The Ebola epidemic that began in the Guinea-Sierra Leone-Liberia border region in December 2013 spread fast through the villages, cities and trade routes of this highly-peopled, economically unequal region. The initial international response by donor and humanitarian agencies faced resistance from many communities because it failed to take account of local customs and practices such as burials. The Economic and Social Research Council (ESRC) Impact Prize award winning Ebola Response Anthropology Platform (ERAP) and Ebola initiative contributed to efforts to bring about the end of the outbreak by providing much needed real-time advice to doctors, nurses, charity workers and others working in affected countries and helped them to target their efforts more effectively and bring an end to the crisis more rapidly.
In August 2014, when the World Health Organization belatedly declared the epidemic to be a "public health emergency of international concern", it was out of control, with scientists predicting millions of deaths. The early international response floundered and encountered much local resistance, including for socio-cultural reasons, failing to take consideration of the customs, lifestyles and values of the communities they were supporting. According the to the WHO Situation Reports, by 14 January 2016 when all countries were finally declared Ebola-free, the death toll was just over 11,000, with 17,000 survivors struggling with the medical and social fallout, and ravaged economies and health systems to rebuild. It has been a devastating crisis – but it could have been much worse.
A team of anthropologists, with extensive experience on social, cultural, community, health and ecological issues in the region came together and formed the Wellcome Trust and DFID-funded Ebola Response Anthropology Platform (ERAP), which became an online focal point for anthropological advice on responding to the crisis in the UK and internationally.
The team was able to draw on a wealth of existing anthropological and interdisciplinary research based from IDS and the University of Sussex, including:
The core team comprised of a group with longstanding expertise in the issues and included:
Photo of former Shadow Secretary for International Development, Mary Creagh, at the ‘Ebola: Lessons for Development’ event.
The team also formed a critical collaboration with locally-based researchers in Sierra Leone, and with networks of anthropologists across West Africa, Europe and the United States, to deliver real-time, evidence-based advice to policy makers and practitioners working to respond to the crisis. Areas of focus included identifying and diagnosing cases; managing death and funerals; caring for the sick; clinical trials and research; improving communications and community engagement, and addressing the social resistance and violence against health workers that was magnifying the epidemic.
In addition a second initiative was launched in association with the ESRC STEPS Centre – ‘Ebola: Lessons for Development’ in February 2015 - looking at wider causes and implications of the Ebola crisis for global health governance, health systems, conflict, ecology, mining, urbanisation, gender, and community engagement. Working with IDS and Sussex-based researchers, West African partners and IDS communications professionals, the team produced nine briefings, and launched and debated these with over a 100 development policymakers, humanitarian agencies and researchers in London in February 2015.
It was evident to the team from their prior knowledge, contacts in the countries and media reportage that:
In response the team rapidly mobilised to build a collaborative platform to provide real-time advice to the humanitarian response to the crisis.
The ERAP website launched in October 2014 and published a broad range of materials. The materials included a mix of journal articles; individual field reports/notes; new literature providing emerging syntheses of the crisis; briefings including expert opinions; blog posts and subsequently peer reviewed articles. The team also translated and publicised other key anthropological works, including across the fracophone-anglophone divide. All the materials were published as open access. Providing a focal point for dialogue as the epidemic unfolded, the website brought together US, European and West African networks. Platform members delivered pre-departure training for 362 clinical personnel; co-designed and delivering teaching content for a MOOC on Ebola in Context; and conducted training sessions on 'Outbreak Anthropology for Epidemiologists' in London and Berlin.
ERAP activities actively shaped strategies and operations of the UK government response, WHO and other UN bodies and a number of academic institutions and NGOs, contributing to a more socio-culturally engaged response. Core ERAP members were the sole or major contributors to 40 rapid response briefings and other written outputs, including briefings solicited by UK Government Scientific Advisory Group for Emergencies (UK SAGE), DFID, WHO and Christian Aid.
The Platform directly shaped the UK's strategy in Sierra Leone. The Platform was co-opted as the social science sub-committee on the UK SAGE, directly advising the Chief Medical Officer and Chief Scientist. Impacts included the decision to develop Community Care Centres for initial triage and isolation of cases, as a more acceptable and accessible alternative to the large Ebola Treatment Units which aroused so much local anxiety, and inputs to their design.
ERAP members were also formal participants or members of the, WHO Science Committee, the UK Government Office of Science, the Scientific Advisory Board for the Favipiravir trial, the WHO SAGE Working Group on Vaccines and Vaccination, the WHO Ethics Working Group and the Wellcome Trust Ebola Trials committee.
In addition, ERAP members contributed in real-time to guidelines, protocols and operational workshops on a range of Ebola response activities, including Safe and Dignified Burials (WHO), Ebola Behaviour Change (DFID), Disaster Risk Management (DFID), Community Engagement (WHO), Community-led Social Mobilisation (SMAC), EVD Survivors (WHO), Vaccine Trials (LSHTM, WHO, University of Oxford) and Risk Analysis for Human-Animal contact (FAO).
On the ground research in Sierra Leone conducted by ERAP members at the height of the epidemic provided much needed insight into the dynamics of behaviour change and local responses.
Although the primary aim was to provide operational advice rather than conduct research, ERAP did conduct three primary research projects:
ERAP contributed to the Social Mobilisation Action Consortium (SMAC) and published their material, and they also conducted operations-linked field studies which helped shape approaches to safe burials. This work showed the need to treat burials in a longer timeframe covering a continuum of care for the extremely sick and dying, and the social significance of this period for kin visits, settling marital and inheritance matters, and ensuring the dying person’s good passage to the spirit world.
