By Jamie Webb
The Overseas Development Institute described the 2014–16 Ebola outbreak as an ‘epidemic of mistrust: the flame of a virus hitting the tinder of suspicion.’ Local communities, sceptical of the motivations of foreign organisations and governments following a long history of colonisation and plunder, were sometimes reluctant to cooperate with healthcare workers or follow externally conveyed guidance on infection control, how to seek care, and good burial practices. Proactive engagement with local community leaders and religious groups, who had well-established local networks and trusting relationships with hard to reach groups, was vital in promoting care-seeking behaviour, combatting misinformation, and getting the epidemic under control. As one member of a group of UNICEF and UN Mission for Ebola Emergency Response (UNMEER) senior advisors explained: ‘Community engagement takes time and we have to invest time, resources to gain respect/influence of the community.’ In contrast, the absence of evidence of goodwill is often fairly interpreted as evidence of absence.
Fast forward to the UK in 2021 and the ongoing coronavirus pandemic. A recent survey conducted by the Joint Council for the Welfare of Immigrants (JCWE) found that almost half of all the migrants questioned said they would be scared to access healthcare if they fell ill during this pandemic, with 60% of migrants from Africa and the Caribbean reporting a fear of seeking treatment. Despite the fact that the majority of migrants are entitled to free NHS care, 30% of those surveyed who do have a visa and are in the UK lawfully expressed a fear of requesting care. The JCWE attributes this reluctance to the culture created by the Government’s hostile immigration policy, where undocumented migrants fear having their data passed from the NHS to the Home Office for the purposes of immigration enforcement, and overseas visitors are charged for treatment. Though exceptions have been made for covid-19 care, many migrants have still been deterred from accessing treatment, risking increased disease spread and mortality. Could this crisis in confidence have been avoided if the government had reflected more on its communication and collaboration with migrant communities who may have a warranted mistrust of government authority, as those involved in the public health response to the 2014-16 Ebola epidemic did?
To take another example, contrast the degree of proactive engagement within communities in Sierra Leone to measure and mitigate the spread of Ebola in 2014–16 with the UK government’s approach to Test and Trace for covid-19. In Sierra Leone, the Social Mobilization Action Consortium (SMAC) organised a network of 2466 community mobilisers, active in nearly 70% of all communities in the country. These mobilisers worked with communities in gathering health data, performing contact tracing, facilitating health surveillance operations, and generally assisting with meeting local health needs, driven by particular local demands: monitoring burials, assisting individuals who needed to isolate, engaging in child protection, reintegrating survivors within their communities, and so on.
In the UK, rather than running its Test and Trace operations directly through the NHS, local health authorities, or community-embedded organisations, contact tracing services were sub-contracted to a variety of private companies. The inexperienced contact tracers they have employed have reported receiving little training, faced a target-driven culture, whilst trying to support vulnerable unwell individuals and gather potentially sensitive health data. Large numbers of contact tracers have been sacked as the number of cases falls, despite a continued need for community support in managing the pandemic. A scathing report from MPs labelled Test and Trace a failure, arguing it had made no positive difference during the pandemic and had not attempted to collaborate with local authorities and other stakeholders until too late. Here, a culture of privatisation and profit was prioritised over meaningful community engagement.
Some might insinuate that insights from past disease outbreaks in less economically developed countries (LEDCs) like Sierra Leone can only be peripherally relevant to the UK’s covid-19 response, given the level of care provided by the National Health Service, its developed information infrastructure, and its chiefly centralised government approach. But as the above examples demonstrate, economic development alone is no guarantee of a fully engaged public or a fully effective government response. Nor does economic development obviate the need to consider how the relationship between authorities and the public can shape the course of the pandemic. This is not to claim that these lessons have never been absorbed into general guidance. For example, a recent WHO report on contact tracing emphasises the need to operationalise community engagement. Nevertheless, looking to concrete cases, including the experiences of LEDCs with Ebola in 2014–16, can be instructive in demonstrating the urgency of these messages.
Engaging with communities on their own terms will continue to be vital as the UK aims at ensuring the highest possible levels of covid-19 vaccine uptake. In a just-published report, the research organisation Traverse collaborated with Healthwatch England to explore the opinions of Black and Asian individuals in the UK towards the covid-19 vaccine and its rollout (a majority of participants had expressed some vaccine hesitancy). Though views on vaccination are deeply personal, Traverse found that hesitancy was best addressed through a localised approach, led by trained community members – for example, known local frontline health workers – rather than through government-led advertising or Black and Asian celebrity-led campaigns, which participants felt had singled out, patronised, and homogenised minority communities. Again, here there are echoes of this in the fight against Ebola, particularly UNICEF’s communication for development (C4D) Ebola strategy. This emphasised the importance of tailoring intervention strategies to local contexts, engaging trusted, community-based health experts in health communication, and utilising channels with wide reach and relevance to particular communities rather than relying on a purely centralised approach. The UK government should look to such experiences in its own communication strategies (and commit to translating and promptly updating its public health guidance in a wider array of languages).
History may not repeat itself, but it rhymes. Public trust, stemming the spread of misinformation, the need to mobilise community resources in stemming the tide of disease: there are lessons to be learned in how these challenges we face today have been met in the past. Those concerned with the public response to covid-19, or planning for pandemics of the future, would do well to look to successful examples of public engagement from Ebola and other previous public health crises around the world.