The symbolic violence of ‘outbreak’: A mixed-methods, quasi-experimental impact evaluation of social protection on Ebola survivor wellbeing

Abstract

Despite over 28,000 reported cases of Ebola virus disease (EVD) in the 2013–16 outbreak in West Africa, we are only beginning to trace the complex biosocial processes that have promoted its spread. Important questions remain, including the effects on survivors of clinical sequelae, loss of family and livelihood, and other psychological and social trauma. Another poorly understood question is what effect social protection and job creation programs have had on survivors’ wellbeing. Several clinical and social protection programs have been developed to respond to the needs of EVD survivors; however, little in the way of impact evaluation has taken place. We enrolled 200 randomly selected EVD survivors from Port Loko, Kenema, and Kailahun districts in Sierra Leone and stratified them based on the amount of instrumental social protection received post-discharge from an Ebola treatment unit. We then conducted a survey and in-depth interviews to assess participants’ wellbeing and food security. Social protection categories II-IV (moderate to extensive) were each significantly associated with ~15–22% higher wellbeing scores compared to minimal social protection (p<0.001). Only social protection category IV (extensive) was significantly associated with being food secure (adjusted odds ratio 6.11; 95% confidence interval, 2.85–13.10) when compared to minimal social protection. Qualitative themes included having a sense of purpose during the crisis (work and fellowship helped survivors cope); using cash transfers to invest in business; the value of literacy and life-skills classes; loss of breadwinners (survivors with jobs were able to take over that role); and combating the consequences of stigma. We conclude that, for EVD survivors, short-term social protection during the vulnerable period post-discharge can pay dividends two years later. Based on the empiric evidence presented, we discuss how terms such as “outbreak” and “epidemic” do symbolic violence by creating the illusion that social suffering ends when transmission of a pathogen ceases.

Ebola and the narrative of mistrust

“…A detailed analysis of how these historical forces become embodied as viral disease is beyond the scope of this study (and we have conducted such analyses elsewhere) 4–7. Rather, in this article, we argue that epidemiological studies that claim to capture the social dynamics of disease transmission in health-seeking behaviours all too readily serve as a smokescreen that enables and perpetuates ongoing structural inequities—notably, by omitting consideration of global power relations, colonial history and contemporary extractive political economies.…”

“…What initially looks like a benign set of statistics compiled by public health experts takes on a different hue when we share its language and framework with those directly suffering the epidemic. Taking the term superspreader, we asked interlocutors in the DRC what they thought, in the midst of the outbreak, and we took the question back to Ebola survivors in Sierra Leone and Liberia 5. These community members directly affected by EVD all found the term inappropriate.…”

Real-time projections of Ebola outbreak size and duration with and without vaccine use in Équateur, Democratic Republic of Congo, as of May 27, 2018

“…As such, the massive mobilization of resources to roll it out should not detract from the prioritization of patient and survivor care, lest we recapitulate the control-overcare paradigm that marred the response to the 2013-2016 outbreak in West Africa. [50][51][52][53] Thus far, there has been a strong local and international response, and deployment of vaccines and rapid diagnostic tests (RDT) occurred early in response efforts. 4 RDTs are being used to screen Ebola suspects while the vaccines are being administered to high-risk groups for EVD, including healthcare workers, contacts, and contacts of contacts.…”

Pandemicity, COVID-19 and the limits of public health ‘science’

“…2 And while 'expert' epidemiologists have been climbing over themselves to brandish their latest forecasts (a phenomenon I have described as #WillToPunditry), it seems worth asking, are their ways of parsing health phenomena useful? Moreover, if one accepts that the boundaries between disease outbreaks and their political economic determinants/sequelae are blurred, 3 the same question should also be asked of other 'expert' modelers, economists in particular.…”