 We have the last session and it's fairly non-controversial. It's all fairly straightforward. I think we know it all or not. I hope that this will be a session that is both informative and challenging. I'm sure it will be. This is something that it makes me think of the words, overwhelmed, delayed, limited. And I could be talking about people returning to their seats, but I'm actually talking about the international response to Ebola. And I think as we heard in the last session how it's not just Ebola, but it's about how we support health systems in troubling times and from Jeremy's talk how we think beyond just a disease in one place but how we think about how we tackle these difficult problems on a global scale. Just earlier this week there was a publication in the New England Journal just looking at a case report of uveitis occurring with confirmed Ebola in one of the healthcare workers nine weeks after viral clearance. This has been reported before, but it just underlines how little we actually know about the pathophysiology of this disease and how best to tackle it. And I think we have much to learn. To help us in that direction we're greatly going to be guided by John Edmonds who's currently a Professor of the Infectious Diseases Modelling Team at the London School of Hygiene and Tropical Medicine and Dean of the Faculty of Epidemiology and Population Health. So I'd invite John to chair the next session. Thank you. Okay, so thank you very much for having me. I feel rather humbled actually to be here as a sort of mathematical modeler. The knowledge of Ebola is really very theoretical and I'm in front of a crowd of people who know far more about all the practicalities of controlling and treating this dreadful disease. So we've got, the way that this session is going to work is that we've got four or five speakers first up who are going to have, give a more of a sort of traditional talk, 10-minute talk and a few minutes for questions afterwards on various aspects of Ebola response and MSF's role in that. And then after that we've got a panel discussion. So in the questions after the speakers' talks if you could keep yourself to the speaker's talk that would be good and wider questions will put to the panel at the end. So first up we have Umberto who's an anthropologist from MSF in Belgium and is going to have a really rather stimulating title about state-enforced Ebola containment measures and so on. So Umberto, over to you. Thank you gentlemen, good afternoon everyone. As an anthropologist working for a medical humanitarian organisation I feel that my scientific work is to give voices to the communities and to translate some apparently obscure social dynamics for improving the health care. And I think that this is even much more important during an Ebola outbreak that has completely devastated the social fabric of the West Africans and also their health. With my presentation today I'm proposing a social cultural analysis of outbreak containment measures in Liberia. What I will present are the social consequences of these measures that's had on Liberian communities. Social consequences that endangered both the outbreak control and the health-seeking behaviours of the population. As it is known in August 2014 the Government of Liberia decided together with international partners for the implementation of two main emergency measures to control the transmission. The first one was a mandatory cremation of bodies positive to Ebola or highly suspected. And the second one was quarantine of asymptomatic individuals contacts of positive cases. Such measures were quickly implemented because they were believed to be the fastest ways to curtail an uncontrolled transmission. Cremation was replaced only in December 2014 with dignified burials while quarantine continued until the end of the outbreak. Now these measures triggered controversial debates both internally within the communities in Liberia and externally in the NGOs and international actors. Existing literature especially on quarantine focus mainly on health aspects and ethical dimensions. For MSF OCB operations during the Ebola outbreak the qualitative study I'm presenting today based on an anthropological analysis was proposed to understand which perceptions people had about these containment measures and how they behaved accordingly. About methodology, methodology was ethnographic aimed to understand local perceptions and social practices. I personally carried out participant observation with the help of two local assistants in eight areas in Moravia and seven villages in Grand Cape Mount County. Moreover focus group discussions and individual qualitative interviews have been also realized grasping all social strata of Liberian population. The location of the research have been selecting according to different criteria. Number of active cases per area, socio-demographic dimensions, for example the presence of a market or not, rural urban differences. The data collected have been analyzed thanks to a social and medical anthropological lens by triangulating different sources, places, and data collection proceeds. As a result of my research I would like to give voices as I said to the people I've interviewed with some quotes. I will start with cremation, with mandatory cremation. The research shows that mandatory cremation was not accepted by the communities in Liberia. At the beginning and it is important to stress Liberians understood the need of the cremation but in the long term the opinion changed and changed quite radically. Cremation insulted the local meaning of funeral and people in the long run felt the need of it with all its complex social and economic significances. As the first person interviewed said, Ebola first kills and then steals. With this the informant means how cremation took away the last chance for the family to be with their relative. Moreover as the second quote shows the messages that accompanied the mandatory cremation where I can say a bit problematic. Ebola kills say the second informant. People got convinced that if they had to die anyway they would prefer to die at home in their familiar environment. Mandatory cremation raised as well social inequalities and this is for me a very much important point. What I mean is that those who could afford to bribe to pay the burial teams were able to obtain the body of their relative back for private burial in private cemeteries. Of course those who couldn't bribe for economical reason couldn't have their body back and they were forced to send it to the crematorium. Second point is the quarantine. People perceived that the state imposed the quarantine as a sort of mechanism of social breakdown. In the same way the virus of Ebola was. People felt abandoned, stigmatized and labeled as Ebola people as they said. People lacked support and felt pushed away. They witnessed the police block like in the picture I'm presenting to you and constrictions of movement without full explanation of the reasons. People under quarantine explained how only sporadically they received food and other important items. This created a social insecurity with people escaping, denying and hiding. Reaching the conclusion of this research a first one informs in my view of the differences between the meanings the aid agencies give to containment