Remco Van de  Pas is currently for a research assignment in Guinea, one of three countries in West Africa affected by Ebola. Together with the national research center for training and promotion of rural health (CNFRSR) of Maférinyah, Conakry, the Institute of Tropical Medicine will explore policies and possibilities to strengthen the public health system in Guinea during the ongoing Ebola outbreak and afterwards.  During his visit, Remco  keeps a journal.  Below you find the fourth and final episode (18/1/2015).

My visit to Guinea made one thing very clear to me: there is considerable resistance within communities to adhere to regulations prescribed by the national Ebola coordination team as a way to overcome the epidemic. Programs like case contact tracing and follow-up, referrals to a health center when a case  is suspected, safe burial practices & disease surveillance at community level  are all functioning sub-optimally. The virus in Guinea  has shown to be tenacious and the epidemic has had a capricious character so far. In a sense, it sometimes goes ‘underground’ and then emerges  again later, leading to a sudden new peak in cases.  The epidemic in Guinea is thus far from over. The virus ‘hides’ in the different communities,  with at least a considerable number of them resisting the approaches favored by the government and international community. Ebola Outreach teams by the government and NGOs often meet angry or even violent mobs. This resistance, which was initially mainly noticeable in the forest region, has now spread all over the country. The question is why?

I don’t pretend to have a full explanation for this phenomenon – I’ve not been staying long enough in this country to understand the delicate sensitivities here.  I did gain some insights though, while being here.  So for what it’s worth, after speaking with a different range of people, this is my take.

The Ebola response is politicized. Political violence (ostensibly?) related to Ebola has its roots in already existing tensions between the different ethnic groups  in the country. The political representatives of these groups, and their representation in government and opposition ‘use’ the epidemic, frustration, and funding  it provides, for their own interests. In addition, and to some extent interrelated, there is the presence of the international community – NGOs, UN agencies and also transnational companies which exploit the rich natural resources (bauxite, gold, ore, diamonds, uranium) in the country. Let us also remind the reader that the country has a particular colonial history and joined during the postcolonial times the Soviet bloc. Many of the older generation of medical doctors have been trained in Cuba and the former Soviet Union. Last week in N’zerekore, some of them greeted me with a “Hasta la victoria siempre”! It is hence not strange that a contingent of Cuban doctors these days manage the Ebola Treatment Centre in Koya. Last but not least, in the 90s the country was on the verge of a civil war. It was affected by “spillovers” of the civil wars in Sierra Leone, Liberia and Cote d’ivoire. These are different countries but they show at least partly a similar ethnic mix of communities, especially in the interconnected forest region.

The initial resistance in this region to visit government health centers and isolate cases for Ebola was not only related to the poor quality of the services. Already before the Ebola outbreak, the government had “intervened” violently with the military in some villages, to quell a strike and opposition. It was in this already tense context that the perception that the government had introduced Ebola to kill certain people found fertile ground, and that injections provided by the health staff would distribute the virus further.

A second unfortunate perception also jeopardized the initial Ebola response. Médecins Sans Frontières (MSF) had planned to leave the country in December 2013. The emergence (and emergency) of the Ebola virus around this very time led to the suspicion that MSF actually wanted to stay, and moreover, wanted to draw blood from the local people to be sold and used in France. The fact that the first patients were treated by MSF in closed tents and died  seemed to “corroborate” this assumption for many people in the region. After this initial stage, MFS tried to undo this perception by ‘sensitizing’ the population and making its treatment centers more transparent to family members of infected individuals. As the epidemic continued, people from different ethnic groups got infected and the biomedical understanding of the virus and public health measures to contain it, increased. Interestingly, there is a political twist as well. The story goes that Bernard Kouchner, the founder of MSF, has close relations with the current Guinean “Président” Alpha Condé. Rumour has it that as a special deputy to his government, Kouchner helped Condé to win the presidential elections in 2010. There are allegations of fraud related to these elections. Moreover, the position of Kouchner, a former French minister of foreign affairs, would also indirectly secure the political-economic interests of the former colonizer. Diplomatie à tout prix! Whatever the real influence of Kouchner is, it is understandable that MSF keeps encountering resistance by certain groups that are opposing the current Guinean president.

Another political element is that the government enforces its control measures on the population in a rather heavy-handed way. They installed 1150 so-called Community Watch Committees (CWC, comités de Veille). These committees are expected to do early warning & surveillance tasks and facilitate communication with the people on how to quell the epidemic. There are 5 committee members per village. Ideally the members of these committees should be elected bottom up by the community. In reality they are selected by (and thus loyal to) the government. Each of these members receive a remuneration of US$50,- per month (in local currency), a considerable amount by Guinean standards. The World Bank and UNICEF provide the (substantial) funding required for the CWCs despite the fact  that their effectiveness has not yet been  demonstrated. The (local) health authorities complain that the government bypasses the existing health structures and governance mechanisms, creating a parallel structure, and furthering fragmentation and distrust in the process.

