Cover image courtesy of The International Medical Corps.
Written by Vaishnavi Kumar, The University of Oklahoma
Abstract
This paper looks at how the nonprofit organization International Medical Corps, helps communities in need in light of a disease outbreak. Many nonprofit medical organizations are scrutinized because they do not provide enough resources for a community to use after they leave, resulting in inadequate care. International Medical Corps (IMC) is a global nonprofit organization that works in various African countries and aims to provide emergency medical relief to communities facing natural disasters, disease, or humanitarian conflicts. The main goal of their work is to provide resources to help these affected communities, in order for them to become self-reliant through sustainability, care, engagement, transparency, accountability, and global lessons. Looking at disease relief specifically, IMC was able to curb the 2020 Ebola outbreak in the Democratic Republic of Congo within 5.5 months from the index case. They were able to do this through previous experience, providing counseling for members in the community affected by the disease, and remaining in close contact with local health officials post-outbreak. IMC, unlike many nonprofit medical organizations, aims to accomplish its goal of supporting a community with adequate resources. They are thorough in their work, and their crisis management post-disaster proves that they never “leave” these communities.
“First There, No Matter Where” [1].
Introduction
The Democratic Republic of Congo (DRC) is a country in Central Africa that has recently faced an Ebola epidemic affecting nearly 3500 people with over 2000 deaths. The epidemic was named the largest in the DRC’s history and it lasted from 2018 to 2020 targeting the eastern region of the country, and officially ended in June 2020 [2]. With the location of this epidemic beginning in the northeastern region of North Kivu, it raised the chance of Ebola being spread to surrounding countries, prompting further control to be taken to reduce the risk. Along with this, the eastern region has more conflicts, making it difficult to provide help than with previous epidemics. Later on, a new outbreak began in June in the Équateur region of the DRC, prompting action to be taken place. This outbreak was declared over in the eastern region in June of 2020 by the World Health Organization (WHO) but was then followed by other outbreaks which ended in November of 2020. International Medical Corps (IMC) is an organization that helped to combat this epidemic in the DRC, as well as previous epidemics in the continent of Africa. Through training local aid workers and providing various resources throughout the duration of the epidemic, this shows that they care about bringing the community to success, instead of glorifying international volunteers. Their dedication to serving and empowering a community in difficult times proves that there are equipped to handle a disease outbreak better than other humanitarian organizations.
Past Outbreaks
There have been many outbreaks of Ebola in various African countries that often overlap with each other—for example, the various outbreaks of the 2018-2020 time period. From this, a lot was learned about the disease and how to manage it. One significant episode of Ebola outlined in Paul Richards’ Ebola: How a People’s Science Helped an Epidemic was in 2000 in Uganda with about 425 cases. Many of the index cases originate from contact with infected animals through hunting or consumption. Other theories include blood samples of currently infected patients. Richards also touched on the culture of these communities and how certain practices may have led to the spread of disease. He stated, “It was widely presumed that Ebola was spread because people in Guinea, Liberia, and Sierra Leone stubbornly adhered to dangerous traditional beliefs…Maybe, for example, anthropologists could help stop people washing dead bodies, or collectively eating rice from a single plate?” [3].
One of the reasons why this outbreak in Uganda was significant is because it was more concentrated in an urban setting, whereas previous outbreaks occurred in a rural setting. With Ebola being in an urban setting, it made it harder to control the disease since disease spreads faster in denser more populated areas. Later on, in the 2013-2015 epidemic, Ebola affected both rural and large urban communities in Guinea, Liberia, and Sierra Leone, creating many challenges [3]. Below is a table outlining the location, year, cases, and species of various Ebola outbreaks in African countries. Many of the cases occurred in rural communities, which explains the smaller numbers. More recent epidemics had higher case numbers since they were in more populated areas proving that Ebola is a communicable disease.
