“Working in silos doesn’t work for outbreak response”: Localising social science response efforts in West Africa
In a follow-up to the blog post “Action not justification: how to use social science to improve outbreak response” from December 2018, Hana Rohan (UK Public Health Rapid Support Team, London School of Hygiene and Tropical Medicine/Public Health England, London, UK), Gillian McKay (London School of Hygiene and Tropical Medicine, London, UK), & Baindu Agatha Khosia (Focus 1000, Freetown, Sierra Leone) discuss here a new West African initiative on social science for epidemic preparedness.
A year into the Ebola outbreak in North Kivu, Democratic Republic of Congo (DRC), over 3000 people have been infected and more than 2000 have died. The outbreak was declared a Public Health Emergency of International Concern by the World Health Organisation in July 2019, the outbreak’s eleventh month. The North Kivu Ebola outbreak – DRC’s tenth – is eclipsed in size only by the 2013-2016 West African outbreak (during which upwards of 28,000 people were infected, and 11,000 died) and has been a particularly complex operational environment. The people of North Kivu have endured conflict and instability for more than 25 years, and local politics is influenced by a fluctuating array of armed groups. The relationship between the province and DRC’s central government in Kinshasa is highly fractious, and after decades of neglect by both central government and the global health community there is a deep – and understandable – mistrust of outsiders. Despite the deployment of new tools such as vaccines and experimental treatments, the contextual complexity has made it extremely challenging for local and international response partners to implement standard Ebola containment strategies. These challenges have contributed both to the growth and spread of the outbreak, and to a very dangerous and dynamic environment for those working in the response.
In the years since the West African Ebola outbreak, there has been a plethora of “lessons learnt” conferences, events, and reports (including by WHO, ODI, The Lancet, the IRC and GOAL), many of which committed the global public health community to ensure that future outbreak response would be more sensitive to the needs and perspectives of local communities. To support this localisation agenda, social science has been identified as a necessary outbreak ‘discipline’ alongside epidemiology, clinical medicine, microbiology, and public health to help ensure that outbreak response is designed in locally appropriate ways. The DRC outbreak has realised some of these lessons, with a dedicated team of cross-disciplinary social scientists embedded and working with other analytical colleagues.
However, it remains that when social scientists are recruited for outbreaks they are often brought in from outside the country or region for complex institutional, structural and systemic reasons. This can be due to poor recognition or a shortage of local social scientists; at other times this reflects the dominance of the Global North in public health activities in the Global South. This means that even the best quality social science research can sometimes miss local context and history, and the scientists themselves must work through translators, losing some of the nuance that local scientists would bring to the table.
It is critical that local, experiential knowledge forms the basis of recommendations provided to response staff. As well as helping to ensure that data are locally grounded, this also helps to structure and maintain community collaboration and participation, and avoid top-down, ‘consultative’ approaches to data collection and response design. Engaging local social scientists allows them to draw on their established social networks that can facilitate data collection activities, especially when timelines are short or access is difficult.
As a first step in localising social science for epidemic response in the West African region, we would like to introduce the West Africa Social Science Epidemic Response Network (WASSERN). The initiative was kickstarted at a meeting in July 2019 by researchers from Sierra Leone, Nigeria, the Gambia, and Liberia, with support from the Ministry of Health and Sanitation Sierra Leone and the UK Public Health Rapid Support Team. Meeting attendees represented institutions as diverse as the Nigeria CDC, Njala University (Sierra Leone), the Medical Research Council’s Gambia unit, the Sierra Leone CHAMPS project and the University of Liberia, as well as several others (see list at the end of this article). The launch event for this network was held at Sierra Leone’s Public Health Emergency Operations Centre in Freetown and provided an opportunity for attendees to meet with their regional and country colleagues, receive briefings on subjects as diverse as outbreak Incident Management Systems, the ethics of conducting research in an active outbreak and methods for rapid operational research, as well as to provide feedback on their training needs to improve their capacity for outbreak response work.
After Sierra Leone’s devastating Ebola outbreak, the country has taken great strides in strengthening its outbreak response capacity. Its experience with outbreak management has valuable lessons for other countries in the West Africa region, and Sierra Leone’s Ministry of Health and Sanitation (MOHS) is working to establish regional networks of surveillance staff, as well as of other outbreak disciplines, for strengthened epidemic preparedness within Sierra Leone and across the ECOWAS region. The MOHS is also keen to develop a cadre of social scientists within Sierra Leone to work with the Health Emergencies programme and further support outbreak preparedness efforts. Sierra Leone’s leadership in these areas makes it an ideal place to launch the WASSERN network.
