Successful disease control depends upon the cooperation of citizens. This was never more evident than during the 2014-2016 Ebola epidemic in West Africa. Public health measures, particularly those focused on containing disease rather than saving lives, require trust in government officials and medical institutions. In West Africa, governments have either not made the effort to earn the trust of their constituents or have lost it through years of neglect and misappropriation. The consequence is poor communication and management, and limited collaboration with communities. The result is suspicion, reticence, hesitancy, and sometimes violent resistance.

According to the US Centers for Disease Control, a total of 28,616 cases and 11,310 Ebola related deaths were reported in Guinea, Liberia, and Sierra Leone, with only 36 additional cases and 15 deaths occurring in other countries. High case numbers and death tolls in Guinea, Sierra Leone, and Liberia are reflective of recent histories of war, state collapse, and crises of government legitimacy that have removed attention and funding from health systems and lost public engagement. The already decimated and precariously weak public health infrastructure in Guinea received only 4.78% of GDP in 2014, Liberia 9.06%, and Sierra Leone 19.7%, up 8% from 2013. By contrast, neighboring Nigeria invested 58.7% of GDP in healthcare expenditures in 2014.

Non-state actors have further contributed to the demise of trust in formalized government and health institutions. Expressed by Paul Wenzel Giessler and colleagues, nongovernmental and humanitarian organizations, pharmaceutical companies, and universities, in presenting a patchwork of health care in the post-war period of Sierra Leone and Liberia, and through periods of economic and political liberalization and globalization in the West African region as a whole, have effectively removed centralized local governments from the responsibility of coordinating a single health care policy. Yet, argues Giessler, national governments remain crucial in medical care, as sources of regulation, employers of healthcare professionals, and establishers of trust, irrespective of their stability or responsiveness.

It is not surprising that civilian responses to disease containment efforts, whether implemented by state or non-state actors, were met with resistance and in some cases, violence. A national lockdown in Sierra Leone was not only considered problematic by Médecins Sans Frontières, but also resisted by residents. Calls to bring the sick to medical containment facilities (hospitals and emergency treatment units [ETUs]), went unheeded in some areas given pre-established rationales regarding the avoidance of biomedical health facilities as well as fears that patients were not fed or properly cared for, experiences of being turned away from overcrowded ETUs or closed hospitals, and new regulations that prohibited family members from maintaining contacted with admitted patients and funerary practices. Burial rites were viewed as problematic and spreading the virus. The public was not trusted to alter ceremonial practices to limit risk, rather official burial teams were assembled, responding more efficiently to the dead than help hotlines did to the living.

Non-compliant behaviors often appear ignorant to public health practitioners aiming to serve the interests of populations. Yet, recognizing that long-standing local frameworks draw on experience, social institutions, and regional histories, helps to inform strategies that are culture-centered, ethical, and effective. For greater insights on the complex and emergent meanings that defined the 2014-2016 Ebola epidemic in West Africa and contributed to public behaviors and attitudes, we have collated a selection of key scholarship. Our interview with anthropologist Sharon Abramowitz articulates lessons learned and operational recommendations to mitigate resistance in future disease outbreaks.

Contributed by Nataly Delcid and Nicola Bulled