Innovations for Successful Societies


AN INITIATIVE OF
THE WOODROW WILSON SCHOOL OF PUBLIC AND INTERNATIONAL AFFAIRS 
AND THE BOBST CENTER FOR PEACE AND JUSTICE



Series: 		Grand Challenges
	
Interview no.:		C 2

Interviewee: 		Jana Telfer			

Interviewer:		Leon Schreiber

Date of Interview:	May 2016

Location:		Monrovia, Liberia
					
	
Innovations for Successful Societies, Bobst Center for Peace and Justice
Princeton University, 83 Prospect Avenue, Princeton, New Jersey, 08544, USA www.princeton.edu/successfulsocieties

SCHREIBER: 	Shall we jump straight in with a bit of personal background? Would you tell us what you were doing prior to the Ebola outbreak? How did you get involved initially?

TELFER:	My official title at CDC (Centers for Disease Control) is Associate Director for Communication Science. Typically I work in environmental health; however, I had done a substantial amount of emergency response and international emergency response involving risk communication. So I was asked to go to Liberia because one of the people who was over there thought that the country could benefit from a risk communication approach.

SCHREIBER: 	So that was someone from the CDC?

TELFER: 	Yes.

SCHREIBER: 	At what point did you arrive then?

TELFER:	I arrived early in September of 2014 and was there for about five or six weeks. I came home for 30 days and went back in middle of November of 2014 until right before Christmas and then was home working on the response domestically. Between deployments I was working in our Joint Information Center. Then I returned to Liberia in July and August of 2015. 

SCHREIBER:    You must have a nice perspective on how the whole story evolved throughout those three periods. I guess they were quite different in terms of the challenges that they presented. If we go back to September when it was the peak of the crisis, what did you find from a communications, social mobilization side when you arrived? What were some of the first things that struck you as serious challenges? 

TELFER:	One of the largest challenges was that, although it had a very skilled and able social mobilization group and approach, the country was overwhelmed just by the size, not only of the epidemic itself, but also of the international response. Not having previously had such an event in Liberia, there was no structure for international agencies to intersect with the Ministry of Health in the health promotion arena. At the same time, Liberia is a very relationship-intensive society. Relationships are extremely important. So it just wouldn't have been appropriate or suitable for CDC to charge in and say, "Here's what we need to do". So it took about three weeks of listening and watching and gathering information to be able to propose an alternative. That was one of the major challenges. What was going on at the time was that by the middle of September there were sixty NGOs in Liberia working on 250 different projects. The country had no mapping of where those NGOs were. The social mobilization meetings were basically committees of the whole with about fifty to sixty different organizations represented all with extensive response experience, all believing that their way was worthy, and all talking at the same time. 

	Then there was a Message Development Group that was staffed by UNICEF, which did an extraordinary job; however, the message and materials development committee meetings tended to follow the same pattern, about fifty to sixty different organizations present, all talking at the same time. 

	About three weeks into my engagement there, I proposed a structure to the director of health promotion for the ministry that was adopted. 

SCHREIBER: 	Was that Reverend Sumo?

TELFER: 	Yes. In the meantime we had been working with the IMS (Incident Management System) manager on some other issues-including an MMWR (Morbidity and Mortality Weekly Report) article that CDC was planning to publish-to be able to help them respond and bring a risk communication frame to that. And, in the same time period, we established the partnership with AGI (African Governance Initiative) which was an atypical partnership for CDC. This addresses one of the other challenges. 

	The first challenge is organization. The second challenge was international communication and ensuring that the ministry had enough advance notification of what partners were doing that might have an effect in the international arena that would have an impact on the Liberia response. The third challenge that we found was that messages were not making it out of the Message Materials and Development Committee. They weren't making it out of the committee to the IMS structure and the partners, nor were they getting to the Ministry of Information, Cultural Affairs and Tourism, the official public communication agency for the Liberian government. So essentially we had to build a bridge between the Ministry of Health and the Ministry of Information. AGI had someone assigned to the Ministry of Information. We worked together to put together what came to be called the Joint Communication Committee. It was led by the Minister of Information and involved the public affairs officers of the major partners. Whereas the social mobilization leaders for the major partners were involved in the health promotion activity, we engaged the public affairs people in the Ministry of Information Joint Communication Council. 

