The Ebola cemetery is one of the quietest places in Liberia. It is known as Disco Hill. That may sound like some sort of cruel joke, but it was named long before, for the gunfire battles that took place there during the Liberian civil war, in which two rebel factions stormed back and forth as if they were dancing.
Disco Hill is silent today. Since the end of the 2013-16 West Africa Ebola outbreak, even the birdsong there has seemed oddly subdued. Occasionally a ringtone or a radio cuts through the quiet, only to be hushed by the wind. Walk among the orange mounds with their thin wooden crosses, rubber trees arching their backs up over the hill, and you’re met with a scattering of flowers—the expression of both love and loss.
And, although more than 3,000 of Liberia’s Ebola dead are buried here, grief is far from the only lingering emotion. Four years after the end of the outbreak, anger still burns. Ebola is spread through fluids, and so the bodies are still sealed in the sterile shrouds in which they had to be wrapped before they could be embraced by the ground. A memorial hut holds 16 oil drums, each one packed with ashes and bone. In West Africa, a decent death demands soil, but the drums hold the remains of souls who died unidentified, their final resting place not earth but tin. In the heat of the outbreak, data was lost on how many unidentified cremations took place, but the ash weighs a total of about 7,000lb. It bears heavy upon the land—like the weight of an elephant, or two London taxicabs.
“Ebola has gone from my body but it is still in me,” a Liberian Ebola survivor, 35-year old Finda Fallah, told me, two years after the end of the outbreak. She lost her seven-year-old son to Ebola, and his remains were among those that went unburied. Without a monument to her loss, she feels it more acutely, she said. “I know it will stay there long life,” she added, “because my heart got spoiled.”
Between 2013 and 2016, Ebola killed at least 11,315 people in Liberia, Sierra Leone and Guinea. It devastated communities, seared through families, and sparked economic and mental health crises which have been extremely hard to recover from. It also taught us a great deal about what can go both right and wrong in epidemic management—lessons that could have been heeded by resource-rich countries such as the UK.
The rest of the world heard many stories like Fallah’s, sympathised—but only looked on. British newspapers ran some sensationalist, fearful headlines, but we also saw the kind of “sensible” journalism that reassured us that nothing on the same scale was likely to happen here, reassurances that sounded plausible. After all, the epidemics in the UK’s recent history—swine flu, measles, typhoid and indeed HIV/Aids—did not have as high a toll in the west as they did in parts of Asia and sub-Saharan Africa.
An October 2015 public briefing document by Public Health England (which has since been withdrawn) said this: “England has a world-class healthcare system with robust infection-control systems and processes, and disease-control systems that have a proven record of dealing with imported infectious diseases. Ebola causes most harm in countries with less developed healthcare facilities and public health capacity.”
That was then. Now, less than five years later we are coming to terms with a number of deaths from Covid-19 that has, in many countries with “world-class healthcare systems,” far exceeded the West African toll from Ebola. How did we overestimate our capacity to respond to a new infectious disease outbreak? Did we fail to learn the lessons of the last one—and, if so, why?
*** In the great Ebola outbreak, there were, as now, drastic PPE shortages. There were stories of health workers fashioning gowns and gloves from plastic bags—518 of them ultimately lost their lives while caring for the sick. As cases surged, clinics and hospitals were overwhelmed. There was no known cure nor even treatment, and a race was on to develop a vaccine.
The postmortem was damning: Ebola was the symptom, the system the disease—and the world had failed to treat it in time. But in its wake, there was a plea to stop anything like this happening again by identifying and tackling the root causes. Governments and international partner organisations published glossy “lessons learned” reports. They documented the underlying problems that sound extremely familiar in the Covid-19 context: ill-prepared health systems fixated on cure at the expense of prevention, broken supply chains, poor co-ordination and a lack of public trust in leadership.
Mixed messaging was up there too, as well as misinformation and conspiracy theories. “At the beginning of the outbreak, each organisation thought that they had all the answers, and many of them sent out public messages without harmonising with the government,” says Joseph Howard, Director of the Center for Justice and Peace Studies, a Liberian civil society group.
This encapsulates the way things went wrong. Effective public health should function as an ecosystem, with important interdependencies and feedback loops between everything from politics and education to business and the media. When the nebulous quality of trust pervades relations between them, they operate in relative harmony, and can settle into an equilibrium that can turn the tide on epidemics. Instead of such a healthy ecology, however, what we initially saw with Ebola in West Africa were sectors operating in silos.
During the first months in Liberia, those responsible for different “pillars” of the response effort—contact tracing, safe burials, community engagement—mostly met separately. The gulf in their co-ordination explains why, as Ebola swept through Liberia, some international NGOs erected billboards with messages like “Ebola is deadly” and “Ebola kills!” They intended to scare people into seeking treatment, but they hadn’t taken an emotional temperature check on how communities were feeling, and so the messages had the opposite effect. Why, people reasoned, should they go to treatment centres, if they would die anyway?
