The enduring Ebola epidemic has taught the world some hard lessons over the last 12 months, which we must take to heart. Despite early warnings, and the extraordinary efforts of local healthcare workers and private medical humanitarian organisations, the epidemic has exposed the institutional failures that saw the Ebola outbreak spiral far out of control, with tragic and avoidable consequences. In particular, we should reflect on the role civil society must play in response, and how it can spur on mandated international bodies to shake off their paralysis and act decisively during crises, instead of leaving it to private organisations, such as MSF, to respond.
Community-Based Ebola Care Centres: A Formative Evaluation
The Ebola outbreak in West Africa differed from others in its unprecedented size and the high proportion of human-to-human transmission occurring in the community. This report presents an analysis of the impact of Community Care Centres (CCCs) on communities in Sierra Leone. Much has been written about the leadership and coordination of the response – or the lack of it. The emphasis of this evaluation is on the views on the development, implementation and relevance of the CCCs from the perspective of the communities next to and near where they were located. The key questions explored are divided into two categories: (1) Community engagement with the development and management of the CCC; and (2) Post- Ebola uses of the CCC.
Africa APPG inquiry: Community led health systems & the Ebola outbreak
The Ebola crisis of 2014-15 has brought questions around the roles of communities and health systems into sharp relief – both in relation to crisis response, and to the challenges of post-crisis recovery and building resilience to future epidemics. The Institute of Development Studies is pleased to make this submission to the APPG inquiry on these crucial questions.
This submission draws upon this work and highlights the need for developing health systems and health crisis response mechanisms that actively seek, engage and adapt to local voices and concerns in the communities they serve. We emphasise the key role that anthropologists can play in facilitating these processes and recommend their inclusion in all future humanitarian crisis responses. In addition, we call for a long term commitment to developing local anthropological expertise, focusing on those countries vulnerable to humanitarian crises.
We present our submission concisely in bullet points and primarily refer to our work in Sierra Leone.
Ebola Crisis Appeal – Response Review
This is the review of the Ebola Crisis Appeal Response in Sierra Leone of the Disasters Emergency Committee (DEC) that unites 13 of the largest UK humanitarian charities to raise funds in response to major international humanitarian crises.
The review team consisted of an external team leader, a DEC member representative and the DEC chief executive with complementary roles and expertise. Fieldwork took place from 8th to 18th February. The team visited Freetown and Western Area, Port Loko Bombali, and Tonkolili. They used semi-structured questionnaires to conduct 19 focus groups in the communities visited. Altogether they spoke with 150 female and 148 male beneficiaries, 30 male and 11 female NGO staff, 11 government staff and 12 partner staff and two members of the security forces.
Specific areas of enquiry of this review are:
Community engagement
Programme relevance
Organisational learning and capacity development.
Resistance in Guinea
There have been numerous recent analyses of the different manifestations of ‘resistance’ and ‘reticence’ that continue to be critical in Guinea. The socio-historical context that has contributed to deep-rooted mistrust of the State and authority (a sense of ‘abandonment’ [the West has only returned to intervene in Guinea to ‘count cases’ and international actors will again abandon the country when cases are ‘acceptably low’]; heavy-handed or repressive interventions; the perception that elites treat people as if they are disposable and unworthy etc.) is well recognised. Yet, as late as June 2015, the Ebola response continues to take insufficient account of this context in the design and implementation of its interventions.
The following key considerations have been collated from the suggestions and insights provided by over twenty-five anthropologists and social-behavioural scientists (based in West Africa and internationally) who answered an on-line call to provide guidance and operational recommendations in relation to on-going community ‘resistance’ in Guinea.
A year on, Guineans finally lay Ebola souls to rest
GUECKEDOU, 28 April 2015 (IRIN) – Forty-six-year-old Maurice Ouendeno stares silently at the arm of his blue plastic lawn chair. He waits a few minutes before beginning his story.
“They said we did not have the right to bury him,” he says, finally looking up. Sadness, mixed with a bit of anger, flashes briefly across his face. “We understood why, but it was painful. It was so painful not to be able to give him the send-off he deserved.”
His father, Tamba Lamine Ouendeno, died from Ebola on 26 March 2014 at the age of 73. He was one of the earliest confirmed victims: his death came just a day after the Guinean government declared the outbreak in four southeastern districts.