	The minister extended the invitation to other branches of government that were involved with the response. For example, the Ministry of Transportation communicated with taxi drivers who were providing ambulance service by default. So those other ministries were also invited. We began to move information, health information, out of the Ministry of Health and across government and across the partners. 

	I think the fourth item was ensuring that that information moved. So we did a couple of things. One through the Joint Information Committee restructuring the news conferences so that they would be a little more organized in terms of what the Ministry of Health could bring forward. Then also looking at instruments that the Ministry of Health could use to share with all partners so that everybody would have a common understanding of what was going on with the response. All of that was risk-communication based, because we were looking at the models of risk communication as well as cultural impact. Those were probably the four biggest things in the first deployment. We also did a national risk communication plan. That was out of the Joint Communication Committee. 

SCHREIBER: 	So the first issue that you mentioned, about messages not coordinating with those sixty NGOs and the government, the messaging committee, etcetera, what were some of the steps taken to fix that?   

TELFER: 	What we did was to put in a sort of joint information center within the IMS structure. If you're familiar with US responses, a joint information center is typically a public affairs type activity because the whole IMS structure derives from police and fire responses to emergency and the need to coordinate amongst local emergency responders. That has since been elevated through FEMA (Federal Emergency Management Agency), the Department of Homeland Security to a national paradigm. 

	However the communication paradigm, the Joint Information Center paradigm, continues to be pretty much public information, public affairs approach. So what we did was to adapt that to what worked for Liberia. Public affairs were not everything because public affairs were really handled by the Ministry of Information. However we needed a liaison with them. 

	The specific challenge was that in terms of span of control, Reverend Sumo had essentially sixty different organizations and all his staff reporting to him. So his span of control was out of control; it was impossible for any individual to be able to do that. So in watching him try to work with that, it seemed as though he needed a way that he could continue to get information, to continue to manage the function, but also one that he could actually control. 

	There was an opportunity also to provide development capability for his staff which was relatively lean; they had about six people in the Health Promotion Department and we needed to organize the international responders because international responders are accustomed to coming into a system and working in a system and Liberia did not have a system in place for this magnitude of a response or for an emergency response. They had good systems for regular activities like measles immunization, maternal and child health. They did not have a system for emergency response. So we looked at how we could build the Joint Information Center within the IMS structure. 

	What we did was to basically look at what were the four things that were most needed in the country. One was training. One was message and materials development. One was field mobilization and support and one was media, to be able to link with the Ministry of Information. Then we basically drew up terms of reference. I sat down with Reverend Sumo. We agreed on the buckets. We agreed on the people in his organization he named who would be the ministry liaison with each of those work groups. 

	We established work groups to support that function that involved an international NGO and a national NGO to convene members of the work group. From an international perspective, I recommended that no international agency participate in more than two workgroups so that we could step away from the meeting of the whole. And also because even though all of us have capabilities in every area, each of us has greater strength in some areas than in others. So, for example, the World Health Organization was the convener for field mobilization and support. UNICEF continued to be the convener for message and material development. There is an organization that has long standing in Liberia called Restoring Basic Health Services; that was the convener for training, because they had extensive experience and capacity in that area and CDC was the convener for media. 

	Then we had a national NGO partnered with each so we could do both capacity development for the ministry and capacity development for the country. Then we invited people to sign up for not more than two, and Reverend Sumo specified himself that the national NGOs not sign up for more than two because he wanted them to be able to focus as well and not use this as a broad-based training opportunity. 

	Many of the national NGOs had sprung up in response to the Ebola outbreak. So there were long-standing national NGOs like Crusaders for Peace. There were also organizations that had sprung up more recently to provide help. So that's what we did and it worked. It brought order to the meetings. The committees convened and reported. 

	By the time I returned in November, all of the work groups were being convened by the national NGO with the exception of Message and Materials Development co-convened by the ministry and UNICEF. It was so exciting to see capacity happening right in front of your eyes. 

SCHREIBER: 	If I understand it correctly, you had the social mobilization pillar and these were essentially four subcommittees that reported back to the main group. Is that right? 

TELFER: 	That's right.

SCHREIBER: 	So the big group, was it still sixty different people in one room for the main meeting? 

TELFER:	It was still sixty different people in one room, but they weren't all talking at one time. They had basically done their business and were making recommendations, doing report- outs from their meetings, and making recommendations to the group and to the ministry. 

SCHREIBER: 	Would these four subgroups meet every day as well? So Message and Materials Development, they would meet every day?

