Analysis Of The Local And International Responses To Western African Ebola Virus Epidemic
Introduction
Ebola Virus Disease (EVD), formerly known as Ebola Haemorrhagic Fever (EHF) is a rare, highly virulent and often fatal human illness endemic to equatorial Africa. EVD is caused by Ebola viruses of the Filoviridae family, four of which are known to cause the disease in humans: Zaire, Bundibugyo, Sudan and Taï Forest. The former, Ebola Zaire, is of particular public health concern as it is the most lethal with a case fatality rate of up to 90%. The particularly virulent nature of Ebola viruses can be partially explained by their ability to disarm an infected individual’s immune system. Macrophages, a type of white blood cell, are amongst the first cells infected with the virus, leading to rapid immunosuppression.
By inhibiting the immune response, Ebola viruses spread quickly throughout the body with devastating consequences. Symptoms of EVD typically begin following a 2-21 day incubation period with a sudden influenza-like illness characterised by fatigue, sore throat, fever, decreased appetite, weakness, myalgia, arthralgia and headache. This is followed by vomiting, diarrhoea, rash, compromised renal and liver function, and in some cases, coagulopathy resulting in significant internal and external haemorrhage. Death typically occurs 6 to 16 days from first symptoms and is usually due to multiorgan failure and haemodynamic shock secondary to extreme dehydration and blood loss.
Although the exact origins of EVD are not entirely known, it is thought that the virus is a zoonotic pathogen, with bats the most likely animal reservoir. The virus is introduced into human populations through close contact with infected animals, and spreads through direct contact with the bodily fluids of an infected individual or an individual who has died from the infection. EVD was first identified in humans in 1976 during two simultaneous outbreaks. One in South Sudan, and the other in the Democratic Republic of Congo near the Ebola River. Since its discovery, there have been numerous outbreaks in several African countries resulting in significant morbidity and mortality. Between 1976 and 2013, the World Health Organization (WHO) reported 24 outbreaks involving 2,387 cases with 1,590 deaths.
The Western African Ebola virus epidemic of 2013 to 2016 was the most significant EVD outbreak in modern history, resulting in considerable loss of life and socioeconomic disruption. Over the span of a single year, the Western African Ebola virus epidemic resulted in more than 10 times as many cases of EVD than the combined total of all previous Ebola outbreaks. By March 2016, when the Public Health Epidemic of International Concern (PHEIC) status was lifted by the WHO, there had been a total of 28,616 cases of EVD and 11,310 reported deaths across Guinea, Liberia, and Sierra Leone. An additional 36 cases and 11 deaths were reported when the EVD outbreak spread out of these three countries.
Since the Western African Ebola virus epidemic, there have been 3 further EVD outbreaks mostly limited to the Democratic Republic of Congo. The most recent outbreak, known as the Kivu Ebola epidemic, is the second largest EVD outbreak in modern history, is still ongoing, and is of particular concern due to the combination of military conflict, infrastructure disruption and civilian distress in the region. The WHO has described the situation as a potential “perfect storm” that could lead to a rapid worsening of the outbreak at any point.
This paper will critically evaluate the unique leadership challenges that faced the local and international responses to the 2013 to 2016 Western African Ebola virus epidemic with a focus on identify lessons that can be learnt to better manage current and future outbreaks. These challenges will be explored in detail through the core leadership principles of situational awareness, risk communication and preparedness using a review of recent literature.
Methodology
Information sources
Authors searched for manuscripts on OVID Embase, PubMed, Google Scholar and JCU OneSearch. The websites of government and non-government organisations such as the Centers for Disease Control and Prevention (CDC), World Health Organisation (WHO) and Médecins Sans Frontières (MSF) were accessed. A Google search was also performed in order to assess grey literature. Reference lists of identified relevant sources were reviewed for additional citations.
Inclusion and exclusion criteria
Papers published prior to 2013 were excluded from the initial search as the search strategy aimed to identify literature relevant to the 2013 to 2016 Western African Ebola virus epidemic. Sources that were not published or translated into English were also excluded. Publications were considered eligible for inclusion in this review if they reported on either the local or international public health response to the Western African Ebola virus epidemic. Sources that discussed leadership challenges, successes and/or failures in response to the crisis were also included. Given the breadth of the subject matter, >100 relevant sources were identified. X sources were selected for inclusion in this review based on relevance and diversity of views.
