Be a Man-Respect Women! Challenging Gender Norms in Bosnia and Herzegovina and across the Balkans

Arielle Juberg – Bosnia and Herzegovina – August 10, 2015

Arielle Juberg, a current PFMH/MSPH graduate student, conducted her practicum with the Young Men Initiative, a program in the Balkans that seeks to promote healthy lifestyles, reduce violence among young men, and prevent gender-based violence.

As a New Yorker, I’m used to keeping track of my time. Six hours of sleep, three hours at work, one hour on the subway; my days are neatly broken up into separate responsibilities and activities. When I read that Public Health and Humanitarian Assistance (PHHA) students were required to spend eight to twelve weeks in an international practicum, I tried to convert this into my hours-and-minutes mode of thinking. Unlike most other certificates at the Mailman School, which measure practicum activity by the hour, the PHHA certificate measures the weeks that students spend completing public health research abroad. Logistics may account for part of this difference; it can be difficult to quantify ‘working hours’ when your job is interrupted by electricity outages or long trips through rural areas. Within a week of my arrival in Bosnia and Herzegovina, I realized that the difference between measuring ‘hours in the office’ and ‘weeks in the field’ is more than just numbers on paper. If we are seeking to contribute positive changes in another country and culture, we must seek meaningful and genuine interactions with individuals and communities outside the environment.

I arrived in the city of Banja Luka in May with few contacts and fewer leads on a place to live. With only ten weeks in the city, renting an apartment seemed unnecessary, while a long hotel stay would be extravagant. Luckily, I found a room to rent with a family whose members included a toddler (I’ll call him Ben). On my first weekend in Banja Luka, Ben, his mother, and I walked through the city. Banja Luka is the second-largest city in Bosnia and Herzegovina, with an estimated population of 200,000. The city is well-known for its parks and green spaces. We wandered into one of the parks so Ben could play. Almost immediately, he noticed a shiny blue tricycle by the playground. Ben is currently infatuated with anything with wheels and quickly claimed the tricycle as his own.  As he happily rode around the playground, the owners of the tricycle, who may have been 3 and 5 years old, took notice. First, they followed him, yelling for him to stop peddling. Next, the older one attempted to stop the bike and pull Ben off. He yelled at his brother to punch Ben. Finally, the younger one cemented himself in front of the bike, grasped the handlebars, and thrusting his head forward, snarled at Ben.

How did a 3-year old and a 5-year old learn to yell, intimidate, and punch? Why were these the first actions they took when faced with the loss of their tricycle? Even as an adult, their immediate and aggressive behavior frightened me. While it may be inevitable that children argue over toys at the playground, their behavior reflects the acts they’ve witnessed and the lessons they’ve been taught.

In many countries, including Bosnia and Herzegovina, boys are brought up to be tough, dominant, and strong. Showing emotions signals weakness, and dominance is determined through violent acts like yelling, bullying, and fighting. I saw this clearly reflected on the playground; when confronted with a problem, even toddlers resorted to physical and verbal violence. This pattern continues as boys get older, with the violence and its consequences growing more dangerous. Young men can be both the perpetrators and victims of violence. In a recent survey, young men in Sarajevo, the capital of Bosnia and Herzegovina, reported troubling levels of violence; 46% had punched, kicked, or beaten another young man in their life, 44% had humiliated a peer, and 46% had participated in a group fight in the past [1].

The harmful effects of a dominant masculine ideology go far beyond young men. Just as boys are taught to be strong and forceful, girls are rewarded for submissive and gentle behavior. These conflicting gender roles have been identified as one of the root causes of gender-based violence. Women may experience physical, sexual, or psychological violence when they disagree with a male member of the household or appear to challenge his authority. In a setting where violence is an established means of settling disagreements and establishing dominance, searching for a ‘reason’ for a specific violent act misses the point. When violence is a social norm, the least empowered members of society will always be vulnerable.

How do you change an established social norm? The Young Men Initiative, coordinated by CARE International with local NGO partners, seeks to reduce both interpersonal and gender-based violence by promoting gender equality and a positive, non-violent model of masculinity. The program has been implemented throughout the Balkans, including Bosnia and Herzegovina, Croatia, Serbia, Kosovo, and Albania. Through a series of interactive workshops led by facilitators, young men in high schools grapple with topics surrounding gender, gender norms, and violence. Early results show how the program can push back against established norms. In Kosovo, 69% of participants initially agreed that physical strength was a man’s most important quality; after the program, only 42% agreed with the statement- a statistically significant result [2]. Beyond the classroom workshops, the Young Men Initiative has launched Budi Muško (Be a Man) clubs in the high schools. The clubs, which include both young men and women, focus on combatting peer violence and gender-based violence while promoting knowledge of sexual and reproductive health. Budi Muško members plan awareness campaigns, host public events, and learn how to work with their peers concerning these topics. Through these clubs, young advocates work together towards a common goal and most importantly, take ownership of the campaign. In the future, they will be the leaders who work for a more equitable and non-violent society in the Balkans.

