The Ebola virus epidemic in West Africa has led to a paradigm shift in the way the global community responds to outbreaks of disease. We have learned, at great cost, that simply treating individuals is not enough to contain disease; nor can we rely on science to rapidly provide a technological solution. The global community has also realized that existing systems of international public health intervention are fraught with potential impediments to efficient decision-making. However, in many ways, the lessons learned from this Ebola virus disease outbreak solidified the importance of the foundational pillars of public health. Community-based initiatives, field epidemiology, and behavior-change interventions have garnered recognition in the broader discussion of global health security. So too did the influence of culture, an often emphasized but rarely acted upon determinant of success.
A book written by Jean-Godefroy Bidima titled La Palabre: Une Juridiction de la Parole can provide some context.Reference Bidima
1
In this book, the author provides an overview of la palabre, the traditional African public discourse and mediation, and proposes that this method be used as a resource to face the challenges facing postcolonial Africa.Reference Bidima
1
In traditional African culture, la palabre is a process of dialogue and exchange leading to a decision, be it the resolution of a dispute or a strategic course for the future of the community, with the sole purpose of preserving social harmony and solidarity.
Although the practice varies across West Africa, the general structure is largely universal. To begin, there is a precipitous event such as the identification of a problem, a choice to be made, or a grievance to air that triggers a palabre. Then, a neutral meeting place is chosen, be it under a tree or in a structure known as a Palava Hut. The chief orchestrates the proceedings and convenes those concerned within the community. The chief also elects a moderator who is tasked with facilitating the discussion and arbitrating the proceedings. The moderator presents and describes the problem to the community and then invites formal discussion of the issues. He first opens the floor to the primary parties involved and then allows any and all members of the community to speak. Everyone has the opportunity to voice an opinion and to propose solutions regardless of standing within the community. The open dialogue is the keystone of the process. The exchanges can last for days or weeks before every voice and position is heard, but it is absolutely essential that every party has the opportunity to contribute. The chief then accepts the permanent consensus agreed upon by all and allows the moderator to explain the final position to the community. The palabre is then traditionally brought to a close with a celebration full of food, dancing, and music.
In the Occident, the term palabre is often misrepresented as meaning a longwinded chat or spinning one’s wheels, an almost pejorative translation. However, another interpretation is that this methodology is arguably a more pure democratic process than that which we uphold in the West. The African palabre encourages equity, ownership, coordination, unity, integration, and partnership. These characteristics echo many of the guiding principles proposed by public health practitioners and seen in fundamental documents such as the Paris Declaration of Aid Effectiveness, the Accra Agenda for Action, and the US Global Health Initiative. Although no universally agreed upon definition of global health exists, Koplan et alReference Koplan, Bond and Merson
2
best capture the ethos of global health in this excerpt from The Lancet:
“Global health has come to encompass more complex transactions between societies. Such societies recognize that the developed world does not have a monopoly on good ideas and search across cultures for better approaches to the prevention and treatment of common diseases, healthy environments, and more efficient food production and distribution. The preference for use of the term global health where international health might previously have been used runs parallel to a shift in philosophy and attitude that emphasizes the mutuality of real partnership, a pooling of experience and knowledge, and a two-way flow between developed and developing countries. Global health thus uses the resources, knowledge, and experience of diverse societies to address health challenges throughout the world.”
The authors propose the dynamic field of global health as a worldwide palabre, tackling challenges facing humanity and emphasizing equality, partnership, exchange, and consensus.
