Responding to COVID 19: Lessons from the Ebola Outbreak
By Lansana Gberie (pictured),
There are a lot of voices currently highlighting lessons to be learnt from the response to the Ebola outbreak that caused such destruction in Sierra Leone (and in Guinea and Liberia) in 2014-2016, in order to fashion an effective response to a potential outbreak of COVID-19. This is natural, and necessary. However, though there are marked similarities between the two outbreaks there are also marked differences. Understanding these differences are important for formulating an effective response.
The recent stakeholder engagement initiated by His Excellency President Julius Maada Bio, at which he invited for experience sharing the leaders of the past regime’s Ebola emergency response team, was a commendable development. Viral outbreaks like what is feared with respect to COVID 19, as we learnt from the Ebola outbreak, demand total national mobilisation. The perception of factional approach would be worse than ineffective; it would undermine the response effort. That is one important lesson to be learnt from our response to the Ebola crisis. In all three most affected countries, ranking government officials clearly saw the Ebola crisis in its initial stages as a distant and far from an urgent mishap; and in Sierra Leone this unhelpful approach was undeniably fuelled by a feeling that it was initially confined to opposition voting areas.
I was in Liberia in 2014, having been appointed a year before by the UN Secretary General to lead a panel of experts monitoring potential breaches of security relating to an arms embargo on that country. The job required me (and my colleagues) to travel within Liberia and to the adjacent countries frequently, to brief the UN Security Council at least three times a year, and to write two reports for it each year. This looked like an easy assignment until the outbreak occurred. Once the spread overwhelmed the state’s response capacity, its implications on security became our focus, as it became, very acutely, for the Liberian government. Critics charged then that treating a public health issue from a largely security perspective was a little over the top. But governments make choices based upon their capabilities, and the army was – and still is – by far the most ready-to-deploy institution in the country.
One must now bracket perhaps the most important cause for the wobbly response to the Ebola outbreak – the fact both that it was new and at the same time indigenous to the region. This also offers an important contrast to the COVID-19 outbreak. Over 30 years before the outbreak, three German scientists conducting serological surveys using blood samples from 433 residents in Lofa and Bong counties – both adjacent to Sierra Leone and Guinea – were surprised to find Ebola and Marburg antibodies in the samples. This led them to conclude, in an article published in the Annals of Virology in 1982, that the region must be “included in the Ebola virus endemic zone.” They warned health workers in Liberia to keep in mind that they probably at some point will encounter “active cases and thus be prepared to avoid nosocomial epidemics.”
I mention this study to underline the serious misconceptions and unhelpful conspiracy theories relating to the origin and spread of the virus and to suggest a lesson to be learnt in fashioning our response to COVID-19. The origin of the current outbreak has been clearly mapped: beginning in the Wuhan region of China, it has spread across the world very fast, a trajectory set by the imperatives of our highly mobile and connected world. We must accept that pathogens like this will continue to stalk us and that we are particularly vulnerable to them: there are a number of ecological and socio-economic factors which will continue to make sure that, by accident or design, highly contagious viruses will escape from animals into the human population, causing widespread death.
A comforting myth has emerged in Africa and elsewhere that COVID-19 thrives only in a cold climate. Like all myths, this one is not without basis: the seasonal flu inflicts its terror only in winter and disappears when the place gets warmer. But COVID-19 is at least ten times more virulent and deadly, and has never occurred before to ensure that the general population had acquired immunity. Moreover, a similar such flu – the swine flu or influenza epidemic of 1918 – killed hundreds of thousands of people in West Africa.
Governments face criticism for not closing their borders early enough during such outbreaks, but this is never an easy decision, so intertwined is the global economy. The parts of Italy bordering with Switzerland were the first epicentres of the COVID-19 outbreak in Europe. Yet the Swiss authorities resisted calls from their citizens to close the borders for weeks. That’s because more 70,000 Italian residents commute to work in the Italian-speaking Swiss canton of Ticino daily, of which 4000 are employed in the health sector. Overall 325,000 residents of France, Germany and Italy commute to work in Switzerland every day. Only after the infected cases in Switzerland rose to around 4000 – and rising exponentially – did the authorities finally close the borders in March and subsequently cancelled all flights. This kind of economic imperative does not apply to Sierra Leone and its neighbours.
COVID-19’s spread has been way faster than Ebola’s in part because of the global dominance of China and the imperatives of global capitalism, but also because of a particularly salient fact about COVID-19: it is far more contagious because the symptoms in the initial stages are far less obvious than those of Ebola, and infected persons who are not obviously symptomatic can infect others getting close to them even without bodily contact. In other words, COVID-19 is airborne. It is the reason why many prominent people who are not medical personnel and have not gone close to a medical facility have been infected, in sharp contrast to Ebola; and why the phrase ‘social distancing’, now so ubiquitous, was not in use during the Ebola crisis.
An Ebola-infected person capable of infecting others would have been too physically debilitated to socialise. There was no danger of such a person hugging another or going to a market or restaurant: only family members or medical caretakers were at risk from such a person. In Liberia during the outbreak, offices, shops (even barber shops) bars and night clubs remained open: currently in Switzerland and across Europe, all bars, restaurants, night clubs and every arena of public gathering have been closed. This difference means that complete lockdowns and stay-at-home orders are necessary during the COVID-19 outbreak, but was ill-advised and demagogic during the Ebola outbreak – which is why only in Sierra Leone was it implemented. President Koroma took the further, purely political, step of keeping the state of emergency in place at least six months more than was needed. In the end, despite adding national prayers to the mix of demagogic responses, Sierra Leone still had the highest rate of infection of the three most affected countries. We cannot now pretend that those who inflicted such an awful policy on the country have suddenly become repositories of much-needed experience and wisdom.
There is an important mitigating aspect of COVD-19: so far the evidence suggests that the corpses of its victims, unlike those of Ebola, do not transmit the disease: the flu virus seems to die along with its victims. Infections by dead Ebola victims probably helped spread the disease much more than contagion from living victims.
Another important mitigation is that coronavirus is not nearly as deadly as Ebola: so far it has killed around two percent of its victims to Ebola’s 40%. This low death toll is both good news and bad: in a region where death from preventable disease is common, the risk of being lulled into a comforting complacency must be seriously tackled. If not, it may lead to more infections and a lot more deaths than that from the dreaded Ebola.
Fortunately, the promptitude and energy with which the government has reacted to the impending outbreak have ensured widespread awareness of the dangers posed by the disease. The measures already taken – the travel ban, deployment of the military to enforce the ban, the Ministry of Health of and Sanitation’s activation of the Emergency Operation Centre to level two, the establishment of an inter-ministerial committee to guide on policy issues in relation to COVID-19 and the Heightened Risk Communications, trainings and prepositioning of supplies at strategic locations – are certainly steps in the right direction. Our dismal experience with the National Ebola Response Centre (NERC) gives one pause with respect to the creation of something similar. My preference would be a presidential taskforce to work closely with the assured leadership of Dr. Wurie at the MOHS to guide our response. The team can draw upon the expertise of some of the credible operations personnel, not political leadership, of the NERC, in particular the Mayor of Freetown Ms. Aki-Sawyer.