How Villagers in Central Sierra Leone Understand Infection Risks Under Threat of Covid-19

Concern has been expressed over how well Africa is prepared to cope with the pandemic of Covid-19. Will rural populations with low levels of education know how to apply community-based infection control? We undertook fieldwork in two villages in central Sierra Leone to gain insight into how rural people faced with Covid-19 assess epidemic infection risks.The Wellcome Trus

Social pathways for Ebola Virus Disease in rural Sierra Leone, and some implications for containment

The current outbreak of Ebola Virus Disease in Upper West Africa is the largest ever recorded. Molecular evidence suggests spread has been almost exclusively through human-to-human contact. Social factors are thus clearly important to understand the epidemic and ways in which it might be stopped, but these factors have so far been little analyzed. The present paper focuses on Sierra Leone, and provides cross sectional data on the least understood part of the epidemic-the largely undocumented spread of Ebola in rural areas. Various forms of social networking in rural communities and their relevance for understanding pathways of transmission are described. Particular attention is paid to the relationship between marriage, funerals and land tenure. Funerals are known to be a high-risk factor for infection. It is suggested that more than a shift in awareness of risks will be needed to change local patterns of behavior, especially in regard to funerals, since these are central to the consolidation of community ties. A concluding discussion relates the information presented to plans for halting the disease. Local consultation and access are seen as major challenges to be addressed

Towards an understanding of resilience: responding to health systems shocks.

The recent outbreak of Ebola Virus Disease (EVD) in West Africa has drawn attention to the role and responsiveness of health systems in the face of shock. It brought into sharp focus the idea that health systems need not only to be stronger but also more 'resilient'. In this article, we argue that responding to shocks is an important aspect of resilience, examining the health system behaviour in the face of four types of contemporary shocks: the financial crisis in Europe from 2008 onwards; climate change disasters; the EVD outbreak in West Africa 2013-16; and the recent refugee and migration crisis in Europe. Based on this analysis, we identify '3 plus 2' critical dimensions of particular relevance to health systems' ability to adapt and respond to shocks; actions in all of these will determine the extent to which a response is successful. These are three core dimensions corresponding to three health systems functions: 'health information systems' (having the information and the knowledge to make a decision on what needs to be done); 'funding/financing mechanisms' (investing or mobilising resources to fund a response); and 'health workforce' (who should plan and implement it and how). These intersect with two cross-cutting aspects: 'governance', as a fundamental function affecting all other system dimensions; and predominant 'values' shaping the response, and how it is experienced at individual and community levels. Moreover, across the crises examined here, integration within the health system contributed to resilience, as does connecting with local communities, evidenced by successful community responses to Ebola and social movements responding to the financial crisis. In all crises, inequalities grew, yet our evidence also highlights that the impact of shocks is amenable to government action. All these factors are shaped by context. We argue that the '3 plus 2' dimensions can inform pragmatic policies seeking to increase health systems resilience

Negotiating Intersecting Precarities: COVID-19, Pandemic Preparedness and Response in Africa.

This article shares findings on COVID-19 in Africa across 2020 to examine concepts and practices of epidemic preparedness and response. Amidst uncertainties about the trajectory of COVID-19, the stages of emergency response emerge in practice as interconnected. We illustrate how complex dynamics manifest as diverse actors interpret and modify approaches according to contexts and experiences. We suggest that the concept of "intersecting precarities" best captures the temporalities at stake; that these precarities include the effects of epidemic control measures; and that people do not just accept but actively negotiate these intersections as they seek to sustain their lives and livelihoods

Engaging communities as partners in health crisis response: a realist-informed scoping review for research and policy