Very few of the WASSERN social scientists had had an opportunity to meet prior to this event, and in some cases even researchers from within the same country or institution were not aware of each other’s work. A better networked social science/infectious disease community means improved surge response in the event of an outbreak, more collaborative research in ‘peacetime’, and improved capacity across the board as we identify opportunities to learn from one another. WASSERN members now communicate regularly through a WhatsApp group and via email, share research and funding opportunities with one another, and discuss ways to collaborate on regional research questions, ensuring local capacity is poised to set the research agenda in this region.
WASSERN is made up of anthropologists, sociologists, health systems specialists and policy researchers, all passionate to integrate outbreak preparedness and response into their skill sets. WASSERN members felt that social scientists should be embedded across all aspects of Incident Management systems and structures, and not siloed within the Risk Communications and Community Engagement pillar or in analytical cells, and therefore that there is still work to be done in mainstreaming social science activities within outbreak response.
“The community and landscape of an outbreak needs to be understood, alongside the pre-outbreak health system and policies; what is there now? What was there before? All of these things will affect how people seek care during an outbreak, and cannot be ignored” – WASSERN launch break out session
This group has made it clear: they need equal standing with epidemiologists and biomedical scientists in outbreak response, since without grounded, localised insights, and adaptive response organisations, outbreaks are much harder to bring under control.
It is only a very few outbreaks (such as the West Africa or DRC Ebola outbreaks, or the 2016 Zika outbreak) that garner international attention. The vast majority of outbreaks happen on a much smaller scale, and never receive the declaration of a Public Health Emergency of International Concern by the WHO. Instead they are managed by national ministries of health, and do not always draw the international funding that would allow for international social scientists to support outbreak response activities. By the time notification of an outbreak has been received, it is generally too late to establish the networks required to support the collection of good quality social scientific data. Networks like WASSERN embed social scientists at the national level, linked up with their colleagues in universities, NGOs, health ministries and national public health agencies, so that they can be called on to offer insights for all disease outbreaks, including more common ones like cholera, measles and malaria, as well as rarer diseases like Ebola or Rift Valley Fever.
A robust localisation agenda can only help to facilitate improved global health security and creative ways of responding to the increasing complexity of the humanitarian/development nexus. By strengthening local and regional networks outside of emergencies and supporting the development of local solutions and response capacities, outbreak-vulnerable regions are better placed to respond when a crisis hits. Initiatives like WASSERN contribute to growing a strong localised preparedness agenda. Local social scientists have longstanding relationships with their communities and institutions, understand local history, politics, context and languages and are therefore best placed to develop recommendations that are appropriate and impactful.
Authors: Hana Rohan1, Gillian McKay2, Baindu Agatha Khosia3
Affiliations: 1 UK Public Health Rapid Support Team, London School of Hygiene and Tropical Medicine/Public Health England, London, UK; 2 London School of Hygiene and Tropical Medicine, London, UK; 3 Focus 1000, Freetown, Sierra Leone
Are you a West African social scientist with an interest in outbreak response? Join WASSERN today! Email hana.rohan@lshtm.ac.uk to be introduced to the group.
WASSERN members: Abdulai Bah (CHAMPS Sierra Leone/Focus 1000), Abolaji Azeez (University of Ibadan), Abu Conteh (Sierra Leone Urban Research Centre), Adama Thorlie (Sierra Leone), Baindu Agatha Khosia (CHAMPS Sierra Leone/Focus 1000), Chimezie Anueyiagu (Nigeria Centre for Disease Control), Erick Kaluma (CHAMPS Sierra Leone/Focus 1000), Fatou Jaiteh (Medical Research Council Unit The Gambia), Kadiatu Bangura (EBOVAC Salone), Mahmoud Haroun Bangura (EBOVAC Salone), Mambu M Massaquoi (Njala University, Sierra Leone), Matthew Ayegboyin (University of Ibadan, Nigeria), Mohamed Lamin Kamara (EBOVAC Salone), Mohammad Jalloh Sr. (Focus 1000), Ojo Melvin Agunbiade (Obafemi Awolowo University, Nigeria) Osman Fofanah, (EBOVAC Salone), Paul Sengeh (Focus 1000, Sierra Leone), Penda Johm (Medical Research Council Unit The Gambia), Roseline Konneh (University of Liberia), Rosetta Isha Kabbia (EBOVAC Salone), Saa David Nyuma Jr (University of Liberia), Saad Barrie (Focus 1000, Sierra Leone), Tommy Matthew Hanson (Njala University, Sierra Leone).
With special thanks to Dr Mohamed A Vandi (Sierra Leone Ministry of Health and Sanitation), and Dan Brunsdon (LSHTM) for their support in running the workshop.
Disclaimer/Acknowledgement
The UK Public Health Rapid Support Team is funded by UK aid from the Department of Health and Social Care, and is jointly run by Public Health England (PHE) and the London School of Hygiene & Tropical Medicine (LSHTM). The University of Oxford and King’s College London are academic partners.
The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research or the Department of Health and Social Care.
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Feature image credit: Gillian McKay.