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Be a Man Club members from Banja Luka, Bosnia and Herzegovina raise awareness about the dangers of drunk driving (photo by Perpetuum Mobile)


Be a Man Club members in Belgrade, Serbia (photo by Center E8)

This is what I’ve learned about going abroad to work for eight to twelve weeks. You may fly to your destination without knowing a soul, but you quickly develop close relationships. While I was in Banja Luka, I could help to protect Ben from the bullies who would punch and hit him for taking a ride on a tricycle. But I wasn’t there for too long, and I can’t protect him as he grows up. By targeting norms surrounding masculinity and violence, the Young Men Initiative can change the society that Ben grows up in. Tricycles will continue to be appealing, and children will undoubtedly still argue over toys at the playground, but violence doesn’t have to be part of this experience.


Be a Man Club members from Mostar, Bosnia and Herzegovina participate in an event for International Men’s Health Week (photo by Youth Power)


Be a Man Club members in Sarajevo, Bosnia and Herzegovina (photo by Association XY)


Monitoring and Reporting Attacks on Education in North Kivu, DRC

In June 2015, Elburg van Boetzelaer, a recent PFMH/MSPH graduate, and Lina Rojas, a current graduate student, worked closely with Rebuild Hope for Africa (RHA) to evaluate the Monitoring and Reporting Mechanism (MRM) of attacks on education by armed groups in North Kivu, Democratic Republic of Congo (DRC). Here they write about their work with RHA and the study. 


Armed violence against schools by militant groups threatens students and school personnel across the world, depriving children from their right to education, and further damaging the already fragile future of states in context of armed conflict. In order to track disruptions of education by armed groups the UN Security Council (UNSC) Resolution 1612 established the Security Council Working Group on Children and Armed Conflict to manage the new Monitoring and Reporting Mechanism (MRM) for grave violations against children. Among the six grave violations tracked by the MRM are attacks on schools, including attacks on school personnel, and threats against these persons. The DRC has had an active MRM for 10 years, having been selected as a pilot site for the mechanism’s rollout in 2005.

In response to the need to strengthen the monitoring and reporting mechanism of attacks on education, and following a study that was conducted in 2014 in South Kivu, the Columbia Group for Children in Adversity (CGCA)—an extension of the Program on Forced Migration and Health–in partnership with Rebuild Hope for Africa (RHA), has conducted a study in the province of North Kivu, Democratic Republic of Congo (DRC). The study aimed to appraise the effectiveness of efforts to monitor and report attacks on education through semi-structured interviews with key informants of 35 organizations including government, UN agencies, and civil society organizations, while exploring the veracity of key informant reports and avenues for improving the surveillance of such incidents.

For the purpose of the study ‘attacks on education’ were defined as follows: intimidation, theft, indoctrination, recruitment, abduction, kidnapping, illegal incarceration, injury, abuse, torture, sexual- or gender-based violence, forced labor, forced marriage, and murder, whether in school or on the way to school, as well as military use of schools, and partial or total destruction of school buildings or other facilities, by an armed group.

Key informants identified a number of challenges that impede the efficacy of the MRM in monitoring attacks on education in North Kivu. Constant insecurity that dominates North Kivu, poor infrastructure, a lacking phone network and the absence of an official mail system make the effective communication and reporting of incidents from affected schools almost impossible. In addition, a vast majority of key informants were unfamiliar with the MRM, including government officials, representatives of international and local NGOs and representatives of the educational system. The few informants that were familiar with the MRM expressed a lack of confidence in the mechanism; the main reason being the MRM’s inability to actually capture attacks on education due to a lack of information sharing between key stakeholders, as well as a lack of financial and human resources to fulfill the requirement of verification of attacks prior to their inclusion in the MRM. The unfamiliarity of key informants with the MRM, suggests a need for awareness raising, training and technical capacity building in order to ensure meaningful participation in the MRM of representatives of education institutions, government, UN agencies and (inter)national NGOs alike.

A total of 113 attacks on education that took place between December 2013 and June 2015 were reported by key informants in Goma, providing a description of the incident, the name of the school and its location, the suspected perpetrators and the date of the event. About 20% of these reported events were chosen by the researchers for on-site verification, based on reachability, security, and diversity of sources that provided the reports. In this way, 23 schools in three different territories were chosen across the province for verification. Of the 23 schools that were chosen for verification, on-site informants including schools directors, teachers, religious leaders, and village chiefs confirmed 19 reports. Therefore, 83% of the reports of attacks on education were considered confirmed. During the visit to the 23 selected schools, interviewees described two additional attacks, which had occurred in those schools that had not been reported by key informants in Goma.  An additional 25 schools that were nearby the initial 23 were visited where no attacks on education had been reported by key informants in Goma. On-site informants at 20 out of the 25 schools (80%) reported that the school had been attacked during the period under study. Some schools were affected by multiple attacks between December 2013 and June 2015, resulting in 27 distinct attack reports within those 20 affected neighboring schools. Thus, a total number of 29 attacks not known to the key informants in Goma were added during the field verification process. The high number of additional attacks that were documented during the on-site verifications (an additional 26%) suggests a probable underestimation of attacks on education in North Kivu when surveillance is solely based on key informants in Goma. Further illustrating the importance of including local and community based representatives from the education and child protection sector in the monitoring and reporting of attacks on education, and strengthening communication and reporting pathways.

