After Ebola, Promoting New ‘Gold Star’ Brand to Increase Use of Health Services

The Health Communication Capacity Collaborative (HC3) team in Guinea is working with the communities hardest hit by the Ebola outbreak to rebuild both trust in the health system and the quality of care received. HC3’s approach incorporates evidence-based Social and Behavior Change Communication (SBCC), capacity-building and quality-improvement interventions.

In collaboration with Jhpiego and the Ministry of Health, HC3 is revamping a quality brand—entitled “Etoile d’Or,” or Gold Star—that will be promoted nationally and regionally through a mass-media campaign that includes radio, television, billboards and community events. The campaign aims to build confidence in as well as increase the use of health services. 

Since 2012, Jhpiego has identified and assisted health facilities to meet quality criteria for service through a months-long accreditation process. Once accredited, a health facility receives a “gold star,” which is prominently displayed both inside and outside the facility. Currently, 15 facilities across the country have already received a gold star and another 22 are undergoing the accreditation process. Unfortunately, few people within these communities or health facilities understand the significance of the gold star label. That’s where HC3 comes in.

The first step in developing the new brand was to create an updated logo and campaign slogan that embody the values that community members think are most important when considering whether or not to use their local health services. These characteristics include: a health worker’s warm welcome, confidence, empathy, availability, respect and confidentiality as well as health facility cleanliness. The new logo is a gold star with a photo of two smiling male and female Guinean nurses inside, along with the slogan, “High quality services, your health is guaranteed!”

Once the logo and slogan are validated by all partners, new health facility signs, billboards, posters, and radio and television spots will be produced and distributed to promote the brand at the national and regional levels. Each community that already has a Gold Star facility will celebrate the campaign by unveiling the new logo at a community-wide launch party featuring speeches, theater and music.

By promoting the brand nationally, HC3 hopes to inspire non-Gold Star facilities to strive to achieve the same high-quality standards that Guineans desire and deserve. The Gold Star Quality Services promotion will encourage people to return to the life-saving health-care services that they stopped using during the time of Ebola.

The Sexual Transmission of Ebola: Scicomm as a matter of life and death – Part 2 of 2

*This post originally appeared in PLOS | blogs.

The resurgence of Ebola in Liberia in late June 2015, seven weeks after the country had been declared Ebola free, put a spotlight on how the disease is transmitted, and brought the issue of sexual transmission to the forefront. With this shift away from coping with a national health emergency to dealing with what may now be a “new normal,”  different public health messages are required for the people of Liberia.

Staff of the Ebola Survivors Clinic at work, Redemption Hospital in Monrovia. Image: WHO/C. Bailey

Staff of the Ebola Survivors Clinic at work, Redemption Hospital in Monrovia. Image: WHO/C. Bailey

While new targeted behavior campaigns are being crafted, Liberians will have many questions about when and how Ebola is sexually transmitted. Journalists on the ground will need to find ways to tell that story.

There are helpful linkages to be found in HIV storytelling, but local media will need to address the fact that, unlike HIV-AIDS, the science on sexual transmission risk in Ebola is incomplete.

Ebola is both a sexually transmitted infection (STI) and not one. These stories should not provoke fear, but should communicate the need for safe sex.

Through viral sequencing we are trying to establish the mode of transmission of the most recent (November) cases. Just as in July, we are also looking to see if it was the same viral strain present in Liberia in 2014”, says Tolbert Nyenswah, the Head of Liberia’s Incident Management System (IMS). “Of course, sexual transmission is a possibility in both cases,” he added.

Nyenswah is a co-author of a New England Journal of Medicine (NEMJ) article titled Molecular Evidence of Sexual Transmission of Ebola Virus, which reports on the examination of  semen and vaginal-secretion samples collected from survivors in Liberia in March and April 2015. The case report describes  one case of human-to-human EBOV transmission through sexual contact.

A pilot study, also published in the NEMJ, Ebola RNA Persistence in Semen of Ebola Virus Disease Survivors showed Ebola is able to live longer in the testes than previously known. Among the samples, Ebola virus RNA was detected in the semen of 11 of 43 (26%) men 7 to 9 months after the onset of disease. The authors recommend that the risk of sexual transmission of the Ebola virus should be further  investigated.

Columbia University epidemiologist Stephen Morse was quoted in a “Popular Science” article,Why testicles are the perfect hiding spot for Ebola saying that he hoped the large numbers (of survivors) will make it easier to figure out when it’s safe for Ebola survivors to return to a normal sex life. “People may want to have children–they may have lost children, and want to go back to normal as soon as possible,” said Morse.

This is one of the questions researchers hope to answer in a National Institutes of Health studyinvolving more than 7,000 people who survived Ebola in Liberia for up to five years as they investigate the long-term health effects of Ebola virus disease. Researchers will seek to determine how survivors can still transmit the virus; also whether  those they infect will present with Ebola symptoms and if survivors are at risk for illness in the future.

