“Ebola is a three-legged animal: medical, political and social”, a Sierra Leonean doctor told me in September 2014. In fact, global health organisations recognised the social side of epidemics long ago — the WHO has included anthropologists in its response teams since 2005. But social aspects are not yet fully addressed in response systems, and this will be vital if we are to manage epidemic and pandemic threats in the twenty first century. The outbreak in West Africa is a good example of why social sciences should be integrated into epidemic risk assessment and management.
‘I know, I want, I can’
Because Ebola is transmitted by contact with bodily fluids, dead bodies are very contagious and transmission risk remains high during funerals, when family members touch their loved one to prepare the body for its last journey. Safe burial practices have been difficult to implement in many places in West Africa, and are still not fully accepted. As a result, the virus can travel with relatives who return to their villages after attending a funeral.
“For future crises, let’s aim to scale up the integration of social sciences into outbreak risk assessment and management.”
Sylvie Briand, World Health Organization
The WHO has deployed social scientists and this has been important in understanding why people do or don’t cooperate with health advice, and how to adapt interventions so they are more accepted and efficient.
‘I know, I want, I can’ are the three prerequisites of behaviour change. First, someone needs to first know that Ebola is transmitted by contact with a sick or dead person, and that touching or washing the body is dangerous. They must then want to protect themselves more than they want to tend to the deceased — rituals are important to ensure a safe journey after death, but life is more important. And finally, they must feel they can wait for the burial team — provided it comes quickly, and not after three days or more, as on some occasions during this epidemic.
To make safe burials more accepted in West Africa, the international response teams adapted recommended practices to local beliefs and religious practices. For instance, this meant burial teams putting the deceased’s belongings in the coffin or mortuary bag, instead of burning them, before the body was taken away. This helped families to accept the safe burial. But months into the outbreak, some families were still hiding corpses and holding secret, unsafe burials. So responders began to work with religious leaders from Christian and Muslim communities to promote burials that were both safe and dignified.
The religious leaders talked to their community, advising that washing the body was not necessary during the outbreak. A social communicator was added to the burial teams to explain to the family how the body was handled, and the family was allowed to follow the burial truck to the grave. These adjustments helped communities to accept the safe burials intervention.
Adding community empowerment to standard public health measures, such as isolating patients, was another new approach — one that has never been used before to tackle Ebola.
Often, we perceive a community as a geographical entity, a village for example. But a community is also a social network. In conventional outbreak response scenarios, medical responders focus on individual patients and epidemiologists on cases. But this overlooks how individual patients, the nodes in the network, are linked to each other to make a community.
“There is a bonus benefit to including social science in response systems: it sensitises biomedical responders to the social dimensions of outbreaks, and this, in turn, encourages better communication with communities.”
Sylvie Briand, World Health Organization
So while individuals may recover, helping communities recover needs responders to relate to and treat them as key stakeholders in managing the crisis. This is done through dialogue, and it helps to ensure resilience in future outbreaks: when people have gone through the process of implementing their own solutions, the next time there is an Ebola outbreak they will know how to deal with it. For instance, in some areas people began to use plastic bags to cover their hands when they did not have gloves to take care of their sick relatives.
Scale up social science
Using anthropologists and promoting community engagement in West Africa’s Ebola epidemic may herald a paradigm shift in global efforts to address emergencies, especially disease outbreaks, by moving from an individual biomedical approach to a more social, community-based one.
For future crises, let’s aim to scale up the integration of social sciences into outbreak risk assessment and management. This would be particularly useful for two aspects of response.
First, adding social scientists to outbreak investigation teams can help the teams better understand the social links within communities that drive disease transmission. For instance, during an outbreak of cholera in Côte d’Ivoire, the investigation team noticed that one of the city’s neighbourhoods was more affected than the others. It turned out that many people who lived there worked as latrine cleaners and so were more exposed to the disease than people drinking contaminated water only. This would have taken longer to discover through standard epidemiological investigation than it did by having insight from social science.
Second, embedding social scientists in response teams will help to monitor how people adapt public health measures to different social contexts, and whether these are implemented in a way that respects social and cultural systems. Each community is different and there are no one-size-fits-all solutions. Mass vaccination campaigns, for example, are well accepted in most parts of Africa and so vaccine coverage is high. But during the outbreak of pandemic flu in 2009, the mass vaccination campaigns organised in France were not well received by people and doctors, and vaccine coverage was very low.
There is a bonus benefit to including social science in response systems: it sensitises biomedical responders to the social dimensions of outbreaks, and this, in turn, encourages better communication with communities. That shared engagement will help in the battle against any disease.
Sylvie Briand is director of the Pandemic and Epidemic Diseases Department at the World Health Organization. She can be contacted at WHO.
This article is part of our Spotlight, Managing health crises after Ebola.