Ebola, informal settlements, and the role of place in infectious disease vulnerability: evidence from the 2014-16 outbreak in urban Sierra Leone.

Studies of vulnerability often focus on the differential susceptibility of marginalised groups to the effects of disaster. This paper considers how vulnerability is also associated with the characteristics of place, especially the social setting of the informal settlement. In this light, it assesses specifically how cultural, historical, and political economic forces resulted in increased vulnerability to Ebola virus disease (EVD) within informal settlements in Sierra Leone during the epidemic of 2014-16. Key informant and community member interviews and focus-group discussions in two communities revealed that increased vulnerability to EVD could, at least in part, be attributed to a set of place-based social factors pertaining to 'community beliefs and practices' (importance of family ties, funeral rites, traditional healing) and 'structural poverty and low socioeconomic status' (poor healthcare provision, mobility patterns, overcrowding). Together, these different factors demonstrate how multiple and intersecting vulnerabilities contribute to the spatial production of disease risk.

Ebola and slum dwellers: Community engagement and epidemic response strategies in urban Sierra Leone.

The Ebola epidemic in West Africa (2013-2016) was a learning process for all - the population, health experts and practitioners, as well as government structures. Learning occurred in all stages of the response, from the initial lack of clarity and denial of Ebola's existence that contributed to public confusion; to the eventual acceptance of the existence of the Ebola threat whereupon fear and stigmatization reigned; to the later stages in which community engagement and ownership of the response arose. In this paper we describe how two urban poor communities in informal settlements in the Western Area of Sierra Leone responded to Ebola Virus Disease and how they deployed efficient strategies like the development and implementation of by-laws for monitoring and surveillance, thus helping to curb the epidemic. For future public health emergencies, we recommend that community engagement be pursued earlier and that efforts are made to ensure two-way knowledge exchange between responders and community stakeholders.

The post-colonialist condition, suspicion, and social resistance during the West African Ebola epidemic: The importance of Frantz Fanon for global health.

The scholarship of Frantz Fanon has been recognized across numerous disciplines as a unique and necessary intervention for critical analyses of the (post)colonial condition. Yet, thus far, his oeuvre has largely been ignored in global health research. In this article we introduce and demonstrate the relevance of Fanon's work for the field of global health. To illustrate, we draw from Fanon's conceptual framework and observations to analyze the 2014-16 Ebola Virus Disease outbreak response in West Africa. During this Ebola epidemic, although not necessarily as widespread as Western media made it seem, numerous instances of "resistance"-sometimes violent-were levied by members of the community toward foreign outbreak response teams. In this article, we argue that the keen insights proffered by Fanon more than half a century ago help facilitate a deeper understanding of some of the reactions of community members and public health officials during the Ebola response. In calling attention to colonial histories and structural relations of power, poverty, and violence, Fanon's work can help us to effectively move towards "decolonizing" global health interventions, thus providing a framework with which to better understand and more humanely intervene in future epidemic outbreaks in the Global South.

Contextualizing mobility during the Ebola epidemic in Liberia.

Based on findings from focus groups and key informant interviews conducted at five sites in Liberia between 2018 and 2019, we explore some of the key factors that influenced people's motivation to travel during the 2014-2016 Ebola Virus Disease (EVD). We discuss how these factors led to certain mobility patterns and the implications these had for EVD response. The reasons for individual mobility during the epidemic were multiple and diverse. Some movements were related to relocation efforts as people attempted to extricate themselves from stigmatizing situations. Others were motivated by fear, convinced that other communities would be safer, particularly if extended family members resided there. Individuals also felt compelled to travel during the epidemic to meet other needs and obligations, such as attending burial rites. Some expressed concerns about obtaining food and earning a livelihood. Notably, these latter concerns served as an impetus to travel surreptitiously to evade quarantine directives aimed specifically at restricting mobility. Improvements in future infectious disease response could be made by incorporating contextually-based mobility factors, for example: the personalization of public health messaging through the recruitment of family members and trusted local leaders, to convey information that would help allay fear and combat stigmatization; activating existing traditional community surveillance systems in which entry into the community must first be approved by the community chief; and increased involvement of local leaders and community members in the provision of food and care to those quarantined so that the need to travel for these reasons is removed.

Contextualizing Risk Perception and Trust in the Community-Based Response to Ebola Virus Disease in Liberia.

The 2014-15 Ebola Virus Disease (EVD) outbreaks in Western Africa became widespread in primarily three countries, Guinea, Liberia, and Sierra Leone. Unlike all previous outbreaks in Central and East Africa, which were confined to rural areas, the virus spread rapidly through West Africa as a result of transmission through high-density urban centres coupled with the effects of public distrust in outbreak response teams and local government officials. Objective: In this study, we examine the EVD epidemic in Liberia, the first country to implement a community-based response that led to changes in the trajectory of the epidemic. The focus on the role of community-based initiatives in outbreak response is often neglected in conventional epidemiological accounts. In this light, we consider the manner in which community-based strategies enabled a more effective response based on the establishment of better trust relations and an enhanced understanding of the risks that EVD posed for the community. Methodology: We conducted qualitative research in five distinct communities in Liberia three years after the outbreaks subsided. Data collection procedures consisted of semi-structured interviews and focus group discussions with residents. Results: We found that the implementation of a community-based response, which included the participation of Ebola survivors and local leaders, helped curb and ultimately end the EVD epidemic in Liberia. As community members became more directly involved in the EVD response, the level of trust between citizens, local officials, and non-governmental organization response teams increased. In turn, this led to greater acceptance in abiding to safety protocols, greater receptiveness to risk information, and changes in mobility patterns-all of which played a significant role in turning the tide of the epidemic.