Though messaging guides during the West African Ebola epidemic all made reference to the possibility of sexual transmission – via bodily fluids – recommendations for changing sexual practices were not a priority for communications during the height of the crisis.

Rania Elessawi, Communications for Development Specialist at UNICEF in Liberia says during the days of the dying all normal human interaction just paused. No kissing, no hugging. What happens in people’s private lives was not even talked about. “Ebola changed the way we loved,” said Elessawi.

The success of the Ebola response, Elessawi says, was that people kept learning as the epidemic unfolded, and kept adjusting and changing the behavior change communications strategy, too.

The  epidemic is now at a phase of much less handling and touching of patients and dead bodies in medical settings and at funerals where Ebola virus, present in bodily fluids, had been the primary mode of transmission.

“Now, the focus in behavior change messaging must shift to the realities of sexual transmission”, says Nyenswah of Liberia’s Incident Management System (IMS).

The UNICEF messaging guide for Ebola puts it this way:

Ebola survivors do not have Ebola, but it might be possible that Ebola can spread through doing man and woman business even after testing Ebola free. To make sure Ebola Survivors protect the people they love, they must use a condom correctly every time they do man and woman business.  Make sure the survivor throws the used condom into the toilet or burn it.

For now, the WHO (interim) advice on the sexual transmission of the Ebola virus disease includes this guidance:

  • Until such time as their semen has twice tested negative for Ebola, survivors should practise good hand and personal hygiene by immediately and thoroughly washing with soap and water after any physical contact with semen, including after masturbation. During this period used condoms should be handled safely, and safely disposed of, so as to prevent contact with seminal fluids.
  • All survivors, their partners and families should be shown respect, dignity and compassion.

These two pieces of advice alone indicate the complexity and intimacy of communications and education around Ebola.

\
Community councillors doing education outreach with Ebola survivors, about combatting stigma. André Smith/Internews

Community councillors doing education outreach with Ebola survivors, about combatting stigma. André Smith/Internews

Even with this new emphasis on human-to-human transmission through sexual contact, the question of Ebola’s origins refuses to go away.  As before, during the height of the crisis, journalists will need to do their best to answer it.

Communicating the Complex Science of Ebola’s Origins to Shed Light on Human Transmission

The viral detective story in Liberia (as told in Part 1 of the PLOS post) has helped us understand more about the chain of human to human infections than has ever been known about Ebola, but, for many, the original question: “where does Ebola come from?” remains of concern. In other words, how exactly does zoonotic transmission – the chain of viral transmission from animals to humans – work?

Warnings about the animal to human “jump” of Ebola, Monrovia. Image credit: André Smith/Internews

Warnings about the animal to human “jump” of Ebola, Monrovia. Image credit: André Smith/Internews

There has been no shortage of attempts to come up with answers.

Karl Johnson, former head of the Viral Special Pathogens Branch at the US Centers for Disease Control (CDC), interviewed for a July 2015 article in National Geographic, said that “despite arduous efforts by some intrepid scientists, Ebola virus has never been tracked to its source in the wild.”

And yet there is a widespread popular assumption – in Africa and elsewhere — that fruit bats were the source for the latest Ebola outbreak.

A 2005 article in Nature, titled “Fruit Bats as Reservoirs of Ebola virus” is the primary source for assertions that the Ebola virus resides in fruit bats, even though the authors made it clear their findings were inconclusive. Robert Swanepoel (now retired) who headed up the Special  Pathogens Unit at the National Institute for Communicable Diseases in Johannesburg showed the virus survived in a single spider and in an insect eating bat. But Swanepoel is quick to add that his findings were proof of principle This means the study’s experimental approach – injecting Ebola virus into a range of plant and animal species, then testing if it would take hold – provided a strong signal that bats could be reservoir hosts but it was unable to draw conclusive evidence. The gold standard in science would be to be able to grow the virus in the lab from the viral fragments found in fruit bats.

Screening those samples back at his lab in Johannesburg, Swanepoel found no evidence of Ebola. So he tried an experimental approach, one that seemed almost maniacally thorough. Working in NICD’s high-containment suite—biosafety level 4 (BSL-4), the highest—he personally injected live Ebola virus from the Kikwit outbreak in 1995 into 24 kinds of plants and 19 kinds of animals, ranging from spiders and millipedes to lizards, birds, mice, and bats, and then monitored their condition over time. Though Ebola failed to take hold in most of the organisms, a low level of the virus—which had survived but probably hadn’t replicated—was detected in a single spider, and bats sustained Ebola virus infection for at least 12 days. One of those bats was a fruit bat.

“Journalists have to resist the temptation to oversimplify the complex and to provide answers where only theories exist”, says Jon Cohen, a staff writer for Science.  “Pinpointing the origin of emerging diseases is a tricky business. A frightened public logically wants to know where a virus came from to protect people. But all too often, scientists only have clues — in the case of Ebola, bats seem like a logical source, and the first known case played in a tree that harbored bats.”

