title: The first mile: community experience of outbreak control during an Ebola outbreak in Luwero District, Uganda.
abstract: BACKGROUND
  A major challenge to outbreak control lies in early detection of viral haemorrhagic fevers (VHFs) in local community contexts during the critical initial stages of an epidemic, when risk of spreading is its highest ("the first mile"). In this paper we document how a major Ebola outbreak control effort in central Uganda in 2012 was experienced from the perspective of the community. We ask to what extent the community became a resource for early detection, and identify problems encountered with community health worker and social mobilization strategies.
  
  
  METHODS
  Analysis is based on first-hand ethnographic data from the center of a small Ebola outbreak in Luwero Country, Uganda, in 2012. Three of this paper's authors were engaged in an 18 month period of fieldwork on community health resources when the outbreak occurred. In total, 13 respondents from the outbreak site were interviewed, along with 21 key informants and 61 focus group respondents from nearby Kaguugo Parish. All informants were chosen through non-probability sampling sampling.
  
  
  RESULTS
  Our data illustrate the lack of credibility, from an emic perspective, of biomedical explanations which ignore local understandings. These explanations were undermined by an insensitivity to local culture, a mismatch between information circulated and the local interpretative framework, and the inability of the emergency response team to take the time needed to listen and empathize with community needs. Stigmatization of the local community--in particular its belief in amayembe spirits--fuelled historical distrust of the external health system and engendered community-level resistance to early detection.
  
  
  CONCLUSIONS
  Given the available anthropological knowledge of a previous outbreak in Northern Uganda, it is surprising that so little serious effort was made this time round to take local sensibilities and culture into account. The "first mile" problem is not only a question of using local resources for early detection, but also of making use of the contextual cultural knowledge that has already been collected and is readily available. Despite remarkable technological innovations, outbreak control remains contingent upon human interaction and openness to cultural difference.
authors.affiliation: Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands. d.h.devries@uva.nl.
authors.forename: Daniel H
authors.initials: DH
authors.lastname: de Vries
authors.affiliation: Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands.|Makerere University College of Humanities and Social Sciences, CeSSRA office, Kampala, Uganda.
authors.forename: Jude T
authors.initials: JT
authors.lastname: Rwemisisi
authors.affiliation: Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands.|Department of Social Work and Social Administration, Makerere University, Kampala, Uganda.
authors.forename: Laban K
authors.initials: LK
authors.lastname: Musinguzi
authors.affiliation: Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands.|Department of Social Work and Social Administration, Makerere University, Kampala, Uganda.
authors.forename: Turinawe E
authors.initials: TE
authors.lastname: Benoni
authors.affiliation: Department of Social Work and Social Administration, Makerere University, Kampala, Uganda.
authors.forename: Denis
authors.initials: D
authors.lastname: Muhangi
authors.affiliation: Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Marije
authors.initials: M
authors.lastname: de Groot
authors.affiliation: Center for Social Science Research on AIDS (CeSSRA), School of Social Sciences, Makerere University, Kampala, Uganda.
authors.forename: David
authors.initials: D
authors.lastname: Kaawa-Mafigiri
authors.affiliation: Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Robert
authors.initials: R
authors.lastname: Pool
mesh_terms: D000884:Anthropology, Cultural; D003140:Communicable Disease Control / Q000379:methods*; D003142:Communication; D003150:Community Health Workers / Q000458:organization & administration; D003469:Culture; D004196:Disease Outbreaks; D019142:Hemorrhagic Fever, Ebola / Q000453:epidemiology* / Q000208:ethnology / Q000523:psychology; D006801:Humans; D062486:Public Health Surveillance / Q000379:methods*; D012111:Residence Characteristics; D057545:Social Stigma; D014454:Uganda / Q000453:epidemiology