The quantity and quality of the total 142 reported attacks on education (113 by key informants in Goma, and 29 during on-site verification) attest to the need for an enhanced monitoring system for attacks on education in North Kivu, as this number is considerably greater than the number that was reported in the UN Secretary-General Report on Children and Armed Conflict, which documented 34 attacks on education in 2014, including the use of schools for military purposes, affecting 31,000 children in the entire DRC.[1] This study demonstrates the feasibility and affordability of an active surveillance system based on key informant interviews and on-site verification to monitor disruptions of education in North Kivu. As regular active surveillance will provide a better understanding of patterns of attacks on education in the province and contribute to more effective advocacy, prevention, response, and protection efforts, the repetition of this study, twice annually and preferably by a local NGO is strongly recommended.

[1] United Nations Secretary-General (UNSG) (2015). Report of the Secretary-General on children and armed conflict in the Democratic Republic of the Congo. S/2015/409. 5 June 2015.

Cyril Bennouna, MPH ’15: Attacks on Education, Research Methods & Lessons Learned

In early June recent PFMH grad Cyril Bennouna presented his latest research looking at attacks on education. Rosemary Nzuki of Columbia Global Center Nairobi reports on the panel and discussion below. You can learn more about the work being done at Columbia Global Center Nairobi here.

Cyril Bennouna

Education under attack report released in Nairobi

11 June 2015; Nairobi, Kenya…

A group of thirty key stakeholders from the education sector in Kenya gathered at the Columbia Global Centers – Africa to deliberate the future of education in areas plagued by insecurity and conflict. The stakeholders were drawn from the Ministry of Education, various United Nations Agencies and Non- Governmental Organizations, such as the United Nations Children’s Fund (UNICEF), European Union, United Nations High Commissioner for Refugees (UNHCR), Adventist Development and Relief Agency, and the United States Agency for International Development (USAID) among others, as well as universities, including the University of Nairobi, Kenyatta University and Columbia University.

The purpose of the meeting was to disseminate research findings carried out in Somalia and the Democratic Republic of the Congo (DRC), especially in light of recent events in the east Africa region. The meeting also presented a valuable opportunity to convene a diversity of experts to explore strategies for better protecting schools and universities from attack, while improving monitoring systems. The research was a result of collaborative efforts between Columbia University and Protect Education in Insecurity and Conflict (PEIC), a program of the Education Above All Foundation.

The research sought to characterize the frequency and type of attacks on education in countries of study and to advance new methodologies to strengthen timely monitoring of such events. In recent years, violent attacks on education have become an important issue for the public and policymakers alike, with major attacks being widely covered by the news media, from the kidnapping of school girls in Nigeria by Boko Haram to the deadly attack on Garissa University College in Kenya by the militant Somali group Al-Shabaab followed shortly after by the bombing of the Ministry of Education in Mogadishu..

In his opening remarks, Dr. Belay Begashaw the Regional Director for the Columbia Global Centers – Africa termed the discussions as timely and welcomed the group as they came together to discuss and identify solutions to this critical issue.


Figure 1: Dr. Belay from the CGC – Africa makes his opening remarks at the start of the presentation

Professor Neil Boothby from Columbia University and one of the authors of the report reiterated the importance of the topic, noting that education in conflict areas had far-reaching implications on the economic and social development of the affected areas.

Dr. Kimani Njogu from Twaweza Communications provided the context of the research.  His presentation dubbed the climate of fear, sought to highlight the actual problems that students in these areas were facing, the consequences of the attacks, and possible  strategies that organizations in the area could undertake to help combat the situation.  These included among others holding people to account, inclusive governance, conducting more research into the nature and scale of attacks, more partnerships and collaborations between the government and industry players.

Cyril Bennouna, the principal researcher, took participants through the research methodology and findings. He highlighted the definitions of attack used for the research, the way his team received reports of attacks and verified the quality and reliability of these reports through triangulation and the existing gaps in the monitoring and reporting process identified during the research. In his conclusion, Mr. Bennouna suggested that there was need for strengthening legislation, policies and practices around child protection issues; there was need for the integration of local knowledge as a source of credible information as well as the strengthening of partnerships between civil society organizations, education administrators and the international community. He also reiterated the need for varied data collection methods to enhance monitoring and reporting of attacks on education.


Figure 2: Participants keenly follow Cyril Bennouna’s presentation

Participants engaged in a panel discussion with the representatives from the Ministry of Education in Kenya lauding the research as a long overdue, noting that the government was keen to have more reports focusing on the cause of conflict.

Participants from Kenyatta University echoed the same when they noted that there was need for a similar research to be carried out in North Eastern Kenya to aid in the development of a contextualized curriculum that would address issues causing the attacks.


Figure 3: One of the participants makes her contribution during the panel discussions


Participants from the Non – Governmental Organizations applauded the research as timely and one that confirmed that inclusion was the ultimate solution to conflict. A representative from UNICEF called for follow-up meetings to explore how the research findings could be used to enhance collaboration in the industry with a common goal to address the problem.

In her closing remarks, Dr. Margaret Sinclair, the main sponsor of the research, thanked the participants for taking time to attend the panel discussions and put out a call to the participants to consider sponsoring more research for more context-specific reports that would allow tailor-made peace building activities that would put an end to the conflict.

