Sharon Abramowitz

Community-Centered Responses to Ebola in Urban Liberia: The View from Below

Background The West African Ebola epidemic has demonstrated that the existing range of medical and epidemiological responses to emerging disease outbreaks is insufficient, especially in post-conflict contexts with exceedingly poor healthcare infrastructures. In this context, community-based responses have proven vital for containing Ebola virus disease (EVD) and shifting the epidemic curve. Despite a surge in interest in local innovations that effectively contained the epidemic, the mechanisms for community-based response remain unclear. This study provides baseline information on community-based epidemic control priorities and identifies innovative local strategies for containing EVD in Liberia. Methodology/Principal Findings This study was conducted in September 2014 in 15 communities in Monrovia and Montserrado County, Liberia – one of the epicenters of the Ebola outbreak. Findings from 15 focus group discussions with 386 community leaders identified strategies being undertaken and recommendations for what a community-based response to Ebola should look like under then-existing conditions. Data were collected on the following topics: prevention, surveillance, care-giving, community-based treatment and support, networks and hotlines, response teams, Ebola treatment units (ETUs) and hospitals, the management of corpses, quarantine and isolation, orphans, memorialization, and the need for community-based training and education. Findings have been presented as community-based strategies and recommendations for (1) prevention, (2) treatment and response, and (3) community sequelae and recovery. Several models for community-based management of the current Ebola outbreak were proposed. Additional findings indicate positive attitudes towards early Ebola survivors, and the need for community-based psychosocial support. Conclusions/Significance Local communities’ strategies and recommendations give insight into how urban Liberian communities contained the EVD outbreak while navigating the systemic failures of the initial state and international response. Communities in urban Liberia adapted to the epidemic using multiple coping strategies. In the absence of health, infrastructural and material supports, local people engaged in self-reliance in order to contain the epidemic at the micro-social level. These innovations were regarded as necessary, but as less desirable than a well-supported health-systems based response; and were seen as involving considerable individual, social, and public health costs, including heightened vulnerability to infection.

International Human Rights, Gender-Based Violence, and Local Discourses of Abuse in Postconflict Liberia: A Problem of "Culture"?

Abstract: In this article we draw on three years of ethnographic observation of postconflict humanitarian intervention in Liberia to consider the process whereby global efforts in the areas of gender-based violence (GBV) and human rights are interacting with local debates over kinship, entitlement, personal rights, and social responsibility. This article draws upon Liberian narratives, complaints, and efforts to regulate, in a national context, social norms and behavior in regard to gender-based violence issues in postconflict life while also engaging with an ongoing international human rights discourse on the subject of GBV. Our ethnography takes a multiscalar approach to give a sense of the process, multiple discourses, and dialectics of power involved in this issue, and to demonstrate how the definition of “the GBV problem” in Liberia, the target of complex GBV interventions, is different from the conception held by agencies, governmental ministries, and nongovernmental organizations (NGOs) that are responsible for implementing global mandates.

Social science intelligence in the global Ebola response

330 www.thelancet.com Vol 385 January 24, 2015 and collaborating on research initiatives. This kind of initiative avoids the wasteful duplication of eff ort, and should be reproduced for other medical humanitarian emergencies. The Ebola response shows the need for new global mechanisms to be established that can rapidly mobilise all experts who can bring relevant local contextual, medical, epidemiological, and political information on global health emergencies. Now is the time to consider how to bring social science into the centre of future pandemic surveillance, response, community preparedness, and health system strengthening. This will take will, vision, and systematic engagement of our full capabilities and expertise.

Medical Humanitarianism: Anthropologists Speak Out on Policy and Practice

In recent years, anthropologists have become increasingly present in medical humanitarian situations as scholars, consultants, and humanitarian practitioners and have acquired insight into medical humanitarian policy and practice. In 2012, we implemented a poll on anthropology, health, and humanitarian practice in which 75 anthropologists discussed their experiences in medical humanitarianism. Our goal was to move beyond the existing anarchy of individual voices in anthropological writing and gain an aggregate view of the perspective of anthropologists working in medical humanitarian contexts. Responses lead to six inductively derived thematic priorities. The findings illustrate how anthropologists perceive medical humanitarian practice; which aspects of medical humanitarianism should be seen as priorities for anthropological research; and how anthropologists use ethnography in humanitarian contexts.

