‘Atomic Bombs’ in Monrovia, The Identity and Stigmatisation of Survivors

Emilie Venables

ABSTRACT: Survivors of the Ebola virus have been widely profi led as the success stories of the outbreak, yet they still face challenges relating to their identity and reintegration. A survivor’s body takes on new meanings aft er experiencing Ebola, and the label ‘survivor’ is as prob- lematic as it is celebratory. Using data conducted during fi eldwork in Monrovia, Liberia, this article discusses the complex identities of Ebola survivors. In Monrovia, most of the stigma and discrimination relating to survivors was directed towards men, who were considered ‘atomic bombs’ because of concerns that they could transmit Ebola through sexual intercourse. Health promotion messages around sexual transmission were oft en misunderstood, and communities requested the quarantine of men to reduce what they felt was a threat to the wider community. Understanding the meanings and sources of such stigmatisation is necessary to be able to work with and support survivors through psychosocial care and health promotion activities.

KEYWORDS: Ebola survivors, identity, Liberia, quarantine, stigmatisation

Since the Ebola outbreak began in West in breakdown of social relationships and ties, and the 2014, there are currently estimated to be 15,000 sur- loss of employment, can also contribute to psycho- vivors across the region, some of whom continue social problems. Psychosocial challenges were in to suff er with physical and mental health problems fact reported by 35 per cent of survivors in a previ- aft er being discharged, including joint pain, tired- ous Ebola outbreak in Kikwit, Democratic Republic ness and chronic fatigue, hearing diffi culties and of Congo (DRC), who reported feeling rejected by problems with their eyesight. The potential for the their communities as well as their friends and fami- ongoing sexual transmission of the Ebola virus is also lies when returning home (Arwady et al. 2014; De an area of concern clinically and in terms of the ongo- Roo 2002). Survivors are oft en unable to return to ing stigmatisation of survivors (Christie et al. 2015; their lives as they were before they became infected Deen et al. 2015; Mate et al. 2015; Sprecher 2015), es- and are thus in need of ongoing support, including pecially as recommendations and guidelines around psychosocial and material support (Lee-Kwan et al. sexual transmission are continuously being updated 2014) to assist them with rebuilding their lives aft er as new research is conducted (Thorson et al. 2016). In a period of traumatic sickness. Rather than focus- addition to being of benefi t to survivors themselves, ing on the clinical and medical aspects of survivors, information about the range of health problems fac- however, this article looks at the complexities of ing them – including viral persistence – is important ‘being a survivor’ and what the identity means to for health-care workers to have access to so that they those who lived through a virus that killed so many can avoid infection themselves (Harries 2016). others. Throughout the article, I consider the mean- The traumatic experience of being inside an Ebola ing and use of the word ‘survivor’ in Monrovia, the Management Centre (EMC), as well as the potential experiences – positive and negative – of those who loss of other friends and relatives in addition to the have survived as well as how male survivors in par-