A WHO Fact sheet describes multiple possible animal sources for the transmission of Ebola to humans:

Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest.

The Skoll Global Threats Fund hopes to create awareness and solutions around this transmission chain and the fact that “humans and animals increasingly share virulent viruses due to loss of green belts, global warming and poverty, raising the risk of highly disruptive pandemics.”

In simple language: it is widely accepted that there appears to be a link between the threatened habitats of chimpanzees and our shared susceptibility to Ebola. Fruit bats could be agents in spreading the virus from chimpanzee to chimpanzee, to other wildlife populations and perhaps even to humans.

Information Tools for Liberian Journalists

In an attempt to help journalists answer the question “where does Ebola come from?”  Internews asked WHO veterinarian and epidemiologist Dr Maarten Hoek to explain this science to a group of environmental journalists in Liberia. He methodically took the journalists through Evolution 101, explained why and how diseases “jump” species and how it happens with greater ease if those species are closely related. He explained how the majority of diseases known to man are zoonoses, i.e. they jump from animals to successfully infect humans, reproduce and then transmit human-to-human. Ancient examples are tape worm, malaria and the common cold. HIV, SARS and MERS are more recent examples, and they jumped from chimps, bats and camels respectively.

One journalist in the Internews training told Hoek plainly: “As an environmental journalist I believe it, but as a person, I don’t. We have always eaten bush meat and bats. The forest has been there and is still there. Where does this Ebola really come from?”

Indeed, the Liberian landscape is lush forest, a sea of green. The valleys and gorges do not appear denuded to the naked eye.

In response to such skepticism, Dr. Hoek pointed to evidence of the decline in the quality and diversity of forest ecosystems. Further, he explains, improved roads and infrastructure are the blessing and curse of development. Whereas a viral infection such as HIV, might have flourished and remained in remote villages, killing all its hosts, our greater connectivity transports both humans and diseases near and far.

An “over-engineered” Liberian road. Image credit: André Smith/Internews

An “over-engineered” Liberian road. Image credit: André Smith/Internews

A World Bank 2010 report indicates about a third of Liberia’s roads are over-engineered relative to traffic levels. And, the 2014-15 West African Ebola outbreak demonstrated how quickly Ebola could spread once it reached urban centers.

In PLOS Neglected Tropical Diseases, Kathleen Alexander and colleagues provide a comprehensive outline of the interplay of dynamics that contributed to the Ebola outbreak in an article titled What Factors Might Have Led to the Emergence of Ebola in West Africa?  A key dynamic discussed was the spillover of the virus to humans from wildlife – with bats as likely carriers. They also quote evidence that in West Africa, human movement is considered a particular characteristic of the region, with migration rates exceeding movement in the rest of the world by more than seven-fold. Solid science, but it still doesn’t make this story – as it relates to Ebola – easy to tell.

Monrovia, Liberia. Image credit: André Smith/Internews

Monrovia, Liberia. Image credit: André Smith/Internews

I asked Jon Cohen of Science for advice on how Liberian journalists might tackle these complexities.“Our job is to tell it like it is, nothing more”. Cohen says as long as journalists explain – in simple language – that with Ebola, analysis of the viral genetic material gives it a fingerprint of sorts that links it to Ebola viruses seen earlier in the Democratic Republic of Congo.

“We know that viruses frequently pass from bats to humans, and there are documented cases of Marburg, Ebola’s close relative, likely infecting people who went into caves inhabited by Marburg-infected bats. We also have a documented case of Ebola moving from a dead chimpanzee to a human who handled the animal”.

Where is Ebola going?

Where is our understanding of the virus taking us? In a simple phrase: to more questions, more inquiry. There are more than 13,000 survivors across the three most affected countries in West Africa: Guinea, Liberia, and Sierra Leone. Scientists, the journalists who report the science and the communities affected are set to learn much more about the long-lasting effects of Ebola virus disease. And with this comes better insights on how to care for Ebola survivors, who strain from ongoing health problems. Many experience stigma, causing them to live in shame and fear. In an effort to prevent another Ebola crisis, the scientific community is working on developing an Ebola vaccine, of which they are cautiously optimistic, as is evident from current scientific discussion. See alsohttp://www.who.int/mediacentre/news/releases/2015/effective-ebola-vaccine/en/

Reporters in West Africa have been learning on the move, whilst living through a most devastating health emergency. Some have been in personal danger; many have been a truth link for their audience, separating gossip from genuine Ebola news. They have had to learn a whole new Ebola science lexicon, and have navigated reportage about issues that span death, dread, confusion, hope and aid politics. It’s too early to say that the dust has settled. But there has been time to think through the stories of the aftermath, to consider how Ebola has exposed the failings in the health system in Liberia and other West African countries – and what needs to be done to address that.

Moses Geply, an Internews trainee journalist in Liberia who is in the Local Voices journalism network, says he and colleagues are ready for this next phase of journalism that makes meaning of what happened in their country.