Never Again: Building resilient health systems and learning from the Ebola crisis
It took the threat of a global health crisis to illustrate the failings of Africa’s health systems. Resilient health systems, free at the point of use, are evidently a global public good. They are essential for the provision of universal health coverage and for a prompt response to outbreaks of disease.
Resilient health systems require long-term investment in the six key elements that are required for a resilient system: an adequate numbers of trained health workers; available medicines; robust health information systems, including surveillance; appropriate infrastructure; sufficient public financing and a strong public sector to deliver equitable, quality services. Global investment in research and development for medical products is also critical.
Policy Briefing on Community-based Ebola Care Centres
A component of the Ebola epidemic control policy in Sierra Leone is triage and isolation in decentralised Community Care Centres (CCCs) or Holding Units, from where transfer to Ebola treatment units (ETUs) is arranged for those diagnosed as positive. The epidemic is currently waning, there are sufficient beds in the ETU, yet new micro-epidemics emerge, raising questions about the future role and relevance of the CCC.
This briefing summarizes the preliminary findings of a formative evaluation conducted by the UK based Ebola Response Anthropology Platform in February 2015 on views of community leaders and residents towards 1) their engagement with the development and management of the CCC and 2) future usages of the CCCs physical structure, equipment and staff. A full data analysis is ongoing. We hope that the views presented here provide various options for the use of the CCCs during the bumpy road to zero.
Ebola’s Ecologies – Limn January 2015 Issue
This issue of Limn on “Ebola’s Ecologies” examines how the 2014 Ebola outbreak has put the norms, practices, and institutional logics of global health into question, and examines the new assemblages that are being forged in its wake. The contributions focus on various domains of thought and practice that have been implicated in the current outbreak, posing questions such as: What has been learned about the ambitions and the limits of humanitarian medical response? What insights are emerging concerning the contemporary organization of global health security? To what extent have new models of biotechnical innovation been established in the midst of the crisis?
How Ebola infection spreads and terminates in rural Sierra Leone
Ebola is a new disease in Upper West Africa. Populations have taken time to learn the nature of the risk it poses. Persons carrying infection initially do not know that they have the sickness. They carry out their daily activities, and seek help from their families and traditional remedies when and where they become symptomatic. Nearly all infection, so far as is known, is associated with the “wet” phase of the illness and handling the corpse of a deceased victim. This period of major infection risks extends for 2-3 days either side of death.
Key strategies for preventing further infection are isolation of the patient in an Ebola care facility, “safe burial”, and quarantine of those exposed to Ebola cases. Equally important is social recognition that isolation, safe burial and quarantine are necessary to break the transmission chain. Thus it is important to ask how,
What causes Ebola Virus disease?
The four villages in this report are found on the edge of the Gola Rainforest National Park, Sierra Leone and have been studied by members of the present team at intervals since 1987. The aim of this long-term study was to understand social composition and social change in forest-edge communities, and how these communities were adapting to conservation rules and opportunities.
These villages have now been restudied as part of the SMAC community mobilization program for prevention of Ebola Virus Disease. This study, which was carried out in December 2014, aimed to find out how 25 villages viewed the Ebola threat, and how they coped with regulations designed to eliminate the disease.
Unsung Heroes on the Ebola Frontline
The “selflessness of aid workers and medical volunteers” was praised both by the Queen in her Christmas message and by TIME magazine, who named ‘The Ebola Fighter’s their person of the year 2014. This emphasis on international staff, particularly doctors and nurses, gives a misleading impression about who is doing what in West Africa, and overlooks the huge contribution that national staff are making in their fight against ebola. Even when national staff are recognised, the focus again tends to be on the doctors and nurses, with some attention devoted to the burial teams.
Village Responses to Ebola Virus Disease in Rural Eastern Sierra Leone: Second Interim Report
This report provides further output from an anthropological study of 25 villages affected by Ebola Virus Disease in eastern and central Sierra Leone, undertaken as part of the DFID-funded social mobilization initiative for Ebola prevention in Sierra Leone. Eight focus group transcripts for 3 villages in Kenema District are presented, covering local responses to health issues, and Ebola in particular. Supporting material from a matching questionnaire-based study of health behavior and perceived causes of Ebola is also provided. Of particular relevance are two summary tables aggregating the questions villagers asked survey teams about Ebola and quarantine-related issues in villages where the epidemic has in effect ceased to be active.
