The CLEME (Community Led Ebola Man- agement and Eradication) programme aims at triggering the behavioural change needed by the communities to strengthen community resilience to the outbreak and prevent further resurgence by ensuring real and sustainable improvements through:
Providing the communities with the means to conduct their own appraisal and analysis of the Ebola outbreak, their safety regarding the disease and its con- sequence if nothing is done;
Instilling a feeling of urgency in engaging in community actions that will prevent the community experiencing infections;
Supporting technically the communities in the implementation of the identified solutions and actions adopted.
CLEME (Community Led Ebola Management and Eradication) is an approach developed under the initiative of Action Contre la Faim (ACF) Sierra Leone hygiene promotion field teams, at the start of the Ebola outbreak, based on extensive experience with the Community Led Total Sanitation (CLTS) approach.
Ebola Virus Disease (EVD) home deaths occur as the result of infected persons not being detected early and sent to Ebola Treatment Units (ETU) where they can access care and have an improved chance of survival. From a public health standpoint, EVD deaths should not occur at home. Individuals suspected of being infected with EVD should be identified through case investigations or contact tracing efforts and then referred to an ETU, thus decreasing their risk of dying as well as minimising the risk of exposing others to the disease.
This report presents results of a rapid anthropological assessment conducted in response to a request from the U.S. Centers for Disease Control and Prevention’s (CDC) Epidemiology Team in Monrovia in December 2014 for qualitative data to better understand why EVD deaths were occurring at home in urban Montserrado County. Data from the International Federation of Red Cross and Red Crescent Societies (IFRC) had indicated that 30% of the 60-90 deceased persons collected weekly from ETUs and community settings in Monrovia by Liberian Red Cross burial teams between early November and early December had tested positive for EVD and nearly half of those had been collected in homes.This raised concerns that EVD case-finding and prevention efforts were not as effective as they could be.
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.
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.
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.
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.
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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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”.
‘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).
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.
