The recent Ebola outbreak in West Africa infected more than 28,000 people and claimed more than 11,000 lives. As Guinea, Sierra Leone and Liberia grapple with the challenges of the post-Ebola period, there’s no shortage of analysis on the operational issues and systemic flaws that shaped both the epidemic and the response. But what can we learn about how local media performed in providing accurate, timely information to the public, to health care workers, and to those setting policy at the local and national level? To answer that question we examined articles and studies carried out or published during the epidemic from January 2014 through November 2015, and conducted interviews with journalists, editors and public health experts directly involved in the response. What we discovered could help shape public health communications strategies for future health emergencies, and help media organisations better tailor their reporting to respond to the real time information needs of their audience.
Local journalists play a central role in times of crisis, and their proximity to affected populations means they are sometimes the first responders. In addition to life saving information, independent journalists provide accountability, signaling gaps in service delivery by investigating and reporting on abuses of trust. And, as survivors grapple with stigma and families and communities process extreme loss, the media can help by enabling these stories to be told and shared.
From the outset of the Ebola crisis, local media was largely overlooked. Decision makers and key donors rolled out a medical/clinical response that focused on treatment and sidelined efforts to provide critical lifesaving information to the public. In Liberia, for example, a Media Working Group failed to include a single member of the Liberian media. When funding started to flow to international NGOs in the summer and fall of 2014 for communications and outreach, many established best practices for communicating with communities during humanitarian crises went unheeded. Top-down institutional messaging was pushed out to the population, with local media used as (poorly) paid platforms to disseminate these messages rather than as professionals tasked with shaping vital lifesaving information. Messages were often contradictory, leading to what has been characterised by one practitioner as a “chaotic” information landscape. With the outbreak spinning out of control in late 2014, it became increasingly evident that public resistance to messaging was a significant barrier to the adoption of health seeking behaviors in communities at risk.
To understand how things could have gone so fatally wrong it helps to look at the form and content of health messaging at the outset of the crisis. The first public health messages to the population in Guinea were built around three pieces of information: Ebola was highly contagious, mortality rate was 90%, and there was no cure. Messages scripted by health ministries and international organisations were broadcast across FM networks and on the few local television stations. Designed to contribute to public education, the messages, in some cases, produced the opposite effect.The focus on viral transmission fed both fear driven responses and the stigmatisation of affected individuals and communities.
As Jeffrey Stern wrote in Vanity Fair magazine, in Guinea “the message from the government and the health workers (and local media) had undercut the incentive to cooperate”. The public service announcements fueled, rather than prevented, panic. As Stern reported, “people in Guinea were as frightened by the response to Ebola as they were to Ebola itself”.
Health experts and blogs from front-line workers in Guinea, Sierra Leone and Liberia have also described this pervasive fear of Ebola, and the challenges of communicating uncertainty from medical experts and scientists without further igniting fear and undermining public trust in health authorities.
The efforts to prevent and control the spread of Ebola were met with reticence, and in some cases violence, from the population. As the number of infections grew exponentially in August and into September 2014, a wide network of public health responders, humanitarian actors, anthropologists, media experts and academics mobilised to address questions of public doubt, fear and resistance to the scientific discourse adopted by public health officials and government.
One group of experts convened at Massachusetts General Hospital in Boston, while in Dar es Salaam another group that included religious leaders, traditional healers and media from East and Central Africa met to gather first hand lessons from past Ebola epidemics. Several important recommendations emerged from these meetings: first, work with communities not against them, involving community leaders to formulate appropriate containment measures; and second, “share early, listen to beliefs and read rumors”. In other words, don’t just counter rumors but read them for information on possible cases (alerts) and to better understand community explanations of the causes of Ebola.
Understanding deeply rooted mistrust
The international organisations tasked with leading the response as well as front line medical teams had been caught off guard, believing that disseminating “correct” messages through the “right” medium would address lack of knowledge in a population deemed largely ignorant. What they failed to take into consideration were the social, political and economic factors that had eroded public trust in the authorities. Writing in African Affairs, researchers Wilkinson and Leach from the Institute of Development Studies described the legacy of distrust in government, the politicisation of Ebola (and electoral politics, especially in Guinea), longstanding experiences of state and foreign actors being seen as “alien, oppressive or self-serving”, and deep social and economic inequality. The authors explained public resistance to risk communication as a rejection not of biomedicine, but of the heavy handed and authoritarian approach by official sources that were not trusted by the population.
A crisis of governance, a crackdown on press freedom
In all three Ebola affected countries, lack of transparency by authorities at all levels of the government and by organisations affiliated with the response contributed to suspicion and reticence. Government officials and donors sought to ensure messages were centrally approved, leading to confusion surrounding the process and important delays. Limitations of press freedom hampered the media’s ability to provide an accurate picture of the epidemic to local audiences and to counter rumors and misinformation.
In the NY review of Books, Helen Epstein explored the rapid and unprecedented spread of Ebola in Monrovia’s urban environment and what she calls the “fundamentally political” aspects of the epidemic. Epstein’s assertion that most Liberians were “so profoundly estranged” from their government that they didn’t believe the warnings echoes is the empirical findings from Liberia during the epidemic. This estrangement or lack of confidence has been widely traced to high levels of corruption and a prevailing climate of impunity. Epstein links public discontent with Sirleaf and her government to Liberia’s failure to address issues of transitional justice as well as limited access to the “material benefits of development.”