As the response scaled up, fieldwork and briefings in this and other areas – such as community adaptations around movement and quarantine, and the roles of local institutions - directly informed efforts by the Sierra Leone government and SMAC. They identified how community learning and behaviour change was stemming the epidemic and how to build on this in ‘Community Lead Action on Ebola' efforts which eventually reached 67 per cent of communities in Sierra Leone.
As the epidemic slowed later in 2015, ‘getting to zero’ was compromised by ongoing flare-ups and resistance. In the coastal and forest regions of Guinea, where this was particularly serious, the ERAP team was able to respond to the UN Mission for Ebola Emergency Response (UNMEER) request for operational guidance, showing how to tailor both the messages and the delivery of the message in communication approaches to avoid the longstanding political and ethnic tensions that were fuelling anxiety and violence.
ERAP played a major role in supporting and collaborating with emerging anthropological networks internationally, including in the USA, France, Holland, Belgium and Germany. Through these and our existing contacts in West Africa, we identified and recommended potential applicants for Anthropology positions within WHO, UNMEER, DEC and a number of research and operational initiatives in West Africa.
ERAP members taught and designed a number of training courses and events related to the socio-cultural dimensions of the Ebola epidemic, including:
In addition, ERAP members have spoken at a number of Ebola-related events in London, Manchester, Bristol, Paris, Antwerp, Halle, Nagasaki, Princeton, Ottawa, Washington and Accra.
Dr Annie Wilkinson working with local partners in Sierra Leone
The Lessons for Development initiative was driven by the realisation that longer-term political economic contexts, including the history of development interventions in the region, were partly responsible for the epidemic having spiralled into crisis. This initiative was largely catalysed by researchers and had some potentially challenging messages for those agencies, workers, governments and others users of ERAP. But it came at a moment in the epidemic when it was welcomed by government and NGO agencies keen to understand the context of the response and to embrace the challenges of system-building differently post-Ebola.
ERAP members continue to contribute to a number of formal evaluations, preparedness and ‘lessons learned’ initiatives that are shaping agencies’ plans and activities for post-Ebola recovery and rebuilding with respect to the rootedness of the crisis in the region’s socio-economic, governance, and health system structures and histories of inequality, foreign intervention and distrust. These have included:
Over the first 12 months, the ERAP's website was accessed by 16,111 users, viewing 62,690 pages. By the end of 2015, the ERAP team had uploaded 71 articles relevant to the socio-cultural dimensions of the Ebola epidemic onto the website, which have been downloaded 3,563 times from the site, with users accessing a further 2,303 articles from external sites.
The ERAP and the Ebola initiative effectively engaged decision makers involved in shaping the response to the Ebola crisis. Chris Whitty, chief scientist at DFID, highlighted the value of the anthropological perspective during the Ebola crisis:
It was clearly a disaster, but could have easily rolled out further over West Africa & without the insights that we got from anthropology… I think we would have got much closer to this spreading even further, and claiming many more lives than it didChris Whitty, chief scientist at DFID Tweet
ERAP, as part of SAGE, helped to shape UK policy in Sierra Leone. Internationally, the UN Special Envoy on Ebola has personally appreciated and thanked ERAP members for their work, emphasising that ERAP is well-known throughout the UN response system.
The need for the social and anthropological insight and contribution to the outbreak was noted by the House of Commons International Development Committee report - Ebola: responses to a public health emergency on DFID's initial response to the crisis: 'We heard calls for the use of social scientists and anthropological expertise to inform how best to engage with communities in an outbreak. The Wellcome Trust funded the Ebola response anthropology platform with DFID, which used social scientists to help develop the response, and emphasised, "The importance of sociological and anthropological support in the epidemic cannot be underestimated."' The Africa APPG echoed calls for greater use of anthropological expertise in order to better understand cultural practices, how they affected the spread of the disease, and how to engage communities, "The inclusion of social science expertise was especially crucial given the breakdown of trust between communities and health systems."'
The World Health Organization (WHO) drew ERAP work into the key scientific and policy/ethics committees shaping the Ebola response. The value of social science perspectives was emphasised by Margaret Chan, Director-General, WHO, in her April speech in acknowledging that:
"We have learned lessons of community and culture…. We have learned the importance of respect for culture in promoting safe and respectful funeral and burial practices. Empowering communities must be an action, not a cliché"
Margaret Chan also listed social science skills amongst the other (clinical, management) skills required for a new proposed Global Health Emergency Workforce. Recent deliberations around the IOM Global Health Risk Framework Initiative, and in the post-Ebola reflections of a number of humanitarian organisations, have made similar points. In addition to this, WHO in 2017, published Guidelines on "Communicating Risk in Public Health Emergencies" (pdf), incorporating ERAP work and briefings.
Coverage of the IDS-led ebola work including the events was featured on BBC News, BBC Science-in-Action, The Guardian, and the Washington Post and shared with policymakers, drawing out lessons for building more resilient health systems in the future.
In a field dominated by medics, epidemiologists, virologists and other natural scientists, IDS and partners showed how valuable social science can be.Melissa Leach, IDS Director Tweet
In a field dominated by medics, epidemiologists, virologists and other natural scientists, IDS and partners showed how valuable a social science perspective can be. Researchers saw early on that the Ebola crisis was more than a medical emergency. The epidemic was also a lens through which much that had gone wrong with development to date could be seen.