Humanitarians are sounding the alarm about the likely impact of Covid-19 on countries and communities already grappling with crises. Death rates – estimated at 1% in high-income countries with well-equipped hospitals – will likely climb when the virus spreads to South Sudan, Syria or Yemen, where health systems have collapsed and many hospitals lack even the most basic equipment.
So how should humanitarian actors respond? Research by the Humanitarian Policy Group (HPG) on the humanitarian response to the 2014 Ebola epidemic in West Africa and work by the Humanitarian Practice Network (HPN) on the Ebola outbreak in the Democratic Republic of Congo (DRC) suggest five key lessons.
1. Engage communities – the key to stopping the spread of disease
Community engagement reduces transmission and resistance to health providers, and instils safe practices of care. In both West Africa in 2014 and DRC in 2018, humanitarian actors got this wrong. Rather than see communities as key to tackling the epidemic in West Africa, they were viewed instead as part of the problem.
Local cultural behaviours - such as communal eating and burial practices - were seen as obstacles to prevention and epidemic control efforts; but top-down, medically oriented messaging focused on the extreme risks of Ebola fostered stigma, triggered treatment avoidance and resulted in people seeking support from traditional healers.
In DRC, where the Catholic Church manages 40% of the health system, faith-based actors were at the forefront of the response. Religious practices were modified to safeguard communities; religious institutions became relief distribution centres; faith leaders had public vaccinations to counter false rumours and – when popular resistance intensified – mediated between communities and international actors. Given the heightened risk Covid-19 presents to older people, work in Sierra Leone and Liberia to engage youth groups on community messaging, aid logistics and psychosocial support may also be instructive.
2. Manage this as a broad-based humanitarian emergency from the outset
The spread of a dangerous disease requires a broad response that goes beyond medical provision. Treating Ebola predominantly as a health crisis meant that the surge capacity and emergency funding characteristic of a large-scale humanitarian crisis were not triggered. Wider implications - for instance for food security, livelihoods and education - were neglected, and NGOs were unclear on how or where to engage. A narrow focus on Ebola also downplayed other health implications, and people with other conditions were left without treatment due to the outbreak.
Covid-19 is not just a medical emergency: it is also upending the socio-economic life of the countries in its path. Recognising this now will be essential to tackling its wider effects.
3. Build on existing leadership and coordination structures
Since Ebola was initially framed as a health emergency in West Africa, the leadership and coordination arrangements typical of a large-scale humanitarian response were not triggered. Instead, the UN Mission for Ebola Emergency Response (UNMEER) was created. As a new mechanism, built in the midst of a crisis, it was not a success. Although imperfect, existing structures such as the cluster system are familiar and can effectively scale-up.
The need for urgent action, comprehensive responses and familiar, inclusive structures means that new mechanisms should be avoided.
In DRC in 2018, a separate health system was established for Ebola which didn’t cater for other health issues, resulting in unhelpful silos and neglected needs. In contrast in Liberia, where the government led the response, there was recognition of its wider leadership role, and international experts and humanitarian organisations were incorporated into existing governance structures.
4. Build national emergency response capacity now
The pace of the spread of coronavirus highlights the need for an urgent response. Ebola quickly overwhelmed the health systems of affected countries, but the international response was slow to arrive. Médecins Sans Frontières accurately estimated that it would take most responders around three months to be in place, by which time the epidemic had spiralled out of control.
With Covid-19 grounding international staff, the focus must be on drawing on local and regional capacities, and strengthening national health and emergency systems.
In West Africa, the African Union fielded a large number of medical responders, who could bring greater contextual expertise and tended to meet less community rejection.
5. Manage the politics, as well as the humanitarian implications
The rest of the world only woke up to the Ebola crisis in West Africa once there was a threat that the outbreak might spread to citizens in the global north.
The risk with Covid-19 is that – given a lack of global leadership and the unilateral closure of borders – the human cost will be de-emphasised, and the focus will be on containment, rather than treatment. Given the likely human cost of Covid-19, the trigger for and focus of international support must be minimising loss of life everywhere, including in crisis contexts.