Communicating The Ebola Crisis In West Africa

ABSTRACT
A comprehensive, reliable public communication before, during, and after a health crisis can save lives, yet critics say the ways that crisis containment policies relating to the Ebola Virus Disease (EVD) outbreak were communicated in West Africa raised anxiety and, in some places, fueled rumors that led to counter-productive behaviors (Ansumana, Bonwitt, Stenger &Jacobsen, 2014). Improved communication by health officials with the media, community leaders, health professionals, and the general public is therefore necessary to reduce misinformation and improve compliance with prevention and control measures.

Planning is required to develop and execute communications effectively. This paper tackles in context of Guinea the communication factors and that must be addressed to improve the chances of success in the fight against the EVD. A desk study from both development communication scholarship and medical practice was conducted to assess the current EVD situation in Guinea.

Keywords: Crisis communication, Ebola Virus Disease, communication planning.

The Ebola Disease
Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals. In Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest. Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe, often fatal illness in humans and EVD outbreaks have a case fatality rate of up to 90% (World Health Organization, 2014).

EVD outbreaks occur primarily in remote villages in Central and West Africa, near tropical rainforests. The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission. Fruit bats of the Pteropodidae family are considered to be the natural host of the Ebola virus. Severely ill patients require intensive supportive care. No licensed specific treatment or vaccine is available for use in people or animals.

Ebola then spreads in the community through human-to-human transmission, with infection resulting from direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluids.

Country Context: Republic of Guinea
The Republic of Guinea is in West Africa. It is bordered by Guinea-Bissau, Senegal, and Mali to the North, Liberia and Sierra Leone to the South, Côte d'Ivoire to the East, and the Atlantic Ocean to the West. It covers an area of 245,857 square kilometers and has 300 kilometers of Atlantic coastline. Guinea has a tropical climate with a rainy season and a dry season (World Bank, 2013). The presidential election of November 7, 2010 marked the return of Guinea to constitutional order after the army seized power on December 23, 2008.

After a difficult period of military transition, the election of the first democratically elected President, Mr. Alpha Condé, and the new political context, paved the way for new economic opportunities for Guinea. A series of reforms were introduced and Guinea reached completion point for the Heavily Indebted Poor Countries (HIPC) Initiative in September 2012.

To complete the political transition, Guineans went to the polls on September 28, 2013 to elect 114 members to the new parliament. The last legislative elections took place in 2002. In 2012, the population of Guinea was estimated at 11.3 million (with a population density of 47.2 per square kilometer and an urbanization rate of 31%).

With a natural growth rate of 3.1%, the Guinean population is young (45% of Guineans are between the ages of 15 and 19). In 2011/2012, the gross enrolment rate was 81% for boys and 73.5% for girls. Per capita GDP was about $450 in 2012. The 2012 Limited Poverty Evaluation Survey showed that 55.2% of the population is considered to be poor, compared with 53% in 2007 and 40.3% in 1995. The number of persons living in extreme poverty has also doubled. Most of the poor are still living in rural areas.

The results of the 2012 survey show that 64.7% of the rural population is considered to be poor, compared with 32.1% for the urban population. However, poverty is increasing more in urban areas, mainly because of the increase in prices for essential goods, the rural exodus, and the employment crisis. The Guinean economy is dominated by mining and the rural sector. Ongoing implementation of the 2012-2014 economic and financial program, supported by the IMF Extended Credit Facility, helped to reduce macroeconomic imbalances.

In 2012, despite the international crisis, economic activity remained strong, supported by higher investments in agriculture and the mining sector. Real GDP grew by 3.9% in 2011 toreach 4.8% in 2012, compared with 1.9% in 2010. However, electricity supply difficulties continue to adversely affect economic activities. Guinea has some of the least developed health, sanitation and hygiene systems in the world.

The levels of health outcome indicators remain mediocre compared to other parts of the world. In particular, while low cost interventions such as prevention and treatment of malaria, or early treatment of diarrhea and infectious respiratory diseases would bring about significant improvements, the level of under-five child mortality still remains high. Apart from the fact that public expenditure least benefits the poor segments of the population, per capita health expenditure as well as health expenditure with respect to total government expenditure is extremely low in Guinea. Health sector budget allocations have been invariably low over the past decade, representing less than one-fourth of the education sector budget allocation, when in most countries this ratio is closer to one-half. 


