Posted by Melissa Minor Peters Response and Resilience Team Anthropologist
The Ebola response has posed new challenges for the humanitarian community, including the challenge of understanding and overcoming the social barriers to complying with Ebola prevention and treatment messages. Anthropologist Melissa Minor Peters was deployed by Oxfam to conduct an anthropological survey to support our programme in Liberia.
Early on in Oxfam's Ebola response, the team decided to find an anthropologist to do a study in Liberia that aimed to support Oxfam's Public Health Promotion (PHP) strategy through a rapid qualitative assessment of the seemingly intractable social barriers to complying with Ebola prevention and treatment messages.
Oxfam had only once before used an anthropologist for humanitarian work, in DRC to look at people's behaviours regarding cholera. I had no previous humanitarian experience, but a certainty that an anthropological survey would be absolutely beneficial in helping to understand and overcome the barriers to stopping the spread of Ebola.
In the first few days, I critically analysed the situation. My initial questions included: how much autonomy can someone ever have with an epidemic? And what rights and individual choices are available to them? There was an assumption that if people had information and options, they will do the right thing. I was impressed with Oxfam's work and the approaches used, and appreciated the attempts to get community buy-in and ownership of the situation and involve local stakeholders.
When I arrived there was still fear and resistance due to negative experiences early on in the epidemic, and my role was to investigate the social factors hindering compliance. Other factors affecting people's ability to deal with Ebola were physical - eg lack of transport, inadequate roads, and no Ebola Treatment Units. But early attempts to try to force changes in behaviour by both the Government and the international community created emotional fears, particularly in how people viewed burial teams and treatment centres.
My next step was to find out what underlay those fears and what Oxfam could do to address it. During active case finding, where Oxfam would try to find people with Ebola like symptoms, I gave daily feedback to the PHP teams after observing the work of Oxfam's community health volunteers. Interaction firstly had to be positive, particularly with people giving out sensitive health information. A second important issue I identified was that while community volunteers were thought of as 'local' by Oxfam, many were not actually from the same communities, and there was a need to localise our work even more to generate greater trust with the communities.
Language can also build fear. Maybe it was the involvement of military actors in this response, but there was a tendency to use words like 'swarm', 'surge' and 'hunting' people and Ebola. In a country recovering from conflict, this language was not perhaps the best way to encourage behavioural change! There was a need to approach communities with care to build trust and show that we were looking out for them.
A final major observation was that generally the response was quite gender blind. Although those affected were almost evenly split between men and women, there did turn out to be gaps in awareness between the sexes. Focus group discussions showed that men had better access to the information on Ebola treatment and prevention messaging, but women wanted more information and had more questions. This meant the teams needed to engage much more with women, particularly as they are generally responsible for domestic surveillance in homes.
I observed the community healthcare volunteers, and found them incredibly fast and dynamic, especially with such a fluid situation, changing day to day. There were small issues observed such as how young men should approach an older woman - are there appropriate ways to do this? Perhaps have female volunteers do it instead? But in general, even when a potential Ebola case was found, the volunteers handled the situation well and in a respectful manner.
The main learning for Oxfam for the future is that Oxfam and the humanitarian community need to better understand health seeking behaviours and what people's first response would be. For example many tried to do self-treatment at home with Liberian health centres shut down. People relied on self-treatment and local informal health care workers rather than resorting to hospitals, and opportunities should be taken to engage with these informal health care workers.
The second major lesson learnt was the need for social mobilisation. Even today the President of Liberia admits the attempt to quarantine West Point was a mistake. People do not react well to coercion, and the focus should always be on positive engagement. The early panic isolated people and communities and overall was a very dehumanising experience for them.
Oxfam is now trialling the use of anthropology in other emergencies. I feel that the anthropological field could be used for a range of situations and not just epidemics like Ebola or cholera. Anthropology is simply about understanding local ways of seeing things and an attempt to understand the experience of people we're working with. It is simply put 'an exercise in using empathy as a research tool'. There will always be a challenge in a rapid response of being able to do a detailed study of people's behaviours, but the Ebola outbreak and Oxfam's significant success in studying behaviour and experience shows there is a certain future for anthropological work in Oxfam's humanitarian work.