Disaster incubation, cumulative impacts and the urban/ex-urban/rural dynamic.

This article explores environmental impacts and risks that can accumulate in rural and ex-urban areas and regions and their relation to urban and global development forces. Two Southern Ontario cases are examined: an area level water disaster and cumulative change at the regional level. The role of disaster incubation analysis and advanced environmental assessment tools are discussed in terms of their potential to contribute to more enlightened and effective assessment and planning processes. It is concluded that conventional approaches to EA and planning are characteristically deficient in addressing the full range of impacts and risks, and particularly those originating from pathogens, dispersed and insidious sources. Rigorous application of disaster incubation analysis and more advanced forms of EA has considerable potential to influence a different pattern of planning and decision making.

A socio-ecological autopsy of the E. coli O157:H7 outbreak in Walkerton, Ontario, Canada.

The socio-political context of modern environmental health disasters tends to be defined as being outside the scope of official public health and epidemiological investigations into the causes of such disasters. On the other hand, popular accounts of these disasters tend to focus exclusively on the role of particular individuals and/or political actors, while minimizing the role of ecological factors. It is argued that an exclusive focus on either set of causal factors gives an incomplete or distorted picture of the origins of an environmental health disaster. In this paper, a socio-ecological analysis is developed to demonstrate how the largest outbreak of waterborne E. coli O157:H7 in Canadian history was the emergent product of a complex interplay and intertwining of social and ecological processes. The socio-ecological autopsy approach that is developed here traces the social and ecological chain of events that ultimately led to the outbreak and demonstrates, in particular, the need for investigative analysis to focus on the socio-ecological "incubation" of an environmental health disaster. Drawing from both the social sciences (particularly, the sociology of disasters and organizational sociology), and from the ecological sciences (particularly disease ecology), the analysis developed here responds to the call for the application of a more transdisciplinary approach to the study of contemporary environmental health problems.

Climate change, vector-borne disease and interdisciplinary research: social science perspectives on an environment and health controversy.

Over the last two decades, the science of climate change's theoretical impacts on vector-borne disease has generated controversy related to its methodological validity and relevance to disease control policy. Critical social science analysis, drawing on science and technology studies and the sociology of social movements, demonstrates consistency between this controversy and the theory that climate change is serving as a collective action frame for some health researchers. Within this frame, vector-borne disease data are interpreted as a symptom of climate change, with the need for further interdisiplinary research put forth as the logical and necessary next step. Reaction to this tendency on the part of a handful of vector-borne disease specialists exhibits characteristics of academic boundary work aimed at preserving the integrity of existing disciplinary boundaries. Possible reasons for this conflict include the leadership role for health professionals and disciplines in the envisioned interdiscipline, and disagreements over the appropriate scale of interventions to control vector-borne diseases. Analysis of the competing frames in this controversy also allows identification of excluded voices and themes, such as international political economic explanations for the health problems in question. A logical conclusion of this analysis, therefore, is the need for critical reflection on environment and health research and policy to achieve integration with considerations of global health equity.

Stigmatized ethnicity, public health, and globalization.

The prejudicial linking of infection with ethnic minority status has a long-established history, but in some ways this association may have intensified under the contemporary circumstances of the "new public health" and globalization. This study analyzes this conflation of ethnicity and disease victimization by considering the stigmatization process that occurred during the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto. The attribution of stigma during the SARS outbreak occurred in multiple and overlapping ways informed by: (i) the depiction of images of individuals donning respiratory masks; (ii) employment status in the health sector; and (iii) Asian-Canadian and Chinese-Canadian ethnicity. In turn, stigmatization during the SARS crisis facilitated a moral panic of sorts in which racism at a cultural level was expressed and rationalized on the basis of a rhetoric of the new public health and anti-globalization sentiments. With the former, an emphasis on individualized self-protection, in the health sense, justified the generalized avoidance of those stigmatized. In relation to the latter, in the post-9/11 era, avoidance of the stigmatized other was legitimized on the basis of perceiving the SARS threat as a consequence of the mixing of different people predicated by economic and cultural globalization.

The New Public Health Hegemony: Response to Severe Acute Respiratory Syndrome (SARS) in Toronto.

The 2003 Severe Acute Respiratory Syndrome (SARS) outbreak presented a challenging period for public health in Toronto. Many old and new public health measures were implemented at local, national and global levels, in an attempt to control the outbreak of the disease. Among these, surveillance mechanisms dominated, which involved new epidemiological techniques and statistical profiling strategies. In this paper, Gramsci's concept of hegemony is used to further understandings of public health governance during the outbreak of emerging infectious diseases. Specifically, the function of the discourse of 'risk' in public health governance is examined, along with public health as a 'moral agent' in the naturalization of specific public health measures. In addition, the pervasive discourse of 'security' is discussed in relation to current public health practices. These characteristics of public health are examined with consideration of their potential for propagating social exclusion and stigmatization of individuals and communities. The specific case of SARS in Toronto is used to examine the implications of public health as a mechanism for social control and reproduction rather than the promotion of equality in health throughout the population.