Within two years there was a successful vaccine, but that alone didn’t end the outbreak. The tide was turned only through a combination of improved medical care, cross-sector co-ordination and a real community drive, in which citizens showed up for one another despite sometimes weak central co-ordination. In Liberia, for instance, more than 2,000 contact tracers went door-to-door, risking their lives for infrequent pay, while a network of 15,000 others reached almost every community in the country, braving rivers and waterlogged roads to ensure people had information about how to protect themselves. “At the local level, there are silent heroes in schools, in government, in healthcare, in business, in the villages and in cities who saved lives,” said the Sierra Leonean campaigner Fatou Wurie.
When the outbreak was declared over, pledges were made: to invest in early warning systems and health infrastructure; to deepen that life-saving community engagement; to share data; and to lift organisational siloes in favour of multidisciplinary taskforces.
Some of these promises have been honoured, especially on sub-Saharan African soil. They have informed the response to subsequent crises like the ongoing Ebola outbreak in eastern Democratic Republic of Congo (DRC), and have been channelled into rapid and compassionate management of the current Covid-19 response in countries including Rwanda, Nigeria, South Africa and Senegal.
Surveying the Covid-19 picture across Africa in the Financial Times at the end of April, the journalist David Pilling marvelled at the cross-border role of the new Africa Centres for Disease Control and Prevention, which had organised video conferences with heads of state to co-ordinate strategy, and had begun pulling together “a continent-wide effort to test, trace and treat involving a million-strong army of health workers.” He noted, too, how states like South Africa, Nigeria and Rwanda had not answered the science with slow bureaucratic grind, but instead acted early: respectively locking down fast, closing their airports and issuing clear guidance to citizens.
And despite inadequate health budgets in many of these places, and political missteps around handling the crisis in individual countries (such as Tanzania, where president John Magufuli has urged his compatriots to come together in churches and pray), across the continent there are some signs that the energy is paying off. As of late May, recorded figures on deaths were still in double or single figures in most countries, and below 500 in every state south of the Sahara.
This isn’t to say there aren’t challenges. As case counts rise, there are plenty. But the contrast with the losses in many wealthier countries, including our own, demands serious interrogation. A medical analogy might help elucidate why leaders and organisations elsewhere in the world have not proved as willing to hold up a mirror to their own actions in the same way as in Africa. Consider immunological memory—the ability of the human body to respond more effectively to pathogens that it has previously encountered. The process is guided by what scientists call Memory T cells; like archival librarians, they keep records of past defeats. The human immune system is an experiential learner—and so, it turns out, are human societies.
Psychological studies have shown how experiencing frightening or threatening events triggers a mechanism in the brain that supports survival. For instance, after getting burned by hot water, a child is likely to avoid the kettle in order to prevent a repeat ordeal. In the worst-affected countries of West Africa almost everyone knew someone who died from Ebola, and further south in the continent the toll of HIV/Aids has likewise been devastating. Grief and residual trauma seared into the collective memory, remaining there long after the rhythm of daily life returned. As a region, West Africa simply could not afford to forget Ebola. But other countries, in other parts of the world, proceeded on the basis that they could.
*** Ebola never truly made it into the long-term memory bank of the Global North. It was seen as too distant, too remote and, given the treatment by some media outlets, to the extent that it registered, it was cast by some as yet another African tragedy; something that “could never happen here.”
Consequently, practical—and life-saving—lessons that could have been learned by the rest of the world were not. One of the most important is to ensure the population as a whole takes ownership of the problem: that public health really is of the public, by the public and for the public.
Writing in the BMJ, a team mostly from the London School of Hygiene & Tropical Medicine outlined how this was eventually done in parts of Africa. In Sierra Leone, for example, thousands of locally hired and trained individuals were employed or else volunteered to work within their own areas through community leaders, families and youth networks to develop the minutiae of tailored responses (such as the precise placement of handwashing stations and isolation spaces), to oversee bylaws and restrictions, and to keep tabs on rumours about the disease.
In Nigeria, the successful containment of Ebola was built on lessons learned from its own earlier experience with polio contact tracing. In both West Africa and the DRC, the Ebola response leadership ultimately developed a holistic recognition of the sprawling requirements of tackling the disease—from psychosocial and survivor care to the logistics of surveillance and isolation support, including food delivery. They also co-ordinated consistent messaging across all channels. In the recent Ebola outbreak in the DRC, the actual delivery of services remained firmly decentralised. Tracing, for example, was not delegated to a wizardly app, but run by local people, whose surveillance was reliable precisely because of their links and the trust they enjoyed.
All of this shows how important community “agency,” that is to say people taking ownership of the problem, is to containing an epidemic. As Ngozi Erondu at the Centre for Universal Health, Chatham House explains, “all of that experience is not just thrown out the window when there’s a new outbreak.” Erondu added: “Populations themselves, if they’ve gone through this before, are also ready to take on the mantle to respond.”
