Sierra Leone: Contact Tracing - Learning Lessons From Sierra Leone

(File photo).
29 June 2020

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Paul Richards argues that when tracing contacts, observations of people's behaviour yields vital information.

He's right. Observing people, however, takes time, requires care, and above all demands empathy for the local people being observed.

Let me explain how this was realised in Kambia in 2015 during the Ebola outbreak in Sierra Leone, based on my experience as an anthropologist working with the WHO.

The initial approach to contact tracing focused on collecting purely medical data. Typically, communities under quarantine were visited by health teams, usually at the same time of day. The members of household were asked to line up to have their temperature taken. Anyone with a high temperature was then taken away to an Ebola Treatment Centre (ETC). In addition, households under quarantine are subjected to endless visits and questions by staff of the various responding teams. A common complaint among quarantine households is the disruptions to their daily lives.

This approach failed. Afraid of being taken away to the ETCs, seen as places from which they would never return, people took paracetamol and other analgesics to disguise their temperature. Others with fever ran into the bush and hid. When asked to report infections and deaths, people lied. Often people were quarantined in cramped quarters - with infection a near certainty should one person fall ill. People who died were buried unsafely in the fields and bush - the official burial protocols for Ebola victims were undignified, an affront to local mores. The photo below was a household where 10 people were quarantined, with the food provided by the response untouched. The children of the household were so severely malnourished that all but 2 survived - a 3-year-old who tested negative (only one among the 10), and a 13-year-old who survived Ebola.

Contact tracing thus failed. The teams could only identify places where infection was already widespread and deaths were common. They were never able to see where the contagion might have spread.

I could see that not working with the community, not respecting their values, and not talking with people - as opposed to telling them what they had to do - was failing. I tried to make the case for a more empathetic and respectful approach, one that would allow observation. Initially, this was brushed aside by expatriate medical experts who said people were dying, there is no time for observation. Instead, they brought in behavioural change specialists from the UK and US who knew nothing about Sierra Leone, to change the behaviour of Sierra Leoneans. They wanted me to help, but not as a local and a trained anthropologist: they wanted a translator.

As infections in Kambia continued, finally the response teams were prepared to try my approach. From then on, things were done differently. We went to villages - and at different times of the day. We sat down with people and talked with them. People began to trust us. We had time to observe things, such as unmarked graves in the fields. We also took a fresh approach to quarantine. Every household indicated was assessed as to their living conditions, their needs for food, for medications. For those cases where people were living in cramped conditions, a tented camp was erected locally where people could stay with more room to avoid contact.

A women only contact tracing team was created - Women in Partnership to End Ebola (WIPEE). The creation of WIPEE, facilitated partnerships with grassroots women in silent chiefdoms of Kambia District. Communities responded positively. We learned far more about what was happening in communities, and who had died and was buried unsafely. We were better able to trace contacts and to isolate those infected or at risk.

Paul Richards has hit the nail on the head. He is right, his approach was proved by what we were able to achieve in Kambia. Working with the community, observing what they do, was no luxury in northern Sierra Leone: it was the key to stemming the outbreak.

Many of the lessons, in particular contact tracing, from the West Africa Ebola epidemic could be drawn upon to respond to Covid-19. Sadly, the focus is still heavily biomedical until things get out of hand. Currently, in the US, some States have started using contact tracers. The State of Massachusetts is one such state. I was made to understand that Partners in Health strongly advocated for the inclusion of contact tracing early in the State's Covid-19 response, drawing on the lessons from Ebola. Initially, however, there was no interest. It was only when Covid-19 infection rates started mounting that contact tracing was implemented.

The UK's new response protocol is testing and contact tracing. One can hope that they drawn upon the lessons of the West African Ebola response. Recently, I read that several people were found dead, some for up to two weeks. A pre-lockdown assessment, especially for elderly people, could have helped to avoid such painful deaths.

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