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Roundtable discussion: Applying Lessons from Polio-Eradication to non-Polio Efforts

Watch as Eric Mafuta & Humayra Binte Anwar tell Olakunle Alonge about applying lessons learned from polio eradication to Ebola outbreaks in the DRC.
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SPEAKER 1: Hello everyone, welcome. My name is [INAUDIBLE] and today we have with me Myra from Bangladesh and Eric from the Democratic Republic of Congo. And we’re going to be talking about the relevance of community engagement as a strategy for addressing Ebola outbreak, all the kinds of outbreaks. If you remember the lecture that you listened to really talked about community engagement and some of its relevance in the polio eradication program. We recognize that indeed, [INAUDIBLE] is also useful for the types of global health program. And we will be looking at the application or the relevance of each for addressing outbreak of Ebola in the Democratic Republic of Congo.
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And also commenting on how it might be useful for all the types of health programs. So I’m going to ask Myra to talk to us about– to let the audience know, what are your views about, from your own experience as an instructor or as a researcher, what is the usefulness of community engagement? Or what is the application or the relevance of community engagement for Ebola outbreak in a place like the DRC or for any other types of disease outbreak in any parts of the world?
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MYRA: Thank you, [INAUDIBLE],, for the question. Actually to me, the success of the whole, the polio program, it was very much dependent on the community engagement. Because we really did the– we really engaged the community. We first identified the target audience and then they identified whom to engage, who can speak to the community, whom the people trust. And then convey what we want to do to them. Then we can have the access to the community. So all of these community engagement worked very good for the polio. But when you are in an active war zone like DRC, eastern DRC and like Afghanistan, then these things are not so simple or easy to do. That’s true.
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And yeah, because the people already, they have the distrust towards the government, distrust towards the military force. And there are lots of border areas in the DRC where they’re porous borders. So they come and go. So it’s very complicated for the surveillance, also. And because also, there is– in DRC, there are some armed rebel group who frequently attacked the health workers, and even murdered them. So also, this violence, also this violence, what causes it? They discourage the civil people to seek for the– to go to the health facility for Ebola treatment. So that’s why that disease is spreading. So to me, it’s tough. Ebola was kind of emergency.
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So I think the even organization and the partners and the government, I think they kind of escape the community engagement part in this case.
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SPEAKER 1: Wow, wow. That’s amazing. Thanks a lot for that reflection. So indeed, you’ve expressed that indeed, community engagement is really relevant, particularly when you’re doing programs that involves a community and population and working with them. And you’ve also highlighted some of the challenges of doing community engagement in specific contexts, like the DRC where we have war and where we have instability. I would like to talk to Eric and see what ideas, from your whole experience, given your worth of experience working in the DRC, [INAUDIBLE] contextual issues that makes it rather difficult to use community engagement as a strategy for achieving health outcomes through global health programs?
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ERIC: Thank you, [INAUDIBLE]. What I can add to what Myra said is that we have to systematize our reflection. So when you use a policy triangle, she talks about context, in the context, what I can [INAUDIBLE] is that the Ebola outbreaks occur during an election period. So in this region, we have a lot of mistrust from the government. So people think that they have to change the situation. And they’re think that they let– the Ebola outbreak was used as a way to put them out of the election process. So it’s what we have or sort of keep in mind. We have also to keep in mind that Ebola’s control was not really the priority for the community.
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The community have their own priority. They need peace. And not the elements that we have to think about, actors. As actors, community was not aware of Ebola. For them, they have other priorities. And they are living in poverty. They have no support or they perceive no support, real support. And with the contour team, they saw a lot of people coming with a lot of resources, don’t speaking their local language. So it’s a mess for them to field all these people coming just for a disease. And we have peace problem, they don’t come here.
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SPEAKER 1: Wow.
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ERIC: And we have also another problem, they are living in a conflict area. And we cannot identify really who’s the responsible of this conflict problem. So we cannot use, for example, Tranquility Bay or Corridor of Peace strategy because they don’t know whose the people of who we have to talk about.
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MYRA: Who’s responsible–
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ERIC: Who responds for them.
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SPEAKER 1: Yeah, I mean this a very important point that you’ve highlighted, Eric. And it’s really great that you use the Ebola example to see why some of the challenges to doing community engagement, and why some approaches might not work. And in listening to you, you did talk about the feelings of a top down approach. That is to say, people come in from the central government to the community, not really understanding the issues within the community. It’s one thing that you did mention. And then you also, one of you did mention mistrust. That is because these people are perceived, I mean, the [INAUDIBLE] that come are perceived as falling to the communities.
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That indeed, the communities are able to– they’re able to engage with the community effectively. And then you also talked about responsiveness. That in a lot of ways, some of the issues that health workers and global health officials are really focusing on, the communities see them as really– or prioritize them as important, or maybe relatively speaking, compared to some other uses within the community. So what I do like both of you to comment on right now is, how do you then do community engagement, given mistrust, given the feelings of the top down approach, and also the lack of responsiveness of the health system to the needs of the community?