TELFER:	They met at least weekly; it depended on what they were doing. Message and Materials Development, for example, at that point, met a few times a week. As the field support and mobilization effort was getting going they met more frequently. The guideline was meet at least once a week and meet in advance of the social mobilization meeting, but it did not restrict groups from meeting more frequently. So it sort of depended upon the level of activity and what was really needed for that particular function.

SCHREIBER: 	When I look at these four things, I'm interested in all four of them, but let's take the Message and Materials Development one first. The feeling that I get from talking to people here is that initially there was a lot of criticism of some of the messages that had come out; they were very fatalistic, "Ebola kills". People really didn't know how to respond to that or frankly why would you respond, if you're going to die anyway. So how did you see the Message and Materials Development committee improving the content of some of the messages that were going out, not necessarily to people in the field, but on billboards, on the radio, at the press conferences?

TELFER: 	Right. Let me say again, UNICEF did an extraordinary job on the message development component. One of the reasons that messages were fatalistic early on was because there were so many people in that space and it was not organized. There wasn't a structure. So it goes back to the fundamental challenge in the country that they hadn't had to confront something like this before. So a structure to do that didn't exist. 

	Accordingly what happened in July and August, early August, for example, is that people were saying what they believed with the best of intentions. Typically what happens in crisis or emergency situations like this is that government officials and science officials do the wrong thing with the best of intentions, because the right thing is totally counterintuitive. The IMS manager typically began with the number of deaths and the case count and was not sharing about all the progress that was being made and the way that the IMS was being organized. 

	One of the things that we did was to work closely with UNICEF. UNICEF was working on a well-developed message pallet by that time to ensure that all of the messages were based on sound science. Throughout the response we would provide input and suggest modifications to messages based on science. By early September UNICEF had traction; however, it is difficult to overcome the first things that people hear. The first person out of the gate is the person who sort of sets the standard and after that everybody else is playing catchup, and that is exactly what was occurring in Liberia. Then when you have so many organizations involved in trying to influence the message development, it was really difficult for the team at UNICEF to be able to make substitute programs, to be able to move the dial as readily as might have been desirable because the organization to support them was not there. 
                          
                          So the other thing that we did at the IMS level with the IMS manager and at the ministry level with the Minister of Information was we established what I would call a risk communication frame. We looked at the four primary models of risk communication that were established or codified in the early 2000's by Peter Sandman and Vince (Vincent) Covello and looked at the practical applications. There are ways that you can counter each of those types of public reactions with a communication method.

	For example, we began to talk about process, about what the ministry was doing. We didn't delete how many people had died, but we talked about what we were doing to bridge the gap. We talked about what we didn't know. The IMS manager was an astute pupil, I would say, of risk communication, an astute learner. As a result, he quickly understood the value and adopted what we would call "anticipatory guidance". That meant that he would be saying to people when something good happened "This is encouraging and this is going to take a long time. We are in this for the long haul. We anticipate that it could get worse before it gets better." 

	He began saying those sorts of things. We switched messages from negative to positive. That was another very deliberate step that we did. I did some rapid sort of trending research, not in- depth formative research, but rapid formative research to ask questions of Liberians about, "What type of messages do you all like to hear? Do you respond better to messages that provide warnings or do you respond better to messages that tell you what to do?" Uniformly people said that essentially they responded better to positive messages. 

	We just switched the frame from negative to positive. Rather than telling people what not to do, we told them what to do. Or, if we were telling them what not to do, then we gave them the corollary of what should they do. If you give people only the negative you leave a gap that your audience then has to fill on its own. They may or may not fill it with what you think they should. But if you don't tell them what to do or make a recommendation, then they're going to fill it to the best of their ability.   

TELFER:	Those were risk communication components that we put in place. We also looked at research that is being more recently folded into risk comm. It was extraordinarily important in West Africa. We had to look at the cultural frame. The majority of research in risk communication has taken place in the United States and the European Union. Developing nations do not have the same paradigms or the same technology as G7 nations. 

	We had to look at the cultural component. We had also to consider very deliberately the fact that the country was only a decade out of fifteen years of devastating civil war. So much of our messaging looked at the cultural importance of talking about how united we could do this. Together we could participate. That set up the campaign. That happened in the second deployment. We started establishing that foundation: government and the people were in this together. By describing what government was doing, we were showing action and then by giving people recommendations about appropriate actions to take, we were giving them a way to intersect with the overall response even when we still didn't have enough beds, enough ambulances or enough ways to get people to treatment-. That was a very deliberate approach. 