ANALYSIS OF THE EBOLA CRISIS
Problem Statement
Ebola virus disease (EVD or Ebola) is a horrifying disease. It seemingly appears out of nowhere, kills people in a gruesome manner, and then disappears for reasons that are not entirely clear. Since Ebola was first described in 1976, it has captured the public imagination and raised questions about how the international community should respond to outbreaks. Of all the strains of the Ebola virus, the Zaire strain (Zaire Ebola virus) isthe deadliest. That is the species now infecting people in Guinea, Sierra Leone and Liberia; in the ongoing outbreak, it has killed more than half of the people who contracted it (WHO, 2014).

In addition to the loss of life, the outbreak is having an economic effect. For instance, Conakry's Palm Camayenne Hotel, which is popular among businessmen and politicians, has less than a third of occupancy rate (Diarra & Hussain, 2014). On Brussels Airlines flights between Brussels and Conakry, there are reduced numbers of people arriving in Conakry but more people leaving Conakry. Regional airline Gambia Bird delayed the start of a route to Conakry due to Senegal closing its border with Guinea because of the outbreak (Diarra & Hussain, 2014).

According to Ibrahima Touré (2014), Country Director of Plan Guinea, an NGO, the poor living conditions and lack of water and sanitation in most districts of Conakry pose a serious risk that the epidemic escalates into a crisis. Also, considering the fact that Guinea's under-resourced health care system faced additional burdens due to the influx of refugees from Liberia and Sierra Leone (Fofana, 2014), ending an outbreak requires communication with local populations about the precautions necessary to prevent infection.

This can prove particularly difficult for outsiders who come into Ebola-infected areas, as they rarely possess an understanding of local practices or cultural contexts. However, a study by Hewlett and Amola (2003) about an outbreak of Ebola in Uganda shows that effective public education practices can often be harnessed effectively to reduce the disease's spread if and when health care workers engage them.

Communication Factors to be Addressed
In the absence of effective treatment and a human vaccine, raising awareness of the risk factors for Ebola infection and the protective measures individuals can take is the onlyway to reduce human infection and death. Health departments must have good, consistent, clear, crisp communications both internally and externally. During crisis situations such as the Ebola outbreak, executives must balance promises (what they say they will do), performance (what they actually do), perceptions (what the public believes they are doing) and expectations (what the public believes they should be doing). A comprehensive and strategic communications plan for the department sets the foundation for executives to develop and execute communications effectively: to reach the target audience in the right place, at the right time, with the right message.

This planning takes leadership, teamwork, internal collaboration and sharing, as well as continuous improvement. Doing this effectively will lead to coordination of team activities, allow for adept reaction and response to current events or crises, produce results, and maximize health outcomes. This spreadsheet will help you to address and organize essential factors of communications planning, execution, and evaluation. Doing this preparation work before you communicate will save you valuable time and resources when and where they are needed most. There is an increasing number of communication factors affecting containment efforts of the Ebola crisis for which responsible agencies should have a crisis or risk communication programme in place. These factors might include the following:

Lack or Limited Use of Comprehensive Communication Plan

It appears, based on the views of (Cham, 2014) that public health communicators involved in handling the Ebola crisis either lack a comprehensive crisis communication plan or fail to make full use of an army of communicators working in the field as well as in the hospitals. Even if this plan was in place, it may be the case that as soon as Ebola was discovered, the crisis plan and arsenal of health crisis information became obsolete.Again, this simply means the communication plan (if any existed) did not anticipate the exigencies surrounding the crisis.

Communicating Precautionary Measures
Public education is a major component of crisis communication. It is not always possible to identify patients with EBV early because initial symptoms may be non-specific. For this reason, it is important that public health workers or communicators communicate to the general public to apply standard precautions consistently at all times. These include basic hand hygiene, respiratory hygiene, the use of personal protective equipment (according to the risk of splashes or other contact with infected materials) and safe burial practices.

These have to be communicated clearly to the public. Communicators need to inform the population about the nature of the disease and about outbreak containment measures, including burial of the dead, which in my opinion has not been done very well. In addition, there is a growing realization that for awareness campaign on such precautionary measures to be effective, it should be a continual and evolving process and not simply a crisis management measure. But we notice from the Guinea case that communication dipped around May this year when no new Ebola cases were recorded.