Analysis
Given the nature of this review, a qualitative analysis of the literature was performed. Several leadership challenges facing local and international public health responses to the 2013 to 2016 Western African Ebola virus epidemic were identified. These challenges will be examined through the lens of 3 key leadership principles:
- Preparedness
- Risk communication
- Situational awareness
Discussion
Situational awareness
Situational awareness is defined as the ability to make sense of ambiguous situations. It requires individuals and organisations to develop processes that support decision-making under uncertainty in order to act effectively. During the 2013 to 2016 Western African Ebola virus epidemic, gaps in situational awareness were not only exposed in the initial perception of the problem, but also in the comprehension of its magnitude and projected global impact, which likely resulted in an exacerbation of the epedemic.
The international community was caught off guard as this outbreak behaved differently to previous outbreaks and challenged well established assumptions on the geographical extension of the disease. In retrospect, it has been identified that several factors that contributed to the undetected spread of EVD and impeded rapid containment were overlooked in the initial response to the 2013 to 2016 Western African Ebola virus epidemic. These include a high degree of population movement across exceptionally porous borders, severe shortage of skilled health care workers and high risk cultural practices in effected countries. Despite increasing and urgent warnings from local authorities, a lack of situational awareness of these factors lead to significant delays in acknowledging the outbreak. The WHO did not publish an official notification of EVD on its website until the 23rd of March 2014, and only declared the epidemic to be a Public Health Emergency of International Concern (PHEIC) on the 8th of August 2014. In her article “World leaders are ignoring worldwide threat of Ebola, says MSF” Ingrid Torjesen highlights that despite MSF’s repeated calls for a massive mobilisation, the response was too little, too late. Naimah Jackson, team leader at the MSF also famously stated during her United Nations address that “we [MSF] do not have the capacity to respond to this crisis on our own. If the international community does not stand up, we will be wiped out. We need your help. We need it now.”
The WHO has since been heavily criticised for its lack of leadership and situational awareness during the crisis. Paul Cosford, director for Health Protection and medical director at Public Health England, stated that the WHO had made “egregious failures” in handling a global response to the Ebola outbreak. Further, in their Lancet report, Moon et al echo these sentiments by claiming that “Ebola exposed the WHO as unable to meet its responsibility for responding to such situations and alerting the global community.” Moon and his colleagues recommended that the WHO create a dedicated centre for outbreak response in order to strengthen preparedness and situational awareness for future crises.
Preparedness
In their article “Preparing for the Future: Critical Challenges in Crisis Management” Boin et al assert that a lack of preparedness is one of the key barriers to providing effective leadership during a public health crisis. As modern public health crises become more complex and difficult to predict, achieving “preparedness” seems like an increasingly impossible task. The 2013 to 2016 Western African Ebola virus epidemic is a frightening example of an “unpredictable” public health crisis which exposed the level of local and international unpreparedness for a major communicable disease outbreak.
Although countries in Africa have experienced EVD outbreaks for many decades, prior to 2013 EVD had been confined to Central Africa and Gabon. Though these countries suffer from weak public health infrastructure and social unrest, they are familiar with EVD, making them relatively well equipped to manage outbreaks when they take place. Clinicians and the community know to suspect EVD when a “mysterious” illness occurs, favouring early detection, and laboratory capacity is well developed. In addition, governments have invested in specialised isolation wards and staff are trained in infection prevention and control.
In contrast, Guinea, Liberia, and Sierra Leone had no past experience with EVD and were poorly prepared for an outbreak on every level from coordinating a national response, early detection and treatment. The first cases of EVD during the 2013 to 2016 Western African Ebola virus epidemic are documented to have occurred in the remote Guinean village of Meliandou in December 2013. A two year old boy and several members of his family are said to have died of a “mysterious” illness initially thought to be Cholera. Local clinicians had never managed a case of EVD and no laboratory had ever diagnosed a patient specimen. As a result, the Ebola virus was able to spread undetected for many months before being identified. Suspected cases of EVD were only reported to Guinea’s Ministry of Health months after the first deaths had occurred, by which point the deadly virus had infiltrating major urban centres and crossed borders, revealing significant inadequacies in disease surveillance and response systems in effected countries.
At the time of the outbreak, the capacity of local health systems was extremely limited. Functions that are considered “essential” were not performing and prevented the development of a timely response to the outbreak. In response to the 2013 to 2016 Western African Ebola virus epidemic the WHO has since identified a need to widen its Ebola emergency preparedness activities so that that it can better detect, respond to, and mitigate risks to health. In his article “Strengthening the Detection of and Early Response to Public Health Emergencies: Lessons from the West African Ebola Epidemic” Mark Siedner states that there is no substitute for prevention, and that in the long term, it will be essential to build more robust health systems. Human resources capacity building, laboratory infrastructure, and epidemiologic surveillance expertise are all urgently needed in to prepare for future outbreaks.