“This was a first-time health emergency for Liberia, so the mantra was: people won’t understand about this virus, how it spreads, and the medicines used to counteract it”, says Anahi Iacucci of Internews. “But what we learnt here is that really, it is not that difficult to transform a complex matter into something simple, you just really need to work very hard and find the right way to do it.”

Ebola is not over until it’s over. It may never be over. And we are just beginning to learn how to report on Ebola – including answering difficult questions about the origins of this disease.

Now the journalists living and working in Liberia need to make meaning of these new insights for their audiences. Not just the facts, but also what these facts mean – for the sake of their own safety, for their ongoing sense-making of this new and devastating disease.

Fighting Fear and Stigma with Accurate Ebola Information

In July 2015, three months after the last person who had succumbed to the dreadful Ebola virus was buried, Liberians woke to the news that a 17-year old young man had died of the virus. Liberia was no longer considered Ebola-free.

Franklin D. Roosevelt’s words, “The only thing to fear is fear itself” have stayed with me since the first news stories broke about the Ebola outbreak in West Africa, quickly followed by stories of chaos and fear. As someone who has worked with and in the media, I also know that lack of accurate information is a big driver of fear and trauma, which in turn can easily translate into stigma and a withholding of sympathy for those affected by the traumatic events, driven by a compulsion to exclude them as “other.”

It’s been well documented that the Ebola crisis was in large part driven by misinformation in the early days of the outbreak. Rumors spread quickly, and massive blasts of communication, which although aimed at helping people understand the disease and how to deal with it, often ended up being contradictory and just plain confusing. Everyone knew that accurate Ebola information was critical. However, what was missed in the scramble to communicate, was listening to the people affected by the crisis. Simply booming messages at people affected by a crisis is bound to fail.

Internews, a specialized partner of the Health Communication Capacity Collaborative (HC3), found more than “300 types of social mobilization and messaging systems in the three worst-affected countries: Liberia, Guinea and Sierra Leone.” As the organization’s Senior Director for Global Initiatives Alison Campbell described it: A “chaotic information landscape [that] consisted mainly of information ‘out’ with little opportunity for community dialogue.”

Internews has vast experience working in humanitarian disasters, so it was a natural fit to partner with HC3 already working in Liberia, to widen the approach to getting lifesaving messages to people knowing full well that in rapid onset epidemics, rumors can kill. Who better to target than local journalists deeply connected with their own communities? Whichever way you look at it, individuals need to know the facts and the science behind the disease they’re covering in the media. Working with Liberian journalists was therefore key to Internews’ approach to ensure people had access not only to a wide range of information from trusted sources, but also to channels for questioning and discussing that information.

Alison summarized five takeaways earlier this year in an article that she thought the international development community should take to heart.

  1. Form genuine partnerships with local media.
  2. Build capacity rather than paying to disseminate prepared messages.
  3. Deliver consistent messages and don’t oversimplify.
  4. Encourage two-way communication with community audiences.
  5. Help local media realize their full potential as a platform for accountability.

Internews’ health journalism advisor, Ida Jooste recently visited HC3 in Liberia. She spoke to me about how working with journalists can address the stigma related to Ebola. She also shared some insights into Internews’ partnership with HC3, which showed that the commitment and community engagement has been sustained, despite the assumption that there may be Ebola fatigue or messaging fatigue. Community radio journalists have continued to be actively involved in Ebola-related programming in a way that shows “they care and are deeply committed to their communities,” Ida noted. “By investing in groups and journalists who had already proactively taken leadership in the Ebola response, the HC3/Internews team merely added a multiplier effect.”

IDA: Internews in Liberia provides training and follow-up mentoring to a select group of journalists, including from counties most affected by Ebola. These five-day training workshops provide journalists with resources and discussion points of the Ebola-related issues that dominate the news agenda in Liberia. Apart from the obvious joy of the country having been declared “Ebola free” by the WHO on 9 May, the most pertinent discussions relate to:

  • The fact that neighbouring countries still have Ebola cases; and
  • Stigma against survivors and survivors’ integration into society.

In the week of 25 May, Internews held a weeklong workshop with main theme: Mental health and Ebola. The group was addressed by Dr. Janice Cooper, The Carter Center’s Country Representative, who leads the Center’s Liberia Mental Health Initiative. In the Ebola crisis, she is bringing her expertise in mental health issues to promote an understanding of depression and of the negative effects related to the “othering” of Ebola survivors. Dr. Cooper explained mental health issues themselves are stigmatized. Traditional beliefs hold that mental health-related issues are a curse or punishment from God. When Ebola survivors show signs of depression (most do), they and their surrounding community first need to understand the biological and mental processes behind depression and anxiety. Through adapting existing mental health approaches, she and her teams are helping survivors by teaching coping mechanisms. The Carter Center’s work also extends to creating acceptance and a supportive environment. Dr. Cooper gave an outline of her work to journalists, and introduced them to an Ebola survivor, who answered journalists’ questions about how they are feeling and how they are being treated.