Anthropology in Action, 24, no. 2 (Summer 2017): 36–43 © Berghahn Books and the Association for Anthropology in Action ISSN 0967-201X (Print) ISSN 1752-2285 (Online) doi:10.3167/aia.2017.240205 ‘Atomic Bombs’ in Monrovia, Liberia | AiA ticular were subjected to stigmatisation from those vision of goods or services provided by other NGOs around them. working in Liberia at the time. This article is based on anthropological research All data collection was supported by local research conducted in Liberia during October and November assistants, who aided in recruitment of participants, 2014. Ethnographic research consisted of participant translation and note-taking during interviews and observation in communities and in the ‘ELWA 3’ Ebola FGDs, and the transcription of audio recordings. Management Centre (EMC) run by Médecins Sans In this context, it was not feasible to interview peo- Frontières (MSF) in Monrovia, as well as in-depth ple with Ebola who had been admitt ed inside MSF’s interviews and focus group discussions with survi- EMC in Monrovia: even if access were feasible, writ- vors, health-care workers, local community mem- ing or recording notes would have been impossible bers and community leaders across the city.1 The re- as nothing could be removed from the high-risk area. search took place in six diff erent neighbourhoods The only possible experience was as an observer, still across the city, which were chosen for their diversity wearing personal protective equipment (PPE) but and because they were areas in which MSF had pre- gett ing a bett er – albeit brief – understanding of how viously worked. Interviews and focus group discus- the inside of the centre worked and trying to under- sions (FGDs) were mostly conducted in English and stand the EMC from the perspective of a patient, as covered a range of topics including understandings well as a health-care worker.2 Working a night shift and local meanings of the Ebola virus and subse- during my time in Liberia off ered a limited glimpse quent service provision; perceived needs for survi- into this world and the experiences faced by people vors and their perspectives on the crisis. – health-care workers and patients – within the ‘high- The context in which the research took place – as risk zone’ of the EMC. with most of the articles in this special issue – was The intense period of fi eldwork, combining obser- complex because the research team were restricted vations in the community with in-depth interviews by strict security protocols put in place to minimise and focus group discussions, also involved a daily the risk of contracting Ebola. I was required to mini- process of data review through discussing the fi nd- mise the numbers of people who took part in focus ings and ideas gathered in the fi eld with the MSF group discussions to avoid creating crowds, and teams on the ground, as well as with other anthro- to ensure that the ‘no touch’ policy was respected pologists in the region and through virtual networks. amongst research participants, as well as ensuring hand-washing protocols were in place. The research team, as was common practice during the Ebola Understanding Survivor Identity: outbreak, did not shake hands with research partici- Who Is a Survivor? pants and did not enter their homes, staying instead in outside areas such as on their porches or in their The identity of being a ‘survivor’ is complex: the gardens. Focus group discussions were conducted in label can become all-encompassing and the only way open-air spaces or community venues identifi ed by people are defi ned, or choose to defi ne themselves. local leaders – some discussions were held in empty ‘Survivors’ are caught between being celebrated classrooms, as schools were closed because of the and at the same time being feared. The identity of a outbreak. These limitations had an obvious impact survivor is highly stigmatised because the person is on the typical relationship between anthropological automatically associated with Ebola infection. The researcher and participant, reproducing the unnatu- fear surrounding Ebola survivors includes concerns ral boundaries and barriers that Liberians were fac- about the potential for the transmission of the virus as ing every day through research that should instead well as fear relating to the experiences the person had be breaking down boundaries. In addition, there inside the Ebola centre. Rumours and gossip spread, was sometimes suspicion about the role of myself meaning that the EMC was feared and associated as researcher and the other members of the research with death, as we also see in Manca’s article in this team, as there were many international organisations issue. On the other hand, being a survivor can enable working in Liberia at the time of the outbreak, and people to access additional support structures, such it was not always clear to community members who as being a member of a survivor association, receiv- was providing which kind of service. It was impor- ing monetary or material benefi ts from organisations tant not to raise false expectations amongst research supporting survivors and, in some cases, being able participants about what their participation could to gain employment at the Ebola centres or in other involve, as many thought we were linked to the pro- Ebola-related activities such as health promotion.