Les Roberts – “P.S. Realizing our Chiefs hide deaths for exactly the same reasons”

Les Roberts – Chicago, USA – April 23, 2015

What a lovely trip to Sierra Leone I have had. I worked with the coolest people… medical students, now contact tracer supervisors, having the education of a lifetime and not yet realizing it, former students and friends of former students. Being there in the era of panic and fear last fall and being back now was a wonderful contrast. Seeing schools start up again 10 days ago with that burst of joy accompanying quiet households and traffic jams for the first time in months was magical! But, what I wasn’t expecting is that the gifts of the trip keep coming even after being home.

I wrote a bit on April 9th about the chief’s lying or hiding deaths. I did not get into all the complexities then but with regard to reporting deaths and testing all bodies for Ebola, the chiefs are in a tough spot.  There are about a dozen dozen chiefs and thus at least a dozen dozen cultures across Sierra Leone, but in general, in the crudest of terms, the chief sits at the pivot point between the ancestors and the traditional forces of the universe and mundane world in which I walk. According to an amazing anthropologist named Joe Opala (who came to SL with the Peace Corps in the 1970s and never really escaped ), the traditional belief system tends to believe that the ancestors and the forces of the universe only want peace and calm. That is, unlike Christianity or Islam, their god-like forces have no capacity of wrath. I had never thought about this but if your god(s) only wants peace and calm, and you live in a world with tangible injustice and threats and things to fear, you need something other than your god to cope. In the traditional village, that is black magic, and most typically is controlled by secret societies. The secret societies have all kinds of beliefs about what needs to happen when an elder dies, or when something special or scary happens. Typically, the chief is the one who calls the secret societies to meet but is not an active member. On rare occasions a chief needs to be removed and they might poison him. The village women’s society tends to perform the female circumcisions, the men’s society that of males. In some real sense, the chief gets his standing within the village, and thus his power, by keeping the secret societies on his side. Thus, when the government says he will be breaking the law when he does not report the death of an elder but the secret society has other plans, he is in a tough spot. No wonder the chiefs often lie!

So, getting to the ongoing gift part… I had an interview a couple days ago with Jerome MacDonald at WBEZ in Chicago. I botched a couple of things (called the ancestors elders, got confused with my own double negative…) but it was by and large the friendliest interview I have ever had. He had followed this blog and he just kept asking questions which he already knew that I knew the answers. He was fascinated about this notion of the chiefs being in a tough spot and hiding deaths and that was mostly what we discussed. As I walked out of the studio, I had an image pop into my head from two days before that made me realize President Obama does the exact same thing as those chiefs. He never discusses how many civilians are killed by drones thus far. He ran a campaign to be elected in 2008 largely in opposition to the war in Iraq, but when discussing the costs and benefits, he and almost no leader, will ever admit how many Iraqis have been killed by us. And the reason is, because if they admit the truths about deaths they will lose support from a key constituent (the defense community) that is needed to maintain power. So again and again, spokespeople and elected officials avoid or lie about deaths for exactly the same motive as those Sierra Leonean chiefs. While however grim the topic of denied deaths anywhere, here is where the story gets nice for me.

When I was five or six years old, one day I accompanied my mother into the small dry cleaners’ shop that my parents used. Being an ignorant little kid, I thought nothing of it when I said to the shop owner, “Mr. Bergman, why do you have that number on your arm?” My mother was mortified and told me to hush… and Mr. Bergman just smiled and went on with his business. In the car afterward, my mother scolded me to never probe into people’s body issues or personal matters because you might offend them.  She told me that the tattoo on his arm was because he had been a Nazi prisoner, and that it was hurtful of me to have brought that up. This was exactly why I should not stare at deformities or ask about people’s personal things, because one never knows what will bring pain to a person. I have not thought of this experience for years, until the last couple days.

On my last day in Freetown, I bought some cloth bags from a guy whose hands had been severed off, I am sure in the war. That was a famous method of punishment in the war in the late 1990’s. He was about 40, we bartered a bit, he was good at it and lighthearted in his bartering. When I agreed to buy six, he separated the bags by untying a sting with his teeth. When I handed him money, he dropped some so I picked it up and held it on a railing until he could take a stump and push the money into his elbow joint to hold it. Then he pushed the money from his elbow joint with the other arm stump into a sack he had on his side. As I held the money and helped him re-sort his bags he was giggling with the struggle of it all… and I think it was genuine lightheartedness as he had now sold almost all of his bags.

As I walked out of that radio station, I suddenly had an image of that man with no hands and I instantly was reminded how recently the war was, which made me realize keeping the black magic happy for the chiefs was exactly analogous to keeping the military happy for the Commander in Chief. I wish I had that insight minutes earlier while I was on the radio! Then I realized, maybe for the first time, that I had touched the stump of the bag seller in Sierra Leone and I had not cared or noticed at the time. I had become the person my mother hoped (but never could have believed would happen) I would become 47 years earlier. I had encountered someone with perhaps the ultimate deformity associated with torture and was able to not have it get in the way of our interacting as two humans.

What a blessing that Mr. Bergman was there to sow thoughts and feelings in the impressionable mind of a six year old. What a great mother I had. What great luck that one of the last people I saw in Sierra Leone seared such a visceral image of how recent the war was, making me realize I was hypocritical to think chiefs hiding deaths was anything other than universal political dynamics. How lovely that in this crisis, unrelated to any legacies of colonialism or abusive capitalism or any political crap, the world stepped up in a big way and I got to be one of that world’s tools of compassion.  What a lovely trip to Sierra Leone I have had!



