Date Published: April 9, 2015
Publisher: Public Library of Science
Author(s): Sharon Alane Abramowitz, Kristen E. McLean, Sarah Lindley McKune, Kevin Louis Bardosh, Mosoka Fallah, Josephine Monger, Kodjo Tehoungue, Patricia A. Omidian, Daniel G. Bausch. http://doi.org/10.1371/journal.pntd.0003706
Abstract: BackgroundThe 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 FindingsThis 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/SignificanceLocal 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.
Partial Text: The West African Ebola epidemic emerged in the forest region of Guinea in late December 2013 and appeared to be contained until May 2014, when it rapidly accelerated its rate of incidence and crossed into urban areas in Sierra Leone and Liberia . Upon entering Sierra Leone and Liberia, the rate of Ebola virus disease (EVD) transmission increased rapidly resulting in 1,711 cases by August 8, 2014, when the WHO declared that the conditions for a Public Health Emergency of International Concern (PHEIC) had been met—the third announcement of its kind in history. Although the tide has since turned, as of January 2015 there were over 21,000 confirmed, probable, or suspected cases of EVD, and more than 8,600 Ebola-related deaths, 3605 of which occurred in Liberia alone .
These data were collected as part of a Government of Liberia/World Health Organization GOL/WHO rapid assessment of community leaders’ perceptions of appropriate management practices for addressing the incidence of Ebola in their communities. The research teams were trained and directed by an applied medical anthropologist and conducted data collection from September 1-20th, 2014 in 15 communities of varying economic, ethnic, and population characteristics in Monrovia and Montserrado County, Liberia. Data are drawn from focus groups, qualitative field notes, and supporting literatures. Liberian research teams conducted 15 focus groups, one in each community, consisting of 15–20 people of mixed gender, for a total of 368 participants. All participants were community leaders, drawn from women’s groups, youth groups, local zonal heads, political groups, clinics, church-based organizations, non-governmental organizations, and recreational clubs. The tone of the meetings was widely reported as cooperative and participants were positively engaged.
Community leaders shared with the research team their opinions regarding “best practices” concerning local community responses to the Ebola outbreak. Using a grounded theory approach, their feedback was analyzed for common themes, which generated an “ideal-type”  framework—a synthesis of commonly agreed-upon elements—for community-based response to the presence of Ebola in and near urban Liberian communities (Fig 1). This included three sequential phases of action and response: prevention, response and treatment, and sequelae. Both the findings and the figures represented in this section detail community responses, and suggest implications that concatenate with the existing literature on social structure, gender roles, healthcare capacity, and conflict histories in the region [34, 36–40].
While the research reported here takes considerable strides towards helping to understand how local communities in Liberia responded, and envisioned their response, to Ebola, this information must not be mistaken as an indication of community political, medical, or social empowerment or institution-building—although this, too, was present. These communities were not empowered, they were desperate and often abandoned. They found resources from within their communities to compensate for the collective failure of state and international institutions to implement systems of surveillance, treatment, and response. What we are observing here is a community-based response to a condition of medical statelessness and structural violence [49–50].