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MYRA: So even Ebola is a outbreak situation, it’s an emergency situation, we should not escape the community engagement. So we should first, as you said, the top down approach, we should do the bottom up approach. So we should find out, identify, who are the responsible person? I mean like, local leaders, local political leaders, then gatekeepers, then religious leaders, and local opinion leaders. So we can target those people. And then we can educate them. We can train them. We can educate them, what is Ebola, how it spreads, why you can’t touch the dead body of your loved ones. Because it’s a very emotional issue for them.
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So if they understand and they can convey this message to the community, even in the war zone, they can convey the message to them. So speaking in their own language, I think they will understand and cooperate.
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SPEAKER 1: Yeah, yeah, thanks a lot. Eric, do you want to build upon the bottom on up approach that Myra talked about? So she did say that we shouldn’t ignore community engagement.
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MYRA: Yes.
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SPEAKER 1: I think we all agree on this table. And that the way to do it might be to really go into the community and educate people and listen to people. That way, you can actually [INAUDIBLE] relationship, that you can then base programming and other activities on. Are there other things that you think are important in doing community engagement activities, particularly for issues like Ebola in a place like the DRC? Eric?
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ERIC: OK. I can just add that in this situation context, what is important is to win trust. And we are confronted to a problem of time. For an emergency like Ebola, we have not a lot of time to deal with our preparation, pre-campaign preparation. So we have to mix the top down strategy, which is really in application, but with a top on down and the bottom up strategy. And we have to mix them in the same time. Because people we’ll have to deal with community must be from this community. If they saw another people coming from abroad, it was difficult for them to trust him. So we have, as if she said, to engage them.
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To try also to engage the local health providers and what we call community health workers, to train them rapidly. Because it’s to them to deal with the problem, the real problem. But we have also to try to integrate because in polio program, we used to integrate all those services so people can know that I can have support from Ebola but also for other problems. So it’s also another lesson that can improve the community engagement in this situation.
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SPEAKER 1: Thank you. We’re going to be wrapping up now. But before we wrap up, I really just like each of you, based on your experience working or learning from the polio program, working in your different country context, what are the key takeaways that you would like our students to go with in terms of how to and how not to do community engagement? I mean, I know each of you actually said, well, maybe there are things that you would like to really emphasize, in terms of OK, this is the way to do it. Or at least based on my experience, in emergency situation like Ebola outbreak or [INAUDIBLE] scenario, this is how we can rapidly engage community.
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I think I did mention some of it in that you need to work with the people that are already on the ground and educate them and really build trust. So how do you do that? Any last words?
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MYRA: Building trust, I think, as in context of DRC, they’re already– they are not trusting the government and the military force. So what we could do that, we can use– because they are successful in eradicating polio. So what we can do, that we can use the same people who work for polio. So the people, the community has trust over them. And also some other programs, like immunization, other immunization programs or family planning program. We can use those people as local volunteers or local health workers. And also, we could also offer some other kind of health services beyond Ebola. So that they doesn’t think that it’s only Ebola we’re focusing.
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So that’s the– like in Bangladesh, we provided vitamin A capsule [INAUDIBLE].. So this kind of, if we promote other kind of nutritional, what– they have– because it’s a war conflict zone. So they need other things, more food and other things. So if we can promote those health services to them, I think they will gain trust again over the health workers, and it will work.
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SPEAKER 1: Thank you. Eric?
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ERIC: Yes, I can add also we have to maintain a community dialogue with our leaders, with traditional rulers, opinion leaders. And to try to improve the social mobilization strategy. In this area, we need that we have radio, we have to need a rapid communication system. And to maintain, even when we control Ebola, to maintain the communication for a long time so people can keep in mind what is necessary when we have this type of emergency and outbreak.
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SPEAKER 1: Wow, this has been a very great discussion. And I would really like to thank both of you for really teasing out the issues and also suggested solutions on how to effectively do community engagement work in an emergency situation like we have in the DRC with the Ebola outbreak. And I think this lesson is relevant again for any other types of outbreak. So thank you again. It’s really been a pleasure to talk to you.
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MYRA: Thank you very much.
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SPEAKER 1: You’re welcome. So this is where we’re going to wrap it up. Thanks a lot for joining us. And until we meet again, bye for now.

Experts discuss the relevance of community engagement as a strategy for addressing disease outbreaks – particularly in addressing the outbreak of Ebola in the Democratic Republic of Congo.

Presenter 1
Eric Mafuta, MD, MPH, PhD School of Pubilc Health, University of Kinshasa, Democratic Republic of the Congo (DRC)

Presenter 2
Humayra Binte Anwar, BDS, MPH, PhD James P. Grant School of Public Health, BRAC University, Bangladesh

Moderator
Olakunle Alonge, MD, MPH, PhD Bloomberg School of Public Health, Johns Hopkins University, USA

After watching this roundtable, revisit your response to the article Applying “Vertical vs. Integrated Approaches”. How did your answers compare to the information that the presenters shared?

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