Do traditions spread Ebola?
In a recent interesting contribution to this platform, Paul Richards rightly questioned the mainstream perception that funerals per se are source of contamination in countries affected by ebola. The author argues that funerals are phenomena which are extremely interrelated to other different aspects of social life, like the overall care of sickness, the concept of authority, and the logic of parenthood. Yet, his brief paper has another value: by stressing the complexity of this social phenomenon, it tunes down the journalistic emphasis that in past months has focused the global attention oo much on traditional funerals performed in the countries hit by the deadly virus. Together with the “bush meat”, the traditional funerals have become one of the main topics of the media coverage related to ebola. Such clamour has produced the effect of framing the discourse about this disease within culturalist categories – such as food or death related practices – minimizing the socio-economic and political aspects of the epidemic.
Village Responses To Ebola Virus Disease In Rural Central Sierra Leone
Bawuya is a small, isolated Kpa-Mende farming village about 3 hours walking time from Taiama, headquarters of Kori chiefdom in Moyamba District, Southern Sierra Leone. Bawuya experienced an Ebola outbreak in September 2014, in which 9 people died and 3 infected persons survived, connected to a prior outbreak in a neighboring village, Fogbo. No further cases have since occurred. Bawuya serves as a representative example of how an isolated rural community becomes infected, and how such outbreaks end, where outside intervention or assistance is limited. The report analyzes randomly-sampled questionnaire data situating Ebola within the context of village social networking and patterns of health seeking behavior. Changes are documented in local understanding of Ebola, from earlier media-led conceptions of an epidemic driven by bush-meat consumption towards an experience-based understanding of the risks posed by body-to-body contact. The case makes clear that transmission of Ebola can be ended by local acceptance of a range of externally-determined and locally self-imposed restrictions on movement and contact with dead bodies.
Anthropology & Ebola Clinical Research
The Working Group on Clinial Trials coordinated by the Ebola Response Anthropology Platform has produced a working document which considers the clinical trials that are planned as part of the Ebola outbreak response from a sociological and anthropological perspective. The document develops a series of critical and empirical questions to guide research that should be conducted within, alongside or separate from clinical interventions. The document goes on to consider questions specific to vaccine, therapeutic and convalescent blood and plasma trials.
Attitudes towards Ebola related funerary practices and memorialization in urban Liberia
This briefing summarises the attitudes of Monrovia community leaders and residents towards cremation, mass burials, memorialization, and remembrance ceremonies based on data collected between August – September 2014.
Community-based reports of co-morbidity, co-mortality, and health-seeking behaviors in four Monrovia communities during the West African Ebola epidemic
This working paper reports on a study to collect data on co-morbidity and co-mortality among urban Liberian populations during the Ebola epidemic from September to October 2014. Particular attention is paid to how local communities defined their symptoms and sicknesses, the patterns of healthcare-seeking that they pursued in a context of highly restricted health care access, the types of treatment regimens that they deployed to support home based care within their communities, and their perceptions of the causes of disease.
Briefing: Ebola – myths, realities, and structural violence
The scale of West Africa’s Ebola epidemic has been attributed to the weak health systems of affected countries, their lack of resources, the mobility of communities and their inexperience in dealing with Ebola. This briefing for African Affairs argues that these explanations lack important context. The briefing examines responses to the outbreak and offers a different set of explanations, rooted in the history of the region and the political economy of global health and development. To move past technical discussions of “weak” health systems, it highlights how structural violence has contributed to the epidemic. As part of this, local people – their beliefs, concerns and priorities – have been marginalised. Both the crisis response and post-Ebola ‘reconstruction’ will be strengthened by acknowledgment of its long term structural underpinnings and from a more collaborative inclusion of local people.
Ebola Survivors: using a stepwise re-integration process to establish social contracts between survivors and their home communities
We propose that the point of discharge of someone who has survived Ebola virus disease (EVD) should become a staged transition back into the community, linked to a social contract that ties targeted support to adherence to infection control practices. This offers important benefits to how people perceive the infectious risk of survivors, improved social cohesion through collectively agreed stages of re-integration, and a mechanism for directing psychosocial and material support to those who most need it.