The Need to Reduce Misinformation
From the word go it was obvious that there was something fundamentally wrong about how government of Guinea was handling communication of the outbreak in the sub-region. Earlier attempts at bringing the situation under control focused on protecting people first. While this was not a wrong approach, there was also the need analyze the situation to judge its newsworthiness.

Rather than gathering the facts – who, what, where, when, why, how and what next, it seems that the authorities had jumped the gun attracting so much media attention before going back to find the facts. . Improved communication of the facts by health officials with the media, community leaders, health professionals, and the general public is necessary to reduce misinformation and improve compliance with prevention and control measures.

Applicable Communication Theory
The communication theory applicable to the Guinea case is crisis communication theory. Reynolds (2002) explained that the goal of crisis communication during a public health disaster is to provide information to the public so that they can make informed decisions about their own health and safety. During a crisis, the communicator is an agent, rather than a participant in the crisis. Reynolds outlined nine steps to public health crisis communication: 1. Verify the situation before acting 2. Notify leadership and other agencies of the situation 3. Assess the scope of the crisis 4. Assign jobs to members of the crisis team 5. Prepare information that will explain the situation and agency response 6. Release the information to the public, media, and stakeholders 7. Gather feedback to be sure the messages are being interpreted correctly and to see what needs to be addressed further 8. Educate the public so that they can respond to the situation better the next time 9. Monitor the information flow, messages, and ongoing situation and make adjustments in the communication plan as needed. It is also important to note the subtle, yet critical difference between risk communication and crisis communication, that is, when the communication occurs.

Risk communication is an ongoing process that helps to define a problem and solicit involvement and action before an emergency occurs. Crisis communication encompasses those messages delivered to stakeholders during an emergency event that threatens them. According to Fearn-Banks (2007), crisis communication "is concerned with transferring of information to significant persons (publics) to either help avoid or prevent a crisis (or negative occurrence), recover from a crisis, and maintain or enhance reputation" (p. 2).

CRISIS COMMUNICATION PLAN
Crisis communication planning can help to deal effectively with those unexpected disease outbreaks, emergencies or other unusual events that may cause health scares. For example, Robinson and Newstetter (2003) conducted an organizational case study of the Centers for Disease Control's response to the anthrax attack and how the organization managed throughout the phases of a major health crisis. Their findings, based on interviews with CDC communicators, revealed that the agency adapted to the crisis and transformed to manage this new health threat.

Before the anthrax outbreak became known, the CDC had a comprehensive crisis communication plan and an army of communicators working in the field as well as in the agency's headquarters. The following crisis communication plan has been created based on the ideas provided by Reynolds (2002). The plan provides a snapshot (a visual) of priority actions that can be taken to mitigate the barriers associated with the Ebola crisis communication. It is intended to be a guide to improve communication about the Ebola crisis in Guinea.

BIBLIOGRAPHY
Ansumana, R., Bonwitt, J., Stenger, D. A., & Jacobsen, K. H (2014). Ebola in Sierra Leone: a call for action. The Lancet; DOI: 10.1016/S0140-6736(14)61119-3 Cham, K. (2014). Scientists fault Guinea's communication strategy for Ebola crisis.

(accessed 4 August 2014). Diarra, A., & Hussain, M. (4 April 2014). Mali suspects first Ebola cases as regional death toll tops 90. Reuters.

(accessed 23 July 2014). Diep, F. (2014). How Did The Deadliest Strain Of Ebola Travel From Central To West Africa? It was not Gwyneth Paltrow.

(accessed 4 August, 2014) Fearn-Banks, K. (2007). Crisis communications: A casebook approach (3rd ed.). Mahwah, NJ: Lawrence Erlbaum Associates Inc. Fofana, U. (2014). "Sierra Leone's chief Ebola doctor contracts the virus," Reuters, 23 July 2014.

(accessed 23 July 2014). The Lancet (2014). Ebola in West Africa: Gaining Community Trust and Confidence. 383:1946, Full Text | PDF(260KB) | PubMed Reuters (2014), "Sierra Leone shuts borders, closes schools to fight Ebola," 11 June 2014.

(accessed 31 July 2014). World Bank (2014). Guinea Overview:

(accessed 3 August, 2014) World Health Organization (2014). Ebola virus disease, West Africa. Update 24 June 2014.