measures in an outbreak from one hand and the meanings the population give to this from the other. In Liberia the quarantine and the mandatory cremation have been perceived much more than simple to say outbreak control measures. They were framed into an historical background of social violence rooted in war and disenfranchisement. I'm showing to you a couple of pictures. The one on the right presents the problematic awareness campaign that's accompanied these measures and the second one shows a self-organized activity by the local leaders in the community. Well in my view it shows the difference between scaring people and involving them. Second conclusion is connected to fear and stigma that these measures have produced and that have prevented a fair access to health care and an understanding of the crisis. Cremation and quarantine as vertical public health measures basically do not involve the publics contributing to the social insecurity as I say it. On the contrary measures that foresee the involvement of the communities as a strategic since the beginning of the outbreak for example by praising health promoters side by side with local leaders and contact tracers show to be more respectful and sustainable in the long term. For the MSF actions the benefits or the lessons that can be taken from this research are basically to consider a community-based approach since the beginning of the epidemic as I said by activating outreach activities alongside with clinics and treatment units. Another suggestion that maybe it's a bit a dream is to have a field operative research unit composed by epidemiologists and anthropologists as well that can support with data the medical coordination and the advocacy unit monitoring social dynamics and adjusting the intervention accordingly. I would like to thank all the participants to this research and those that have supported me in this activity and thank you very much to you. Very stimulating talk and for keeping to time. So over to the audience for questions and we've got online question. I have a question from Anas Alamoudi who's an MSF logistician and student nurse who's asking how effective was state enforced Ebola containment in Liberia? It was effective socially, not really from my point of view because it has produced, as I said, a lot of fear and stigma that have endangered the control of the epidemic itself. Can I ask a follow-up? Did you observe changes over time? Did the population become more compliant with the public health measures? And did the public health measures become more flexible and move towards the population? I actually have seen a sort of movement like the epidemiological graph that sometimes I see with my colleagues. In some cases the motivation got higher but in other very low. The social dynamics are very flexible but overall what I can say is that these social dynamics that were not accepting these vertical containment measures were a sort of resistance to this that have not been listened to much. Quarantine continued until the end of the epidemic despite the fact that people were not really accepting it. Yes. So can we have a microphone now? And remember to say your name as well. I'm David from Care International. There's a lot of criticism about state-imposed quarantines and restriction of abilities and safe burial practices. But in situations like the Ebola outbreak in West Africa what other options are there? Other dense state-imposed quarantines, et cetera. Even if it means taking away some of the the human rights issues involved in these restrictions in your opinions. How do you respond to the criticisms and if there's another option in terms of a public health action? Thank you. Well it's a very big question of course that involves a lot of aspects. Me as a medical anthropologist what I can say is that the communities and the people have much more resources that sometimes we think we expect. And if, as I try to say, we involve them since the beginning for example with clear, fair and participative awareness messages that explain what is the crisis about and don't just say it kills or it does or it does not. It's the first step. Then MSF has tried and I think in some cases quite successfully to work together with the communities not only with the local leaders the so-called local leaders or religious leaders but even with people, with normal people market women for example, taxi drivers but also the health workers that were working in our facilities. These are citizens of Liberia or the other countries. So I don't know if it's a solution but I've also read in the literature in public health that the real involvement of the communities is a key factor and a key lesson to learn and to implement. One last question. So the lady in the middle. Sorry, there's a lady at the back with a microphone. Hi, I'm Margaret Fitzgerald from Dublin and I arrived in Monrovia the day the quarantine started and there was a huge... I was with Gorin WHO there was a huge sense of shock at the imposition of quarantine and you said where was the public in that public health measure? Where was the health in the public health measure? Because I didn't meet anyone who thought that it was justified on health grounds it was imposed by the president by our understanding and I think I agree with you that the key to the relative success in Liberia has been the community and... but that means as you said the messages need to be adjusted to the changing circumstances because definitely cremation was very important in stopping the escalation of the outbreak in Monrovia City and Pierre Fomenti was very instrumental and perhaps they didn't keep an eye on the cultural aspects You can make it very quick Thank you Aileen Kitchen from Public Health England just recently returned from Sierra Leone I was working with WHO it's a question about burials you suggested or perhaps I've interpreted from your presentation that cremation was not acceptable but the burials were a preferred approach which would be very different to the experience in a lot of Sierra Leone where many communities were very resistant to the safe and dignified burials and preferred to bury their own dead dead Could you talk a little bit about that in Liberia and the acceptance of the community towards the burial teams? Okay Very quickly the burials in the funerals performances or practices are very different according to the locations, to the ethnic groups to the religion so it's difficult to talk in general What I can say quickly is that when I arrived in Morrovia at the end of September quite at the peak of the epidemic I remember that I was requested to monitor the Muslim community in Morrovia because the fear was that they were performing traditional burials it was on the media as well in newspapers the same day I read on a local newspaper in Morrovia that's one of the most important and influential Imam in Morrovia was publishing an article on the newspaper saying we the Muslim community we have modified our practices to better respond to the outbreak and to avoid the transmission it was quite interesting for me because there was this idea that the Muslims were not complying with the proceeds but actually they were cremation I'm sorry I think we're going to have to move on I think we should thank Conberto once again for his talk