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Action not justification: how to use social science to improve outbreak response

Authors: Hana Rohan 1*, Daniel G Bausch1, Karl Blanchet2

Affiliations: 1UK Public Health Rapid Support Team, London School of Hygiene and Tropical Medicine/Public Health England, London, UK; 2London School of Hygiene and Tropical Medicine

*Room 324, 15-17 Tavistock Place, WC1H 9SH, hana.rohan@lshtm.ac.uk, +44 207 927 2287


 

The current outbreak of Ebola virus disease (EVD) in North Kivu, Democratic Republic of the Congo (DRC), was announced nine days after another, in DRC’s Equateur Province, was officially declared over. While the Equateur outbreak reached urban areas and therefore raised serious concerns about disease spread, the North Kivu outbreak is even more complex due to active and prolonged conflict in DRC’s eastern province that borders Uganda, South Sudan, and Rwanda. Both outbreaks have shown that, even in countries experienced with a particular infectious disease, international and specialist support may be needed to help structure the response to bring an outbreak under control. While diverse skills and research are needed, a critical component of that international response should be to rapidly identify and deploy national and international social scientists, with knowledge of the local context, who can work together to develop the protocols and tools needed to implement social science research so essential for outbreak control.

Outbreaks and their attendant responses can be scientifically, socially, and structurally dynamic. It is therefore imperative that social science data are collected and translated in real-time to help inform attempts to continue to deliver more effective and appropriate response interventions and coordination structures. Routine engagement of social scientists in the response to EVD outbreaks began in the early 2000s. However, this early involvement tended to be oriented more toward classic ethnographic study, with findings often communicated post-outbreak [1-2]. Gradually, the need has been recognized for a more systematic and proactive approach to rapidly partner with affected communities to translate community values and understanding into actionable outbreak response countermeasures. This more systematic approach responds to the requirement at the onset of an outbreak for rapidly generated data and in-depth information to help design and deliver contextualized, effective and appropriate response interventions.

Social science can provide information on social risk factors and mechanisms for disease transmission, local cultural interpretations of disease and response interventions, and the functioning of the health system and local structures of power and authority. This information is essential in developing effective community engagement and health promotion strategies and ensuring that every pillar (e.g. epidemiologic surveillance, laboratory diagnosis, case management, infection prevention and control) of the outbreak response is fit-for-purpose at the local level. The need for this work is highlighted by reports from the Equateur outbreak of two patients who were removed from the Ebola Treatment Centre and ‘taken to church’, which potentially not only led to further virus transmission, but also temporarily halted outbreak control efforts due to security concerns [3].  The multiplicity of armed actors in North Kivu and complexity of engaging with those groups further highlights the need for locally appropriate interventions and response design [4].

Ebola public health wall message in Freetown, Sierra Leone. Image credit: LSHTM/Tom Mooney.

The 2013-2016 West African EVD outbreak led to a growing volume of ‘lessons learned’ literature [5], organizational scrutiny and restructuring, and commitments from the global public health community to ensure that future outbreak response would be more sensitive to the needs and perspectives of local communities [6]. Among the lessons learned has been the acknowledgement that social scientists ought to be embedded within multi-disciplinary response teams from the beginning of an outbreak, working alongside epidemiological, clinical, and other public health colleagues to help ensure that all components of an outbreak response are locally appropriate [7]. Social scientific engagement with outbreak response has improved markedly since the West African outbreak, insofar as social scientists more frequently have a place at the response table, are consulted to provide background briefings and context, and are better internally networked to help provide support when it is requested. Indeed, the World Health Organisation (WHO) held a training for emergency social science interventions during disease outbreaks in October 2017 and established an initial registry of social scientists who might staff an outbreak response [7].  Unfortunately, there is very limited funding available to deploy those WHO social scientists. Nor do they currently have a formal mandate from WHO or other multilateral donors. Furthermore, social scientists are still not routinely included by governments when they request outbreak specialists from WHO, and on the rare occasion where social scientists are deployed to outbreaks, the epidemiological curve has usually peaked. Social science is also often viewed as relevant only for ‘risk communication’ or health promotion activities during outbreaks, which continues to ignore that human behavior, customs, and perspectives interact with and affect every aspect of an infectious disease outbreak.

