Lessons for India from the Ebola epidemic
A good system that responds to viral threats is not an emergency system but an everyday system that responds to emergencies
The West African Ebola epidemic, which infected 28,616 and killed 11,310 in Sierra Leone, Liberia and Guinea between 2014 and 2016, may seem at first like a localised, regional public health emergency compared to the global Covid-19 pandemic. Yet, at a time when the second wave is crushing India, at both the micro- and macrolevel, there are lessons to be learnt from the Ebola crisis.
First, like Ebola, Covid-19 must be treated as a caregiver’s disease. In his book, Fevers, Feuds and Diamonds: Ebola and the Ravages of History, globally renowned infectious diseases doctor and anthropologist Paul Farmer, who was involved on the ground in Ebola treatment in West Africa, makes the crucial point that thousands contracted Ebola while caring for the sick and dead. Recognising Covid-19 as a caregiver’s disease is important not only to validate the efforts (and vulnerabilities) of doctors, nurses and paramedical caregivers but also to recognise small, everyday acts of caregiving in the home, hospital, clinic and cremation grounds.
Beyond vaccination, the Indian State must develop a concrete plan to address the challenge of frontline workers burning out. The risk of an acute shortage of key frontline workers in future is extremely real. We must further ask, are acts of caregiving in cremation grounds, graveyards and mortuaries — most often by those who belong to lower caste and class backgrounds — even recognised by the State? Are there any forms of insurance the government has created for these invisible frontline workers (and their families) who perform caregiving’s very last gesture? Caregivers must be treated as seriously as the afflicted, for viruses such as Ebola and Sars-CoV-2 blur the boundaries between caregivers and patients.
Second, efforts directed at the containment of the virus must be prefigured by capacity-building to care for the afflicted. Announcing lockdowns and enforcing these only through coercion is not a solution in itself.
As Farmer discusses in the case of Ebola, public health and biomedicine are foremostly part of the State’s social contract. Without ensuring safe and effective caregiving is in place, the policy of containment has its limits. Such a “control-over-care paradigm”, as Ebola has shown us all too well, not only endangers the lives of the afflicted but also leads to resentment against the State that may take the form of mistrust, resisting contacttracing, vaccination and containment.
Third, on the face of it, the current crisis in India is the result of severe burdens on secondary- and tertiarycare hospitals, and the State’s failure to address their basic needs — oxygen, beds, equipment, medicines and vaccines. This mirrors the Ebola crisis in West Africa’s clinical desert, which lacked the basic staff, material, space and systems of care. Independent Ebola treatment units in West Africa were set up through community mobilisation and sustained over two years in the absence of secondary or tertiary medicine.
The Indian State, too, must develop forms of care that de-centre tertiary hospitals whose limits are being exposed in horrifying scenes of people dying outside hospitals, in parking lots, streets and pavements — not so much because of Sars-CoV-2 but the absence of basic medical infrastructure. A focus on community care facilities such as oxygen-hubs, portable prefabricated health units and testing-treatment wards at the meso-level prevent overburdening hospitals and ensure triage before tertiary systems collapse.
Fourth, we can’t neglect the social determinants of health in a viral pandemic. In India’s current second wave, infections and the failure of medical systems are impacting the middle- and upper-middle classes. This is different from the first wave in 2020, in which the first to be debilitated were migrant workers, informal labourers, the poor and the social and
economically disadvantaged. We must ask ourselves — why did the State, media, citizens (including netizens) and medical systems fail to recognise and respond to the full-blown crisis of the intervening period? What does the present moment reveal about how our notions of crisis and care are determined by class and caste? A serious commitment to public health cannot start after the most vulnerable have suffered.
Fifth, viruses always track weaknesses in society and invade their cracks and fissures. As Farmer said in an interview, “There is a confusion at the beginning of epidemics that a novel pathogen is going to be some sort of ‘great leveller’. This is almost never the case.” To understand and stymie the movement of viruses, we must understand our social systems more effectively and sensitively.
In the case of Ebola, Farmer traces historical reasons such as colonialism and post-colonial civil wars, ethnic strife and exploitative structural adjustment programmes resulting in West Africa’s “clinical desert”. In the Indian context, the State’s longitudinal lack of attention to health is exacerbated
by divisions of caste, class, gender and ethnicity, which have summarily prevented public health from taking shape as a social or governmental priority.
It is common for the responsibility of ailing health systems to be shifted onto the afflicted. Alongside scientists and virologists, whose efforts are important, the Indian government must involve social scientists, community volunteers and those who routinely track society at a granular level, in its disaster preparedness. Not just Ebola, the record of global pandemics such as AIDS too reveal the need to identify vulnerable groups to address their distinctive needs, and remedy existing chasms of care.
Learning from Ebola, we must remind ourselves that a good system that responds to viral threats is not an emergency system but an everyday system that responds to emergencies.