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Interviews and discussions with staff working tional media and survivors themselves, but what in the EMC revealed that people who did not have makes someone a survivor and what does this name Ebola and who had never tested positive for the virus really mean? Medically speaking, the term ‘cured’ also considered themselves survivors because they does not apply in the case of Ebola, because there had been admitt ed to the centre. Indeed, when a per- is – as yet – no cure for those who are infected. In- son arriving at the EMC in Monrovia was suspected stead, we talk about those who survived, through of being infected with Ebola, they were fi rst admitt ed their own immune response rather than because they to the triage area, where the clinical team (dressed in were treated with a specifi c medication or therapy. light PPE) would decide – based on a set of clinical Any treatment given is symptomatic and supportive criteria and screening questions – whether or not (such as oral rehydration and the provision of IV fl u- they should be admitt ed as an Ebola ‘suspect’. If it ids and nutritional support) and, outside of clinical was decided that they could have Ebola, they would trials, not against the virus. In addition, systematic then be admitt ed to the suspect area and be tested for treatment for potential co-morbidities (such as anti- Ebola. The Ebola suspect area thus contained people malarial treatment and antibiotics) was given. with and people without Ebola. Patients discharged Survivors of Ebola – those who were admitt ed with a negative Ebola test oft en considered them- to an EMC and recovered – were given a certifi cate selves exposed, as they oft en slept one or even two by EMC staff declaring that they were ‘Ebola free’. nights in the ‘suspect zone’. They felt that they had Certifi cates became a form of public currency: rather experienced the same trauma, stigma and discrimi- than being a confi dential medical record, they were nation as those who had been infected, and should viewed as documents that proved someone was Eb- have access to the same support and benefi ts as them. ola negative, and something that others felt entitled People on the ‘outside’ who had never seen the in- to have access to as a means of protecting themselves side of an EMC also made litt le distinction between from what they perceived to be the risk of becoming people who had tested positive or negative for Ebola, infected. It was not uncommon during FGDs to hear and considered anyone who had been admitt ed to an people saying that ‘they [survivors] must show their EMC as still being at risk of transmitt ing Ebola or hav- certifi cate’ or ‘I would need to see their certifi cate’ ing an experience that they could not comprehend. when talking about how they would feel if survivors Those who had survived Ebola, however, felt that came back to their communities. they were diff erent from those who had not actually Survivor certifi cates became a source of pride and been infected with the virus, such as this 67-year-old emotion as they were a reminder about how close man from the Chicken Soup Factory neighbourhood someone had come to death, but they also became a of Monrovia: passport to ease access to material resources, benefi ts and support structures. For others, certifi cates were There is a diff erence, there is a diff erence. The diff er- the proof that the survivor was no longer infectious ence is that I went under treatment and those people and for the individual person, the certifi cate was an – I know because I’ve been in the camp [EMC] there – (un)welcome reminder of their experience. The cer- when you are negative, they don’t keep you and they tifi cate was also a source of stigmatisation: despite will tell you to go and do this and that; but if you are positive, you will remain there and sustain every stating in writing that the individual was Ebola nega- treatment until you get out. They are far off from us, tive, it was proof that they had experienced the inside they are far off . of an EMC and were thus associated with the fear of death and disease. Whilst it may seem clinically clear who is or is not a survivor, people’s individual experiences diff er and the label ‘survivor’ is heavily loaded. For some, Celebrating Ebola Survivors the experience of the EMC makes them a ‘survivor’, whereas for most people, they take on the identity if Survivors were also celebrated upon departure from they have been infected with the virus and survive. the EMC, which included being given a certifi cate, new clothing and basic food supplies; singing, danc- ing and even interviews with local and international Proving Identities media organisations. Despite this, it was diffi cult to ask survivors to refl ect critically on the label ‘survi- The term ‘survivor’ was used by humanitarian agen- vor’ that had been given to them because – despite cies, EMC and outreach staff , the local and interna- the challenges of reintegrating into their lives aft er

38 | ‘Atomic Bombs’ in Monrovia, Liberia | AiA the EMC – they were all obviously happy and re- wards us was not there … Here, nobody used to pass lieved to be alive aft er their near-death experiences, here, they were on that side, just like that [indicating and considered surviving as a positive, celebratory across the road]. I was feeling bad because at least if state. They compared themselves to those who had something like that happens you can come around not survived, and talked about how they had been and say ‘oh my brother, hello’, but nothing … Since we brought these documents [survivor certifi cate] ‘saved’ when others had not: and all these kind of things, some of them started Yes, yes if you call me survivor it’s no problem with coming around and this and that and so and so. […] me. People go there and never came back and I went [T]hrough these papers and those kind of things they there and came back, so you called me survivor. It started gett ing brave to come closer to us but before can’t make me vexed [upset]. (Male survivor, Liberia, that it was … Until now even some of … even my age unknown) children or my very close friends say they are still in doubt of this thing. (Male survivor, Chicken Soup A young woman talked to me about how she liked Factory, 67 years old) the term ‘survivor’ because it was a reminder to her that she was alive when she could have died, as The female survivor cited below talked about how many others did: people in her community were scared of her and enforced their own 21-day period of quarantine to I like the survivor name. When we were coming protect themselves against the threat they perceived home from the hospital, they were calling us the she still held: Ebola Survivor name. Some people go there and they did not survive, and me I survived from it: that is I feel bad because people ran away from us. They why I like the name. (Female survivor, 24 years old, never used to come here; before they put us for 21 Chicken Soup Factory) days and they never brought food, nothing. When it became safe for people to come around me, they The celebrations surrounding individual survivors were scared. People ran away from us; they put us on were extremely welcome, and rather than suggesting 21 days: no going in the market, no going anywhere. that such public and private displays of joy should My pastor used to bring things and put them on the not take place, I am instead off ering a more complex road for the children to take. Not a small thing we go refl ection of the situation in which such survivors through. Now people are coming around me because found themselves aft er being discharged from an I [have] no sickness, nobody is dying in the house so EMC. people can come now. (Female survivor, 24 years old, Chicken Soup Factory)