(accessed July 28, 2014). Youde, J. (2014). outbreak-in-guinea-liberia-and-sierra-leone/"http://www.e-ir.info/2014/07/26/the-ebola outbreak-in-guinea-liberia-and-sierra-leone/

APPENDIX
GUIDANCE: (Step 1) Verify the Ebola Crisis
While it is not always possible to confirm all aspects of the Ebola Situation or verify all sources, the facts must be established and verified to protect the public and its confidence in Guinea's health system.

What happened?
To whom did it happen?
When did it happen?
Where did it happen?
How did it happen?
Guinea's health care system is under-resourced health care system is already under-resourced therefore ending the outbreak requires communication with local populations about the precautions necessary to prevent infection.

Notifications:
GUIDANCE: (Step 2) Conduct Notifications
As soon as a situation is diagnosed as Ebola, essential leadership, authorities and partners must be notified.

Who must be notified (internally and externally)?
How should they be contacted and by whom?
When should they be notified?
(See “Notification/Coordination Roster” below)
Crisis Level – Communication Response Needed:
The Ebola virus disease has reached the crisis level where the number of recorded cases and deaths is increasing. At this level, the public's perception of the level of a crisis and the actual threat to public health are sometimes not in sync. It is therefore important to assess the actual public health risk and the level of communication response needed.

GUIDANCE: (Step 3) Assess level of crisis.
Assignments for Team Leaders:
GUIDANCE: (Step 4) Make Assignments.
Alert the leadership of each communication team.
Make clear assignments.
(See: Event, Checklist, Team/Function: Master Assignment List”

Spokesperson Preparation Required:
GUIDANCE:
Who is the best person to create trust and project credibility on this issue?

What must be done to help the spokesperson prepare (background, facts, review risk communication principles, Q/A prep)?

(See: Pre-Event, Tools, “Crisis Communication Spokesperson Checklist”)

Target (s) Audience
GUIDANCE: (Step 5. Prepare Information.)
How are different segments of the population affected or potentially affected?

What audiences and subgroups must be addressed?
====Possible Audiences-Concerns====
Public in the crisis, for whom action messages are intended-personal safety, family safety, pet safety, stigmatization, property protection

Public immediately outside the crisis, for whom action messages not intended-personal safety, family safety, pet safety, interruption of normal life activities

First responders-resources to accomplish response and recovery, personal safety, family safety, pet safety

Public health and medical professionals responders-personal safety, resources adequate to respond

Family members of victims and first responders-personal safety, safety of victims and response workers

National community-vicarious preparation, readiness efforts

International neighbors-vicarious rehearsal, readiness efforts

International community-vicarious rehearsal, exploration of readiness

Stakeholders and partners specific to the emergency-included in decision making and access to information

Media-personal safety, access to information and spokespersons, deadlines

GUIDANCE:
Develop key messages for each audience and subgroup.

Make sure the important emergency risk communication concepts are integrated into the messages for all audiences.

Communication Channels:
Start text for selection of communication channels here.

GUIDANCE:
What delivery channel(s) must be used to reach each audience? Each subgroup?

Who is responsible for delivery and in what timeframe?

Channel-Examples
Face-to-face -health care professional to patient, or your organization's staff member to state partner agency or individuals in the community

Group delivery -small group meetings or public meetings

Organizational-constituents of influential community organizations

Mass media -radio, television, newspaper, or direct mail

Community-employers, schools, malls, health groups, or local government agencies

Combination-a combination of any of the channels listed above

GUIDANCE:
Alert review and clearance teams.
Streamline processes so information release can be completed as quickly as possible.

Provide subject matter experts to review content
Facilitate clearance of printed materials
Maintain multiple clearance channels
Distinguish between previously cleared and new information for timely release

Audience Materials:
GUIDANCE:
What materials are needed to deliver messages to target audiences? For example.

Web pages
Telephone contacts
Briefings
Small group meetings
Public meetings
Presentations
Fact sheets
What special requirements must be considered for materials for any subgroups (e.g. language, format, special delivery channel)?

What exists? What must be created?
Provisions for Releasing to Public:
For Immediate Release:
Projected Time of Next Release:
Process Being Used to Obtain Further Information:
GUIDANCE:
Get cleared information out as quickly as possible

Provisions for Monitoring
GUIDANCE:
Tracking, who is analyzing?
Who is feeding information back to leadership?
Provisions for Evaluation
Start text here.
GUIDANCE:
What elements of your evaluation plan will require special attention following this event?