Internews-Ebola-Aug2015

Survivors typically experience self-stigma, guilt (because they survived and others didn’t or because they may have infected others); they are fearful of the recurrence of disease; they re-live the dread of having been so ill and of losing loved ones and they also may still be severely ill and fear that ongoing symptoms will not disappear or get worse. They are widely stigmatized, because some believe they must be bewitched or “the walking dead”, because they managed to survive a disease — around which the initial messaging had been “Ebola kills”! All of this information and accounts of these experiences were passed on to the journalists, who are planning to use the material in their radio talk shows, or radio, TV and print feature stories.

Internews also developed a Rumor Tracker (DeySay – a reference to how people speak about rumors in Liberia), which responds to rumors and debunks myths picked up through the extensive rumor tracking system. These (rumors and factual corrections) are then disseminated to partners through a humanitarian info newsletter, intended for dissemination amongst those who communicate with communities. “DeySay” uses dedicated outreach workers from local partner organizations, as well as local journalists who report rumors through SMS messages to a hotline, where these rumors are categorized by topic and regional scope. Sources include Facebook groups, hashtags on Twitter, influential bloggers, and local media including those from the diaspora, mapping online conversations and triangulating with SMS information from outreach workers. The Rumor Tracker’s information is then fed back to the community of social mobilizers, local media, public officials, and faith-based organizations, as well as to the international humanitarian community in a weekly newsletter that highlights trending issues by community or area. It identifies the most prevalent rumors, provides insights into local and social media coverage, and provides recommendations for addressing the information gaps identified.

Callie: How did this link to HC3’s social and behavior change communication campaign/messages?

IDA: HC3 has been responsive to the issue of most concern in Liberia, stigma against survivors and produced a comic book that communicates messages which helps integrate survivors into communities through normalizing behaviors. Internews distributes these comic books to trainee journalists as a resource. Billboards with the message, “Everyone is a survivor” are commonly seen in Monrovia and in counties. By aligning journalism training with the emerging issues in the country and the issues HC3 has identified as pertinent for its communications strategy, Internews training is responsive to the current information needs in the country.

Callie: How big a problem is stigma?

IDA: The survivors we spoke to, as well as those working in the mental health and counselling field, say it is a really huge problem. Apart from the stigma issues highlighted above, survivors also face the stigma of poverty. In many cases, harvests could not take place because of Ebola. All “Ebola households” were destroyed, meaning sick people and their families lost everything they owned. The belief that survivors benefitted with huge cash payouts does not help their plight. These are all issues that communicators and journalists are working to address.

When you take these factors into account, it is clear why combatting stigma is such an important aspect of Internews’ and HC3’s overall response. More than working to change behavior related to the frightening disease, what needed to happen was to work with communities to tackle the fear and associated stigma that cast such a deadly pall.

For other Internews-related work in Liberia using radio to stem an epidemic, click here.

As Ebola Epidemic Wanes, Transform Complacency with this Ebola Preparedness I-Kit

ebola-preparedness-i-kit-image

Ebola Preparedness Implementation Kit

It’s a win for Ebola prevention efforts that over 120 people in Liberia were placed under observation due to a resurgent outbreak in the country, even after it was declared Ebola-free. This signals that Liberia’s containment efforts are still strong. But it’s essential to remain vigilant: as the epidemic wanes, public complacency around sustaining behaviors that prevent Ebola transmission could be a barrier to stemming the flow of new cases for good.

This new Ebola Preparedness Implementation Kit (I-Kit) explains that all emergencies evolve in phases, as do emergency communication efforts. The Ebola outbreak is in Stage 4 of emergency communication: Resolution. Reported new cases have decreased significantly, SBCC interventions are well underway and regular informing of the public is ongoing. We’re certainly on “the Road to Zero,” and sustaining momentum so that preventative behaviors like hand-washing remain the status quo is crucial for actually getting there.

In the I-Kit, we outline creating a centralized mechanism for Ebola communication response, focusing on social mobilization and media/communication coordinating mechanisms; we also provide guidance on developing an Ebola communication strategy with step-by-step illustrative examples.

Some of the most helpful features in the I-Kit are interactive, like our Checklist for putting a communication coordinating mechanism in place. The I-Kit’s appendices are also rich with resources, like a conceptual framework for control and prevention of Ebola, and an overview of the relevant health communication theories put explicitly into the Ebola communication context.

We encourage you to explore our Ebola Preparedness I-Kit and to pass it along. Headlines in the West may have shifted the public’s focus away from Ebola—but the global response is far from over.

Liberia’s MICAT To Use Audio Equipment from HC3 for Public Health Outreach

Liberia’s Information Minister receives audio equipment from HC3’s Teah Doegmah.

Liberia’s Information Minister receives audio equipment from HC3’s Teah Doegmah.