It is in this context that the West African Disaster Preparedness Initiative (WADPI) finds its place. Spawning from the Operation United Assistance (OUA) US Department of Defense Ebola response effort, WADPI seeks to build a regional foundation for future generations of disaster managers and government leaders by developing human capital, exchanging lessons learned, and providing targeted programmatic assistance in support of an integrated, whole-of-government and all-hazards approach to disaster preparedness. The program invited participants from various government ministries, among 17 partner nations, across West and Central Africa, to Accra to undergo a 3-week curriculum that included national-level Ebola response plan and emergency operations center standard operating procedure development and review; Ebola awareness and first responder training; emergency operations center management and Incident Command Structure education and exercising; a composite track encompassing logistics, civil-military cooperation, and humanitarian assistance; a module of training in organizing One Health systems; and an information technology training and experiential component that comprised hazard mapping through geographic information systems and the use of open-sourced data integration and sharing platforms such as Sahana Eden and Ushahidi as potential tools for improved coordination and communication during disaster. The goal of the Initiative is to broadly elevate national-level and subregional capacity and capability for preparedness. One desired outcome is to enhance the leadership role of the subregional geopolitical organization, the Economic Community of West African States (ECOWAS). Through proactive fostering of regional collaboration and engagement, ECOWAS is chiefly expected to play a coordinating role leveraging both African expertise and international resources to collaborate on capacity building initiatives.
The true value of the training sessions, however, comes from starting a conversation and bringing a community—the West African community—together in a unified way forward by setting an agenda for global health security and disaster preparedness for the years to come, which is the first step, framing the problem, of a palabre. A separate ECOWAS conference, as a rallying event subsequent to the series of partner nation engagements, will develop regional priorities and an agenda for future initiatives. The issues highlighted through interaction and discussion during the training sessions and the regional coordinating event are summarily documented and will be brought forward at a follow-on Sub-Saharan African Partners Conference, where high-level representation from partner nations will have the opportunity to engage the subject of community preparedness in an even larger palabre as well as interact with international donors to potentially coordinate and plan follow-on activities. Follow-on activities in support of further capacity building are, at this juncture, conceived to be born out of the myriad of inputs from community stakeholders, which is the final step, formulating consensus, of a palabre.
The parallels between WADPI and the African palabre are striking and lead one to reevaluate how to measure the importance of a program such as this. By the benchmark techniques of traditional public health impact assessments or evaluations, WADPI appears to produce little immediate impact at great expense. Using the schema of the palabre, however, which is ongoing on multiple levels through the US government interagency and international community, within and among partner nation delegations, and regionally through ECOWAS, one is led to a likely much different conclusion. There are undoubtedly broader, longer-term impacts that deserve alternative approaches in order to assess their significance.
The future is uncertain. However, it is evident that the conversations and transparent engagement ongoing in Accra, and potentially beyond, could be of enormous value contingent upon the leadership and ownership of responsibility by ECOWAS as well as national governments to carry the torch forward. The sustainability of this palabre depends on ECOWAS, or some coordinating body, stepping up to the moderating role to maintain the conversation. There must also be facilitated implementation of the strategies decided on by the stakeholders. A palabre is a decision-making tool and not simply a conference. As Bidima writes, “Palabre is precisely this moment of tension between a society’s achievements and its potentials.”Reference Bidima
3
The West African Ebola outbreak has created the impetus to catalyze and synergize action and constructive collaboration. It is an event that galvanizes the tenets of the Global Health Security Agenda. For those in disaster medicine and global health, this current tension between the events that have occurred and the potential for bringing about impactful change is palpable and promising. To be able to effectively tell this story of WADPI and demonstrate the value of this initiative will require a rethinking of how we measure and evaluate both achievements and the potential of global health engagement. Quantifying the value of a discussion over dinner, a collaborative planning session, or evaluation of the lessons learned from a tabletop exercise among community members is asking to weigh an intangible future benefit against a very tangible investment that afforded the opportunity to commune. Creating the counterfactual case is a conundrum for purely quantitative analysis. An initiative on the scale of the Global Health Security Agenda and complementary programs such as WADPI requires a new yardstick against which we can measure success.