It is extremely promising that social scientists have been deployed to the outbreak in North Kivu, and that the infectious disease and social science communities are working to identify the critical research questions that could help inform the response there. Nevertheless, there are still ways that our technical preparedness for social science engagement could be improved for future outbreaks to ensure that social science insights are developed at speed and fed back to other components of the response:

  1. Identify key questions and develop associated research protocols that can be rapidly adapted to different local settings in the event of an infectious disease outbreak. These should be organized by disease type and by different stages in the outbreak cycle, e.g. the critical questions at the onset of an outbreak are likely to be quite different from those posed later on, especially in a protracted outbreak.
  2. Develop a ‘bank’ of open access social science research tools as a public good that can be rapidly adapted, in line with the protocols described above, to facilitate research that can be delivered in real-time and in accordance with local requirements. This, together with the above protocols, will facilitate more rapid initiation of social science data collection activities, and therefore more rapid provision of recommendations to other response colleagues.
  3. Improve social science advisory services to operational response staff by developing better and formalized relationships between social scientists across different outbreak-vulnerable countries to ensure that the provision of social scientific contextual insight is generated by local experts as far as possible.
  4. Improve surge capacity by developing teams of ‘citizen social scientists’ who are trained in the use of social science research tools, ethics, and data transmission. This would build local capacity to enhance the production of context-sensitive, experiential social science research that can support different aspects of an emergency response. Engaging local residents in research can utilize their established social networks that can facilitate and speed up data collection activities, especially when timelines are short or access is difficult.

The above suggestions are of course, not exhaustive, but in order to meet any social science preparedness objectives, human and financial resources must be put into social science research before outbreaks occur. Furthermore, social science insights must be integrated horizontally into outbreak response architectures. Globally, several multidisciplinary rapid response teams have been created to redress some of the gaps identified in the post-EVD shakedown. However, few include social scientists.

The social science of infectious disease community is working collaboratively to establish some of the systems and tools identified above that could help ensure better preparedness for outbreaks and facilitate the rapid collection of data to improve the way we respond in affected communities. For example, the UK-Public Health Rapid Support Team is working with the Institute of Development Studies and others to revitalize the Ebola Response Anthropology Platform into an Epidemic Response Anthropology Platform that launched on the 11th June 2018. This will help centralize important contextual information and provide operational staff with easy access to social science colleagues who can be called upon to quickly provide advice. However, while it is critical to improve technical aspects of social science preparedness, significant political and financial work remains to ensure that those technical improvements are fully realized and integrated into the way that outbreak response approaches local communities and the design of interventions.

The 2013-16 West African as well as more recent EVD outbreaks in the DRC have demonstrated to the global health community that integrated social science is a critical component of outbreak response [8]. It is now time for that integration to become realized, and for social scientists to be able to improve how they respond, rather than to have to justify why.


Disclaimer/Acknowledgement

The UK Public Health Rapid Support Team is funded by the United Kingdom Department of Health and Social Care. The views expressed in this publication are those of the authors and not necessarily those of the National Health System, the National Institute for Health Research or the Department of Health and Social Care.

References

  1. Hewlett B, Epelboin A, Hewlett B, Formenty P, 2005. Medical anthropology and Ebola in Congo: cultural models and humanistic care. Bulletin de la Société de Pathologie Exotique 98: 230-236.
  2. Hewlett BS, Amola RP, 2003. Cultural contexts of Ebola in northern Uganda. Emerging infectious diseases 9: 1242.
  3. BBC, 23rd May 2018. Ebola outbreak in DR Congo: Patients ‘taken to church’. Available at: http://www.bbc.co.uk/news/world-africa-44229346. Accessed 30th May, 2018.
  4. Social Science in Humanitarian Action Platform, 2018. Key considerations: the context of North Kivu province, DRC.
  5. Smith MJ, Upshur REG, 2015. Ebola and Learning Lessons from Moral Failures: Who Cares about Ethics?: Table 1. Public Health Ethics.
  6. WHO, 2015. Report of the ebola interim assessment panel. http://www.who.int/csr/resources/publications/ebola/report-by-panel.pdf?ua=1.
  7. Stellmach D, Beshar I, Bedford J, du Cros P, Stringer B, 2018. Anthropology in public health emergencies: what is anthropology good for? BMJ Glob Health 3: e000534.
  8. Sams K, Desclaux A, Anoko J, Akindès F, Egrot M, Sow K, Taverne B, Bila B, Cros M, Keïta-Diop M, Fribault M, Wilkinson A, 2017. Mobilising experience from Ebola to address plague in Madagascar and future epidemics. The Lancet 390: 2624-2625.

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Feature image credit: CDC Global (Frederick A. Murphy)

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