Medical humanitarianism: research insights in a changing field of practice.

In the past two decades, ‘medical humanitarianism’ has come to constitute not only an increasingly powerful set of organizations and interventions, but a significant topic of scholarly research. Medical humanitarianism e the delivery of health-related services in settings of crisis e has a prominent international presence in contexts of violence, famine, natural disasters, as well as conditions of extreme poverty, deprivation, and structural violence. The definition of what constitutes ‘humanitarianism’ and a ‘humanitarian crisis’ has of course evolved historically in close parallel with changed forms of humanitarian responses (Calhoun, 2010; Fassin and Pandolfi, 2010a; Allen and Schomerus, 2012). Increasingly, social scientists find themselves working alongside humanitarians, in fieldwork conditions best characterized as states of emergency, complex emergencies, or crises. They do so as researchers studying conflict and post-conflict settings, responses to natural disasters, or pathways of risk, resilience, and recovery, with a specific lens on local beneficiaries, local service providers, or humanitarian global organizations; they may be themselves actively involved in the grass-roots delivery of humanitarian work. States of emergency prove compelling to many social scientists, be they anthropologists, sociologists, global health specialists, psychologists, historians, or scholars of conflict and peace building, working alongside healthcare practitioners and policy-makers. In February 2013, Social Science & Medicine issued a call for papers focused on medical humanitarianism. The lead editors of

Correction: Community-centered responses to Ebola in urban Liberia: the view from below.

There is an error in the affiliation for authors Mosoka Fallah, Josephine Monger, and Kodjo Tehoungue. The correct affiliation is: the World Health Organization.

Community-based reports of morbidity, mortality, and health-seeking behaviours in four Monrovia communities during the West African Ebola epidemic

ABSTRACT The goal of this study was to assess morbidity, mortality, and health-seeking behaviours during the 2014 Ebola outbreak in Monrovia, Liberia. This study examined commonly reported symptoms of illness, pre-clinical diagnostic practices, typical healthcare-seeking strategies, and health resources available to populations, in order to identify salient needs and gaps in healthcare that would inform local emergency response efforts. Semi-structured interviews were conducted with household members in four Monrovia neighbourhoods. Researchers used a multi-stage cluster approach to recruit participants. Within 555 households sampled, 505 individuals were reported sick (69%) or recently sick (38%) or deceased (7%). Common self-diagnoses included malaria, hypertension, influenza, typhoid, and Ebola. The most cited health-seeking strategy was to purchase medications from the private sector. Respondents also obtained healthcare from community members known to have medical experience. Findings suggest that non-formal healthcare systems played an important role in managing morbidity during the West African Ebola virus disease (EVD) outbreak. Lay community members engaged in complex assessments of health symptoms and sought biomedical care at rates perhaps higher than anticipated during the response. This study highlights how informal networks of healthcare providers can play an important role in preventing and curbing future emerging disease outbreaks.

The Opposite of Denial: Social Learning at the Onset of the Ebola Emergency in Liberia

This study analyzes findings from a rapid-response community-based qualitative research initiative to study the content of Ebola-related communications and the transmission of Ebola-related behaviors and practices through mass media communications and social learning in Monrovia, Liberia during August–September 2014. Thirteen neighborhoods in the common Monrovia media market were studied to appraise the reach of health communications and outreach regarding Ebola prevention and response measures. A World Health Organization (WHO) research team collected data on social learning and Ebola knowledge, attitudes, and practices through focus group–based discussions and key informant interviews over a 14-day period to assess the spread of information during a period of rapidly escalating crisis. Findings show that during a 2-week period, Monrovia neighborhood residents demonstrated rapid changes in beliefs about the source of Ebola, modes of contagion, and infection prevention and control (IPC) practices, discarding incorrect information. Changes in practices tended to lag behind the acquisition of learning. Findings also show that many continued to support conspiracy theories even as correct information was acquired. The implications for community engagement are substantial: (1) Under conditions of accelerating mortality, communities rapidly assimilate health information and abandon incorrect information; (2) Behavior change is likely to lag behind changes in beliefs due to local physical, structural, sociocultural, and institutional constraints; (3) Reports of “resistance” in Monrovia during the Ebola response were overstated and based on a limited number of incidents, and failed to account for specific local conditions and constraints.