join HIFA:

HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All – ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org   FB:

Thank you for sharing this discussion []. There is good reference to the origins of reluctance: colonialism, mistrust of government and habituation to disease-related deaths. It is important as well to note the published materials that discuss the use of this outbreak by non-state actors to generate tension and community mistrust, as the NSAs strive toward non-related political aims. A good part of Ebola’s success can be attributed to the ongoing violence and attacks on health facilities and workers as well as on communities.

And the proposal to pay people for accepting vaccinations is interesting, as would be the elaboration of this idea with payment or a stipend for care-seeking/accepting care. My fears in this regard are:
–          If one is compensated or rewarded just for Ebola care-seeking or vaccination, would that need to trickle to all health care/services?
–          If not just for Ebola, then where does the rewarding for care-seeking and care acceptance stop?
–          Would it still be perceived as exploitive and as a scheme by external forces?
–          Does this approach increase the community’s understanding of the dangers and of the need for care-seeking? Does it increase trust overall?
–          Can the system handle the demand that compensation would generate?

Perhaps on a broader scale, it’s intriguing to imagine a world where we could, writ large, afford to pay not only all workers delivering health services by all patients seeking these services. As we are in the midst of striving to provide primary health care as a guaranteed human right in the quest for universal health coverage, imagine what happens when we have the resources to incentivise actions for healthy lives. … but also imagine the needed resources.

What are other community-focused approaches that are founded in the quest to understand community reluctance more fully?

Catherine Kane
Community Health Worker Guideline Communications & Advocacy
Human Resources for Health Policies & Standards
Health Workforce Department
World Health Organization
Avenue Appia 20, CH-1211 Geneva 27

HIFA profile: Catherine Kane is a member of the WHO Health Workforce team, responsible for advocacy and dissemination of the Guideline on health policy and system support to optimize community health worker programmes. She has experience with community health worker programmes at strategic and operational levels through WHO, the International Federation of Red Cross and Red Crescent Societies and at one point as a social worker supporting migrant communities. She is a member of the HIFA working group on CHWs.  Twitter: readycat