Identifying and Enrolling Survivors to Donate Blood
Survivors are rapidly becoming a strategic population for the Ebola Outbreak response. The public health potential of this group appear to be manifold—from safe burials and the care for orphan children to community outreach and the donation of blood for clinical trials. There are a number of stories emerging from the field of survivors who refuse to leave Ebola Treatment Units, offering their support in caring for new patients. Data regarding the status and experience of survivors is somewhat thin, although anthropological experience of the use of blood for care, and in research, can be called upon. This brief raises a number of questions and suggestions about how best to engage survivors in containment efforts relevant for the procurement of convalescent blood, which is particularly relevant for current clinical trials of this therapeutic method.
Infectious disease: Tough choices to reduce Ebola transmission
Christopher J. M. Whitty and colleagues explain why the United Kingdom is funding many small community centres to isolate suspected cases in Sierra Leone.
The UK government is leading the international response to Ebola in Sierra Leone, providing technical, financial and logistical help. This article sets out the scientific basis for the UK government’s strategy to assist Sierra Leone’s government to reduce transmission. In addition to substantially scaling up conventional capacities at hospitals, the UK plan to help to build and support community isolation centres where people can voluntarily come to be isolated if they suspect that they have the disease.
Do Funerals Spread Ebola?
Some attention has been paid to the alleged role of funerals in spreading Ebola Virus Disease in Upper West Africa. This has led to attempts to control funerals, causing both distress and active resistance. Critical examination of the role of the funeral event as a mechanism of Ebola transmission seems in order. In this paper, it is argued that funerals are inseparable from care for the sick, as far as Ebola transmission is concerned. The focal issue then becomes not control of funerals but reduction of Ebola transmission risks in and around final sickness.
Increasing early presentation to ECU through improving care
Current Ebola epidemic control policy in Sierra Leone focuses on (a) triage and isolation in decentralised, ideally community-based Ebola Care Units (ECUs), leading to (b) transfer to Ebola treatment units (ETUs) for those diagnosed as positive. Increasing early presentation to ECUs is essential for this strategy to be effective in reducing Ro. This note outlines ways in which improved and socially-appropriate care – in ECUs, and at home – can assist this.
Mobilising youth for Ebola education: Sierra Leone and Liberia
This brief summarises some key considerations about mobilising youth and youth groups in the Ebola response in Sierra
Leone and Liberia. The details have been collated from suggestions and insights provided by networks of anthropologists in the UK and US who work in Sierra Leone and Liberia (both in-‐country and remotely). These are general considerations that are broadly relevant to mobilising youth in the response, but further investigation into local specificities is required.
The French version of the brief is available here.
Sierra Leone: Gift giving during initial community consultations
This brief summarises appropriate gift giving during initial community consultations in Sierra Leone. It is intended to provide an overview of good practices to support UNICEF, the WHO and other agencies as they interact with Paramount Chiefs prior the implementation of CCCs. It does not focus on the community consultation process more broadly, but specifically on gift giving during the first meeting.
The details have been collated from suggestions and insights provided by networks of anthropologists in the UK and US who
work in Sierra Leone (both in-‐country and remotely). These are general considerations that are broadly relevant for the Sierra Leone context, but teams should check with local counterparts for regional specificities.
The French version of the brief is available here.
The AAA/Wenner-Gren Ebola Emergency Response Workshop
As of November 4, 2014, the current Ebola outbreak in West Africa is confirmed to have infected 13,268 individuals, with 4,960 total deaths estimated. The global Ebola response is evolving rapidly, and as it has evolved, it has become increasingly apparent that the causes of this epidemic outbreak result from the underdevelopment of local regional healthcare systems, and several initial errors in the global Ebola response that lead to an underdevelopment of emergency response capabilities, and resulted in complications with triage, treatment, community mobilization and engagement, and communications efforts.
The steering committee of the AAA-Wenner Gren Emergency Ebola Response Workshop convened a meeting with policy makers, practitioners, donors, and NGOs involved in the global Ebola response. The goal of this meeting was to consult with a range of partners about their needs and priorities for anthropological guidance. Attendees included: the U.S.
Field situation: How to conduct safe and dignified burial of a patient who has died from suspected or confirmed Ebola virus disease.
