I’d like to share this report with you because I think it has so muchto teach us. Given the rising suspicion, and even hostility, being expressed about ‘Charities’ and ‘International Aid’. It brings good
news about what is being done as well as offering sobering lessons about how ‘aid’ needs to be ‘delivered’. It is from Misean Cara Ireland, and describes the methods used by the Missionary Sisters of the Holy Rosary, led by Ann Kelly, in dealing with the recent Ebola epidemic in Liberia.
John McCluskey mhm
Misean Cara: Mission Support from Ireland
BUILDING TRUST IN CRISIS
An integrated psychosocial approach to Ebola Virus Disease prevention and containment
carried out by the Missionary Sisters of the Holy Rosary in Lofa County, Liberia, 2014-2016.
- Ebola Epidemic in West African countries [Guinea, Liberia, Sierra Leone]: Jan 2014-March 2016. “The most severe acute public health emergency in modern times” [WHO] There were 28,616 reported cases leading to 11,310 deaths, which represents a fatality rate of 40%. [p2]
- Ebola is a severe, often fatal, infectious disease, caused by the Ebola virus that typically results in the death of about 50% of those affected. It is spread from person to person, mainly through contact with bodily fluids.
- No one knew what it was when it first struck, in the early months of 2014, and patients were initially treated for malaria or something similar. It spread rapidly within communities and “for the first time, urban centres became epicentres of intense virus transmission”. [p3]
- The crisis was made worse in these countries because they were struggling to emerge from a prolonged period of civil war [1995-2006], which meant that there was a complete breakdown of health care facilities, combined with a deep distrust of state authority and institutions: government officials, police, army…
- The years of conflict had also resulted in people fleeing from one country to another, seeking safety, and this continued to be a problem after the war ended: there was little or no border control, which meant that people could, and did, move freely—bringing the virus with them.
- The problem was exacerbated still further by this combination of ignorance [no one knew, or understood, what was happening] and distrust [people, local communities, preferred to deal with cases themselves]. As a result, they refused to bring cases to hospitals or health centres, and resisted attempts to persuade/force them to do so. They also distrusted public warnings about the danger of the disease, regarding it as ‘government propaganda’.
- Perhaps the most serious consequence of this combination of ignorance and distrust was the clash between what ‘the authorities’ insisted were ‘Public Health Requirements’ and firmly held traditional culture values—particularly to do with care of sick family members and respect for the dead. Put bluntly, ‘Public Health Warnings’ not to touch any suspected case of Ebola, and not to bury/carry out the traditional burial service, went clean contrary to their most deeply held values, seeming to require them to abandon their loved ones in their time of greatest need.
- Response to the Ebola Epidemic
- There was an immediate and major international response to the crisis, no effort being spared in rushing medical expertise, equipment and volunteers to as many centres as possible in the areas affected.
- It quickly became apparent, however, that something was amiss. While the international aid effort was driven by the conviction of the need for swift and drastic measures to contain and prevent the spread of the virus, the people they were desperate to help did not understand what they were being told they had to do, and did not trust ‘the authorities’ who were trying to convince them.
- What was critically lacking in the international response was an awareness of, and a sensitivity to, the culture—the deeply rooted traditional values—and the fears of the people and communities they were trying to help. There was gulf that needed to be bridged between ‘the expertise’ of the aid agencies and ‘the understanding’ of the people they were desperate to help.
- The Misean Cara Report tells the story of how that gulf was bridged, and analyses the lessons to be learned in dealing with all similar emergencies. It examines in detail the approach taken by the Missionary Sisters of the Holy Rosary [MSHR] in one area in northern Liberia [Lofa County] which “was at the epicentre of Liberia’s EVD [Ebola Virus Disease] outbreak in March 2014, but was also the first county to achieve a confirmed decline in the epidemic curve (December 2014); a particularly impressive feat given its border with Guinea where intense virus transmission was ongoing”.[p5]
- MSHR Response and Reasons for its Success
- Key to the approach of the MSHR was the fact that they were recognised and welcomed as part of the communities they were helping. They had been involved with these communities during the years of war and its aftermath, staying with them in refugee camps and following them when they returned to Lofa County in Liberia in 2007.
- During these years, prior to the outbreak of the Ebola Epidemic in 2014, they had established and developed an educational programme: ‘Social Empowerment Through Learning Liberia’ [SELL]. This meant that members of local communities were already trained in the skills that were going to be needed to ‘bridge the gap’, and that, working with the Sisters, they had the trust of the people.
- Integral to the Sisters’ approach was the absolute priority given to the primacy of the local culture—the traditions and beliefs of the people themselves—which meant that their experience and fears had to be listened to, and they had to be helped/given the tools needed to express/articulate their needs and concerns.
- Only when this had been done, or begun to be addressed, could progress be made in helping them to understand the entirely new threat that the Ebola Virus had brought into their communities. And in this way a foundation was laid for more willing cooperation with the international aid agencies.
- The Report summarises their approach as follows:
“For a number of years, SELL worked in villages across Lofa County promoting adult literacy, and through this raising awareness and building solidarity on a range of issues including children’s rights, land rights, inheritance rights, micro-finance, business education, skills training, gender-based violence, social services, and liaising with the Lofa County Association for the Disabled (LOCAD).