Background: Health is increasingly affected by multiple types of crises. Community engagement is recognised as being a critical element in successful crisis response, and a number of conceptual frameworks and global guideline documents have been produced. However, little is known about the usefulness of such documents and whether they contain sufficient information to guide effective community engagement in crisis response. We undertake a scoping review to examine the usefulness of conceptual literature and official guidelines on community engagement in crisis response using a realist-informed analysis [exploring contexts, mechanisms, and outcomes(CMOs)]. Specifically, we assess the extent to which sufficient detail is provided on specific health crisis contexts, the range of mechanisms (actions) that are developed and employed to engage communities in crisis response and the outcomes achieved. We also consider the extent of analysis of interactions between the mechanisms and contexts which can explain whether successful outcomes are achieved or not. Scope and findings: We retained 30 documents from a total of 10,780 initially identified. Our analysis found that available evidence on context, mechanism and outcomes on community engagement in crisis response, or some of their elements, was promising, but few documents provided details on all three and even fewer were able to show evidence of the interactions between these categories, thus leaving gaps in understanding how to successfully engage communities in crisis response to secure impactful outcomes. There is evidence that involving community members in all the steps of response increases community resilience and helps to build trust. Consistent communication with the communities in time of crisis is the key for effective responses and helps to improve health indicators by avoiding preventable deaths. Conclusions: Our analysis confirms the complexity of successful community engagement and the need for strategies that help to deal with this complexity to achieve good health outcomes. Further primary research is needed to answer questions of how and why specific mechanisms, in particular contexts, can lead to positive outcomes, including what works and what does not work and how to measure these processes

Epidemics and community conflicts: the value of indigenous institutions in addressing development shocks in rural Sierra Leone

This work looks at the effect of institutions on development in Sierra Leone.  Problems of underdevelopment have been linked to institutional failures.  This thesis examines that argument, in relation to agrarian challenges contributing to the civil war of 1991-2002 and epidemic of Ebola virus disease in 2014-15. Chapter 2: The outbreak of Ebola Virus Disease in Upper West Africa 2014-15 is the largest ever recorded.  This chapter describes the epidemic in Sierra Leone, and explores some of the social factors responsible for spread of the virus. Molecular evidence suggests infection depended on human-to-human contact.  To understand the epidemic and how to stop it social analysis was necessary.  The chapter focuses on the spread of Ebola in rural areas, the least fully documented part of the epidemic.  Various forms of social networking in rural communities and their relevance for understanding pathways of transmission are described.  Particular attention is paid to the relationship between marriage, funerals and land tenure.  Funerals were identified as a high-risk factor for infection.  Chapter 3: This chapter considers local responses to the introduction of a large-scale Ebola Treatment Centre in eastern Sierra Leone in 2014-15.  Our study used qualitative methods to gather responses from patients, members of the families of survivors and victims of the disease, social liaison workers, and members of the general public. Scepticism and resistance were widespread at the outset. Direct experience of the disease changed perceptions, however. Even relatives of deceased victims agreed that the centre was valuable.  However, we also present evidence of scepticism in the minds of members of the general public, who continued to consider that Ebola was a crisis manufactured for external benefit.  Our conclusions stress the importance of better connectivity between communities and Ebola facilities to facilitate experiential learning. There is also a need to address the wider cognitive shock caused by a well-funded Ebola health initiative arriving in communities with a long history of inadequate health care. Building trust requires Ebola Virus Disease to be re-contextualized within a framework of concern for the health of all citizens. Chapter 4: This chapter discusses an institutional innovation intended to address some of the problems apparent in public response to large scale Ebola Treatment Centres apparent in chapter 3. These centres were distant from where new cases were emerging, and not well designed to allow families to maintain contact with patients.  This challenged local institutional values, rooted in ideas about mutual care for the sick and dead.  Families were slow to reveal Ebola cases to the authorities, and infection spread. A need to accommodate family-based enclave values was recognized and new smaller, decentralized facilities (Community Care Centres) were established.  As a result, families began to feel they were playing a meaningful part in the treatment of their patients, even though basic biosafety principles still had to be followed. Communities were also involved in providing land and in the building of the centres.  Responders stumbled over land tenure issues until local institutional perspectives on land ownership were accommodated. The chapter argues that it is not necessary or helpful to impose “formal” top-down institutions on Ebola response.  It may be better to try to work local institutional values into the development “mix”. Chapter 5: This continues the theme of institutional clash, but now applies the argument to a new case.  The civil war in Sierra Leone (1991-2002) fought for diamonds, or was it a peasant insurgency motivated by agrarian grievances? The chapter argues the case for agrarian grievance, derived from an examination of the anthropological literature concerning land, labour and marriage.  The argument is tested using econometric tools applied to data from a randomised household survey undertaken in 178 villages surrounding the Gola Forest in eastern and southern Sierra Leone, the cradle of the war.  It is shown that peasant disputes over marriage mark out an institutional clash concerning inter-family labour, evidenced by cases presented in local courts and family moots.  Disputes mainly involve a village elder suing a young man with weak social protection.  Fines are exceptionally high.  Most fines are paid off in the form of farm labour.  The chapter reports that a temporal distribution of cases is strongly associated with two periods of peak labour demand on upland rice farms.  It is concluded that local requirements to maintain social cohesion through marriage clashed with the growing individualism of labouring youth, and contributed to conditions fostering insurgency. This agrarian hypothesis, in turn, helps account for the otherwise puzzlingly high levels of peasant-upon-peasant violence associated with the civil war in Sierra Leone. Chapter 6:  Chapter 6 offers a reflection on issues of institutional conflict raised throughout the thesis. When the decade-long civil war ended in 2002 NGO motorbikes penetrated to all parts in the relief and rehabilitation effort. This encouraged ex-combatants to buy cheap Indian bikes to take up work as taxi riders.  Young women – a highly targeted group during the war – were prominent among their passengers. When interviewed, they explained that they wanted to trade in the villages but were unsure about local conditions after over a decade of conflict and chaos, so preferred ex-combatant riders who knew how to handle any potential security challenges.  The ex-fighters were no longer feared because they were now the providers of a valuable transport service. Some riders started to lodge in the villages, and even to build houses, marry and have children. A resident rider is especially valued for being able to ferry passengers for medical treatment at any time of the night. As a result, the institutional values of market and enclave began to co-exist more comfortably. This brings us to the overall conclusion of the thesis; in African development, it may be better to allow people to find their own way, using their own institutional styles of accommodation

