Community Engagement to Advance the GHSA: It's About Time

We commend Armstrong-Mensah and Ndiaye ¹ for highlighting the important role of communities in strengthening implementation of the Global Health Security Agenda (GHSA). Currently, community response and control efforts are proving central to addressing the ongoing Ebola virus disease (EVD) crisis in the Democratic Republic of Congo (DRC), where community engagement is used to promote awareness, seeking early care, early hospitalization, and isolation of those experiencing symptoms of EVD and to enable safe and dignified burials. These activities have likely averted many thousands of secondary infections, as they did in the 2014-2016 outbreak in West Africa. ²

While community engagement to advance the GHSA is critical, timing is everything. The time to start engaging with communities is not in the middle of a health emergency, when confusion and chaos prevail, and “outside” actors such as international organizations and public authorities are often viewed by communities with suspicion. In the DRC, suspicion and mistrust of authorities and external actors, due in large part to a long history of conflict and failure to support local communities to address their development needs, is increasingly acknowledged to have critically undermined containment of the ongoing EVD outbreak. ³ Research suggests a correlation between low levels of institutional trust compounded by belief in widespread misinformation and reduced likelihood of communities and individuals adopting preventive behaviors such as accepting Ebola vaccines and seeking formal medical care, thus increasing the potential for spread of EVD. ⁴

The authors note that establishing community trust is pivotal to enabling effective community engagement. This is true, but trust is complex, multifaceted, and must be mutual between all relevant parties. ⁵ Communities are often expected to place their trust in response efforts led by external, unknown actors—yet there is so much to be gained if “the response” affords greater trust in the communities it aims to serve. ⁶ Communities around the world have their own indigenous systems of epidemic control, many of which predate colonial times, are biomedically sound, and steeped in local knowledge, experience, and practices relevant to containing the spread of infectious disease.^6,7 Positioning communities at the center of all GHSA action packages—not just the 3 proposed by Armstrong-Mensah and Ndiaye ¹ —will shift the rhetoric of community engagement beyond the commonly perceived role of being a local extension of the response workforce or conduit for improved behavior change, to a critical driver of detection and response intervention design.

Developing trust also takes time and requires sustained investment of human, financial, and technological resources to build on existing community strengths. Communities in the DRC question the focus on EVD when people are dying in larger numbers from more common and treatable illnesses such as measles and malaria. ⁸ Recognizing the need for a broader approach to engagement and sustained resourcing and strengthening of frontline health services to ensure day-to-day public health priorities are met has contributed to greater community confidence in the health system. Seeing patients emerge “well” from health centers having been treated for common illnesses such as malaria, typhoid, sepsis, and cholera, has driven improved trust in the provision of healthcare overall, including increased trust and acceptance of the Ebola treatment units, which were previously perceived with suspicion and fear. ⁸ Similarly, health literate community volunteers play a crucial role in epidemic disease prevention, early detection, and response. But, it takes time and investment to train and equip volunteers with appropriate skills and communication materials, and for these volunteers to gain the trust and respect of their community peers and develop the necessary credibility for community members to listen to them and heed their advice when outbreaks occur. ⁶ Humanitarian and development actors require funding to support long-term programs that prevent or minimize epidemics and establish a critical foundation that can be leveraged for rapid, effective epidemic and emergency response operations when needed.

Building partnerships and trust with communities to strengthen implementation of the GHSA is best achieved through long-term investment in preparedness. This requires a deep understanding of complex and dynamic sociocultural, political, and economic realities and constraints; attitudes and practices impacting on disease prevention and transmission; local leadership and governance structures and processes; and social networks and communication channels and preferences to ensure that relevant, contextually appropriate, agile interventions are developed with and co-owned by affected populations. Working with and through existing community structures is more effective than creating parallel or temporary structures and builds trust and long-term capacity that is positively reinforcing. ⁶ In Kenya, this approach of working through local community structures, building capacity of local volunteers, providing culturally relevant information, and developing trust is yielding results in epidemic preparedness. Local volunteers participating in monthly community meetings—a routine community structure already established by the local leaders—have received discrete notes from community members raising an alert of cattle in the area with possible signs of anthrax. The response from Kenya Red Cross and government veterinary officers who investigated and provided vaccinations effectively controlled the potential outbreak and further improved community relationships. ⁹ The confidence of the community to recognize and report on this issue of high sensitivity to local farmers is testimony of their trust in local organizations to adopt a community-centered approach in resolving issues when they arise. Conversely, the failure of responders to understand the community's sociocultural context can contribute to mistrust and miscommunication and can lead to ineffective interventions, as witnessed in the recent responses to EVD, Zika, and the 2009 H1N1 pandemic. ⁶

As with other disaster risk reduction efforts, the need to engage communities in epidemic preparedness well in advance of disease outbreaks—whether it be EVD or outbreaks of vaccine preventable diseases like measles—and the role of well-connected local organizations in achieving preparedness goals are consistently overlooked and underfunded. ⁶ Local organizations such as the Red Cross Red Crescent are embedded in communities. Their staff and volunteers are community members themselves; present before, during, and after crises and able to access areas and communities that other actors simply cannot. They can provide a bridge between the health system and communities and are playing an increasingly critical frontline role in strengthening health security through initiatives, such as community-based surveillance, and augmenting government outbreak response efforts. ⁶ Importantly, they understand the local context and social dynamics and are aware of the community concerns and rumors that can rapidly develop and change during health emergencies.

Research has shown that the impact of disasters and crises on communities can be mitigated and the cost of response interventions reduced, if greater investment is made to reduce risk and build resilience. ¹⁰ Yet, spending on mitigation and preparedness is a meagre fraction of international aid. ¹¹ While the economic impact of epidemics and pandemics is clear, and the return on investment in epidemic preparedness is substantial, ¹² donors continue to prioritize response over preparedness. ¹⁰ The result is a clamor to “engage” with communities at precisely the time when tensions and anxiety are heightened and the ability to build strong partnerships and mutual trust is constrained by the urgency of the operating context.

Epidemics begin and end in communities. The role and importance of communities and local organizations and their vast networks in strengthening implementation of the GHSA cannot be understated. Well-prepared, health literate, connected communities that are empowered to act when a threat is detected are critical to determining if health risks escalate from a local containable outbreak to national, regional, or even global threats. Investment in community preparedness is a win-win for everyone.