Nearly two years have passed since Emile Ouamouno, a toddler in Guinea, became the first person infected with Ebola in what has become the worst-ever outbreak of the virus. After a notoriously slow start, the Ebola response is finally winding down. Liberia, Sierra Leone and Guinea recently passed their first week with no new reported cases since the beginning of the outbreak.

There are now a myriad of reports outlining ‘lessons learned’ from the response. Yet most evaluations fail to consider a fundamental aspect of the response: fear. 

From affected communities to governments, international NGOs to companies: fear influenced decision-making. We must acknowledge this, or risk failing to learn how fear can undermine outbreak response.

Aid workers were more afraid of Ebola than warzones

In researching the Ebola response and its wider implications, we spoke to seasoned aid workers happier heading to Iraq, Somalia or Afghanistan than the Ebola-hit countries. They feared contracting the disease, transmitting it to others and being unable to evacuate. These serious misgivings made recruitment very difficult.

Fear at an individual level was magnified at an organisational level. The risk of catching Ebola was multiplied by the fact that even large NGOs were working outside of their comfort zones: undertaking safe burials, running Ebola treatment centres, and conducting community sensitisation in remote villages – some of which were violently resistant.

The reluctance of critical industries – such as airlines and insurance companies – to provide their services in the region made evacuations difficult and undermined initial efforts to guarantee staff safety. These issues delayed deployments or made them exceedingly short, so staff turnover was a major challenge. As a result of panic-induced flight bans, low recruitment, and the challenges of having to work out what would happen if staff became infected, there were simply not enough responders on the ground at the beginning.

If crisis veterans were scared, imagine how communities felt

Fear was even worse among affected communities. They were scared not only of contracting Ebola, but of the response: strangers in personal protective equipment removing villagers who were never seen again; enduring long journeys to remote, overflowing, ill-equipped treatment centres; and stark messages such as ‘Ebola is incurable’.

These fears arguably fuelled the outbreak by increasing stigma, deterring people from seeking treatment and steering them towards their families or traditional healers. Mistakes on messaging are particularly symbolic of the corrosive, cascade effect fear had on the early phase of the response.

Fear is a serious obstacle but it can be overcome

Fortunately, the fear that hampered the Ebola response in its early stages was ultimately overcome, in a similar way to the early phases of other diseases (most notably, HIV).

Messaging improved and people began to accept that getting Ebola was not a death sentence. Treatment centres were built, health worker infections slowed, and procedures for keeping infected staff alive were established. Thousands of people were deployed from countries all over the world. Once the response to Ebola began to catch up with the outbreak itself, fear gradually dissipated.

Why the aid community needs to face up to the fear factor

Fear is an emotive response, not an educated, scientific, or rational one. But fear itself is not the problem. The problem is that aid organisations do not yet treat it as a pressing issue when planning and carrying out health responses.   

The aid community needs to wake up to this, as the world will experience outbreaks of far more contagious and poorly-understood viruses than Ebola.

Most analyses of the Ebola response have had a technical and operational focus. Yet fear is just one example of the underlying issues that are far more difficult to quantify, predict, and account for, but that have a profound impact on both outbreaks and responses.

Technical discussions of best practice do not tackle the root causes of the response’s early failures. If humanitarians are to avoid falling into the same fear-induced traps in future, the system has some serious self-reflection to do.

We need to address the fact that the culture of aid organisations headquartered in New York and Geneva bears as much, if not more, responsibility for the pitfalls of the response than any West African tradition or custom. Before we can tackle the next Ebola, we need to get our own house in order.

Read the full report, The Ebola response in West Africa: Exposing the politics and culture of international aid