Les communautés voient beaucoup plus loin que la Riposte

(Picture (c) Alexis Huguet)

An ethnographic project that examined the 10^th Ebola epidemic in Democratic Republic of the Congo 

Rachel Niehuus

The 10^th Ebola epidemic in Congo was declared in North Kivu on August 1, 2018. The international response to the epidemic was massive—nearly half a billion dollars of international aid flowed into the country; and yet, the epidemic lasted twenty-three months and claimed 2287 lives. A newly approved, highly protective vaccine was utilized, and novel therapeutic agents were tested and found to reduce mortality. And still, on 25 June 2020, when the epidemic was finally declared over, it had become the largest epidemic to affect Congo, and the second largest and longest globally to date. 

Not only was the large public health apparatus that assembled to fight Ebola not able to contain the disease; it also generated significant conflict. While official counts differ, likely there were some 200–300 episodes of violence tied directly to the Ebola epidemic and/or the national and international coalition known locally as the Riposte.^[1] Because it was so large and generated so much conflict, the 10^th epidemic has drawn significant attention from academics and practitioners.^[2]

In the fall of 2019, the European Union commissioned a study to investigate why the large public health response to the 10^thepidemic had caused so much friction in communities. As an anthropologist and a physician who had worked in the area for years, I was hired to lead one arm of this study. A team of twelve Congolese researchers and myself developed a mixed-methods study that sought to understand what roles the Congolese health system, the Riposte, and the community each played in managing the epidemic. After a week-long intensive workshop in ethnographic methods, a group of researchers with social science backgrounds began studying the different ways that the community and the Riposte approached Ebola prevention, treatment, and after-care—and the ways that these differences sometimes generated conflict. Fundamentally, this arm of the study was motivated by the claim made by Paul Richards and the Ebola Gbalo Research Group during the West African epidemic that “a people’s science” could end an epidemic.^[3] Each team member worked independently to collect their quota of data. But the research was also collaborative. During the three-month period of data collection, the team devoted one day a week to discussing everyone’s provisional findings. Stories were relayed, interpretations debated, and future directions proposed. These sessions of iterative, collaborative analyses significant deepened each researcher’s understanding of their own field site as well as all of our understanding of the epidemic more generally.^[4]

The goal of a project thus conceived was not merely to produce a report about the 10^th Ebola epidemic—this could have been achieved with far less investment from all involved. Rather, as a team, we were interested in 1) what might be produced when a group of critical, independent researchers who had never before read the critiques of humanitarianism that circulate in Western academic work, formulated their own critique of international epidemic management and put their heads together to suggest an altogether different approach; and 2) the professional development of a group of scholars, who had always been relegated to the role of research assistant,^[5] who instead designed, implemented, analyzed, and published the results of their first independent research project.

Many of our group’s findings were published in a report entitled “Ebola in the DRC: The Perverse Effects of a Parallel Health System.” A quantitative analysis of the impact of Ebola on the Congolese health system is also under review with an academic journal. This series of papers is the project’s third product, and perhaps its most important. The result of research designed from conception to publication by a group of Congolese scholars, these papers provide unique vantage points from which to view an otherwise heavily-studied epidemic. When read alone, their conclusions might seem modest: careful analyses of important sites of the 10^th Ebola epidemic. When taken as a whole, however, they challenge the very foundations of international epidemic management. Instead of recommending ways to do international epidemic management better, as analyses of humanitarian action are prone to do, this group of papers proposes an altogether different approach: they allege that international epidemic management involves ceding to a group of foreign experts who possess, at best, a surface-level understanding of a very complex region; and they suggest that local knowledge and local institutions might have the capacity to manage an Ebola epidemic more effectively in eastern Congo. 