Table 1.1 Pre-2013 African outbreaks of Ebola Virus disease (excluding single cases) [3].
Each of these epidemics leads to more research on how to mitigate the disease in large populations, which was important particularly to outside organizations helping during the recent 2018-2020 epidemic. One of the main organizations that claimed to have played a key role in combatting the epidemic is the International Medical Corps (IMC), which used experience from previous epidemics to fight this one.
What is IMC?
International Medical Corps is based in Los Angeles, California, United States, and was established in 1984. It is a global, nonprofit organization aiming to provide emergency medical care for countries facing natural disasters, disease, or humanitarian conflicts. The main goal of their work is to not only serve but also train people in the community and provide them sustainable resources in order to be self-reliant and serve as first responders themselves. According to their website, they have over 7200 staff members with the majority of them being local to their communities [1]. One way they promote self-reliance is through their “Humanitarian Response Training Unit” where they work with local residents, governments, and non-governmental organizations to encourage independence and confidence, especially in times when it’s needed most. In the context of the 2018-2019 Ebola epidemic in the DRC, IMC provided medical relief in light of the disease outbreak and continued to remain a resource for them throughout the epidemic and even afterward. With training local members to become first responders, and utilizing previous experiences, as well as experts in the disease to create a plan for the epidemic, this proves that IMC is prepared with effective disaster relief in disease-ridden communities.
The DRC has been impacted by multiple and unpredictable Ebola outbreaks along with longstanding humanitarian conflicts. With a population of 81.3 million and an average life expectancy of 58-62 years of age, some of the challenges the DRC is faced with include weak healthcare systems, sexual and gender-based violence, malnutrition, and lack of clean water, sanitation, and hygiene. The IMC has helped by training 88,000 local community members in health education and supporting 64 health facilities. Along with this, their work in Ebola treatment has helped improve health outcomes for the community.
IMC helped control the disease by working with the DRC Ministry of Health, as well as the World Health Organization to set up Ebola Treatment Centers. By working closely with the Ministry of Health as well as the local health officials, they are able to respond accordingly when needed for any more help or resources. IMC is in charge of disease treatment, surveillance, and infection prevention within each province, and training healthcare staff. Along with this, they supply hygiene resources like handwashing stations, personal protective equipment, water basins, and soap [4]. Throughout the various Ebola epidemics both in Africa and worldwide with the 2014 epidemic, IMC has worked with the community to train them in how to control the virus. For the 2014 West Africa epidemic, they trained nearly 1500 people and treated almost 500 active cases in their treatment centers. Along with this, they worked with governments to prevent the further spread of the virus. Finally, something that IMC does that is different than other organizations, are they stay afterward to continue developing health infrastructure in the communities, and also provided mental health help to the community affected by the disease. These are all things that they’ve continued to do during the 2018-2020 epidemic as well.
Dr. Levine’s Approach
Dr. Adam Levine was the technical lead of the IMC Ebola response and created a response plan as the outbreak continued to grow. An interview conducted with him in May 2018, right around the start of the epidemic, helps to show the thought process and approach IMC took for this epidemic compared to previous epidemics.
During previous epidemics, no research was gathered; rather what they knew about it was through personal experiences and stories instead of evidence-based research. Dr. Levine noted that going into the 2014 West Africa epidemic, there was not much research on what Ebola was. So, they were going into it quite blindly. They were able to learn more about the symptoms and epidemiology of the disease from that epidemic, to apply to the 2018-2020 epidemic, and were even able to develop treatments and vaccines to reduce mortality.
He says “the structure of our response will be very similar to the one in 2014. We must focus on community education, public health messaging, health worker training, establishing screening to discover those suspected of having the disease, and proper lab testing to confirm cases…This also requires the commitment and the will from large donor nations whose funding is needed to make it all happen” [5].