	So making sure it was a scientific foundation that was very credible, switching from negative to positive framing and looking at the cultural considerations, these three examples. 

SCHREIBER: 	That's very, very useful. I want to take it right from there to go to media. On media, could you describe a little bit how it worked practically with the press conferences from the Ministry of Information? You mentioned the joint committee that had been set up, but day-to-day, how would that work when it started getting better? And one or two thoughts on other mediums like the radio, for example, that played a big role. 

TELFER:	Sure. So the way that the Ministry of Information was operating initially in order to be able to have information flowing to the national media and to other avenues into community radio, for example, was to conduct a daily news conference. The daily news conference was scheduled for 11 o'clock. The IMS meeting did not end until 11 o'clock. So essentially immediately after the IMS meeting, first AGI and then myself in partnership with AGI, were knocking out five or six what we called press lines for the incident commander. 

	He raced across town, arriving late every time to the news conference with these five or six lines in hand. Before I got there, it pretty much led with, "How many people had died today."  So we changed the approach to his messaging and began to give him information about process, "What the IMS had done that day." Then the second thing that we did was to work with the Minister of Information and the IMS manager and proposed an alternative structure for the news conferences which would provide the IMS commander the opportunity to evaluate and analyze his information and also to provide the country an opportunity to focus on something besides people dying and besides the epidemic itself.

	What I recommended to both was that we change the news conference structure to three times a week: Monday, Wednesday and Friday for health focus. On Monday, that would allow the IMS manager or the ministry representative to report on what had happened in the Friday IMS meeting; on Wednesday they reported what had happened in the Monday meeting, and on Friday they reported what had happened in the Wednesday meeting. There was an opportunity to look at information as it was coming in, make some decisions about it and be more deliberate about sharing. So then we looked at how the information was framed and what kinds of information we were providing. At the same time, we provided three times a week a bulletin called the Ebola Update to all partners and to the Minister of Information so that everybody had the same two-page summary to use and all of those messages were constructed within a risk communication frame. We then incorporated more spokespersons. So the incident commander did not have to be the only person who spoke. We began, as we were talking about process information, to incorporate other taskforce leaders as the spokespersons for the news conferences. If we were talking about case management, for example, Dr. Kateh or Dr. Fallah would be the person who would speak about that. If we were talking about health promotion Reverend Sumo would make the presentation. 

	The way Liberian news conferences worked there is typically a formal presentation and then there are very orderly questions from the people in attendance. We also ensured that there was a partner present for each area that we were discussing. So for example, if we were discussing case management, then the partner that was most active in that particular part of the response was also present to be able to give a partner perspective and show that there was a lot of collaboration happening. That also allowed the media to essentially triangulate their information. They could hear from the ministry, they could hear from the people, they could hear from the partner and then they could assess that and perhaps report more broadly. 

	That over time worked well. At the point that I left in December, I suggested to the person who followed me that it might be time to switch the health conferences from three days a week to two days a week. Then the other two days, during the period that I was there, the ministry could invite other parts of government to report on what they were doing. So it allowed the opportunity for media to report or to reflect some sort of normalization in government operations and to be able to vary the kind of information that was going on so the entire focus was no longer on how many people died the day before. 

SCHREIBER: 	How about the radio specifically or other mediums that this information would go to? I have a sense that the radio is at least worth mentioning in this story. 

TELFER: 	Right. Radio is extraordinarily important in Liberia. It is community radio specifically. It is the best way other than face-to-face communication to get information throughout the country. So a couple of things happened there. One is there were a couple of national radio shows every week, one from the Liberian Broadcast Agency that is operated by the Ministry of Information and one from UNMIL, the United Nations Mission in Liberia. That was a national broadcast. 

	So immediately after or the day following the news conference, one of the ministry officials would be the featured guest on the UNMIL program and one of the ministry officials would be the featured guest on the National Broadcast. 

	There were multiple ways of reaching community radio and not necessarily one consistent way other than what was sent out from the Ministry of Information. So UNICEF and UNMIL had ties with some community radio stations. IREX (International Research & Exchange Board) had ties with some community radio stations. Internews, when it came in, had ties with some community radio stations. So what we did is we made sure that they had those three- times- a- week Ebola updates so that they could incorporate those in the information that they were sending to the community radio station. 