The Mossi people of Burkina Faso (a partner nation in WADPI) seem to summarize it best: “Quand une histoire ou un fait est bien raconté, il peut recevoir une bonne écoute, laquelle bonne écoute conduit à une bonne compréhension, laquelle permet de tirer une bonne conclusion [When a story or a fact is well told, it can be well heard, that which is well heard leads to a good understanding, which allows one to draw a good conclusion].”Reference Kondombo
4
The Ebola virus epidemic in West Africa has led to a paradigm shift in the way the global community responds to outbreaks of disease. We have learned, at great cost, that simply treating individuals is not enough to contain disease; nor can we rely on science to rapidly provide a technological solution. The global community has also realized that existing systems of international public health intervention are fraught with potential impediments to efficient decision-making. However, in many ways, the lessons learned from this Ebola virus disease outbreak solidified the importance of the foundational pillars of public health. Community-based initiatives, field epidemiology, and behavior-change interventions have garnered recognition in the broader discussion of global health security. So too did the influence of culture, an often emphasized but rarely acted upon determinant of success.
A book written by Jean-Godefroy Bidima titled La Palabre: Une Juridiction de la Parole can provide some context.Reference Bidima 1 In this book, the author provides an overview of la palabre, the traditional African public discourse and mediation, and proposes that this method be used as a resource to face the challenges facing postcolonial Africa.Reference Bidima 1 In traditional African culture, la palabre is a process of dialogue and exchange leading to a decision, be it the resolution of a dispute or a strategic course for the future of the community, with the sole purpose of preserving social harmony and solidarity.
Although the practice varies across West Africa, the general structure is largely universal. To begin, there is a precipitous event such as the identification of a problem, a choice to be made, or a grievance to air that triggers a palabre. Then, a neutral meeting place is chosen, be it under a tree or in a structure known as a Palava Hut. The chief orchestrates the proceedings and convenes those concerned within the community. The chief also elects a moderator who is tasked with facilitating the discussion and arbitrating the proceedings. The moderator presents and describes the problem to the community and then invites formal discussion of the issues. He first opens the floor to the primary parties involved and then allows any and all members of the community to speak. Everyone has the opportunity to voice an opinion and to propose solutions regardless of standing within the community. The open dialogue is the keystone of the process. The exchanges can last for days or weeks before every voice and position is heard, but it is absolutely essential that every party has the opportunity to contribute. The chief then accepts the permanent consensus agreed upon by all and allows the moderator to explain the final position to the community. The palabre is then traditionally brought to a close with a celebration full of food, dancing, and music.
In the Occident, the term palabre is often misrepresented as meaning a longwinded chat or spinning one’s wheels, an almost pejorative translation. However, another interpretation is that this methodology is arguably a more pure democratic process than that which we uphold in the West. The African palabre encourages equity, ownership, coordination, unity, integration, and partnership. These characteristics echo many of the guiding principles proposed by public health practitioners and seen in fundamental documents such as the Paris Declaration of Aid Effectiveness, the Accra Agenda for Action, and the US Global Health Initiative. Although no universally agreed upon definition of global health exists, Koplan et alReference Koplan, Bond and Merson 2 best capture the ethos of global health in this excerpt from The Lancet:
“Global health has come to encompass more complex transactions between societies. Such societies recognize that the developed world does not have a monopoly on good ideas and search across cultures for better approaches to the prevention and treatment of common diseases, healthy environments, and more efficient food production and distribution. The preference for use of the term global health where international health might previously have been used runs parallel to a shift in philosophy and attitude that emphasizes the mutuality of real partnership, a pooling of experience and knowledge, and a two-way flow between developed and developing countries. Global health thus uses the resources, knowledge, and experience of diverse societies to address health challenges throughout the world.”
The authors propose the dynamic field of global health as a worldwide palabre, tackling challenges facing humanity and emphasizing equality, partnership, exchange, and consensus.