Levine brings up two important points when explaining the approach. The first, which is implementing public health interventions, and the second being donations. In the documentary “In the Shadow of Ebola” covering the 2014 West Africa Ebola epidemic, one man named Emmanuel Urey states that his country [Liberia] has “little or no public health infrastructure” [6]. Because of its poor infrastructure, there were very few regulations taken place which led to misinformation of the disease, as well as mistrust in the government system. All people knew about the disease that was killing them, and the system only instilled more fear in them when attempting to encourage isolation. In Susan Shepler’s article “The Ebola virus and the vampire state” she describes “When someone has the symptoms—fever, vomiting, diarrhea—they are supposed to report to the health center, where they will be taken away from family, and if they die, be buried by men in protective gear with no family present” [7]. So simple interventions as Levine described such as education through handwashing posters, or information to limit the spread of the disease would provide the community with more knowledge so that they do not feel as helpless, especially in a government system that is not providing them the proper information.
The second factor Dr. Levine describes is funding from “large donor nations.” When asked a follow-up question about how these efforts would be financed, he explained that he fears big nations such as the United States and European countries may wait to provide funding until the outbreak grows. However, the goal was to keep the outbreak at bay. He goes on to describe how the 2014 epidemic cost about 3 billion dollars, which the United States funded about two-thirds of. These efforts by the IMC are mainly funded by traditional donor governments and private sectors but heavily rely on donor governments.
Lastly, Dr. Levine talks about the vaccine campaign and the possibility of it being carried out. He says “There are a lot of hurdles. The vaccine must be kept at extremely cold temperatures to maintain its effectiveness. If the vaccination campaign proves even moderately effective, though, it will be one more tool in our tool kit to fight this deadly disease” [5]. Later on, in the epidemic, the vaccine campaign was launched.
Timeline of Epidemic
With Dr. Levine’s plan in mind, IMC outlined its progress throughout the 716 days it took to end the epidemic and what it did as an organization to cope with challenges including growing numbers and humanitarian conflicts. Their work starts in August 2018 and the epidemic ended in June 2020, however even after the epidemic ended, their work didn’t stop.
In August of 2018, the World Health Organization recognized an outbreak in the North Kivu Province of the DRC. This conflict-ridden area served as a challenge for any organization to send resources and tamper with any outside efforts being made.
In September 2018, 15 treatment centers were built and opened in the Ituri province which the outbreak had spread to (about 400 kilometers away from the North Kivu province).
In October 2018, two healthcare workers were killed by Congolese rebels creating a challenge to serve affected individuals in an environment where the cases continued to rise.
In November and December of 2018, with the rise of attacks, a few Ebola Treatment Centers were forced to shut down leading to limited care for Ebola patients.
In January 2019, after a long few months, the first Ebola survivor was discharged from the health care facility, showing hope for future cases and a reason for celebration. However, despite a few survivor cases, there was still a steady rise in cases in the DRC which can be outlined in the graph below.
“716 Days” [8].
In February and March of 2019, surveillance had been increased, “Our screening referral units (SRUs) have now screened more than 600,000 people for the virus” [8]. However, they had just reached over 1000 cases of the virus.
In April 2019, the case number was steadily rising despite the index case being 8 months prior. However, over 1000 health care workers had been trained by the IMC and strides were being made through screening and surveillance of the virus.
Throughout May and June of 2019, there were 1500 to 2000 positive cases of the virus. However, in July of 2019, about 100 patients had been cured of Ebola through the Ebola Treatment Centers. From July to September of that year, the Ebola epidemic was labeled a global health emergency by the WHO, but more and more people were continued to be screened, and more patients were recovering from the virus.
By October 2019, a few cases of Ebola were reported in South Sudan, prompting action to be taken place in order to prevent the spread of the virus. By November 2019, with ample research conducted on the virus at this point, the Ebola vaccine has been approved for patients. With this vaccine, it provides more hope to the community, healthcare workers, and even the possibility of travel to those wanting to travel to African countries that have been prone to Ebola in the past.