WHO has developed a protocol to provide information on the safe management of burial of patients who died from suspected or confirmed Ebola virus disease. These measures should be applied not only by medical personnel but by anyone involved in the management of burial of suspected or confirmed Ebola patients. Twelve steps have been identified describing the different phases Burial Teams have to follow to ensure safe burials, starting from the moment the teams arrive in the village up to their return to the hospital or team headquarters after burial and disinfection procedures. These steps are based on tested experiences from the field.
Care and Burial Practices in Urban Sierra Leone
Funeral practices in Freetown are varied with differences between typical Muslim and Christian practices. Muslims typically bury the body the same day, or the day after, the death, whereas Christians might wait for up to several weeks while arrangements are made. Muslims normally bury bodies in a shroud, whereas Christians use a coffin. The bodies are typically prepared for burial (washed) by family members. This background paper gives more information on care and burial practices in Urban Sierra Leone.
Liberia: handling of bodies and national memorials – community perceptions from Monrovia
This brief summarises attitudes of community leaders and residents in and around Monrovia. It is intended to provide an
evidence-base to support the SOP on safe and dignified burials, and to contribute to ongoing discussions about mass-graves and national memorials.
The French version of the brief is available here.
Summary of Discussions of the Ethics Working Group on Ethical issues related to study design for trials on therapeutics for Ebola Virus Disease
The first round of trials on novel therapeutics for Ebola are set to begin imminently. Members of the Ebola Response Anthropology Platform, Ann Kelly and Clare Chandler, represented the Platform by participating in the WHO Ethics Working Group meetings in September and October 2014 to discuss ethical considerations for trials of new vaccines and therapeutics for Ebola viral disease.
At a previous WHO consultation in August 2014, the Panel concluded unanimously that it would be acceptable on both ethical and evidential grounds to use as potential treatments or for prevention unregistered interventions provided that certain conditions were met. In the subsequent meetings, the details of the design and conduct of these trials was discussed.
In this latest report, released on 5th November 2014, the working group members reviewed different possible study design options and put forward recommendations for ethically appropriate designs for “monitored emergency use of unregistered and experimental interventions”.
Local beliefs and behaviour change for preventing Ebola in Sierra Leone
‘The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long’ (Margaret Chan, 26th September 2014, WHO).
This report focuses on the local beliefs and practices around illnesses and death, the transmission of disease and spirituality, which affect decision-making around health-seeking behaviour, caring for relatives and the nature of burials. It also considers how this can inform effective behaviour change interventions for preventing Ebola in Sierra Leone. Four key transmission pathways are considered; unsafe burial, not presenting early, care at home and visiting traditional healers.
Indigenous beliefs and responses to Ebola are rarely mentioned and when they are images of ignorance, exoticism and superstition are what prevail (Hewlett and Hewlett 2008).
Mobilising informal health workers for the Ebola response: potential and programme considerations
Informal health workers are important care providers in the region and continue to be so during the current Ebola Virus Disease (EVD) outbreak. Many are well respected and trusted members of the community who can mobilise large numbers of people for a particular activity and lend legitimacy to a particular programme.
Burials in times of Ebola: Dos and Don’ts – issues of acceptability
Burials in times of Ebola or Marburg outbreaks have to follow strict biosafety rules to avoid transmission of Ebola/Marburg virus. At the same time, they should be acceptable to families and communities to avoid resistance against disease control. This document deals predominantly with acceptability issues.
Ebola strips Africans of their humanity
After long months of relative silence, the world finally heatedly debates on Ebola. The quantity of aid is widely considered to be the major problem. The quality of the aid being offered however, is not under scrutiny. Everybody seems to agree that all the outbreak needs is: more clinics, more medical personnel, more military personnel and central coordination. All this is, of course, necessary. It is questionable though, why and how foreign soldiers will be deployed. The slogan the United Nations uses for the Ebola outbreak may be “Ebola is war”, in reality Ebola is a virus that threatens and affects the poorest people of the affected societies.
Author Ginny Mooy is a Social Anthropologist and Sociologist of Non-Western Societies. She works as an anthropologist in Sierra Leone since 2006.
Read more here
Ebola: The Challenges: Event summary of roundtable held as part of African Studies Association Conference 2014
Held as part of the African Studies Association conference 2014, Ebola: The Challenges united an esteemed panel of speakers to discuss ways in which academia can mobilise to support those effected by the ebola outbreak.
