Ebola diaries: Regaining the people’s trust
Cristiana Salvi, a risk communications specialist from WHO’s European regional office was deployed to Guinea at the end of April – early May 2014 to provide social mobilization support to the Ebola response. Social mobilization involves working with communities to gain their acceptance of the need for early identification of people with illness, early treatment and identification and follow up of all people who have been in contact with people confirmed to have Ebola virus disease. Cristiana was among the first from WHO offices other than Headquarters and the African office to provide support to the field response, many others followed from the “wider WHO”. She travelled to Gueckedou where communities had begun to hide people who were sick, fearing treatment centres, believing rumours Ebola response teams were there for sinister purposes. This is what she found.
“We flew on this tiny aircraft and arrived in the middle of nowhere. There was a landing strip and nothing much else - large spaces dotted with trees, savannah land, you also had these little constructions around. That was ‘the airport’.
Then there was a 2-hour drive down a really difficult road into Gueckedou. When we got there we immediately started, met up with the head of the health unit, Dr Pépé Bilivogui. He was the local head of the response there and he was just one of the best people I ever worked with. Ebola was totally new to him and everyone else there. Not only the population, the health care workers but also the government responders were totally taken aback by this disease. He told me they really relied heavily on WHO for advice and help.
I was part of the social mobilization and communications team that was supporting the local health authority. It was a great team, had an effective way to work, very practical, very concrete, no one was imposing anything on others. Basically it was WHO, Plan Guinea, UNICEF, Red Cross, Espoir Guinea, MSF, all working together to support the government of Guinea. We met every morning, each one had clear idea of what to do, reporting back to each other and we were really working together in such an effective way. In a short time we achieved so much.
Trusted people opened village doors
The main thing we needed to do was change the messages - the ones being used were too general. Most of them had been taken from outbreaks in other countries, like the Democratic Republic of Congo (DRC), and those materials did not take into account specific circumstances. What we did at that point was to identify the behavioural barriers and right target audience and the perceptions driving those barriers. I was in DRC in 2007 and the reasons driving resistance were mainly religious but in Gueckedou it was especially mistrust of foreign people.
We found that the big problems were resistance to cooperating with response teams, stigmatization, mistrust of treatment centres, mistrust of burials, hiding sick people, lack of information, vulnerability of women and dangerous rumours that were circulating. One of the most crucial things we did to change this was engagement of wise people to tackle resistance. That was really the challenge, the resistance of the population to the responding teams.
Basically the idea was to engage with the wise people - those people who are part of the community and very much respected, very much trusted - who could open the doors of the villages to the responding teams. We had a ‘wise woman’ - she was sixty but every morning would get on a motor bike and would go to many villages that were resistant. She would talk to them in a language they would understand. I don’t mean only spoken language but the language of tradition, of culture, of brotherhood. She would talk to them for many hours - this really made a lot of difference. Before she and the other wise-people came, there was a lot of resistance because there were all these foreign teams coming in and there was a lot of mistrust.
One of the main problems was that people were not showing up in the treatment centres. They were not saying they were sick because they believed they would be neglected, would not be fed, they would die, and when they died their bodies would be deprived of their organs and their blood. So we needed to tell them this would not be the case.
Also we needed to tell them that the sooner they went to the treatment centre the sooner they would receive care to help fight the disease. At the beginning of the outbreak what was needed was to alert the population about this new and dangerous disease, so the accent had been on its severity and fatality.
This turned out to be backfiring as people started thinking there was no survival from Ebola, so they preferred to die at home. So we did three things. First we involved the survivors because this way they could bear witness that this was not so. We asked them to explain that they were fed, they were treated, and they got better.
"The idea was to engage with the wise people - those people who are part of the community and very much respected, very much trusted - who could open the doors of the villages to the responding teams."
Cristiana Salvi, WHO
Support for families of people with Ebola
But also we advised very strongly that families needed to be given incentives. We advised that all the families with a patient in the ETU should be given one telephone so they could be in contact and this way the patient could tell them they were being treated and being fed. We also suggested families be given free taxi trips so they could visit the person in treatment centres.
Finally, we radically changed the message focus to say loudly that you can survive Ebola.
We realized in that area 2 in 3 cases were women. So I organized a focus group to really understand what was behind it. For instance even though we knew the women were taking care of the sick people, we didn’t know it was an obligation. Sometimes they were not happy to do that, but they had to do it. This was their obligation, by custom, whether they wanted to or not. The men decided what actions to take but it was the women who had to care for the ill and to prepare the dead for burial.
We learned from all the people we spoke to, what their problems, what their needs and what their concerns were. So we acted. When the minister for health planned to visit the area, we asked him to support assistance for the families of people with Ebola - to provide the telephones, taxi rides, food for families whose breadwinners had been hospitalized. These things were announced during the minister’s visit and were provided for the families."
Guéckédou was among the first areas to become free of Ebola in Guinea. Cristiana went back to Guinea later in the outbreak, this time to the capital Conakry to use her field experience there. A broader version of the wise-people was established in Baisse Guinea where the outbreak had moved: these were the “Watch Committees” a group of people coming from the community and working for the community. The concept was the same: winning resistance through the people that people trust.