Until about April of 2020, more patients were recovering from Ebola, and more surveillance units were being built. By June 2020, despite 4 healthcare workers in the Equateur province dying from Ebola, the outbreak in the eastern region of the DRC was declared over by the WHO and Ministry of Health, making the epidemic last about 716 days. The timeliness of the resources provided by IMC helped this epidemic terminate faster than previous ones, given the severity.
Addressing the Attacks on Healthcare Workers
These violent attacks on health care workers were a huge concern as they impeded the process to get proper help to affected communities. As outlined in a paper titled “Investigating the Dynamics of Violent Attacks on health Care During the Ebola Outbreak in the Democratic Republic of Congo” the author states, “The attacks on healthcare in the DRC appear to be perpetrated by a mixture of local militias, structured rebel groups, and community members who do not trust the Ebola response efforts” [9]. The attacks were not specific to foreign aid workers despite attacking Ebola Treatment Centers, as well as different organization’s health officials like the World Health Organization’s health official for instance. Even during the 2014-2016 epidemic, attacks were targeted towards any sort of health official. Some of the attacks from people who do not trust the Ebola Response efforts may be because of a lack of trust in the government or health system. This was outlined in the Shepler which describes how the lack of information caused people to spread rumors about the disease. For example, talking about a chemical spray that will be sprayed on you if you have Ebola and that being what actually kills you. Along with this, the rumor is that the health ministry is profiting off of deaths, so the more deaths that are reported, the more money they get. She states, “They said that the government already got $1.8 million in March, so they know there is money in it” [7].
These attacks were reported through a surveillance system through the World Health Organization and constituted as “any act of verbal or physical violence, or obstruction that interferes with the availability, access and delivery of curative and/or preventative health services” [9]; [4]. In the IMC timeline of the disease, the attacks on healthcare workers were most likely IMC members, since many attacks were towards Ebola Treatment Centers (specific to IMC). However, IMC did not further explain whether these attacks were made on their members or how they managed it if they were.
Ebola and COVID-19
It is important to note that the Ebola epidemic also coincided with the COVID-19 pandemic. IMC discusses how they were able to combat Ebola in light of the COVID-19 pandemic. Community Health Workers through the IMC are there to educate people in rural communities about the infections and report any Ebola or COVID-like symptoms that people were experiencing to authorities. Community Health Workers serve as a friendly face in the community while also enforcing that certain practices should or shouldn’t take place. One Community Health Worker shared “with Ebola and COVID-19, which require that we refrain from shaking hands and engaging in other physical contact—especially touching an infected or dead person—and that we regularly wash our hands” [10]. The Community Health Workers gained trust in the community and allowed people to feel empowered for helping combat both diseases. A member of the community shared “Learning by doing makes life better and healthier” “We appreciate International Medical Corps and its partners for this education, which will prevent Ebola and other infection in our community’s families” [10].
Foreign Medical Aid
At this point, it is important to highlight whether foreign medical aid is really helpful or not. IMC is an international organization and works to train locals to be able to help in a disease outbreak/epidemic, instead of relying on international volunteers who would only stay temporarily. IMC also provided resources like Ebola Treatment Centers, as well as Screening Referral Units to stay up to date on current cases. Both of these resources have proven to be helpful in the epidemic. However international aid workers also have helped during past Ebola epidemics, but how much did they actually help?
Much of the debate around international medical aid is that it costs a lot of money to host international volunteers when the money could go to developing communities and funding local workers better instead. In Elettra Pauletto’s article “The Shocking Inequality in Foreign Aid Nobody Talks About” she says, “On average, national staff are paid four times less than their expat counterparts, despite similar levels of experience and education” [11]. In a paper published in the British Medical Journal, however, the author claims that UK health workers have a key role in international disaster relief. Volunteers and employees through the National Health Service (NHS) England, Médicins San Frontiéres, and the Department of Health applied and were interviewed and upon acceptance were went through a training period where they were informed on Ebola, personal protective equipment, and the sociopolitical context of the outbreak in the 2014 epidemic. Their work and testimonials of volunteering during the epidemic highlighted what they gained professionally. One volunteer shared “Although professional development was far from my primary intention, I cannot help but acknowledge how much I have gained. I was often the most senior clinician and therefore independent clinical decisions on a daily basis” [12].