SCHREIBER: 	Interesting, so you were filtering it down through everyone else?

TELFER:	Yes, making sure that everybody had the same foundational information to work from. We framed it in a certain way. We had a riskcomm frame as we were going in. But they then incorporated the very necessary cultural approach. 
                          
                          Standard English is the official language of Liberia. Liberian English, a bona fide language but not a written language, is more like the lingua franca. Then there are sixteen tribal languages. So that information could then be converted by these different agencies into the different languages. So if IREX, for example, had a tie with a community radio station where the population was primarily Kru they could provide the information in Kru. I asked our incident commander one time,  "Do we need to be phrasing this in Liberian English?" and he said, "No, I do that as I'm reading." I said, "Great, I thought that was the case." So he just basically translated off the cuff as he was going. 

SCHREIBER:    I want to switch at this point to the two remaining pillars here. The one on training, would that be training specifically for people who would go out and be social mobilizers or what did training mean in this context? 

TELFER: 	Training meant really looking at a group of people called general community health volunteers (GCHVs) and ensuring that they had all of the information that they needed to be able to conduct local visits, house calls, whatever might be needed. The ministry made sure that health education people in each of the districts had consistent information and the county health officials and district health officials had consistent information. All of the same information went to all of the NGOs so that training could be dispersed depending on who was in a particular county. Then they had the same materials to work with to be able to disseminate to their groups. In the period that I was back in the states, in October, the ministry was putting into place a remarkable program called Reach Every District (RED). It was basically a social mobilization effort to ensure that every district had information. The week that I returned to Liberia they were launching this program in collaboration with a number of partners, including CDC and The Carter Center, at a meeting of the national association of tribal leaders and chiefs. That helped disseminate information through the traditional government as well as through the political.

SCHREIBER: 	 Was this around 17th of October?  Does that sound about right? 

TELFER: 	The RED activity began in November, in the middle of November and was finished by the second week of December. In that period, the ministry put all of its personnel into the field, all of the social mobilization in the field. They covered 77 districts in thirty days.

                          They did not do Monrovia, they saved that for the second wave, which happened in December, but they covered all of the rural districts. It was a remarkable effort.  

SCHREIBER:    if I say social mobilization at this point, I'm referring to people who were going door-to-door or in communities. In addition to these community health volunteers, you had UNICEF training their own social mobilizers and running an operation. You also had ECAP (Ebola Community Action Program) later. Mercy Corps has claimed that they reached 2.5 million people. Could you speak on that at all, like the fact that there were essentially three different organizations training social mobilizers? Did that create problems or were they all basically using the same material?   

TELFER: 	ECAP occurred later after the ministries' program and I really have no knowledge of that because it was implemented in the period when I was back in the States for about six months. So I really can't speak to whether it caused problems or not; that would have to come from Reverend Sumo or somebody within the country. 

SCHREIBER: 	How about UNICEF? Did they work closely with the ministry in training social mobilizers? Did you get that sense?  

TELFER:	Absolutely. 

SCHREIBER: 	Would you say they were one team? When you were talking about Reach Every District, would that have automatically included UNICEF, for example? 

TELFER: 	Yes. The Reach Every District program was an effort that was spearheaded by the Ministry's health promotion department with support. We're talking about a lean organization, very, very small. So in order to do something like that it was essential to have support from a broad range of NGOs. I did not do the evaluation, and I don't know if evaluation has been done, but I'm hopeful that the structure that was put in place helped facilitate more orderly support for the ministry by the NGOs. Working with the Carter Center, for example, was a linkage that we helped promote. Certainly they already had some of these linkages, but what we tried to do was create some structures that would strengthen them. The Carter Center was a wonderful link along with the Ministry of Interior to reach the traditional leaders. There was both an NGO outreach to traditional leaders and a government outreach to traditional leaders. 

	There was scarcely a thing that occurred in Liberia that didn't have partners engaging with a ministry. You really needed all hands on deck. It wasn't something that any one partner, nor the ministry could do on its own; it really took everyone. Just to speak really briefly-to give you a corollary example in the RITE, Rapid Isolation and Treatment of Ebola strategy that CDC helped the ministry put together-the brilliant part of that strategy was that four-person teams would go from the county health office or the district health office as soon as they received notification of a possible case. Those four-person teams could be comprised of any group of ministry and voluntary organizations that were in that area. 