Life back to normal: This kind of crowded activity has only been visible the last couple weeks since school restarted.

Life back to normal: This kind of crowded activity has only been visible the last couple weeks since school restarted.

Finally, it is true!

Finally, it is true!

Les Roberts: “Seeing Ebola through the dead.”

Les Roberts – Freetown, Sierra Leone – April 19, 2015

I am getting ready to go and I have found that my main point from all of my field work is a hard sell here in Freetown. There are three ways we are finding out about new cases these days:

  1. People call 117 or walk into a facility because they suspect they are sick (and this has been most new cases in the last couple months)
  2. People are screened at a clinic or a road check point or a house visit during quarantine and get detected
  3. As every corpse is supposed to be tested for EVD and probably half are, we detect some from death swabs.

As a humanitarian community, category 2 above consumes about 90% of our surveillance energy and has, over the last couple months, probably produced about 10% of our new cases. Thus, I want to cut back our energy on those things and spend more effort finding and swabbing every corpse… but few are at peace with that suggestion.

In the most Ebola lingering District in recent weeks, Kambia, they had 880 blood samples taken in March and one was positive. There have been a couple of positive samples so far in April, so it is likely the rate of positives in April will be a couple times higher. That contrasts with four percent positive death swabs in Kambia during March. That means per sample taken, a death swab is at least ten times more likely to identify a new case. Finally, about half of all deaths in Sierra Leone, perhaps a little more, are being tested for EVD. If we assume that people experience a fever of 38°C and three of the potential Ebola symptoms (e.g. headache, body ache, exhaustion, diarrhea, vomiting) on average once per year, then not one in a thousand people who should be coming for testing are coming in. Thus, when you combine the rate of positives with the effort needed to get samples with the coverage rate, you would think all the effort would be going into getting more and more deaths sampled and safely buried.

But, others use other calculus. Some people value finding people who are still alive because one can get them into treatment and perhaps save them. Given that 20 or 30% who do not go for treatment survive and that 30% or sometimes 50% survive in the ETU’s, the marginal increase in the chance of survival is perhaps 20 or 25%. (There are folks who will protest this but they usually do not distinguish those detected by others with the self-induced early treatment seekers or include all the chances of death after being tested while waiting for transport, being transported…). There are others, especially Sierra Leoneans, who know that getting more chiefs and remote villages to call in deaths involves huge cultural barriers.

I just repeated a sensitivity exercise in two high incidence Districts that we had assessed in October. The system is no better. We missed two thirds of cases then, we probably have missed two thirds in 2015. The solution would be to put a lot more effort into monitoring all deaths. That is not going to happen…. and it might not be that big a deal. The outbreak is winding down because of social changes and widespread safe burial practices and services. In the grand scheme, it may not be important that the surveillance is poor.

Epidemiology… it might not always matter? Clearly, time for me to go home!



Les Roberts – “Part b: Hope”

Les Roberts – Port Loko, Sierra Leone – April 18, 2015

While the exaggerating village we visited yesterday was not a positive story, the visit to the clinic was… almost unimaginably inspirational. The nurse, Mariatu, who runs the clinic, was very good-natured and sharp as a tack. When we came to her to verify the claims that over a dozen people had come to her clinic and died, she verified that and told us oh so much more. Back in October, patients with Ebola started coming. Because if they do not die, they would typically spend three weeks, it got crowded. As they have only a couple beds in the facility, most of the October – November period of hell involved the majority of patients laying on the floor vomiting and defecating. She runs a health post and was absolutely not supposed to accept Ebola patients, but they were her people and she said she could not turn them away. Every day she repeatedly called 117 and asked for help. But, as I wrote back in the Day 54 blog, at the peak of the outbreak there were no beds available so none of the supportive services worked, including ambulance pick-up.

Mariatu had no protective clothing. She had no gloves. She kept calling her superiors asking for these things, and for help, but none came. She did have chlorine. She had some knowledge about infection prevention… and she had guts! Every day she would have the patients drag themselves onto the veranda and she would pour chlorine solution over the floor. They buried the body when a patient died. She kept giving them fluids and food. By late November she could refer patients, and an ambulance would come when she called; by then she had treated 16 patients and 7 of them had lived. Miraculously, neither she nor her assistant became sick! Whether she was astonishingly brave and lucky or astonishingly brave and smart (or both), I cannot assess. I can only say, wow was it humbling to meet her!



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Mariatu in front of the graves behind her clinic. She was so chuffed that I wanted to take her picture so I could tell my students about her!

Les Roberts – “Part a: Triangulation – a scientist’s best friend when data quality is not an option.”