In another paper by Abigail Anness titled “Should I Stay or Should I Go? Working as a doctor in the developing world” discusses the pros and cons of working in a developing country and comparing it to working at home. One section is titled “Make the most of opportunities to boost your CV” and ends with a Final Advice section asking the question “With depth of experiences and career enhancing opportunities available in the developing world, why not take a detour?” [13]. Both of these papers seem to promote the personal gain of volunteering abroad rather than the help they are doing in the countries they are serving.
IMC during the Ebola epidemic specifically, focused on training locals and provided resources, rather than sending international volunteers which would’ve been expensive and potentially less helpful, and even pose a greater risk of spreading Ebola internationally.
Conclusion: Looking Forward
IMC’s work in the 2018-2020 Ebola Epidemic should be commended for providing appropriate and ample resources. At the same time, the organization focused on building confidence among the community by training locals and Community Health Workers to engaging with the community and promote correct information and regulations to prevent the spread of disease. Amongst all of this, working under dangerous conditions in areas of the DRC high in conflict posed a huge challenge and delayed the process of providing resources to the community. However, what is most notable are their statistics regarding the number of people that were treated and discharged from the Ebola Treatment Centers, as well as the number of people screened for Ebola. Finally, the research from the cases resulted in “25,000 pages of epidemiologic data on more than 2,500 patients in the midst of the largest epidemic of the viral hemorrhagic fever to date” [14]. This research and experience from the epidemic will help to prepare for the next outbreak or epidemic to lead to a better response from humanitarian organizations.
Lastly, there has been a recent Ebola outbreak that began in February 2021 from a woman who had nasal bleeding. With the bleeding, health care workers obtained samples to test for Ebola since her husband was an Ebola survivor. The bloodwork came back positive for Ebola despite her husband being negative. The woman later died of the disease. More cases emerged from the North Kivu province constituting another Ebola outbreak which was declared over on May 3rd, 2021. IMC had immediately begun working with the Ministry of Health to suppress the disease in this area, ultimately ending 4 months after the index case. This proves IMC’s promptness in ending these epidemics and use of improved methods from the past to implement for current and future outbreaks, ultimately leading to better health outcomes and decreased fear for members in the community.
This post may have been edited by admin for clarity and length.
Bibliography
Adams, Sydney N. Investigating the Dynamics of Violent Attacks on Health Care During the Ebola Outbreak in the Democratic Republic of Congo, August 2018 – January 2020. 2020. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=ddu&AN=3553738ED501AB0A&site=ehost-live.
Anness, Abigail. “Should I Stay or Should I Go? Working as a Doctor in the Developing World.” BMJ: British Medical Journal, vol. 351, 2015. JSTOR, www.jstor.org/stable/26521513. Accessed 18 Apr. 2021.
Centers for Disease Control and Prevention. (2021, February 23). 2021 Democratic Republic of the Congo, North Kivu Province. Centers for Disease Control and Prevention. https://www.cdc.gov/vhf/ebola/outbreaks/drc/2021-february.html.
“Community Health Workers in DRC Help Stop Spread of Ebola and COVID-19.” International Medical Corps, 12 Dec. 2020, internationalmedicalcorps.org/story/community-health-workers-in-drc-help-stop-spread-of-ebola-and-covid-19/.
Ebola outbreak: Emergency response. (2021, May 03). Retrieved May 10, 2021, from https://internationalmedicalcorps.org/emergency-response/ebola-response/.
