In this post Sabina shares her personal experience supporting the response to the Ebola epidemic in Guinea. She explains that listening and community engagement gave responders a better fighting chance – by locating contaminated areas before the disease spread, and by increasing community willingness to collaborate with epidemic protocols. She points out helpful listening methods, and argues that her experience shows it is possible – and that responders must – take the time to listen even in the heat of the response.

It can be hard to find the time to listen in a humanitarian emergency, when every second counts. This is true in natural disasters, where there is a singular event or series of events that requires rebuilding. It is even more true in epidemics, when disease is like a wildfire, unpredictable – when one tiny unnoticed spark can set off another blaze.

I came to Guinea during the last two phases of the response to the Ebola epidemic – I was called up to work with IOM on a program to encourage Guineans to report any signs of Ebola (or other epidemic-prone diseases) to local health authorities.

One of the greatest challenges of the response was finding ways to listen to communities to find out where the disease currently was – one contaminated person on a motorcycle could take the disease from one region of the country to another within a matter of hours.

In the Ebola response, medical professionals and burial teams were like firefighters, dispatched to villages and neighborhoods across the country to extinguish the flames of Ebola before they could spread.

But if the government and partners didn’t know where the virus had spread, or if an affected family or village refused to let responders access a suspected case, then the spark of the disease could spread unchecked and consume entire communities. And in Guinea, more than its neighbors in Sierra Leone and Liberia, many communities resisted Ebola-related interventions.

Sometimes the resistance (or “reticence” as it was called in the field) was passive: hiding a sick person, holding a clandestine burial ceremony, or refusing to give information about contacts. Sometimes it was active: meeting aid workers with machetes, stealing supplies, or burning vehicles.

An effort to educate communities on safe response to Ebola cases. Image: U.S. Centers for Disease Control and Prevention 2014

So before the medical professionals and burial teams could be sent out to extinguish an outbreak, communities had to tell responders that something was wrong, and let us in the door.

There were lots of efforts to educate Guinean communities about these questions, with communications campaigns designed by local and international experts and delivered by brave Guineans.

These campaigns were effective in many cases, and yet still, almost two years after the start of the outbreak in Guinea, communities on the frontline of the epidemic (such as Forecariah and Macenta) were still resisting the assistance of Ebola responders.

The question remained:

How do we get reticent communities to share information and cooperate with epidemic protocols?

One approach was to continue to talk at communities, scolding them like they were children for not following the rules. This approach often resulted in communities shutting down, and finding more creative and clandestine ways to carry on what they were doing.

In some contexts, there was the use of military force to ensure cooperation when words failed. While this was efficient, it often shattered what little confidence communities may have had in responders.

Another approach was to listen. This approach was pushed by socio-anthropologists, specialists in communication with disaster-affected communities, and community health veterans.

This approach was messy – it took time, resources, energy, and patience, all of which are in short supply during an epidemic. It meant going to affected communities and listening more than talking. But by listening, these people could better understand the fears of communities, the source of rumors, the most concerning questions.

This information was then used to change the way that the response was being carried out (like changing the color of bodybags) or the information that was being delivered (such as the likelihood of being cured with treatment).

This eased the friction between communities and responders, and helped create a set of rules and protocols that both sides could adhere to, while still based in the science of stopping epidemics.

The space to speak

Safe and dignified burial in Liberia. Photo: UNMEER 2015

In Forecariah, a colleague of mine was part of a delegation that went to talk to a community that was refusing safe burials. She watched as her peers criticized the community and talked down to them, and watched the community shut down. So she went back the next day on her own, and just asked to sit down and listen to the community. After a while, community leaders opened up, and told her they only had one small complaint with the way the burials were being carried out.

When she asked why they didn’t bring it up at the meeting the other day, they responded that the aid workers hadn’t given them the space to speak, and that they didn’t feel like they’d be listened to. When she brought the information back to the group, they made a small change in the protocol, and the community began to accept the burials.

Other groups listened with the help of phones and radio. Organizations such as EHealth Africa and Internews systematically collected rumors and questions through their respective platforms (a call center and interactive radio shows).

By developing listening systems, they were able to catch misinformation, analyze it, share it with other partners, and come up with more evidence-based ways to address the rumors.

Red Cross effort to better engage remote communities about the dangers of Ebola. Photo: Corinne Ambler, IFRC

The Red Cross even brought a ‘mobile radio’ to Ebola-affected communities to give them a platform for people to publicly voice their concerns and perspective.

This could have a calming effect on tense situations between a community and responders – people had an outlet for their fears and ideas, and knew they were at least being heard.

Understand community priorities and anticipate community frustrations

I had a large team working with communities across 11 prefectures in Guinea, and every single one received training on listening and community dialogue.  This helped them to catch rumors, better understand community priorities, and anticipate community frustrations.

Our whole program was centered around encouraging Guineans to speak up about epidemic-prone diseases, and if we want to encourage communities to speak, we had to show them that we know how to listen.

As public health workers we cannot fight epidemics if we don’t know where they are, or if we can’t access the affected communities.  Listening takes time, but if we don’t take the time to listen in the heat of the response, we may find that we are fighting the wrong fires.