	It could be the county health officer, MSF, International Red Cross and CDC. It could be the district health officer, Global Communities, Save the Children and IMS. It could be any constellation, whatever happened to be there. They had standard protocols and standard actions to take, but the grouping could vary. My observation would be that was fairly true in many aspects of the response. The ministry was always in charge and our job was to support them so that we could end the epidemic. 

SCHREIBER: 	If we could speak for a few moments about field mobilization. I assume that refers to the foot soldiers going out into the communities. Could you describe a little bit how that one worked?

TELFER:	Field mobilization and support had two components. One was training. So the way it worked was sort of cascading. The Message and Materials Development Committee developed the messages and materials. The training committee used those messages and recommended specific types of training materials, working with the Message and Materials Development work group, and developed the training plan. Then the field mobilization and support did the implementation. 

TELFER: 	It was a collaborative effort. Each of the workgroups had a responsibility. Then the media workgroup supported the link with the Ministry of Information so that that information could get out broadly and also supported the dissemination of consistent information through the partners. 

SCHREIBER: 	But what does it mean when you say field mobilization provided support. What did that mean practically? 

TELFER:	It could mean that they had people in the district as well. It could be that they were working with the ministry to help plan the process, how it was going to proceed, who was going to be where. It could be putting forward a stipend so that people could afford to come, finding a meeting room. So it could be a range of things. The World Health Organization was the lead for that. Liliane Luwaga I believe was the WHO person. 

SCHREIBER: 	So it sounds like general support then, support services to social mobilizers out in the field. Would that be correct? 

TELFER: 	Right. I think that would be a reasonable statement. That support could take a variety of forms. 

SCHREIBER: 	With all of this in place now, how did you see those initial challenges that we spoke about. How did you see the situation improving? 

TELFER:	The first one was organization and having a structure for the international and national NGOs to intersect with-to provide coherent support, if you will, to really have a good way of providing support to the ministry. As I noted, when I returned in November, after only a 30-day absence from the country, the national NGOs were convening the meeting. The social mobilization meetings were completely different. They were very orderly. There were presentations from each group. There were decisions made by the group, decisions made by the ministry and all of the conditions were in place to be able to support that extraordinary Reach Every District effort. 

                          As international NGOs, for example, WHO, UNICEF, MSF, CDC, Global Communities-all of us have an organizational e-mail system. The Liberian Ministry of Health has no e-mail system. The government of Liberia has no organized e-mail system. So everyone has a personal e-mail. Having the ability to funnel information through specific workgroups really helped the leadership be able to have a better span of control and to have a grasp of everything that was going on, but not to have to cope with messages from sixty different organizations. 

                          With regard to the second piece, the messaging, Liberia has, to this day, the most sophisticated message manual of any of the three countries that were most affected by Ebola. Under the leadership, the joint leadership, of UNICEF and the Ministry of Health, the message manual was refined and revised and updated and new information and issues added throughout the entire response. So today, if Ebola happens again, they have a concrete message manual to serve as reference that is very oriented to be able to support a future response. The messages we know are scientifically accurate, and they provide a positive or self-efficacy personal action frame. 

SCHREIBER: 	The big thing I'm looking at in the story though, is about winning trust from the communities themselves. They have to change behaviors that are in many cases just normal human behaviors and in others are more culturally influenced. So from the very broadest level, what do you think were some of the key things that actually built that trust, when as you mentioned it was really lost in the beginning, to the point where people were eventually willing to cooperate and change those behaviors? 

TELFER:	My personal observation-and this is my personal observation, I am not representing the opinion of the agency; let me be very clear about that. The turning point occurred between the fourth and the eighth of October when the Ministry of Health convened the National Council of Tribal Chiefs in Gbarnga in Bong County for a four-day meeting. Every ministry and every workforce or workgroup that was part of the response was present at that meeting to brief traditional leaders on what was happening. Out of that meeting came a ten-point resolution from the National Association of Traditional Chiefs that said that they would support the ministry and the government in this response. 

	I believe much of trust in Liberia was from bridge building. It is not one of those things-understandably I believe-where you can come in and just because I'm from CDC does not automatically make me a trusted emissary. It just means that I am from CDC and they know CDC is a partner. So just in my sphere of activity, it took three weeks to really build that trust and demonstrate that I was responsive to the needs, that I could produce products that were useful, that I was truly there to support the ministry. And then we were able to make really good progress. That needed to happen in every sector. 

