“We just pulled up in the middle of the village and had a chat,” our health promotion coordinator told me of her day’s work. It was November 2014 and we were sitting in the office of the Médecins Sans Frontières (MSF) Ebola Management Centre in Bo, in eastern Sierra Leone, discussing new outreach activities.
Worryingly, over six months into the outbreak, she was finding her teams were the first to bring Ebola messages to many villages. And for every gap in information, people develop their own explanations: ‘Ebola is black magic’, ‘Ebola is spread in the chlorine spray used by burial teams’, ‘MSF only takes people to hospital to harvest their blood and organs’, and so on.
The government and many organisations were working in the area, so what had gone wrong? The reasons seemed to include a lack of funds for simple things such as petrol for social mobilisers’ motorbikes, a lack of vehicles and the local coordination structures just not prioritising outreach work — especially for remote, rural communities.
Imaginative outreach, resonant messages
While communication methods can be as straightforward as informal conversation, getting the content right is trickier.
MSF found imaginative approaches to community outreach, such as likening the spread of the virus to how ‘shine-shine’ (local word for glitter) would spread if it were on your hands. Everyone seemed to know exactly what shine-shine was and how it gets everywhere.
But there were greater challenges. In my first week in Sierra Leone a local social mobiliser explained to me: “Our beliefs are this: if my aunt dies, I must lay on her body to show her spirit that she is not forgotten and that she can depart in peace. If I do not do this then I will surely die soon.”
Her words highlighted a major difficulty: the official message not to touch a corpse but to call the authorities to come in their ‘space suits’, hose it down and take it away, clashed with people’s beliefs and cultural practices. MSF and other organisations needed anthropologists, and staff from Sierra Leone, to work with communities to understand local concepts of health, illness, Ebola and the afterlife — and to formulate messages that resonate, so people choose to act to protect themselves.
We couldn’t rely on existing communication materials transplanted from another context. This is something that needs to be taken into account in future outbreaks beyond Ebola and West Africa.
Beyond the content of messages, a broad understanding of ‘communication’ is needed if responders are to work with local people effectively. Psychologists estimate that some 80 per cent of communication is non-verbal. The Ebola response reminded me of this, particularly in MSF’s attempts to combat the stigma experienced by many survivors.
The only human beings MSF volunteers were allowed to touch in West Africa — when not wearing full protective suits — were survivors, when we took them home. On these occasions, we were told we had to hug them! After weeks of avoiding even the slightest physical contact with another person, this was a weird experience. But that hug was intended as a strong statement to the community. It demonstrated that the survivor posed no risk, that they should be welcomed back and celebrated for surviving, not ostracised.
Well-coordinated communication is also essential for effective disease response. One day I received an email from an MSF health promoter on the other side of Sierra Leone, asking after two young children from one family who had fallen ill and were taken away in an ambulance two months earlier. That was the last the family had seen or heard of them. No one had contacted them to say if their illness was Ebola or not, if the little ones had survived or where they had been taken.
I heard similar stories frequently. This failure of coordination must have had a major impact on families and their willingness to engage with response efforts.
However, we did identify gaps and improve our practices. When the 200th survivor left our Ebola management centre in Bo, local response coordinators were shocked: they had no idea so many people were surviving.
If these coordinators, right in the middle of the response, didn’t know, then the communities certainly didn’t know either. On realising this, coordinators, community workers and MSF jointly organised radio shows to spread the message across the district.
Community learning channels
So how can we ensure we communicate better in future?
First, the outbreak in West Africa is not yet over. There is still urgent work to be done, particularly to tackle the stigma experienced by survivors — rapid anthropological research is needed here to understand the how, what and why. The results must then be used to shape the methods and content of our communications.
We cannot waste time. This problem is not theoretical or academic: survivors in Sierra Leone are facing discrimination, homelessness and isolation as you read these very words.
Then we can look to future outbreaks. Better community engagement could be achieved by establishing ways to quickly share good practice and new learning — locally and nationally. This would allow a response to improve in giant leaps, not small steps.
In Sierra Leone, the districts regularly report outbreak data up to national level where it is analysed, summarised and then rapidly shared outwards again to all districts and responding organisations. A parallel channel for the real-time reporting and dissemination of new learning in community engagement would be feasible. We just need the will to do it.
Rosamund Southgate is an NHS public health registrar seconded to the Manson Unit of Médecins Sans Frontières (MSF-UK).
This article is part of our Spotlight, Managing health crises after Ebola.