The Health Communication Capacity Collaborative (HC3) has provided audio equipment to the Liberian Ministry of Information, Cultural Affairs and Tourism (MICAT) in Monrovia to help it improve its outreach to the public in case of another public health crisis such as Ebola.

“We are pleased to support MICAT and help in any way we can to improve communication and outreach to the Liberian people,” said Teah Doegmah, HC3’s Social and Behavior Change Communication Program Officer. “Especially in light of the Ebola outbreak last fall.”

The equipment, valued at close to $3,000, includes an audio mixer, audio cables, microphone stands, speakers, and a laptop. The equipment will be used for public addresses, including press briefings, and audio editing.

MICAT Minister Lewis G. Brown, who received the equipment, expressed his gratitude to HC3, which is a five-year global health communication project funded by USAID and based at Johns Hopkins Center for Communication Programs. HC3 has been active in the global response to Ebola by providing social and behavior change communication support in Liberia, Sierra Leone and Guinea.

Brown said the equipment will help MICAT provide important public health information to the public in a timely manner.

Radio Program “Kick Ebola From Liberia” Shifts Focus; Addresses Immunizations, Education

bbc media ction‘Kick Ebola From Liberia’ is a weekly radio programme produced in Liberian English that launched last November. The show is broadcast across the country 112 times a week on more than 20 partner stations. Early on, our aim was to provide information and discussion about how to avoid catching the Ebola virus, obtaining early treatment, practicing safe burials and breaking the chains of transmission. But now that the crisis has entered a new phase, we are shifting our focus, addressing issues such as immunisations, livelihoods and education after Ebola.

The programme is produced by BBC Media Action, which has partnered with the Paul G. Allen Foundation to deliver communication training to media, officials and humanitarian workers in 10 countries at risk in Africa.  The partnership includes producing media outputs – such as ‘Kick Ebola From Liberia’  and the mini-drama series Mr. Plan Plan – to help people take action to protect themselves and their communities in Liberia, Sierra Leone and Guinea.

For ‘Kick Ebola From Liberia,’ we work with a team of Liberian journalists to produce our stories. From individual tales of inspiration to serious interviews with government officials to in-depth stories about community-based solutions, we aim to address the issues that matter most, tackle rumors, and address issues of stigma. The focus is on discussion and collaboration, encouraging Liberians to band together and support each other through the crisis and into the immediate recovery phase. Listeners are invited to submit questions and contributions via text, Facebook and WhatsApp, which we incorporate into each the radio show.

Rebuilding Trust in a Place “Worse than War”

Anna Helland, far right, in the HC3 Monrovia field office with Marietta Yekeh (center) and Teah Doegmah (left)

Anna Helland, far right, in the HC3 Monrovia field office with Marietta Yekeh (center) and Teah Doegmah (left)

As soon as I arrived in Monrovia – actually before I even arrived, as I flew in from Brussels on a near empty plane – I was forced to face the emotional effects of the Ebola outbreak, greeted by airport officials wearing gloves and masks, washing my hands in bleach water for the first of many times, and agreeing to have my temperature taken, also for the first but not last time.

As we drove to town from the airport, traveling in a vehicle that smelled of the bleach water sprayed for my benefit and passing two of Monrovia’s at-capacity Ebola Treatment Units, I asked my driver if this felt like a war. Was it bringing memories of the war back to people? The war is still so close to the surface in Liberia, with many of my conversations with Liberians eventually moving towards the sharing of tales, both funny and tragic, of the many years of civil strife.

I certainly felt as if I had entered a state of emergency and was afraid this would bring stressful memories of the war bubbling up to the surface. It felt to me like war. How my driver responded surprised me: he said it was worse than war. “At least during the war, you knew who had a gun. With Ebola, it could be your brother who infects you without knowing.”

It’s this not knowing – in the community, at the health facility, even within a family- that is bringing about changes in behaviors and social norms that highlight an underlying emotional context, one of unease and distrust.

A new normal seems to be developing and at its base is this feeling of distrust. In previous trips, I hadn’t quite mastered the Liberian handshake, which requires multiple changes in hand positions and ends with a snap (The snap is what’s still giving me trouble). As through much of the continent, a handshake begins all new social interactions, leading to queries on the family and the previous night’s sleep and thanks to God for bringing us to a new day. But touching is no longer allowed, and the strain this causes in social situations is clear as those talking keep their hands in their pockets or their arms crossed to prevent the temptation to put out a hand or even casually touch an arm for emphasis during a conversation.

The ever-constant bleach water containers for washing hands and the security guard to take your temperature are also part of the new normal. Taxis are no longer crammed with passengers. Now they are allowed to take only three in the back seat, and even then, people seemed to be trying hard not to touch their fellow passengers, for fear of becoming contaminated.

All of this fosters an environment of distrust, and the feeling permeates through various layers of society.

Health care workers haven’t been too keen on caring for community members, fearing Ebola will come from those entering their clinics.

