Ebola: managing to save lives

Experts on Ebola discuss the importance of rapid response, coordination and community engagement in the management of an epidemic.

José Félix Hoyo (pictured far right) with Doctors of the World colleagues in Sierra Leone.

"An ounce of prevention is worth a pound of cure." That saying has never been truer than in the face of the West African Ebola epidemic, which in little more than a year saw around 24,000 infections claiming more than 10,000 lives. Its spread was partly facilitated by a phenomenon more prevalent today than when the disease was first identified in 1976: globalization.

"No epidemic is just local," says Peter Piot, the Belgian microbiologist who was part of the original team that discovered the virus almost 40 years ago. "With increasing global mobility, epidemics on the other side of the world are a threat to us all."

This makes preventing the spread of infection that much harder, as does a raft of other factors that anyone operating across borders will be familiar with today: institutional shortfalls, lack of international coordination, poor engagement with local stakeholders and a failure to appreciate sociocultural norms. All of these combined to create what Piot calls "a perfect storm."

Although the outlook is brighter than when the first case was detected in Guinea, there is still a long way to go and many lessons to be learned in managing a crisis of this scale. But as José Félix Hoyo, head of Doctors of the World Spain, attests: "As with all catastrophes, you get over the seeming impossibility and, step by step, start to build something that works."

Management mistakes

Hoyo gives a stark account of some of the challenges he faced on the ground in Sierra Leone: "You have to get information across to people -- but they don't read. You tell people they have to wash their hands with soap and water -- but soap is a luxury and there's no running water. How do you set up an effective monitoring system when it takes several hours to travel from one village to the next? How does someone showing signs of the virus get in touch with a treatment center when they have no telephone, no money or no mobile coverage to make a call?"

On top of these realities, there were local practices to contend with: convincing people to abandon their age-old customs regarding healing and burial rituals, and instead put their trust in a group of foreign experts whose arcane protocols were miles away, in both literal and figurative senses, from their own ways of doing things.

This situation was compounded by years of underinvestment in health services and low public trust in government officials and other authority figures in general. The principal countries affected -- Guinea, Liberia and Sierra Leone -- had porous borders and other environmental conditions that made containment, isolation, contact tracing and logistics even more complicated.

But the gravest management mistake of all was simply taking far too long to respond, says Piot. In the early stages of a crisis, a rapid response counts for everything.

At the time of the initial outbreak in March 2014, there were fewer than 100 cases, and those were limited to Guinea. It wasn't until the U.S. Centers for Disease Control and Prevention (CDC) warned that the number of Ebola cases could hit 1.4 million by 2015 that the international community sat up and took notice.

You can't look the other way, says Hoyo. In a global context, a high degree of international coordination is needed to ensure a fast response in emergencies like this.

Respecting cultural sensitivities

In September 2014, the United Nations formed the Global Ebola Response Coalition (GERC) to coordinate international efforts to contain the disease. The affected territories were divided into zones, and monitoring systems were set up for controlling the epidemic.

Despite the progress made, the situation was not easy to manage. With many governments lacking resources and manpower, the GERC had to step in and fill the gaps. That included having to address not only the socioeconomic issues but the sociocultural dynamics as well.

The dead, for example, are supposed to be buried in the towns and villages where they were born, a tradition that suddenly became extremely dangerous, as Piot explains: "There were highly contagious Ebola corpses traveling back and forth across the borders in pickups and taxis. The result was that the epidemic kept flaring up in different places."

In order to control this situation, cultural sensitivities and trust-building with local communities had to be managed just as thoroughly as the technical operations. Failure to communicate well with local stakeholders from the start only fans the spread of fear and misinformation -- and, in turn, the disease itself.

If the international effort is organized vertically, with orders coming from above and very little bottom-up community involvement, then winning trust will be a losing battle, as it sometimes seemed to be for people like Hoyo.

It hasn't been easy convincing people to change high-risk practices, such as preparing bodies for burial, as Hoyo explains: "Imagine if you had to abandon your own funeral rituals and instead replace them with clinical procedures that meant taking away the body of your loved one. People need to be given an enormous amount of information to understand why that must happen."