In all three countries, the legacy of decades of civil conflict and the ongoing and sometimes bumpy democratic transition has resulted in a complex and problematic relationship between the authorities and the press. The impact of government interference on access to lifesaving information and the transparent and accountable deployment of resources is addressed in reports from international press advocacy groups Reporters without Borders, Committee to Protect Journalists, and The Media Foundation for West Africa, as well as in articles by the international media. Documented incidents include attacks, curfews, undue restrictions, censorship, harassment and threats. Ebola’s “massive toll” on freedom of expression was especially acute in Liberia and was largely seen as being political.
Meeting the information needs of women
Women were particularly vulnerable throughout the crisis, not only to exposure and infection due to their roles as caregivers but also to an increase in sexual violence. As well as being more exposed, a study in Liberia by Oxfam also revealed there were important differences in access to Ebola prevention and treatment information for men and women. Lower literacy and economic status, reduced access to radio either because they didn’t own one or didn’t control the use of the family radio, and less unstructured time to access radio, all contributed to a lesser consumption of public health messaging. According to the Liberian Demographic and Health Survey (2013) 56% of women lack exposure to mass media on a regular basis.
Going beyond messaging
Perhaps the most interesting finding from the empirical research we reviewed has to do with Public Service Announcements, or PSAs – the nearly ubiquitous short messages broadcast on radio and television with the intent of raising awareness or change behaviour. Contrary to common practice and belief, the literature reviewed in this study suggests that an overreliance on PSAs as a format for the transfer of information to the population could be linked to significant information gaps as identified by survey respondents in all three affected countries.
In Liberia, a qualitative study carried out in two counties surveyed individuals engaged in self-reliance in order to contain Ebola in their communities. Respondents told researchers they were not seeking more basic information on Ebola but better information on practical steps to take in the face of health sector collapse. The repetitive messages on “What is Ebola?” provided enough information for people to be afraid but not enough to respond effectively given the realities of health service delivery. Health messaging failed to provide the ‘higher order’ practical information that communities were desperate for. There was a failure to respond to questions in real time and to provide accessible information that could meet people “where they are”. A real-time evaluation00796-1/abstract) of community based social mobilisation strategies in Guinea found that “static materials such as informational posters and pre-taped PSAs” had negligible effects.
Multiple studies confirm that high levels of basic knowledge of Ebola did not translate into health seeking behaviors. Studies in all three countries expose the very complex and overlapping social aspects of the disease that would be difficult to address in unidirectional 30 second PSAs. Focus groups carried out in Guinea for Save the Children revealed a demand for greater technical information on Ebola. Limited health reporting and messages that were highly “directive” had left an information gap: lack of understanding, or false understanding, of the virus (including confusion between Ebola and HIV); disconnect between the messages and reality (messages to go to the hospital, but hospitals didn’t have rapid tests); and lack of clarity (confusion between “survivors” and “convalescent patients”).
Conclusions and recommendations
The lessons from the Ebola response are numerous. We’d like to conclude by summarising two in particular that stand to have a sustained impact on the quality of health information for populations in low resource settings, and on the media’s particular responsibility in holding authorities to account:
1. Invest in local capacity for science and health journalism and broadcast technology.
Credible local media in each of the three countries struggled to cover the costs of fielding journalists and fueling generators for airtime, while international NGOs, some without in-country experience, received donor funds for communications campaigns. These same organisations, while claiming to partner with local media, often set the terms of that engagement without seeking to better understand what support local media needed to respond to the information needs of the audience. Stipends to cover broadcast fees were unilaterally decided in INGO budgets; local media, strapped for cash, had no choice but to take what was offered.
By pushing out PSAs across radio and television, not only did we miss an opportunity to fully respond to the populations’ need for information in real time, but there has been little or no long term benefit for the journalists that will continue to report from the front line of public health. An investment in building journalistic skills and broadcast reach is a long-term investment in a country’s health, and can be an important preventative measure in resource poor settings. Support for the establishment of local associations that include members of the media, academics from the health sciences, government/non-governmental organisations working in community health can strengthen knowledge transfer. These local associations could be the focal points for future responses.
2. Build an evidence base
Donors, academics and implementing organisations should make independent and rigorous evaluations using qualitative and quantitative research methodologies a part of all public health communication projects. Lack of time and funding for evaluation meant that baseline studies as well as comparative studies between country strategies and outcomes, with the potential to provide addition texture to our understanding of socio-cultural factors in the uptake of health information, have not been conducted.
Furthermore, we identify the need to study the impact of media development, defined to include not only the professional capacity of journalists to report on science and health, but also the enabling environment for an independent and pluralistic media sector, on the delivery of public health information. There is evidence[AB14] that conflict can be a primary driver of health inequalities, as “fragile states” are unwilling or unable to deliver basic services to their population. The impact of a free and independent media in these settings could inform a more integrated approach to post-conflict interventions aimed at improving long term health outcomes that include greater health sector accountability and service delivery.