The quartet begins with Steward Muhindo, who analyzes the way that Ebola was managed in Mangina in the three months before the first Ebola tests were run and the epidemic was declared. Through a careful tracing of the early chain of transmission, Muhindo demonstrates that traditional methods of minimizing infection transmission were remarkably effective at controlling the spread of Ebola. Next, Serge Sivya describes the Ebola testing and treatment apparatus developed by the Riposte. Sivya illustrates the deleterious effects of the Riposte’s militarized, fear-based approach to testing and treatment, and then suggests that, if existing personnel and institutional structures were used to manage Ebola instead of imposing new structures, decades of trust in the Congolese health system could have been leveraged to engage the population in control measures. In the third paper, Bienvenu Mukungilwa offers an exclusive view of a new category of people created by this epidemic: Ebola survivors. While people have certainly survived previous Ebola epidemics, improved clinical algorithms and novel therapeutics greatly reduced mortality. For those who presented early in their disease course, Ebola was no longer a death sentence but rather a preventable and treatable disease. And so, new measures were introduced for survivors: survivors were systematically given material goods at discharge from an Ebola treatment center; they were enrolled support groups; and they were mandated to follow a very regimented health surveillance system. By demonstrating the ways that the Riposte’s policies fomented fear of survivors, Mukungilwa challenges what role international humanitarian organizations should play in the reintegration of survivors back into Congolese society. The final paper, co-authored by Steward Muhindo and Elie Kwiravusa, the latter of whom worked independently but in parallel to our research group, acts as a sort of conclusion to the quartet. Muhindo and Kwiravusa offer concrete recommendations for improved epidemic management. More radically, they also propose the possibility of a different form of accounting in epidemics—one that tallies trust and familial duty instead of “Ebola suspects,” that counts dignity and respect rather than “rings closed” or “secure burials complete.” 

Ultimately, I am proud of our work. The publication of these four articles marks the achievement of one set of our team’s goals. Changes in the field of epidemic management are harder to quantify. It will take time to change who is doing the work and what work is being done, that is, to decolonize that space. But as with the research sector, movement is underway. And it must be. For, as many a Congolese peasant remarked during the 10^th epidemic, “les communautés voient beaucoup plus loin que la Riposte.”

Rachel Niehuus is a surgeon and medical anthropologist focusing on public health and violence in Central Africa. She holds an MD/PhD from the University of Berkeley. Most recently she co-led Congo Research Group’s work on Ebola in Eastern Congo.

Brief overview of the four papers in this series:

Muhindo, Steward & Kwiravusa, Elie (2021): Repenser la Riposte Ebola. Leçons apprises et nouvelles perspectives des ripostes contre les épidémies. Suluhu Working Paper 5, at http://www.suluhu.org/papers.

Muhindo, Steward (2021): Faire face à une maladie inconnue. La riposte communautaire pré-Ébola à Mangina. Suluhu Working Paper 6, at http://www.suluhu.org/papers.

Sivyavugha Kambale, Serge (2021): Réponse et Contre-Réponse. Soins formels et informels pendant l’épidémie Ebola au Nord-Kivu. Suluhu Working Paper 7, at http://www.suluhu.org/papers.

Mukungilwa, Bienvenu (2021) « Ce sont nos guéris » : La Réponse face à l’échec de réintégration des survivants d’Ebola. Suluhu Working Paper 8, at http://www.suluhu.org/papers.

---

^[1] See Congo Research Group’s report, “Rebels, Doctors and Merchants of Violence: How the Fight Against Ebola Became Part of the Conflict in Eastern DRC.”

^[2] At the beginning of the epidemic, when rifts between communities and the Riposte first became visible, a group of researchers assembled to provide feedback to the Riposte that might improve its relationship with the community. This group, eventually named Cellule d’Analyse en Sciences Sociales (CASS), conducted hundreds of studies over two years. In addition to CASS’s research, universities, aid agencies, and NGOs sponsored other research projects. The report entitled “Ebola in the DRC: The Perverse Effects of a Parallel Health System” includes much of this research in its bibliography.

^[3]  See especially (Richards 2016; Ebola Gbalo Research Group 2019).

^[4] In addition to the ethnographic arm, there was a quantitative arm. Five researchers with medical backgrounds worked together to complete a 4000-household survey aimed at quantifying the impact of Ebola and the Riposte on health behaviors and outcomes in the affected region. And two researchers with experience in health systems research visited 53 health centers in the region and collected qualitative and quantitative data on the impact of the Riposte on each center.

^[5] The Bukavu series (Nyenyezi Bisoka and Kash 2020) nicely differentiates between the roles of a research assistant—whose role is limited to collecting data for someone else’s study—and a researcher—who shapes the research from its conception to its conclusion.