Guest blog written by Peter Harrington
As the world grapples with the first truly global pandemic, a crucial struggle is emerging between different ways of seeing the current coronavirus outbreak. On the one hand, it is a virus that medical science can tell us how to combat. On the other hand, it is a complex social challenge to which human behaviour and norms are the key. In truth it is both, but if we fail to understand this, and understand that it requires adaptive learning to overcome, far too many will die.
Five years ago, I worked alongside the late statistician and epidemiologist Hans Rosling in Liberia on the Ebola epidemic sweeping the country and its neighbours. I had gone back to Liberia having previously spent three years in the country with the Africa Governance Initiative, working in the office of President Sirleaf. Like many, including Rosling, I came out of a sense of duty. Looking back on that experience, it holds powerful lessons for how we respond to coronavirus today.
Rosling said something memorable in 2014, that ‘Ebola is both a biological and a social phenomenon’. In other words, beating it was as much about behaviour as beds, as much about trust as treatment. The huge spike of cases in Liberia – which at one point threatened to collapse the country – peaked around November 2014. Privately, many of the foreign epidemiological experts in Liberia admitted it is unlikely that the (belated) influx of beds, logistics, money and aid workers explains the decline in new cases around the country after that.
So what happened? It is actually really useful to look at what happened as an exercise in mass problem-driven iterative adaptation (PDIA). The headline problem was abundantly clear – an out of control epidemic with a mortality rate of over 50%. And the country lacked the capabilities to handle this epidemic. What followed was a mass learning process, encompassing many actors. Starting with the authorities: they had to learn how to set up an Incident Management System, the name for a completely new institution dedicated to the eradication of the outbreak, to avoid overloading the Health Ministry and other existing institutions. They had to learn to set up emergency response phone numbers, special burial teams, to build special Ebola treatment Units (ETUs), set up and run testing labs, mobilise mass logistics to distribute these resources, all without abandoning those in need of other healthcare.
At the same time, the stampede of outside organisations wishing to help had to learn too – to take their ‘expertise’ with public health, epidemics, logistics and communications and translate that to the local context. Some organisations – like the American CDC who came with ears and eyes open – proved very good at that. Others like the WHO proved very slow indeed. The difference was the willingness to learn.
Most important of all was the learning at the local level. At first, many in Liberia did not believe that Ebola was real, or believed that it was a conspiracy. Those views were big factor in the early spread of the virus and size of the outbreak, slowing cooperation and preventing people from changing their behaviour. Slowly though, people started to adapt. Norms of behaviour which were helping the virus spread (physical contact, burials and disregard of quarantine) started to change. People learned how to outwit an organism which is deadly but a trillion times less sophisticated than humans. If you ask the experts, more than anything else, it was communities, people, Liberians (and Sierra Leoneans and Guineans), who changed their behaviour and turned the tide.
This learning was difficult, iterative and required constant adaptation towards effective solutions. It took place in the face of terrible hardship and tragedy. The messages and models which were copy pasted by the experts failed quickly, and local versions had to be developed. In this case it was not a small team doing PDIA – in the way BSC usually facilitates the work – but a big, loosely coordinated network of actors all mobilised to solve a huge problem. A large-scale PDIA was taking place, not formally coordinated and facilitated but no less real, and within which hundreds of smaller PDIA processes were happening, nested like a fractal. Authorisation for the problem was there, acceptance and ability had to be built amongst different actors. There were mistakes, failures, redundancies and dead ends. And there was constant, relentless learning and emergence.
What does this teach us when addressing the current Covid-19 crisis? I think there are several really important lessons.
First, we have to recognise this pandemic, just as Rosling said of Ebola, as both biological and social. It is a complex problem, not just technical. Defeating it requires that we pay attention to both the medical science and to the behavioural and social aspects of the pandemic. Solutions have to be adapted in different places. What worked in China – a complete lockdown in Hubei province – will not necessarily work in other countries with different cultures. When the Liberian government quarantined West Point, one of Africa’s poorest slums, in 2014 the move massively backfired. The botched attempt to quarantine the entirety of northern Italy a few weeks ago suggests caution.
Second, we must acknowledge, that we do not yet possess all the learning required to defeat this effectively. Some of that must take place within the institutions tasked with battling the crisis. But an even more important locus of learning happens at community level, where a mindset shift has to happen. Viruses prey on human social behaviours – touching a sick child or parent, greeting or shaking hands, face to face meeting. It takes a real change for those behaviours to be suspended. The term ‘social distancing’ is striking because it is so oxymoronic. To defeat this we must go against our social instincts as species, or at least we must adapt them.
Third, we therefore have to realize the kind of leadership and communication required to address this is different from simple command and control. Ebola taught us that trust between the authorities and the public is the single most important currency in fighting a pandemic. Behaviour change communications during Ebola had to radically evolve, from top down messages which were not trusted, to messages and media (for e.g. via local leaders) which people would respond to. Europe and other countries are not West Africa, so they will need their own version of this, but in democratic society with individualistic culture you cannot defeat a pandemic with control measures alone; it requires the consent of the public. This in turn requires a form of leadership that is both truthful and consultative.
We have the ability to defeat novel coronavirus, but in countries new to such crises we still have a lot to learn. PDIA offers powerful principles and tools for this. It will also require leadership at every level of society, trust and above all the same compassion and will that West Africa showed the world five years ago.