First There, No Matter Where. International Medical Corps, internationalmedicalcorps.org.
In The Shadow of Ebola, intheshadowofebola.com/.
Pauletto, Elettra. “The Shocking Inequity In Foreign Aid Nobody Talks About.” Medium, BRIGHT Magazine, 8 Aug. 2018, brightthemag.com/inequity-foreign-aid-workers-security-pay-gap-international-humanitarian-62ae974cca3?gi=bb1d9b51f82d.
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Roshania, R., Mallow, M., Dunbar, N., Mansary, D., Shetty, P., Lyon, T., … Levine, A. C. (2016, September 29). Successful Implementation of a Multicountry Clinical Surveillance and Data Collection System for Ebola Virus Disease in West Africa: Findings and Lessons Learned. Global health, science and practice. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5042696/.
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“716 Days.” International Medical Corps, 14 July 2020, internationalmedicalcorps.org/story/716-days/.
[1] First There, No Matter Where. International Medical Corps, internationalmedicalcorps.org.
[2] Centers for Disease Control and Prevention. (2021, February 23). 2021 Democratic Republic of the Congo, North Kivu Province. Centers for Disease Control and Prevention. https://www.cdc.gov/vhf/ebola/outbreaks/drc/2021-february.html.
[3] Richards, P. (2016). Ebola: how a people’s science helped end an epidemic.
[4] Ebola outbreak: Emergency response. (2021, May 03). Retrieved May 10, 2021, from https://internationalmedicalcorps.org/emergency-response/ebola-response/.
[5] “What We Know about Fighting Ebola: A Q&A with Expert Dr. Adam Levine.” International Medical Corps, 16 Jan. 2020, internationalmedicalcorps.org/story/fighting-ebola/.
[6] In The Shadow of Ebola, intheshadowofebola.com/.
[7] “The Ebola Virus and the Vampire State, by Susan Shepler.” Mats Utas, 9 Sept. 2014, matsutas.wordpress.com/2014/07/21/the-ebola-virus-and-the-vampire-state-by-susan-shepler/.
[8] “716 Days.” International Medical Corps, 14 July 2020, internationalmedicalcorps.org/story/716-days/.
[9] Adams, Sydney N. Investigating the Dynamics of Violent Attacks on Health Care During the Ebola Outbreak in the Democratic Republic of Congo, August 2018 – January 2020. 2020. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=ddu&AN=3553738ED501AB0A&site=ehost-live.
[10] “Community Health Workers in DRC Help Stop Spread of Ebola and COVID-19.” International Medical Corps, 12 Dec. 2020, internationalmedicalcorps.org/story/community-health-workers-in-drc-help-stop-spread-of-ebola-and-covid-19/.
[11] Pauletto, Elettra. “The Shocking Inequity In Foreign Aid Nobody Talks About.” Medium, BRIGHT Magazine, 8 Aug. 2018, brightthemag.com/inequity-foreign-aid-workers-security-pay-gap-international-humanitarian-62ae974cca3?gi=bb1d9b51f82d.
[12] Rokadiya, Sakib, et al. “UK Health Workers Have Key Role in International Disaster Relief.” BMJ: British Medical Journal, vol. 351, 2015. JSTOR, www.jstor.org/stable/26524404. Accessed 18 Apr. 2021.
[13] Anness, Abigail. “Should I Stay or Should I Go? Working as a Doctor in the Developing World.” BMJ: British Medical Journal, vol. 351, 2015. JSTOR, www.jstor.org/stable/26521513. Accessed 18 Apr. 2021.
[14] Roshania, R., Mallow, M., Dunbar, N., Mansary, D., Shetty, P., Lyon, T., … Levine, A. C. (2016, September 29). Successful Implementation of a Multicountry Clinical Surveillance and Data Collection System for Ebola Virus Disease in West Africa: Findings and Lessons Learned. Global health, science and practice. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5042696/.