“The international community” is represented in Conakry – big time. By now many organizations have jumped on the Ebola Bandwagon (and yes , I admit, our institution is one of them) . I even met this morning a “famous Dutchman” (a BN, or a “Bekende Nederlander”) who has initiated his own charity to provide aid to Ebola victims. His wife even introduced herself to me; “Hi I’m the wife of Mr X., a BN’er” which was just hilarious.  (I was about to answer ‘Hi, I’m Remco van de Pas, on my way to become a BNer’. )

The Ebola coordination response includes actors like WHO, different UN agencies, NGOs, the Guinean government, US Centers for Disease Control, the European Union delegation, Institut Pasteur, the Red Cross, Foundations (Bill and Melinda are present of course, noblesse oblige), academic institutions, etc. Without any question coordination is taking place. There is however a wide variety of interests and pressure is huge, also because money needs to be spent quickly and there is little institutional absorption capacity at district level. Consequently, the response coherence is thus far from ideal in many cases, with sometimes very different and confusing messages eventually reaching the villages. What really seems to be lacking though, is a meaningful “people’s representation” and sociocultural sensitivity. Even the survivors have only recently started to organize themselves in an alliance. Their needs are not yet considered in the Ebola response programs.  A consortium of three research programs (with ITM part of it) is under pressure to finish the trials for possible Ebola treatment while the epidemic is ongoing  –  respectively vaccinations, antiviral medication and donation of blood plasma containing antibodies. Although all scientists involved hope the epidemic will be over soon, they also would like their cohort group (Ebola patients) to be large enough to publish results. This is a bit of a paradoxical situation, as you can imagine (We hesitate to call it a ‘conflict of interests’).

In sum, the Ebola outbreak response in Guinea is a vertical one, almost military-style in its execution, and international assistance is being channeled through a sovereign state arguably lacking support from a (substantial) part of its population. It’s all perfectly understandable as many actors involved sincerely want to end the epidemic as quickly as possible. At the same time there are some basic weaving errors in the response (accountability, checks & balances are missing) though, allowing political agendas to interfere with the actual programs on the field. E.g. the Red Cross with its urban representatives comes to a village to tell the forest people what to do in case of a burial, rather than adapting its safe burial practices to the traditional needs and customs of the people. There is one notorious case where a body (in a bodybag) was just ‘thrown’ on a truck to be taken to another place for a safe burial. This sort of episode creates resentment and even if only one of such bad practices happens, it is difficult to undo afterwards. Guinea has a growing number of unemployed youth. It is these youth who resist the government and NGO programs, feel politically violated and respond, sadly, often in an equally violent way.

To end with a positive note; alternatives do really exist. I have been able to speak with the intelligent and highly motivated director of a medium-sized NGO,  Dr. Aboulaye Sow. Dr Sow chairs the organization Fraternité Médicale Guinée (FMG) and runs around 6 clinics in the country. The clinics integrate several health services (HIV/AIDS, TB, maternal care) and include psychosocial ambulatory care. Their polyvalent staff, salaried by the organization, use a number of approaches, show quite some flexibility, and receive ongoing training on the job. The clinics are linked to several social programs in the communities, with quite some ownership and autonomy for the local people in defining priorities for program direction. He explained us that he didn’t encounter any community resistance during this Ebola outbreak. His team listens much better to the people, and maintains an open dialogue – these skills are also part of  “professional competency”… as other actors sometimes tend to forget.

In short, it is this kind of dialogue and these kinds of pilot programs that should guide the strengthening of the health services and workforce once the Ebola outbreak is over (and possibly even while the crisis is still ongoing).  One could imagine a health forum being installed at district and national level, at first to have a more inclusive discussion on the Ebola response, but afterwards broadening to other health issues.

In spite of all its flaws and shortcomings, it is to be hoped that the “international community” will remain engaged for a longer period as the effects of this epidemic will last for a while. Long term engagement in supporting solid health financing,  qualified workforce,  medical supplies, surveillance mechanisms as well as institutional reforms, will be crucial.

For now it remains to be seen how the Ebola epidemic will further unfold and whether all the efforts taken will be able to quell the outbreak in an acceptable way for the people. The epidemic might still simmer for a while, not clearly visible anymore for the authorities, to suddenly flare up again. If this scenario were to materialize, and go on for a while, it could further destabilize the already fragile relations between the different groups in society.

As I return home, preparing for a second phase of our research collaboration later in the year, I would like to express my sincere thanks to my colleague Dr. Eugene Lama for his hospitality and friendship and the great discussions we had. I have great respect for the dedication of the health workers to continue working with limited means and limited protection material while knowing all too well that a considerable number of their colleagues haven’t survived this epidemic.

These health workers are the real heroes of the Ebola response.