Les Roberts – Port Loko, Sierra Leone – April 18, 2015

I had a wonderful experience yesterday about my own inability to be analytical. We were repeating a sensitivity assessment that we had done in November to see where things stand and to document any improvement in surveillance over time. The process goes like this: in each village we ask the chief about the details of any deaths this year, articulated as since Christmas, and if there have been any Ebola cases in his or the neighboring village this year. After starting with the chief, we always try and triangulate the findings with some other source like counting recent graves or speaking to a local clinic nurse. In the end, we see the fraction of credible reports that had been detected by the surveillance system… and while not perfect, it gives us a reasonable insight into the system sensitivity. We went to a village… maybe with around 300 people… where the chief reported five survivors and about 17 deaths this year, all but one from Ebola. This was really uncool in several ways. This would be more cases than this Chiefdom (their equivalent of a county) had recorded for this entire year. If this were true, this would be a huge undetected flare-up and cause us to doubt the entire knowledge about the state of the outbreak in this District. According to the chief, six of the cases had been in March and one was just last week. Even before analyzing the data fully, I was sensing that the surveillance system was not performing well but this was a monumental oversight. Making it worse, most of the cases had gone to a local government clinic and died there making the under-reporting more inconceivable. On the other hand, the chief and the villagers around him seemed unusually unsure about the dates of the deaths and we had seen elsewhere that people often report deaths from 2014 as being in 2015, so I was not completely distraught yet.

We did our usual procedure; at the end of the interview with the chief we asked if we could go see the graveyard where he has told us all of the safe burials occurred. In this rather remote village there was not one graveyard but the chief graciously gave us a tour and showed us 14 graves, some of which could have been four or five months old.  It has not rained since October and lack of vegetation proves little.  But, a couple were very fresh, like only a couple weeks old and probably another seven sure looked like they were from this year. Given that most of the 20 deaths had supposedly happened at the clinic and the patients were buried there, this sure seemed to verify the chief’s report. Making it more disturbing and plausible, the six deaths reported for March had all not gone to the clinic and had died at home.  People grew to think if you go to the clinic you will die, so late in the outbreak they tended to stay home. I was bummed. We thought we were at ten cases a week nationwide. If we could randomly pick 12 villages in Port Loko and just by chance find a village like this, how many hundred others must be out there under the radar?

The surveillance system has so many shortcomings that this was completely possible. Given how major a surveillance failure this was, we decided to go to the clinic where most of the deaths had taken place.

On the drive there, I was thinking of how to break this news to my boss Dr. Yoti, who has been here for months and months working unbelievably hard and barely seeing his family in Uganda… and the NERC (National Ebola Response Centre) in Freetown… oh my gosh will they be apoplectic! I started to write my e-mail to Dr. Yoti in my head. Should I come back with a team the next day and interview the families and get all the details before bringing this to my superiors? With so many graves and so many deaths reported by the chief, something had to be going on.

When we arrived at the Cadick Maternal and Child Health Post we were lucky enough to encounter both the nurse and her assistant. They were really impressive, and more importantly, had kept great records.  They confirmed every name and every death that the chief had attributed to this clinic, but showed how almost all had been in November and October, back when we knew there were widespread undetected cases. Whew! The one death the chief said happened at the clinic last week did indeed, and while it was suspected EVD, the lab results were not yet known. Thus, even with many fresh graves, there apparently was not a huge outbreak that had gone undetected in recent weeks.

A team of local staff went back to the village today and now the chief says only two deaths happened this year. Based on the graves I saw I do not believe that either. I suspect that this chief wanted support and aid for his village where ten percent have died since October and they have been given little beyond the blessing of quarantine. In this case, I suspect they had a bad outbreak in 2014 and a few cases spilled into early 2015 but he was allowing the families to bury their own so the last cases went unreported… but this was not evidence of a recent (post February) massive outbreak going undetected.

Oh my gosh! Thank goodness for triangulation and the ability to put some check on crude and deceptive data. Thank goodness I don’t tweet (… which if we are honest, sounds rather rude in polite company).



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A pretty recent grave! That is weeks not months.

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A grave probably from recent months but not recent weeks.

Les Roberts – “Curiosity may have killed the cat but it might not kill Ebola!”

Les Roberts – Freetown, Sierra Leone – April 12, 2015

There are some amazing events that keep passing-by just beyond my comprehension, and I really want to explore them, but I know they will do little or nothing to stop the present outbreak, so I have to resist.

We were doing a sensitivity assessment in Bombali District this week, looking at the system for recording deaths. The idea is, you pick some villages at random, you go out and find out about the deaths there since New Year’s Day, and then you see how many of those deaths were recorded by the surveillance system. We did this in a village way off the beaten path on a road barely passable by car. It began as usual with a conversation with the Chief. Early on, in my asking about deaths, the 30 men and children hanging around got rather agitated and I was a little worried, briefly, that we might get beaten, but that passed. There were three deaths, and one was a little suspicious on the Ebola front as it was a middle-aged woman dying with a headache, no fever. Upon further probing, it turns out she had arrived from Freetown just a couple days before her demise. But, they insisted that she was without fever and that there was a safe burial team that buried her and she was Ebola negative… and the Chief could show me. He returned with some of her medical records and it turns out, she had been living in Freetown, was HIV+, had entered an ETU in December and been discharged after testing negative on the 12th, re-entered a different holding center almost six weeks later on January 19th, and was discharged with a letter showing her negative test for Ebola on the 21st. She died 10 or 11 days later. That delay would make me think that she got infected while in the holding center, except that the Viral Hemorrhagic Fever database (VHF) shows that when entering the facility in Freetown she had fever, vomiting, diarrhea, body pain, and severe fatigue. Thus, maybe she took a long time to have detectable virus in her blood? I don’t know. It is just an interesting case. Perhaps most disturbing is that the District Alert database and the CDC’s VHF database both show that she had a swab taken at her death, as should have happened, but there was no test result recorded. Thus, we may never know for sure if she is an Ebola case, but my counterpart in Bombali is trying to chase down that test result. Looking back on the agitated crowd, I think they thought she was EVD+ and they feared I would bring quarantine to the village. If they knew, they might have bribed the burial team to lose the sample… which would be useful to know in terms of fixing the present system. But the rest of the fascinating case, I just want to know about that out of curiosity and my fondness for historical records.