As such, organizations such as the Red Cross had to put in a lot of effort to make sure that Ebola victims received not only safe but dignified burials.

Every culture has its own unique set of customs, values or norms that demand a high level of attention and care. If you don't consider the cultural context of your message, then it's unlikely to get through to the people you're most trying to reach.

It's vital that the information you're giving out is concise and easy to understand, with clear objectives and comprehensible ways of achieving them. Also, the messages should be positive, insofar as possible, to avoid a hostile reception. Sometimes the positive message may be as basic as understanding that, by collaborating, you or your family won't contract the virus.

For Piot, local leaders played crucial roles in this task: "It is imperative that international organizations work closely with national governments as well as local community leaders to get important public health messages out into communities." Above all, throughout the process, people need to be treated with the utmost respect, he adds.

Training and protocols: leave nothing to chance

Adherence to protocols is as critical to healthcare as it is to business operations management. In a treatment center such as that run by Doctors of the World in Sierra Leone, all staff -- from the cleaners right up to the director -- must follow protocols to the letter.

This starts by making sure that everyone has received adequate training. In Sierra Leone, this took place in three stages. The first stage covered general training in personal risk management. The second stage concerned the procedures specific to the job that the trainee would be performing, and was mandatory for every member of staff, regardless of rank. The third stage involved group training with other trained staff who did not yet have assigned responsibilities. This consisted of going through drills that replicated real-life situations.

Each process had to be double-checked. Nothing could be left to chance or made to wait. For example, health workers were not allowed to enter a high-risk treatment area more than three times during an eight-hour shift, with each visit limited to 50 minutes, and each person h
ad to be disinfected as soon as he or she came out.

More complex protocols -- such as taking samples from patients for diagnostic tests, intravenous rehydration or the handling of a corpse -- involved more than 30 steps, each one essential to avoid spreading the infection.

The majority of health workers who contracted Ebola had either not followed the established protocols strictly enough or weren't properly safeguarded by their protective equipment.

As strict as the protocols are, one needs to remember they are also dynamic procedures that must be constantly adapted to the current context in order to remain relevant.

Keeping up morale

At Ebola's peak, there were some 500 new cases a week. Staying on top of a breaking situation like this will invariably put strains on productivity, and fatigued, stressed-out workers are bound to make mistakes. "Health workers tend to be highly motivated, which means they can sometimes underestimate their own tiredness or levels of risk," says Hoyo.

He recommends having a team of counsellors on hand to lend support, and staff should adopt shorter work patterns and take frequent breaks so they can rest. Given the stress levels, confrontations will inevitably flare up. These should be reviewed on an individual basis in order to reach a satisfactory outcome in each situation.

Hoyo believes the sign of good leadership is being strong, to keep control of the team, but with a human touch, to keep morale high. What is valued is a leader who stays on top of the little things; who doesn't just respond to demands but is able to anticipate them.

When working in a foreign territory or an unfamiliar context, a flat organizational structure is helpful for improving knowledge flows and connections between staff -- a point that many international organizations sometimes forget at their peril.

Planning for life after the emergency

While it may seem that the Ebola epidemic is finally under control, Piot says it's possible that it will break out again. "Up to now, our only tools have been containment and isolation. What we need are effective treatments and vaccines, as well as better surveillance and a faster, more coordinated response. We all have lessons to learn, because more epidemics are inevitable."

Even in the countries where the virus has been contained, Hoyo says that going back to how things were before is not so easy. "It's hard to forget that for an entire year, Ebola has been, and continues to be, the overriding social issue on the radio, in posters and in advertisements; it has restricted movement, closed schools and shut down public events."

The normalization of daily activities and routines will take some time. "Fear is not something that can be easily eradicated," says Hoyo, adding that those who have had the virus and survived will likely be stigmatized for a long time to come.

"We still have much work to do," he says, "but at least now there is some light at the end of the tunnel."

A version of this article was published in IESE Insight #24 (First Quarter 2015).