It is in this context that the West African Disaster Preparedness Initiative (WADPI) finds its place. Spawning from the Operation United Assistance (OUA) US Department of Defense Ebola response effort, WADPI seeks to build a regional foundation for future generations of disaster managers and government leaders by developing human capital, exchanging lessons learned, and providing targeted programmatic assistance in support of an integrated, whole-of-government and all-hazards approach to disaster preparedness. The program invited participants from various government ministries, among 17 partner nations, across West and Central Africa, to Accra to undergo a 3-week curriculum that included national-level Ebola response plan and emergency operations center standard operating procedure development and review; Ebola awareness and first responder training; emergency operations center management and Incident Command Structure education and exercising; a composite track encompassing logistics, civil-military cooperation, and humanitarian assistance; a module of training in organizing One Health systems; and an information technology training and experiential component that comprised hazard mapping through geographic information systems and the use of open-sourced data integration and sharing platforms such as Sahana Eden and Ushahidi as potential tools for improved coordination and communication during disaster. The goal of the Initiative is to broadly elevate national-level and subregional capacity and capability for preparedness. One desired outcome is to enhance the leadership role of the subregional geopolitical organization, the Economic Community of West African States (ECOWAS). Through proactive fostering of regional collaboration and engagement, ECOWAS is chiefly expected to play a coordinating role leveraging both African expertise and international resources to collaborate on capacity building initiatives.
The true value of the training sessions, however, comes from starting a conversation and bringing a community—the West African community—together in a unified way forward by setting an agenda for global health security and disaster preparedness for the years to come, which is the first step, framing the problem, of a palabre. A separate ECOWAS conference, as a rallying event subsequent to the series of partner nation engagements, will develop regional priorities and an agenda for future initiatives. The issues highlighted through interaction and discussion during the training sessions and the regional coordinating event are summarily documented and will be brought forward at a follow-on Sub-Saharan African Partners Conference, where high-level representation from partner nations will have the opportunity to engage the subject of community preparedness in an even larger palabre as well as interact with international donors to potentially coordinate and plan follow-on activities. Follow-on activities in support of further capacity building are, at this juncture, conceived to be born out of the myriad of inputs from community stakeholders, which is the final step, formulating consensus, of a palabre.
The parallels between WADPI and the African palabre are striking and lead one to reevaluate how to measure the importance of a program such as this. By the benchmark techniques of traditional public health impact assessments or evaluations, WADPI appears to produce little immediate impact at great expense. Using the schema of the palabre, however, which is ongoing on multiple levels through the US government interagency and international community, within and among partner nation delegations, and regionally through ECOWAS, one is led to a likely much different conclusion. There are undoubtedly broader, longer-term impacts that deserve alternative approaches in order to assess their significance.
The future is uncertain. However, it is evident that the conversations and transparent engagement ongoing in Accra, and potentially beyond, could be of enormous value contingent upon the leadership and ownership of responsibility by ECOWAS as well as national governments to carry the torch forward. The sustainability of this palabre depends on ECOWAS, or some coordinating body, stepping up to the moderating role to maintain the conversation. There must also be facilitated implementation of the strategies decided on by the stakeholders. A palabre is a decision-making tool and not simply a conference. As Bidima writes, “Palabre is precisely this moment of tension between a society’s achievements and its potentials.”Reference Bidima 3
The West African Ebola outbreak has created the impetus to catalyze and synergize action and constructive collaboration. It is an event that galvanizes the tenets of the Global Health Security Agenda. For those in disaster medicine and global health, this current tension between the events that have occurred and the potential for bringing about impactful change is palpable and promising. To be able to effectively tell this story of WADPI and demonstrate the value of this initiative will require a rethinking of how we measure and evaluate both achievements and the potential of global health engagement. Quantifying the value of a discussion over dinner, a collaborative planning session, or evaluation of the lessons learned from a tabletop exercise among community members is asking to weigh an intangible future benefit against a very tangible investment that afforded the opportunity to commune. Creating the counterfactual case is a conundrum for purely quantitative analysis. An initiative on the scale of the Global Health Security Agenda and complementary programs such as WADPI requires a new yardstick against which we can measure success.
The Mossi people of Burkina Faso (a partner nation in WADPI) seem to summarize it best: “Quand une histoire ou un fait est bien raconté, il peut recevoir une bonne écoute, laquelle bonne écoute conduit à une bonne compréhension, laquelle permet de tirer une bonne conclusion [When a story or a fact is well told, it can be well heard, that which is well heard leads to a good understanding, which allows one to draw a good conclusion].”Reference Kondombo 4
Acknowledgment
The West African Disaster Preparedness Initiative was funded through Operation United Assistance, an initiative of the US Department of Defense. The funder had no input into the decision to submit for publication.