Likewise, on the same day that Bombali counterpart, Oleg Storozhenko, who is following up on the lab test, went to a tiny village with less than 150 people that experienced 48 cases of EVD in late 2014 with 42 of them dying. The Chief was very clear and up-front about it all. Someone came from outside and died. They had a funeral where people drank the body rinse water, and then lots more got sick… Of those 48 reported cases, it appears only 3 are recorded in the VHF. We asked a WHO colleague who was there all this time and he remembers the village being decimated but says record keeping was so bad that, yes, it is possible only 3 out of 48 got properly recorded. A part of me wants to go to the village and spend a couple days confirming the information to try and understand how a quarter of a village could be infected and why it stopped… and how the surveillance system missed them or mis-recorded them. But, that was five and six months ago, and it might not teach us much about improving our systems and services right now. So, I will try and block it from my mind and figure out how deaths are getting missed in the next District. It is painful to think about the lessons we are not learning.

Cheers, Les

Les Roberts – “Liar, liar, your country is on fire!”

Les Roberts – Makeni, Sierra Leone – April 9 2015

As an outsider, with only a couple of months experience in Sierra Leone back in 2001 and 2002, it is really hard to digest the nuances of the culture here. For example, when people lie to you or to the record, it is hard to know if you should be ticked-off.

About two weeks ago, I was with a couple of colleagues investigating a case involving a woman who had died in the District hospital; almost everything went wrong. She died just before the three days lockdown so it took four days for the District health officials to start investigating and then:

  • She had arrived with clear symptoms of Ebola but she was related to the head nurse, so when a nurse wanted to call the “Ebola Alert” line to take her as a suspect case to a treatment center (in the next District over), the head nurse said “no”, she was fine.
  • She died around 36 hours after arriving but it then took 12 hours for the body to be picked up by the safe burial team with her lying dead in the full ward for that period.
  • None of the nurses were practicing any of the minimal infection control practices (wearing gloves, washing hands between patients…).
  • When the safe burial team sprayed chlorine around the bed, they did not spray the mattress and instead set it outside in the sun. When a new patient arrived some hours later, she was put on that mattress.
  • When during the inquiry four days later, my colleague saw a women vomit and brought it to the attention of the staff, they realized she had a temperature of 38 degrees Celsius, they said it was not an issue because she had been fine before. They could not be talked into calling the 117 Ebola Alert line… nor could the hospital safety officer… it just goes on and on.

So when I heard the chief nurse yelling at someone, mad as hell because she was now quarantined with nine other nurses, claiming that her nurses on the women’s ward always wash their hands between patients when I had just witnessed the opposite 20 times, I felt a little miffed! Many of my Sierra Leonean counterparts have had their lives ruined. The schools have been closed for a year. Selfishly, it has been weeks since I woke-up next to my wife. I have students that have waited two months to get papers back – that has never happened before. And hundreds of others and I are here now because of a systematic series of sanitary catastrophes, still happening 12 months into this outbreak. I later learned that four of the seven deaths logged in that women’s ward were never registered as a death within the District. Our local co-workers insist that this is because the families bribe the burial teams to give them the body so they can have a traditional burial… which if true, only increases my miffedness.

On the other hand, I have visited about a dozen Public Health Units (PHUs) in the past days and all of them are ignoring the rules about screening febrile patients. The government insists that anyone with fever and three symptoms must be turned away from the PHU and sent to be tested for Ebola at a Community Care Center (CCC) or Ebola Treatment Unit (ETU) for further screening, and when appropriate, testing. Often this involves travelling great distances. Even when the CCC is nearby, it means having your blood drawn and staying for a day or two before getting the results back. In the rural district with the highest attack rate this week, they had one positive blood sample out of around 880 taken at the screening centers in March, so almost all people tested experience two days of fear and loneliness for no benefit. Most people will just not go to these treatment centers. They are scary. There are human-like figures in PPE. It is hot and away from people, which is unnatural here. Thus, the nurses at the PHUs just do not enforce the screening requirement. They see a woman walking in with her child, the child is 1,000 or 10,000 times more likely to have malaria than Ebola. If they enforce the screening rules, that woman and child will not come to the clinic and that child will not be treated. The nurse knows the rules, she knows the risks, and she is choosing to do what is best for that mother and child while ignoring what is best for catching those last couple cases of Ebola in the country, which is my agenda. When I arrive in my nice WHO vehicle and she lies to me about having no patients that matched the suspect Ebola case definition, and I see dozens of malaria and typhoid cases diagnosed in the past weeks which mostly had to fit the suspect Ebola definition, I feel nothing but affection for her. My agenda and the Government Ebola agenda are not well aligned with her life-saving agenda.

