Summary of JOIE article ( 03 April 2023) by Sabine Iva Franklin, The Whitney and Betty MacMillan Center for International and Area Studies, Yale University, New Haven, Connecticut, USA. The full article is available on the JOIE website.
As we approach the 10-year anniversary of the West African Ebola Virus Disease (EVD) Epidemic and now the end of the COVID-19 pandemic, there is a lot to learn about public health emergency management. This paper contributes to a small aspect of the lessons learned of community engagement during a disease outbreak.
Traditionally, public health interventions for disease outbreaks focus on supply-side management, which provides clinical and biomedical resources. We can think of these public health goods as vaccines, available treatments, and other clinical resources for healthcare providers. However, this reduces the perspective of public health emergencies to the biological consequences of disease spread, thus to “treat or cure” our way out of an epidemic. However, supplying biomedical and clinical resources can have social, political, logistical, and economic barriers. We observed outbreaks becoming politicized, where opposing political parties were blamed for the epidemic or the response of a current administration being politicized to the point where it affected decision-making at the community level. For example, the decision to take a vaccine or visit a healthcare center. These barriers are the demand-side of public health goods, because from an economics perspective, supplying the goods alone is not an effective strategy if the demand for these goods drop. Thus, since addressing a disease outbreak is needed through collective action, how can we resolve these collective action challenges, to increase demand for supplied public health goods and cooperation with emergency management?
Thus, the argument for this paper is that community-based institutions led effective social mobilization and legislative strategies during the EVD epidemic. Specifically, what I term, Traditional Local Institutions (TLIs), which are the norm and rules governed by Paramount Chiefs, chiefs, clan leaders, councils, monarchs, youth leaders, and secret society leaders (Franklin, 2023). Traditional leaders are broadly respected and influential in local affairs and politics across sub-Saharan Africa.
This paper was conceptualized using this public health goods framework and a polycentric framework of nested externalities. Thus, most economists and political scientists may be familiar with polycentrism as specific institutions designed to address very specific issues and the outcomes of these issues via production or consumption (i.e., externalities). TLIs are an institution that were designed to address local community issues and garner cooperation from community members. Including, the type of communal cooperation that is needed to address a public health emergency. Second, the externalities of a public health emergency can be considered nested externalities (Oström, 2012), since defining this as production or consumption is too narrow. As social scientists and public health experts, we understand that externalities will always occur during a public health emergency through decision-making, and these externalities can be positive or negative depending on the decision. Thus, my decision to wear an N95 mask during COVID, should have a positive externality for me and anyone that I am come into close contact. However, the externalities are greater if we all wear an N95 mask or if most of us choose not to: these are the nested externalities. The spread or containment of infection depend on individual and communal decision-making that result in positive or negative externalities.
So, what was the turning point of the world’s largest outbreak of the Ebola virus disease?
The findings are categorized into two sections: government failure and the response from community-based institutions. Excerpts from interviews conducted in Liberia and Sierra Leone discuss a range of government failures and issues, however, the paper focuses on information dissemination (referred to as information asymmetry in the paper) and how this led to mistrust, confusion, and a breakdown of cooperation from healthcare workers and community members. There was a lack of training of healthcare professionals (i.e., giving them information about the disease: standard protocols, case definition, or training to use complex PPEs), which led to many misdiagnoses and uncontained spread, as healthcare workers did not know that EVD commonly presents as flu-like symptoms and not the most graphic symptoms of bodily hemorrhaging.
For the community members, they witnessed loved ones travel to a healthcare center to treat “Malaria” only to never return. In rural communities, neighbors and friends became critically ill after attending a local clinic, which spread fear in the community, and healthcare workers also become patients and eventually succumb to this mysterious illness. On the backdrop of Liberia and Sierra Leone being post-conflict countries, the spike in mortality triggered the traumatic memories of war and loss for many residents. And the ministries of health or government leadership felt absent.
The community response differed in Liberia and Sierra Leone. In Liberia, many communities organized to address collective action failures. For example, in a neighborhood in Monrovia, a taskforce of volunteers went door-to-door to distribute soap and check for sick persons being cared for at-home. A huge risk, as EVD is highly transmissible through caregiving. Their goal was to prevent EVD spread and refer every person with any signs or symptoms to a local secondary tier clinic. There was also another neighborhood where volunteers organized a checkpoint, as they saw that quarantine and stay-at-home orders were not being monitored and enforced by the government.
In Sierra Leone, TLIs came together to collectively pass bylaws in each chiefdom. Bylaws are local laws that Paramount Chiefs have the legal authority to pass, monitor, and enforce. Enforcement normally includes fines after a tribunal hearing. Chiefdoms make up every part of the country except for the capital city, Freetown. Thus, putting more than 80% of the population under emergency management through local authorities.
The primary data collected for this research was triangulated with the epidemiology data provided by the World Health Organization, which confirms the argument of this paper. The lesson from this research suggests that public health policies need to adapt to local social, political, and economic conditions in such a way that key community stakeholders and influencers are part of the interventions and engagement is bilateral. This means that strategies formed need to be bottom-up just as much as they are top-down, to encourage stronger cooperation.
Franklin, S.I. (2023). “‘It was organized from the bottom’: the response from community-based institutions during the 2014 Ebola epidemic”. Journal of Institutional Economics. doi:10.1017/S1744137423000085
Oström, E. (2012) “Nested externalities and polycentric institutions: must we wait for global solutions to climate change before taking actions at other scales?”. Economic Theory 49(1), 353–369. doi:10.1007/s00199-010-0558-6.