Risk communication
The 2013 to 2016 Western African Ebola virus epidemic is also characterised by unique communication challenges. Risk communication refers to the exchange of information between experts and individuals facing threats to their wellbeing, and is a fundamental tool in the management of any public health crisis. This is particularly relevant in the case of EVD as the mechanism of transmission is influenced by the behavioural practices and cultural beliefs of individuals.
High-risk behaviours associated with burial and funeral practices for example were deeply embedded in the social fabric of many effected community, making it difficult to convey the importance of adherence to preventative measures. Data reported by Guinea’s Ministry of Health suggested that 60% of cases in the country could be linked to traditional burial and funeral practices. Similarly, in Sierra Leone it is estimated that 80% of cases could be linked to these practices. In their article “the impact of traditional and religious practices on the spread of Ebola in West Africa: time for a strategic shift” Manguvo et al reflect on the lack of consideration of these traditional and religious practices in risk communication strategies. For example, many restrictive policies defining how bodies of Ebola victims are to be handled and subsequently buried were introduced and cremation was strongly encouraged. Cremation is however in direct conflict with many traditional customs and highly stigmatised. In an attempt to avoid having their relatives cremated, many people chose not to report their deceased relatives and secretly continued with traditional burial practices which had the unintended consequence of accelerating disease transmission. Rather than imposing restrictive measures on traditional practices, Manguvo et al propose that traditional leaders be consulted in order to modify cultural rituals to levels that are effective in prevention of disease but still culturally acceptable.
In addition, years of civil war and unrest in effected countries decimated road and telecommunication infrastructure. This made it extremely difficult for governments and public health organisations to promote preventative measures and coordinate relief efforts in vulnerable communities. A long history of oppression also lead many to distrust public health messaging. In post-conflict Liberia for example, it is well documented that attempts to involve communities were threatened by a lack of trust in authorities. Mistrust towards health workers and the government, partly due to lack of communication, resulted in resistance towards Ebola response teams. This culminated in an attack on local officials, healthcare workers and journalists in September 2014 in the Guinean town Womey, in which 8 people were killed by angry residents. The example highlights the importance of risk communication during a public health crisis.
Limitations
Given the nature of this review, there are several limitations that must be considered. Firstly, as with all literature reviews, the personal attitudes and biases of the author are likely to have a profound impact on the conclusions that are drawn. Although the author of this review attempted to critically evaluate the literature without bias by referencing literature the a diverse range of opinions, the personal views of this author are such that there was a significant lack of leadership during the 2013 to 2016 Western African Ebola epidemic and may have inadvertently biased the analysis. Further, the publications and media articles referenced through this review have their own internal limitations and biases. For example, epidemiological studies referenced throughout this review are likely limited by a paucity of reliable data and rapidly changing circumstances during the 2013 to 2016 Western African Ebola epidemic. Regarding the media articles and other publications referenced, it is worth noting that a high proportion of sources were highly critical of the leadership response to the crisis and overlooked the many positive examples of leadership throughout the crisis.
Conclusion
The Western African Ebola virus epidemic of 2013 to 2016 is a terrifying example of a public health crisis. This review aimed to critically evaluate the unique challenges to providing effective leadership during this crisis through the lens of several key leadership principles. The literature demonstrates that inadequate preparedness, situational awareness and risk communication considerably hindered the local and international responses to the outbreak, resulting in significant morbidity and mortality. It is hoped that lessons learnt from the 2013 to 2016 Western African Ebola epidemic can be applied to current and future outbreaks. The response to the most recent outbreak in the Democratic Republic of the Congo highlights the positive impact of lessons learnt from previous shortcomings.
It is also worth noting that the literature contains many examples of truly successful and inspirational leadership during the 2013 to 2016 Western African Ebola epidemic. This is perhaps best exemplifies in the study by Gire et al. The authors of this paper were able to provide real-time epidemiological data, which ultimately contributed to the development of several preventative strategies to reduce further outbreaks across Africa. Not only was this a multi-national collaboration, but it also included various community leaders who worked in direct contact with those affected. Subsequently, five contributing authors to this paper died of EVD. This is a poignant reminder of the sacrifice that a public health leader must make during a time of crisis.
