'Vaccines are for children only'? Some institutional roots of popular scepticism about vaccines for COVID-19 in Sierra Leone.

Vaccines for COVID-19 began to be available in Africa from mid-2021. This paper reports on local reactions to the possibility of vaccination in one West African country, Sierra Leone. We show that the history of institutionalisation of vaccine is highly relevant to understanding these reactions. Given lack of testing for the disease, medical authorities could not be sure whether there was a hidden epidemic. In addition, many people associate vaccination with care of children under 5 years, and not adults, and an emphasis on vaccinating the old at first seemed strange and worrying. This paper examines evidence from ethnographic studies in two rural areas selected for varying exposure to Ebola Virus Disease (EVD), supplemented by some interviews in two provincial urban centres, Bo and Kenema. We describe local ideas about vaccination (maklet) and body marking with leaf medicine (tεwi). We asked about attitudes to the idea of COVID-19 vaccination both before and after vaccines were available. A number of reasons were given for scepticism and hesitation. These included lack of experience with vaccines for adults and lack of experience of COVID-19 as a severe disease. Medical evidence suggests the vaccination protects against serious illness, but local people had their own views about control of infection, based both recent experience (notably EVD) and the history and institutionalisation of vaccination and public health measures in Sierra Leone more broadly.

How villagers in central Sierra Leone understand infection risks under threat of Covid-19.

BACKGROUND: Concern has been expressed over how well Africa is prepared to cope with the pandemic of Covid-19. Will rural populations with low levels of education know how to apply community-based infection control? We undertook fieldwork in two villages in central Sierra Leone to gain insight into how rural people faced with Covid-19 assess epidemic infection risks. METHODS: Two communities were selected based on prior contrasted exposure to Ebola Virus Disease-one with substantial number of cases and the other having resisted infection through strong community sequestration measures. We assessed understanding of infection risks via an experimental game. This asked players to express a preference for one of two diseases, one resembling Ebola with lower risk of infection and the other resembling Covid-19 with lower risk of death. Players were not told the identity of the diseases. RESULTS: In total 107 adult villagers played the game (58% women). Half (52%) preferred the disease model with lower risk of infection, 29% preferred the model with lower risk of death, while 21% saw the combined risk of infection and death as being equivalent. Differences in reactions between the two locations were small despite different experiences of Ebola. Asked to explain their choices 48% of players cited information on infection risks modelled by the game and 31% stated that their choices reflected awareness of the need for personal action and respect for local regulations. We concluded that villagers thoughtfully assess disease risks and that some are good intuitive statisticians. CONCLUSIONS: Results suggest rural people in Sierra Leone retain the lessons of experience from the Ebola outbreak of 2014-15 and will be able to apply these lessons to a new infectious disease for which have no prior practical experience. Our expectation is that rural populations will understand Covid-19 control measures, thus reducing need for draconian enforcement.

Rural populations exposed to Ebola Virus Disease respond positively to localised case handling: Evidence from Sierra Leone.

At the height of the Ebola epidemic in Sierra Leone in November 2014, a new decentralized approach to ending infection chains was adopted. This approach was based on building local, small-scale Community Care Centres (CCC) intended to serve as triage units for safe handling of patients waiting for test results, with subsequent transfer to Ebola Treatment Centers (ETC) for those who tested positive for Ebola. This paper deals with local response to the CCC, and explains, through qualitative analysis of focus group data sets, why this development was seen in a positive light. The responses of 562 focus group participants in seven villages with CCC and seven neighbouring referral villages without CCC are assessed. These data confirm that CCC are compatible with community values concerning access to, and family care for, the sick. Mixed reactions are reported in the case of "safe burial", a process that directly challenged ritual activity seen as vital to maintaining good relations between socially-enclaved rural families. Land acquisitions to build CCC prompted divided responses. This reflects problems about land ownership unresolved since colonial times between communities and government. The study provides insights into how gaps in understanding between international Ebola responders and local communities can be bridged.