Today, in the Covid context, some of these principles are—some of the time, in some places—being respected further afield. In these pages last month, Stephen Buranyi highlighted Germany’s testing masterclass and found that decentralisation and local initiative were a huge part of the success. Massachusetts in the US has, the London School of Hygiene & Tropical Medicine team noted, “eschewed mobile contact tracing apps, electing to hire 1,000 local contact tracers instead.”
And in the UK, a large NHS Volunteer Responder network has been summoned, even if it has so far been entrusted with limited responsibilities. But elsewhere in the response of the wealthier countries, there has been a clunky reliance on top-down fiat, which has often arrived dangerously late. It has been as if Ebola never happened.
*** A well-oiled epidemic preparedness and response system should function like the cogs on the cassette of a bike, co-ordinating to drive the evidence base forward, spurring research into action. Instead, public health and science are often forced to compete with other political priorities. Witness the partisan games being played around the re-opening of different US states, and also the tendency of politicians to frame the response as a competition, pledging, as Boris Johnson did in May, a “world-beating” contact-tracing system for a UK which is in truth rushing to catch up, or inaccurately bragging, as Donald Trump did, that “America leads the world on testing.” An effective test, track and trace strategy is definitely the way out of this mess but with a virus that has no respect for borders, “beating” other nations is beside the point.
In this fractious context, despite the brilliance of many individuals working on Covid-19, the system does not co-ordinate internationally, and hence fails to run as it should. It sputters forward on the wheels of good intentions, stalling at green lights, stumbling at blind spots, and is apparently incapable of seeing far ahead down the road—or, for that matter, back to the fading memory of past crises like Ebola.
Through it all, the language of war is ubiquitous. Health workers are “heroes” “fighting on the frontlines,” PPE is “armour” and a vaccine is “a weapon,” all talk that might serve a useful political purpose in elevating potentially avoidable loss of life into a “sacrifice.” (Even if too few lessons have been drawn from the Ebola playbook, this rhetoric certainly has been. During the initial months of the current Ebola outbreak in DRC, the response effort was named, in French, la riposte, or “the fight,” tricky talk in a country at war).
If we do insist on deploying the language of war in this pandemic, we might also consider borrowing something else from the military: its practice of counting its losses and memorialising the dead. There are few memorials to the casualties of disease. Would the massive toll of epidemics like Ebola and now Covid-19 feel less acceptable to us if, perhaps, we gathered every year to count and honour those we have lost?
Such a ritual could attenuate our tendency to forget, and facilitate that internal processing that precedes future preparedness. It might grant us closure and a collective touchstone; a time and a place to mourn the dead, but also to reckon with our shortcomings: our mistakes, our failings, our humanity. A way, above all else, to learn from them, not abandon them—and thereby ensure they did not die in vain.
*** It’s important to recognise what we have seen in Africa as progress, but were it progress enough for the world as a whole, we wouldn’t be in this fix. Were our systems more resilient, agile and prepared, and our leaders more humble, and our expert disciplines less siloed, 2020 might have gone quite differently. All of which might have been possible if we had had our eyes properly open to the last great epidemic.
Learning from past crises isn’t easy. During Ebola, I sat with more than 200 Liberians as they processed lessons. At the highest levels of public health leadership and governance, implementing change was tough, even in the immediate aftermath of a national tragedy. Yet in the face of Covid-19, Liberia rapidly closed its borders, implemented testing of cases and contacts, and opened a centre at which members of the public can voluntarily get tested. The approach has kept case counts low, although the mortality rate, sadly, is high. Here, too, political decisions are undercutting public health advice; and expertise and experience still have to contend with very limited resources.
But Donald Trump’s talk about impoverished “shithole countries” with nothing to teach us embodies a spirit of contempt for which 100,000 Americans have now paid with their lives. It is not only offensive but absurd to slur as “weak” populations that are repeatedly showing themselves to be strong—populations that, through their courage, wisdom and creativity, have steered epidemics to an end.
At the same time, we must avoid the temptation to write a singular counter-narrative that has African public health systems spectacularly succeeding where all others have failed. The truth is nuanced and, uncomfortable though that is, we must make room for it: we all still have a lot to learn. We might start by ditching the framing of the Covid-19 response as an international competition, and instead simply learn, with humility, from one another. We could then hope to harness the diverse experiences of our different societies, and bring it all to bear on a common threat.
Instead of casually forgetting the last tragedy, wise societies would build a mental shrine to it, marking it as a point to pause, reflect and indeed to learn. If we can achieve that sort of wisdom then we might, perhaps, see ourselves in the stories of Ebola survivors like Finda Fallah. Soon after recovering from Ebola, she told me how she woke in the night after a terrible dream. Her seven-year-old son had appeared to her. “Mama,” he cried out, “bring me some rice.” Fallah got up, climbed out of bed, and set a pot of water to boil on the fire. “I wanted to put the food on his grave and say, “my son, here is the food you asked for. But where is the grave?” she said. “No grave.”