Community members themselves fear service providers as they’ve heard so many of them have already died of Ebola and wonder if maybe there is something to the rumors circulating that Ebola is actually injected at the treatment centers.

Distrust has bubbled up to the government level as seen in the unfortunate events in West Point in August, where the government attempted to quarantine an area with high numbers of Ebola cases and overcrowded conditions. Many from West Point are angry with the government for this botched response and the subsequent violence. Residents from West Point have been stigmatized outside their community as coming from an Ebola area, much like those coming from Lofa County were stigmatized at the beginning of the epidemic.

And finally, the health system, which had only just begun to improve during this first decade of peace, has failed them all – health care workers and community members alike. When Ebola made its way to Lofa County from Guéckédou in Guinea in the spring, the Liberian health systems – and it can be argued the global community- were caught off guard, without the needed weapons to fight this type of war.

If this is worse than war, as my driver asserts, intense efforts are needed to foster hope and a renewal of trust- between health care workers and their clients, between the government and its people, and even between brothers as families work to keep themselves and their communities Ebola-free. Trust is not only the key to getting ahead of the epidemic, it’s also the key to rebuilding the health systems in Liberia, which are weak but had been getting stronger. Regaining trust means community members and health care workers feeling confident in their relationships with each other and the services provided. It means trusting themselves and each other to identify the solutions that work best for their communities.

While trust is the solution, social and behavior change communication efforts are the key to fostering this change. These health promotion efforts provide accurate information through strategically crafted messages designed to rebuild trust in the health care system and its workers.

A glimmer of good news from Liberia the last few weeks, with a drop in Ebola cases and more beds available, may help establish trust again. The successes seen in Lofa County, which earlier this year had the highest number of cases in the country, seem to rest squarely with local leadership and community ownership and engagement. Health promotion efforts like ours have encouraged communities to engage by allowing community members to identify their own solutions. This begins to build that trust between them and the healthcare system that promises to provide the best care possible while being sensitive to local customs if care comes too late and a burial is required instead.

Trust allows for these small successes to grow into larger and larger successes and to rebuild what is now a devastated health system. Social and behavior change communication efforts foster the trust to not only getting the outbreak under control but also in leaving systems in place to be better prepared for the next emergency, if and when it comes.

This post originally appeared on the Johns Hopkins Bloomberg School of Public Health Ebola website

On the Ground in West Africa: Elizabeth Serlemitsos

Elizabeth Serlemitsos hand wash ebola prevention Liberia

Elizabeth Serlemitsos in Monrovia, Liberia.

Everywhere I go in Monrovia, the capital of Liberia, they take my temperature. Eating at a restaurant? There’s someone wielding a thermometer at the door. Headed into a building for a meeting? Same thing. Even when I pull up to park at the apartment building where I am staying, I have to roll down my window so an attendant can hold a thermometer up to my face to make sure I don’t have a fever. A fever is the first sign of Ebola and I am living in the epicenter of the outbreak.

This is just the new normal here. We don’t shake hands when we greet each other. We wash those hands all the time, mostly at washing stations set up by the entrances of every building. There was some hysteria here in the early days of the outbreak, I am told, but shops and restaurants on the streets I walk here in Monrovia are open now and it is business as usual. We are vigilant, but we are calm. It is hard to get Ebola. We know that it’s not casual contact that spreads this horrible disease. It is nurses and doctors who care for the sick who are at risk, relatives who physically comfort those with the disease, those who try to prepare the dead for a proper burial.

I arrived in Liberia on October 10 and plan to be here for as long as it takes to turn things around. By next month we will be a team of six on the ground (three Americans and three Liberians) here with the Johns Hopkins University Center for Communications Programs, funded by USAID to support the Liberian government’s response to the Ebola outbreak. Our work here is to communicate with Liberians about Ebola, quieting rumors and fear and giving them the information they need to help protect themselves and their families from Ebola.

The first message, back in the early days of the epidemic, was that Ebola is real. There were many questions and doubts. Conspiracies were everywhere. That message is now getting through. Now we have moved on to new messages: Practice good hygiene, like regular hand washing. If someone in your house is sick, get help and don’t try to treat him yourself. Keep the sick person isolated. If someone in your house has died, get help and don’t touch her body. We have been helping to strengthen the call center that was set up to provide that help. We think the messages are getting through.

Soon we hope to move to phase three: welcoming survivors back into the community, as the heroes that they are.

When I open my laptop and read headlines from the United States, I find it hard to believe the level of hysteria so many miles away. The risk is so miniscule. Only those who have directly treated patients in the United States have gotten sick and yet people are afraid to travel to Dallas? It makes no sense.

Shortly after I got here, I attended a big WHO briefing and heard a report from Lofa, a county in northern Liberia. The data indicates that things are starting to turn around up there. Strong, motivated leadership coupled with an engaged community look to be making the difference. It’s not the story everywhere. This epidemic is different in different areas. But in an outbreak like this, the bright spots are something to celebrate. Just without the hugs or the high-fives.

