Two years ago, on Aug. 8, 2014, the World Health Organization declared a Public Health Emergency of International Concern (PHEIC) for Ebola. Public health experts have written about the WHO’s slow reaction to Ebola and the weakness of health systems in Liberia, Sierra Leone and Guinea, the centers of the outbreaks.
But there’s a story that hasn’t yet reached the public: How communities mobilized to fight the outbreak. My fieldwork in Liberia this year yields five insights.
1. Communities have vital information in health emergencies.
Because they know one other, local people can predict behaviors that will affect a community’s health. For example, officials at Firestone Hospital outside Monrovia knew that many Firestone workers had relatives in Liberia’s Lofa County, the site of the country’s first Ebola cases in March 2014. They predicted that those family members would travel to Firestone for health care. This intimate knowledge of the community helped the hospital prepare for its first cases.
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2. Traditional practices can be adapted to save lives.
Some Western media outlets emphasized the backwardness and dangerous exoticism of African culture. Some blamed cultural practices, such as the eating of bush meat. Even practices rooted in compassion, such as hugging, caring for the sick by hand and handling corpses in accordance with local customs, were emphasized by some of my research informants as activities that spread the virus.
But some traditional practices were quite useful. For instance, in the societies of the Mano River Area (in Liberia, Guinea, Sierra Leone and Côte d’Ivoire), when a stranger arrives in a village, they report to the chief. To protect villagers, the chief keeps an eye on the visitor. During the outbreak, some chiefs were able to use their knowledge for disease surveillance and contact tracing. NGOs trained chiefs to share information on disease prevention by social distancing and hand-washing. As a result, many villages — even some in heavily hit regions — had no Ebola cases.
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3. Religious organizations can be crucial players in health crises, as research on the AIDS response has already shown.
During the Ebola crisis, they did this in a variety of ways. For instance, the Episcopal Church of Liberia distributed food to quarantined communities, enabling people to remain in isolation. By counseling and praying with patients who often received little attention in health-care settings, priests encouraged them to see the quarantine through.
One Methodist Church informant told me that the denomination used SMS messages to educate villagers about the virus. The Inter-Religious Council of Liberia urged the government to consider cultural practices and to make decisions openly and with community input. When asked why they acted on Ebola, many Liberian nurses and doctors replied that doing so was “God’s work.” Others said their love of family, community and God meant they had no choice but to put on the stifling hot personal protective equipment and work in the Ebola Treatment Units (ETUs).
4. Communities took responsibility for themselves – and took action to slow and stop Ebola.
Some academics — notably, economist Mancur Olson and ecologist and philosopher Garrett Hardin — have theorized that without incentives or punishments, most people will let a dedicated few provide a public good that benefits everyone. But in Liberia, what motivated those who helped care for those with Ebola wasn’t government-promised hazard pay. In fact, many nurses, ETU workers and ambulance drivers still had not been fully paid by summer 2016.
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Instead, more than two dozen interviewees said that many Liberians acted because if they didn’t, death threatened them, their loved ones and their communities. The public good — immediate survival — was their motivation. High-level government and NGO officials credited widespread mobilization on multiple levels — complying with messages about hand-washing and social distancing, distributing food to quarantined people, contacting the Ebola “help line” to report cases, and transporting victims to health centers — with stopping the epidemic.
In the “hot zone” of Dolo Town, for example, 20 people — mostly young men in their 20s and 30s — set up a task force to convey health messages and take suspected sufferers to clinics. Government officials spent 14 to 20 hours a day designing policies and public health messages.
Elinor Ostrom’s research suggests that people will contribute to a public good when concerns about reputation and graduated sanctions for non-participation are present. Many interviewees told me that most people they knew were driven by personal responsibility and concerns for their reputations. One said, “No one wanted to look like they weren’t contributing.”
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When some people could no longer work in difficult situations, they faced no punishment. Health workers at Kakata Hospital — where 13 of 17 health workers who contracted Ebola died — empathized with the few workers who were traumatized and quit but also said that others continued the work.
5. If communities don’t trust the government, the government can’t act effectively.
Early in the epidemic, many Liberians were “Ebola deniers” who distrusted the government — and, therefore, its pronouncements about the disease. In August 2014, the government quarantined the neighborhood of West Point. That led to riots, a security crackdown and one death. Distrust and suspicion were so strong that Liberia had to lift the quarantine early.
According to government and NGO officials, it was not until the government brought traditional chiefs, Christian and Muslim leaders, and local health representatives into the formal decision-making processes that tensions lessened. Local representatives expressed the need for training, health information, and bleach and personal protective equipment. They proposed safe but culturally sensitive burial practices for Ebola victims that did not include cremation.
The government and NGOs responded. They trained and supplied clinic and community workers, increasing their confidence that they could safely provide care without infecting themselves or other patients. One nurse said, “Once we had training, I felt safer in the hospital than outside, because outside you didn’t know who you were going to touch or be with.”
Interviewees involved with the government response acknowledged that the more openly and honestly the government discussed the facts of the epidemic, the more willingly communities cooperated with local health care workers.
These echo lessons from the AIDS response and the polio eradication campaigns. Inclusive, transparent actions foster trust — and that’s essential for protecting public health.
So here’s what public health professionals can take away
As health experts look to combat other infectious diseases that cross international borders, such as Zika, they must think local. Public health officials need to consider how to bring in community leaders and to use traditional practices in culturally appropriate ways.
Amy S. Patterson is professor of politics at the University of the South in the United States. She is completing a book on African responses to global health policies.
