Ebola is back. Is Africa ready?

A health worker in protective clothing is working at an Ebola treatment center in Beni, eastern Congo, on 9 September. (Al-hadji Kudra Maliro / AP)

Ebola is back – and a threat to people in Congo. In late August, the head of the World Health Organization, Tedros Adhanom Ghebreyesus, warned that the latest Ebola outbreak in the provinces of North Kivu and Ituri has not yet been 90 people dead and at least 130 probable or confirmed cases.

In Zimbabwe, the government recently declared a cholera emergency in the capital, Harare, after the death of at least 20 people and 2,000 patients. The response to these public health crises and others in Africa underscores the need for action by multiple authorities.

Our research shows that, while WHO plays a very visible role in responding to such crises, Africans directly involved in health promotion ("stakeholders") have significant power over health.

[African governments are far from powerless in global health initiatives like those against AIDS]

In the space of a decade, we interviewed nearly 250 government officials and community leaders working on AIDS, the Ebola virus, noncommunicable diseases such as diabetes and the fight against epidemics. We spoke with people in Liberia, Ghana, Nigeria, Zambia, Tanzania, Uganda, Burkina Faso, Togo and the United States.

In Liberia, our research focused on community-led actions during the 2014-2015 Ebola outbreak in Liberia. In Burkina Faso, Nigeria and Togo, the work has challenged the response of the West African Health Organization (WAHO) to the epidemic.

Local actions can have great results

Africans are not passive participants in the presence of global health organizations such as the WHO – but have the power to influence health outcomes through what may seem like small activities. Our research shows that religious leaders, traditional healers and community activists carry out specific tasks, such as sensitizing people to epidemics, mobilizing their supporters to help the sick, and providing medications and initial treatments.

As Katherine Marshall, an expert in religion and global development, points out, they are often the first responders in health epidemics because they live in the community and know their inhabitants. These leaders can also serve as intermediaries between community members who may criticize outsiders and global health experts who may not understand local customs or belief systems. In Congo, for example, WHO has turned to local religious leaders and village chiefs to gain access to rebel-controlled territory.

Local leaders do more than negotiate. They explain the health problems in an understandable way for the local population. Here's an example – many Zambian pastors told their supporters that AIDS treatment was a "gift from God," an explanation that made HIV-positive people take their medications faithfully. In Liberia, church leaders described Ebola as "the devil" that needed to be fought with hospital care for the sick and prayer for healing and protection.

And these actors find themselves on the world stage

African actors also demonstrate much greater power over health issues. For example, a number of African presidents delivered high-profile speeches at the United Nations on AIDS in 2001 – and the global media on Ebola in 2014. These statements made it difficult for powerful states to ignore these crises.

African countries have themselves organized health interventions, not expecting international assistance. Before the WHO intervention in the Ebola outbreak in West Africa, WAHO, two days from the outbreak declaration Ebola by Guinea and Sierra Leone, paid $ 12 million for a regional intervention. OOAS has supported the rapid repair of health facilities in Sierra Leone.

[Here’s why the WHO responded so differently to Zika and Ebola]

OOAS also supported teams that traced the contacts of infected people in Guinea, Liberia and Sierra Leone. And the Agency provided essential supplies: 14 ambulances, 2,000 infrared thermometers, 200 disinfectant products and 1,000 safety boxes for the transport of vitamins and supplements in areas where people are infected.

These actions often occur in contexts highly dependent on foreign aid. Congo, for example, gets 39% of its health money from donors. About 70% of WAHO's operational funding comes from external partners.

Despite this dependence, African stakeholders have managed to make aid work on their terms. They rejected health policies that they consider inappropriate in their cultural or religious context. For example, Liberian religious and traditional church leaders demanded an end to the cremation of bodies infected with the Ebola virus.

Traditional healers in Burkina Faso and Togo have sought scientific evidence of the effectiveness of their therapies. They have also received training on intellectual property rights to ensure that they can maintain control of traditional medicines in the face of pressure from pharmaceutical companies.

What gives stakeholders a power to intervene in health?

Research indicates that local people need to "trust the messenger" before adopting health behaviors such as vaccinating children. In surveys conducted in 36 African countries by Afrobarometer, a non-partisan research network, the majority of respondents in all countries reported trusting "enough" or "a lot" to traditional leaders. Our research indicates that when information is limited – such as an Ebola outbreak – people rely heavily on these leaders to help them understand and respond to events.

However, trust is not absolute. Research on African pastoralists and the AIDS epidemic in Uganda indicates that trust declines when people perceive that local intermediaries are benefiting economically from global health programs. Mistrust of West African governments has made people less inclined to listen to public health messages – and this has amplified the influence of community leaders.

Trust also takes place in a specific historical context. Although trust in religious and ethnic lines improved in Liberia after its war years (1989-2005), it was less evident in the areas most affected by the Ebola virus. This fragile trust meant that people turned to their own ethnic and religious leaders for information.

In a similar situation, the long-term conflict in eastern Congo has made local authorities indispensable for combating violence. But village chiefs, community leaders, and religious leaders have not always protected the people – and the trust of the local population may have deteriorated. In such contexts, leaders themselves may not be effective messengers of health.

[Here’s how the Ebola outbreak shaped citizens’ opinions of Liberia’s government]

These can be front-line messengers

Although none of our fieldwork has been conducted in a country that has experienced a protracted war like the Congo, our findings on stakeholder power and trust are widely applicable. We recognize the challenges of coordination and adequate resources in health crises such as the current outbreak of Ebola in Congo, but our findings suggest that improving the health of local populations requires knowledge how African actors affect the results.

Emmanuel Balogun is an assistant professor of international relations at Webster University and author of "Convergence and Agency in West Africa: Building Regions in ECOWAS" (Routledge, forthcoming in 2019). Twitter: @EA_Balogun

Amy S. Patterson is a professor of politics at the University of the South and author ofAfrica in Global Health Governance: Domestic Policy and International Structures " (Johns Hopkins University Press, 2018).