Rural populations exposed to Ebola Virus Disease respond positively to localised case handling: Evidence from Sierra Leone

At the height of the Ebola epidemic in Sierra Leone in November 2014, a new decentralized approach to ending infection chains was adopted. This approach was based on building local, small-scale Community Care Centres (CCC) intended to serve as triage units for safe handling of patients waiting for test results, with subsequent transfer to Ebola Treatment Centers (ETC) for those who tested positive for Ebola. This paper deals with local response to the CCC, and explains, through qualitative analysis of focus group data sets, why this development was seen in a positive light. The responses of 562 focus group participants in seven villages with CCC and seven neighbouring referral villages without CCC are assessed. These data confirm that CCC are compatible with community values concerning access to, and family care for, the sick. Mixed reactions are reported in the case of "safe burial", a process that directly challenged ritual activity seen as vital to maintaining good relations between socially-enclaved rural families. Land acquisitions to build CCC prompted divided responses. This reflects problems about land ownership unresolved since colonial times between communities and government. The study provides insights into how gaps in understanding between international Ebola responders and local communities can be bridged.</p

Rural–urban connectivity strengthens agrarian peace: Evidence from a study of gender and motorcycle taxis in Sierra Leone

Rural-based insurgencies disrupted the forest margins of Upper West Africa in the 1990s. A subsequent return to peace was accompanied by strong growth in small-scale trade in foodstuffs and other agrarian produce in high demand in towns. Motor cycle taxis are a feature of this increased rural–urban market integration. It was a mode of transport pioneered by ex-combatants. Where rural women were once attacked by rural young men without job prospects press ganged into fighting for the rebels, bike taxi riders now carry them to rural periodic markets, many of which are new since the end of conflict. The study provides an analytical account of these developments, drawing on discussions with villagers in three heavily war-affected localities of Sierra Leone. The evidence indicates that communities divided by conflict have quietly built new cooperative links conducive to peace based on local agricultural production and petty trade

Changing women's lives and livelihoods: motorcycle taxis in rural Liberia and Sierra Leone

In rural Liberia and Sierra Leone about half of motorcycle taxi passengers are female, with this proportion increasing on market days. However, all motorcycle taxi operators in rural areas are male. This study assessed if and how motorcycle taxis have contributed to the livelihoods of rural women and whether there is appetite among them to become operators themselves. Data were gathered through male and female focus group discussions, roadside traffic counts and operator and passenger surveys. The study was conducted in three districts in rural Sierra Leone and one rural county in Liberia. The Liberia field site was the location of a pioneering pilot project on upgrading footpaths to motorcycle-accessible tracks. This project, funded by a German development agency, aimed to connect remote villages to the feeder road network. Both men and women were involved in track construction and this study assessed whether the women’s involvement made them more likely to take up commercial motorcycle riding. Women nearly universally praised rural motorcycle taxis, indicating that they have made access to markets and (maternal) health much easier. However, while many expressed the desire to become operators themselves, they identified a number of barriers, the most significant being lack of friends or business persons willing to rent motorcycles to female operators.</p