In Ebola-hit DRC, wins and challenges of community engagement

MANILA — A few weeks before an attack on an Ebola treatment center run by Médecins Sans Frontières in Katwa, in the Democratic Republic of the Congo’s North Kivu province last month, a particularly troubling message was circulating on mobile chat platform WhatsApp among youth in the district:

“If you go to the doctor, you risk contracting Ebola through the medicine you’re given. The doctor and the response team are there to exterminate people. The people of the response, Medecins Sans Frontieres, Astrames, OMS, TDR, psychologists and local doctors are corrupt.”

Though not linked directly with the attack, experts say the WhatsApp message is reflective of the pervading perceptions of Ebola-affected communities in DRC. The Katwa attack was followed by one in Butembo, forcing MSF to suspend its operations, and prompting aid responders to reassess their interventions, in particular, their community engagement efforts.  

“We need to be doing much more around making communities understand who we are and what we do collectively and why we’re there in full force,” said Ombretta Baggio, senior adviser on community engagement and accountability at IFRC.

There have been 964 confirmed cases of Ebola out of 1029, and 577 confirmed deaths out of 642 in Ituri and North Kivu provinces since the start of the outbreak, as of March 27, according to DRC’s Ministry of Health. At present, 239 suspected cases are under investigation.

The situation

Security has been a particular challenge in containing the outbreak, and mistrust amongst the community has added to the task.

“In the wake of violent attacks on health workers and treatment units, there is growing recognition that more needs to be done to gain community acceptance,” Dr. Vinh-Kim Nguyen, medical team leader for MSF working in the Ebola response in DRC, wrote in an opinion piece on The New England Journal of Medicine.

One of the common narratives in the ongoing Ebola outbreak in DRC is that responders are better prepared this time than five years ago in West Africa. The ring vaccination, experts say, is helping curb the spread of infection.

But that same medical breakthrough has become a source of suspicion and mistrust against the government and health workers. Some communities suspect the vaccines are used as weapons to spread the virus, or that it would cause sterility and disability, according to a compilation of surveys and community feedback produced by multiple stakeholders in the response.

While such rumors aren’t unheard of in outbreaks where vaccines are a key component of the response, those are not helpful in the context of North Kivu, where the Ebola outbreak has changed directions multiple times for the past eight months.

From Mangina and Beni, the outbreak’s epicenter has moved to Katwa and Butembo, a city that has its own history of insecurity, frustrations, and mistrust in outsiders. The city’s exclusion from the national elections in December did not help in allaying suspicions of Ebola as mainly a government scheme, particularly in a known opposition-stronghold.

For responders, that meant having the need to restart their community outreach and reorient new response teams.

Use of behavioral data

Social science and behavioral data have become more prominent in the response in North Kivu, but making use of the available information they provide has its own challenges.

“There are challenges in making use of all the social science and behavioral information effectively and in a timely manner,” said Juliet Bedford, founder and director of Anthrologica, a research-based organization using an anthropological lens to address global health issues.

Some of the factors contributing to this have to do with coordination and structural issues. For example, social scientists may recommend responders not to arrive in long convoys of jeeps as this attracts attention, or not have police or military at burials. But some organizations aren’t always able to follow this, especially when there are security concerns in the area of the response.

Social science data and behavioral information have also often been applied only by those working on risk communication and community engagement, as opposed to being used across the response.

“What we, working remotely, have made a big effort to do is to make sure that that kind of social science intelligence is shared across the response much more strategically,” she said, ensuring that social and behavioral data are given as much value and weight as the clinical and epidemiological information.

Improved efforts for community engagement

The application of social science information and methodologies that allow responders to capture and analyze community feedback, however, have achieved some successes in dispelling rumors and suspicions, as well as calming down aggression toward international responders.

One of the information made available early on in the response in North Kivu, for example, was about how important it is for families to see the deceased’s body.

This information was complemented by community feedback captured by national Red Cross volunteers who go household to household to impart information regarding Ebola and the response. Through a methodology developed by the International Federation of Red Cross and Red Crescent Societies and the U.S. Centers for Disease Control and Prevention, this information is placed in an excel file and coded by local volunteers, allowing IFRC and CDC to interpret and analyze the biggest concerns and most frequent questions raised by the communities.

Through this mechanism, they learned about circulating rumors in Beni of how burial teams are placing stones instead of the bodies of the deceased in body bags, or how responders are using and selling organs of those who died.

“So we started procuring transparent body bags for the first time ever,” IFRC’s Baggio told Devex.

Baggio shared how the community feedback mechanism has helped them understand how they can focus and redirect their actions, dispel myths, and address rumors.

Meanwhile, Grant Leaity, UNICEF’s deputy director of emergency programs in New York told Devex tapping into social science intelligence has helped the program in understanding the different sociocultural and political dynamics specific to communities in the outbreak.

“There's this kind of reaction which is to some extent almost an anger related to the fact that the only interest of the Ministry of Health and the international partners is really about bringing an end to the transmission of Ebola,” he said.

“If we understand these kinds of reactions or perceptions, then that helps us in the way we approach discussions,” he added.

In November, for example, Leaity and some of his colleagues engaged in a Q&A session with a community just outside of Beni, where groups of young men have been seen to beat cars containing responders that pass along the area. They presented a video explaining Ebola and its risks, and asked a survivor to share his experience.

“Sometimes, these things are about sitting down in the community, listening, taking time … There's no kind of magic wand, but it is a process of working through these things with those different community groups,” he said.

Response complications

Efforts to win communities’ trust and understanding, however, are sometimes impeded by capacity issues and insecurity.

In a survey done by UNICEF in December 2018 in Kalunguta and Katwa, for example, they received reports of bodies not properly being buried according to local customs and beliefs. This included reports of bodies being buried in “dirty” clothes, and the deceased’s head not facing the village or mountain as is the local custom.

“What we have found was sometimes … clear messaging was given in the community around safe and dignified burials. However ... there are cases where the response is not conducted in line with what has been told [to the community],” Leaity said.

Bedford explained that such nuanced customary practices are not always well known and therefore incorporated in the response immediately. Yet, this has prompted questions in the community, which some may classify as community resistance.

But Leaity said it’s both a capacity and security issue.

“The situation of insecurity [is] an aggravating factor. Let's not underestimate that,” he said, noting the high insecurity responders face in North Kivu.

Don’t blame the communities

Community feedback gathered by Red Cross volunteers from Butembo and Katwa showed a common picture of mistrust and fear of the Ebola treatment centers, and “aggression” against the responders, IFRC’s Baggio said.

The WhatsApp message from Katwa, which was received by Anthrologica’s Bedford and her team, continued: “To put an end to Ebola, we need to drive away the whole team, and cut off its financing. Or, make them stop their activities and go examine the laboratory and medicine that they use.”

Like most responders, Baggio cautioned against blaming the communities.

“They’re coming from a very difficult situation. They are among the most resilient communities we’ve ever seen, and they have questions [and] want to engage in the work,” she said.