	Then we built a bridge between the ministry and first, between the Message and Materials Development Committee and the rest of the response, to be able to move those messages into the IMS and into the partners' hands. Then we built a bridge between the Ministry of Health and the Ministry of Information so that by  the 19th of December, the IMS commander and the Minister of Information jointly presented to the President the Ebola Must Go campaign. It was a joint activity.  

	Similarly a bridge needed to be built between the political government and the traditional leadership in order to have the most effective reach into the communities. That supported the connection at the county and district levels where people were well acquainted. It sort of gave it the official mantle and said the entire government is in line with this. Shortly after that meeting what we call the epi curve bent and cases started to decline. The crisis certainly wasn't over, but it wasn't still escalating. 	

                          My personal observation is that looking at the timing of events, because at that time we still didn't have enough ETUs (Ebola Treatment Units) then. We still didn't have enough ambulances. We still didn't have the right system in place. So those structural things were still missing, but the curve still began to bend. 

SCHREIBER: 	As a devil's advocate on that exact point, couldn't it also be that with the peak of the crisis being so bad, that people were seeing so much death, that at a certain point it's just too much. You may on your own start changing some behaviors. What do you think about the idea of this community learning essentially as part of that explanation? 

TELFER: 	That is a plausible hypothesis. Community learning needs to be supported with what are the actions. 
 

TELFER: 	Hand washing does not prevent Ebola. What we were asking people in West Africa to do was to change deeply-held beliefs and longstanding cultural traditions. It is not the same as use less salt, consume less sugar. It is change in the way that you care for your family members whether they are ill or dead. That is a profound change. So on one hand, yes, people could learn that. On the other hand, in terms of asking people to do something different, this was such a big ask that it needed to be, I believe, somehow supported by other methods. Whether that was information, whether it was outreach from general community health volunteers, whether it was reinforcement from the tribal leadership I don't know. I don't believe that evaluation has been conducted except that we do know that a large percentage of people remembered receiving a visit from a general community health volunteer. Unfortunately the message people most remembered was, "Wash your hands." Nonetheless, enough change was made to be able to change the course of events. Conceivably people could have done it on their own. My hypothesis would be that it might have taken longer than it actually did. Dr. (Tom) Frieden himself, our CDC Director said that things changed in Liberia when the community became involved. In the period of October to-middle of October to middle of December, lots of things happened. 

	The government had enough of a structure to be able to reach the communities and have the resources for the communities to be able to use, and the people were given concrete actions through the Ebola Must Go campaign, for example, that they could take actions that would allow them to intersect with the structure that was there. So it was multifactorial.

SCHREIBER: 	Right. I think my working hypothesis at this point is certainly the point you make, even if I completely on my own decided, "Okay, I need to change something now." Then, at the very least, I would have had the correct information at hand to know what to do now. 

TELFER: 	Exactly. 

SCHREIBER: 	Even if the trigger for me changing my behavior wasn't necessarily someone showing up at my door, at the very least getting that information and knowing what steps to take were certainly very important, because I could imagine if someone wanted to change something and didn't know what to do that would have been like a nightmare scenario.

TELFER:	Exactly. Then what people do is they do what is prudent. I can give you an example. Early in the response one of our people visited with a county health official who had a report of a potential outbreak in a village. I remember this vividly. She was recounting what the county health official had told her. He said-after he left the road, he walked for eight hours. He crossed two rivers and when he arrived at the village there were 22 graves and there was no one left, because the people had fled. 

                          Fleeing is not panic. Fleeing is taking personal prudent action to distance yourself and your family from an illness. Sadly, that spread the illness. But in terms of a chain of thought, "Stay in place and tell someone" was a primary message that we had to get out so that people would not flee and not take the illness with them and spread it further.

                          So being able to change that behavior also required, I believe, layering if you will. So the information was going out through the traditional chiefs. The information was going out through the town criers. They were provided megaphones so they didn't have to just shout and could save their voices, because they were doing a lot of talking. Messages went out through the community health volunteers. Those same messages were being heard on community radio. Those same messages were in the newspaper. Those same messages when we got the campaign going were in posters and on flyers being delivered by a multiplicity of different groups. So people were hearing it from a lot of different directions. 

SCHREIBER: 	 I will not take any more of your time, but that was really a fascinating conversation. Thank you so much for taking the time to talk to me.

TELFER: 	Thank you. I hope it is useful.

SCHREIBER: 	Thank you so much. 



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