*This post originally appeared on the Johns Hopkins Bloomberg School of Public Health website. 

Let’s Not Poison the Well – How the Media Can Help Combat Ebola-related Stigma

USAID official being interviewed by local journalists about its initiative with the Paul G. Allen Family Foundation to provide 9,000 household protection kits as part of the response to help Liberians fight Ebola. Each kit includes biohazard bags, soap, PPE, and gloves. Photo by Morgana Wingard

USAID official being interviewed by local journalists about its initiative with the Paul G. Allen Family Foundation to provide 9,000 household protection kits as part of the response to help Liberians fight Ebola. Each kit includes biohazard bags, soap, PPE, and gloves. Photo courtesy USAID, by Morgana Wingard

I’ve been reading a book on HIV prevention in which the French anthropologist, sociologist and physician, Didier Fassin[1] is quoted as saying that epidemics are moments of truth for society, when power and knowledge become manifest. I keep thinking of Fassin’s words in light of the Ebola outbreak, the fear and panic that is integral to the story, and the profound effect that stigma has on the lives of those affected by such a polarizing disease.

Fear and stigma are very often common human reactions to disease, especially one that is highly infectious, spreads quickly, and for which there is still no known cure. Because it is such a frightening, dehumanizing disease, rumor and misinformation are quick to follow as people try to make sense of the illness.  With a handful of cases having cropped up in countries other than the ones in Africa where the virus is taking a massive and deadly toll, it seems that fear itself is out of control, as is the deepening stigma of those affected – not only the individuals, but also the countries: Liberia, Sierra Leone and Guinea.

One of the best ways still to counter misinformation and rumor is to work with the media in their role as public educators – especially if it offers two-way communication channels for information exchange with communities affected by the outbreak – so that they can participate in the dialogue. In Guinea for instance, where Internews is working with journalists to gain the skills needed to report on this humanitarian crisis, the interactive power of radio (along with mobile phones) provide exactly this kind of platform that engages people in the conversation related to their health and well-being. Radio remains one of the most trusted sources of information in this area, and in the municipalities where Internews works, is still the only form of media available to people, and an important way to address issues of stigma, through well-sourced, accurate and actionable information.

In the context of the three countries directly affected by the outbreak, Internews president, Jeanne Bourgault, and Daniel Bruce, chief executive of Internews Europe, also recently addressed the problem of misinformation and stigma, and how, in this climate of fear, local media can help to save lives in a blog on The Guardian. “In recent weeks, fear and misunderstanding have claimed new kinds of victims, including the three journalists killed in Womme, Guinea, along with five health workers, after they were attacked by villagers so terrified of the disease that they feared any outsider could infect their village,” they wrote. They also quoted a  Liberian official who said that misinformation was hampering efforts to tackle the outbreak there, citing rumors that an educational film shown to villagers is intended merely to distract people while officials literally poison the wells. “In such a climate, it is vital that governments and the international community understand that epidemics are exacerbated by misinformation, and that medical efforts to combat the disease must be accompanied by work to curb the spread of rumors and false news.”

Bourgault and Bruce make the critical point that “unless trust has been established, getting the message ‘right’ does not mean that it will be accepted. Credible sources of information in the local language have the greatest impact: this is why word-of-mouth is so powerful, often dangerously so. But it is also why local media can be so effective.”

Local journalists therefore have a very important role to play. If they have the resources and understand the science of the disease, they can help expand the conversation to include the voices of local communities. They quote René Sakèlè, a journalist with Radio Rurale in N’Zérékoré, Guinea, and member of a team working with Internews to produce a humanitarian radio program on Ebola in Guinea, as saying that the experience had helped to expand journalists’ view on “who is qualified to talk about the disease […] I [now] know that there are not only ‘official’ sources. There are also [health] experts, civil society, youth and women – who can all say something about Ebola.”

But journalists need the tools and the skills to report on such a complex medical issue as Ebola, as they, like the health care workers, are often on the frontlines of reporting the disease, combatting rumor and stigma. Public health messages are a critical component, but messaging alone and in isolation will not convince people who have heard and believed rumors from their friends and families. People gather information in 360-degree environments. They need to “own” the information – feel that it makes sense, speaks to them directly, and is something that is so convincing and real that they want to share it forward, and make sure that others hear the message too. In this way, radio is still a powerful tool with which people can engage.

As Bourgault and Bruce noted: “Journalists alone cannot turn the tide against Ebola, but they must be part of the solution.”

[1] Fassin, D. (2007). When bodies remember: Experiences and politics of AIDS in South Africa. Berkeley, University of California Press.

Reported Cases & Percentage of Households with Mobile Phones

reportedcases1mobilephones10_13Reported Ebola Cases & Percentage of Households with Mobile Phones, as of October 13, 2014 (Full Size JPG)