Thus, I am not sure what to think and how to feel when I catch Chiefs in a bold-faced lie. For example, three out of five villages in Kambia District where the Chiefs told me they had no deaths this year had fresh graves in the cemetery. Not fresh like no vegetative cover, fresh like in recent days where the soil is not yet dried out and sun-bleached. I know they fear quarantine. I know they have broken the law by hiding deaths. But, what I cannot fully understand is their motives and how much these lying, Chief hiding deaths are markers for those populations that practice unsafe burials, and how much they are inducing risks for the collective good. The wounds of the war are fresh. Many tribes don’t trust their District leaders. I don’t fully understand the implications of their deception.

There are a lot of deaths still hidden in the rural areas. But I take great comfort that two weeks to the day after the debacle with the dead woman in the hospital ward, no secondary infections have arisen from her nurses or fellow patients. Last week we only had nine cases nation-wide in spite of all these widespread appalling practices. Thank goodness Ebola is only an intermittently infectious disease.

Onward! Les

Onward!   Les

Les Roberts – “What if the baseline does not equal zero?”

Les Roberts – Freetown, Sierra Leone – April 4, 2015

I had a call from our alum Laura Miller this morning. She was bummed… and a little freaked out about an infant case that arose in Kailahun where there has not been a case for quite a while. This is where the outbreak seems to have entered Sierra Leone. The child’s parents are EVD negative. Something similar (psychologically but not epidemiologically) has happened in Liberia in recent days, and if I believe the newspapers, perhaps those are linked to sexual transmission. Laura and thousands of others have been really demoralized by embers of Ebola arising where we thought the outbreak had come and gone.

I think in part this is because everyone around me has been promoting this phrase “Getting to Zero.” It is driving me crazy, as it is probably an impossible concept. It strongly appears that Ebola has been present in the region for years and was simply unrecognized. Evidence of this includes:

Analysis of hundreds of frozen blood samples from 2011 – 2014 at the Kenema Hospital Lassa Fever Ward found 22% of Lassa Negative patients were EVD +. See: Boisen ML et al. Multiple circulating infections can mimic the early stages of viral hemorrhagic fevers and possible human exposure to filoviruses in Sierra Leone prior to the 2014 outbreak. Viral Immunol. 2015 Feb;28(1):19-31. doi: 10.1089/vim.2014.0108.

A 1996 WHO press release described a 25 year old male on the Liberia / Cote d’Ivoire border “was confirmed by serological tests carried out at the Institute Pasteur in Paris” as EVD positive. See:

A population-based random blood sample of 433 residents “in rural areas” of Liberia in 1978-’79 found 6% to be EVD positive. They tested for anti-bodies (range of positives 1/16 to 1/1024). See: Knobloch J. A serological Survey on Viral Hemorrhagic Fevers in Liberia. Ann. Virol. 1982, 133E, 125 – 128.

Frozen sera from 592 residents of mining company settlements were taken in 1973 and analyzed in 1986 and 14% were EVD positive and 21% positive for Marburg. See Neppert J et al. No evidence of LAV infection in Liberia, West Africa, in the year 1973. Blut (1986) 53: 115-117.

While I know little about virology and I know there was a lot of kibitzing about the precision/specificity /cross-reactivity of those indirect immunofluorescence anti-body tests back in the ‘80’s, I think the 1996 case and the recent Kenema data make it probable that there have been tens or hundreds of cases in Sierra Leone in recent years and that getting to a non-outbreak baseline is not the same as getting to zero. Surveillance has been very very poor in the region.

Back in a 2001, a gang of us from the Ministry and IRC did a 500 households random survey about mortality in Kenema District. Only around 16 of 78 reported febrile deaths had even gone for any medical care before dying. And, we all know, a health post or a Primary Health Unit (PHU… a fancier clinic with beds for in-patients usually staffed by a nurse) would have never diagnosed EVD before this past year. (An aside, back then IRC had a network of hundreds of TBA’s and several ambulances who were proud that there were zero known household maternal deaths in Kenema District in 2000, only those few hundred at the hospital; that is, they were perfect in their complicated birth referral record! We estimated there were 1900 and discovered that IRC’s TBA’s were actively hiding them because their training had emphasized how terrible and unacceptable maternal deaths were, creating stigma about reporting. If stigma about reporting maternal deaths arose so easily, think of what household and village quarantine is doing to Ebola surveillance now!)

Adding to the counter-productivity of the “Getting to Zero” concept is the notion of ecological equilibrium. If in past years there was a certain viral load in the animal community, ecological equilibrium would suggest that typically a certain number of human cases would be induced based on how often people killed game, were shat upon by passing bats, had a dog bring back an infected squirrel… Perhaps it was just purely human-related luck in 2014 that triggered these favorable human transmission events (like just by chance a couple of the victims had large body-rinsing funerals), but it is more likely the animal load is now higher. Thus (and I am making this up for the sake of discussion), if nationally the baseline was 10 animal based transmission events for an average of 30 cases a year, we should expect far more sporadic cases this year… and now we can test for it and now we are looking!

I hate campaign slogans predestined to fail. “Yes we can” is the perfect slogan because it is so ambiguous you are never sure if it succeeded or failed. “Getting to zero” is anything but ambiguous. Talk about setting yourself up for failure!

Onward! Les