Ebola: A Behavior-Driven Crisis

Whether it is SARS, H1N1, Ebola or, now, the Zika virus, emerging pathogens continue to challenge public health experts. Because of the emergent nature of the pathogen, effectively responding to these outbreaks in real time always requires the use of social and behavior change communication (SBCC) while other solutions (vaccines, treatments, etc.) are sought.

This was the case with Ebola, which spread to Liberia in spring 2014 from Guinea and then within West Africa. When all was said and done more than 11,000 died, but SBCC played a crucial role in stemming the spread by calming fears, dispelling rumors, providing answers and pulling together a coordinated response.

Medical interventions were not stemming the outbreak and throughout June, July and August of 2014, more and more people were dying and very few were surviving. The Liberian Ministry of Health (MOH) along with international and national NGOs quickly realized prevention messaging and community/social mobilization efforts were needed to reach communities to underscore the need to change behaviors related to long-standing cultural practices. Communities needed timely and credible information, but it was also critical that they felt ownership of their response to the crisis. Early messaging such as “Ebola Kills” created fear and confusion. The MOH had to convince communities that Ebola was deadly, but you could survive if you sought help early.

Gathering research in such a chaotic time and place was clearly a challenge. Doubts about methods of transmission and prevention strategies further created confusion, fear and mistrust among those in the affected areas. At the time, data was not available about the public’s level of knowledge of the Ebola virus, its modes of transmission and what kind of information communities needed to guide their response and help curb the epidemic.

Surveys were conducted via text messaging using mobile phones to quickly gather on-the-ground perceptions and knowledge of the virus among affected communities. This high-tech, low-touch method kept door-to-door surveyors away from potential exposure to the virus.

In November 2014, the USAID-funded Health Communication Capacity Collaborative (HC3) partnered with an SMS-based survey company called GeoPoll to design and disseminate a questionnaire that would produce a rapid assessment.

In September 2014, Ebola hit its peak in terms of death toll in Liberia, although that would not be apparent until later. Before significant international assistance arrived, SBCC materials and community and social mobilization were some of the only tools available to fight the virus and reduce cases. Village chiefs, and community and religious leaders became engaged and talked to their communities about the disease, stigma, prevention and treatment. Materials corrected misinformation and rumors and provided credible information. While Monrovia struggled, Lofa County was seeing a true decline due to its social mobilization efforts.

In October 2014, the international community responded in force, and by November financial, material and human resources began pouring into the country. By this point, however, the number of cases and deaths began to subside (September and October were the peak months, by the end of November the number of cases per day had been more than halved). In December and January, newer Ebola treatment units (ETUs) were not filling to capacity. It was clear that behavior change through messaging and social mobilization was the primary driver of reduced infections and deaths, not the arrival of the new ETUs.

On May 7, 2015, Liberia was declared Ebola free. But the celebration was short-lived. Six other cases emerged in June and July. The country restarted the countdown process and was again declared Ebola-free September 3, 2015. But after it flared up again in November, the country was declared virus-free in January 2016. Yet another case emerged in April 2016.

Reflecting on the trajectory of the outbreak underscores the need to incorporate SBCC in risk communication and emergency preparedness planning. While experimental vaccine trials for Ebola are now underway in West Africa and the health systems are undergoing an overhaul there, SBCC was all that was available at the start of the crisis in Spring 2014. SBCC can be applied to other emerging health threats such as Zika, as it has successfully been applied to existing threats like HIV/AIDS, malaria, child survival and maternal mortality.