When Liberia’s EVD epidemic hit in 2014 they began applying the same education approach to tackle the issues of EVD prevention and containment. SELL used an integrated psychosocial approach, based on a critical pedagogy ‘social analysis’ model, utilising community drama and reflective discussion to teach communities about EVD prevention and containment strategies while simultaneously providing trauma counselling and emotional support to people affected”. [p1]
- In its conclusion [pp23-26] the Report made a number of points and recommendations:
▪ SELL was successful in convincing community members to accept Ebola Virus Disease as a real medical condition, and countering commonly held false beliefs and myths.
▪ As a result people were more willing to change their behaviour, adopt preventative practices and healthcare-seeking behaviour.
▪ Engagement with the programme led to improvement in the psychosocial wellbeing of those affected directly or indirectly by EVD which further bolstered their efforts to adopt preventative and treatment-seeking behaviours.
▪ Besides working directly with local communities, SELL workers collaborated strategically with other response agencies (UN agencies and NGOs) sharing local knowledge and pressing for more socially and culturally sensitive response efforts.
The reasons given by participants for changing their attitudes and adapting their behaviour, with positive benefits both in terms of disease containment and prevention, and of psychosocial wellbeing in affected communities, were directly related to specific aspects of the SELL approach, including:
▪ SELL’s work on awareness-raising, education and training;
▪ The use of community drama as an awareness-raising and collective learning tool, particularly in
- enabling people themselves to expose false beliefs and scare stories for what they were;
- giving people a greater sense of belief in and ownership of the solutions agreed on, which in turn increased the chances of sustained behaviour change;
▪ Materials and equipment provided by SELL for containment and prevention (buckets, equipment for latrines etc.);
▪ Repeated home visits in affected communities, which was seen by local people as a sharp contrast with the practice of UN agencies and some other NGOs who were said to have visited once, and when met with a hostile reaction, never returned;
▪ The application of a culturally sensitive psychosocial approach; working at a level that local people could understand and relate to;
▪ Listening to people’s concerns; offering counselling and accompaniment;
▪ The fact that many people had already come across SELL and had learnt to trust them based on experience with earlier projects;
▪ Financial support for families who had offered homes to children orphaned by EVD.
These findings provide compelling evidence of “what works”, and in so doing further highlight the importance of context-appropriate community engagement through integrated psychosocial approaches in humanitarian crisis responses. For example, communicating risk in a way that was sensitive to people’s fears and attempted to quell them, was a more effective way of promoting risk-reducing behaviours than other approaches common at the time which were based on heightening fear in an effort to force people to change.
The way the Missionary Sisters of the Holy Rosary accompanied local communities as they confronted the Ebola crisis in many ways epitomises the Missionary Approach to development as understood by Misean Cara (Misean Cara, 2017)
One of the foremost characteristics of this approach is its embodiment of long-term commitment. Because missionaries make such a commitment and are rooted in the communities they serve, they not only earn the trust and confidence of local people, but also have an understanding of local context and culture that leads to more sensitive and effective interventions, as this study has demonstrated.
Another key characteristic is the holistic approach of missionary work. Whatever the immediate concern of a missionary project (in this case the urgency of responding to the Ebola crisis), missionaries look beyond specific health or education needs to consider the needs of the whole person, in line with their commitment to human dignity. From this comes the missionary commitment to “accompaniment” or walking alongside individuals or families in times of need, which is exemplified in the SELL approach described above.
Although this study considered just one context-specific response to the Ebola crisis, many of the lessons learnt can be effectively put to use in other emergency or humanitarian crisis situations. In that regard the following recommendations are noted for consideration:
- Recognise the principle of human dignity: Human dignity is a core value in every culture, not just in Liberia. Respect for human dignity is particularly important when people are ill, and continues to be important after they die. Emergency measures taken to control epidemics are unlikely to be effective if they fail to recognise this fundamental principle.
- Draw upon the resources of those who know local communities: Workers such as missionaries, who really know communities, can be a valuable resource to NGOs and international agencies newly arrived in an area facing a humanitarian crisis. Engaging with missionaries and relying on their knowledge and understanding of local people and their needs can help to avoid costly mistakes.
- Draw upon the knowledge and skills of local people: There is great value in training local people as front-line workers in an emergency response context. They understand the context and culture, know the language, are fully engaged in the situation, and are likely to be accepted and trusted by local people like themselves.
- Encourage and facilitate critical reflection: Community drama can be seen as a particularly useful approach in supporting humanitarian interventions, as it pushes people to explore for themselves the myths that are circulating in their communities. Rather than being “told what to think” by outsiders, people are able to discover for themselves why these myths cannot be true, and come to a valid understanding of their situation through critical reflection and analysis. This process also gives them a greater sense of ownership of solutions agreed on, and thus greater motivation to make and sustain behaviour changes.
- Take time to build trust: In order to build and consolidate trust, repeat visits to families and communities, and particularly persistence in the face of initial rejection, are very valuable.
- Motivate with trustworthy information: Promoting fear is not a reliable way to motivate people to positive action. Such action is more likely to be triggered by hope and trustworthy correct information. Therefore the giving of trustworthy information should be an essential part of crisis intervention strategies.
- Recognise that listening is as important as information-giving: In times of crisis, listening to people, showing empathy and trying to understand their concerns may be just as important as information-giving.
- Share learning: The findings of this study, and other similar studies of experiences during crisis, should be disseminated through appropriate media to help advance public and wider sectoral understanding of what works well in crisis situations