Both of these experiences show how their commu- Challenges and Negative Experiences nities reacted to their return home, as well as how of Being an Ebola Survivor an additional 21 days of quarantine (the incubation period for the virus) was enforced by the community Although, upon leaving the EMC, survivors were to minimise what people still considered the risk of publicly celebrated, outside the protective confi nes of transmission (see also Pellecchia 2017, this issue). such an environment, their Ebola status was not nec- As the other articles in this special issue also dis- essarily known to others and was not always some- cuss, the history and context of a country cannot be thing they wanted to share. Some people wanted a ignored – Liberia’s history of civil war cannot be public ceremony to welcome them home, whereas forgott en when analysing the epidemic, and for many others preferred to take unmarked transport home people, Ebola felt like a new batt le that they were (without an MSF logo or a staff member wearing fi ghting within their society. The language of war was identifi able clothing) and slip back into their previ- adopted readily and regularly – people described ous life unannounced. The experiences of survivors themselves as fi ghting against Ebola, but they also when returning home varied, but many were ex- began to batt le against the perceived threat of male posed to stigma and discrimination and faced dif- survivors who were viewed as outsiders. fi culties in reintegrating into their home life. During In the FGDs, conversations centred around the interviews, survivors spoke about their experiences, idea that survivors should be welcomed back into and the reactions that people had towards them, such their own communities. Thus participants made a as this man describing his story: distinction between survivors from their own neigh- [S]ome of them used to pass by to speak to us, talk bourhoods and those from ‘other’ outside areas, who to us but the manner of contributing something to- were considered a threat. Survivors from their own

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community were welcomed home and they sug- that there were organisations off ering assistance and gested that survivors should be given work as health employment to survivors such as himself. promoters or in community outreach teams, but said During the time of this fi eldwork, MSF began to that they would not trust or accept survivors coming employ survivors to work in the high-risk zones of from other communities, particularly if they were the EMC and in outreach and health-promotion ac- going to be engaged in paid employment. These tivities in Monrovia, as they understood the situation sentiments were based on the fear of being infected that EMC patients were in and were able to off er by someone from the ‘outside’ but also alluded to the other patients support. Within the EMC, they were need to protect themselves through engaging in ac- able to comfort children and babies who may have tivities of economic benefi t. There was a sense of fear been lost or separated from their parents, and they that an ‘outsider’ from another community could take could stay inside much longer because they did not a job that they wanted or needed themselves. have to wear full PPE, wearing instead a lighter ver- Whilst much of this discussion focuses on the sion which kept their faces visible and did not restrict stigma and discrimination experienced by survivors, their movement in the same way as the ubiquitous, not everyone had the same kind of experience and anonymising yellow suits. Although many survivors many survivors were welcomed home by their com- appreciated their status and wanted to be able to munities, friends and families and reported being ‘give something back’ to others aft er their own EMC given gift s of food and clothing upon their return. experiences, there was some concern amongst Libe- rian staff about their presence as they believed they were being put at risk because the survivors were Are There Any Benefi ts not following the restrictive and stringent safety to Being a Survivor? regulations that they had been trained to abide by on a daily basis. In addition, survivors needed support Apart from the obvious celebratory fact of being alive from the mental health team before coming back to and having survived a terrible disease, there are sev- work in the EMC because of the trauma they had eral ways in which the identity of being a survivor experienced as patients. was also observed to have been a means to access es- Although providing survivors with essential ma- sential benefi ts and resources. On arriving in a neigh- terial and psychosocial support and opportunities bourhood near the ELWA 3 EMC in Monrovia one aft er they have been infected with Ebola is justifi ed morning, I was stopped and called over by a woman and necessary, the identity of who is and who is not – a survivor – who I had interviewed a few days a survivor becomes even more poignant when there earlier. She waved her phone at me excitedly, saying are resources involved. The individual survivor must that she had ‘registered’ and wanted to know when accept being publicly known as a ‘survivor’ to access we would be giving her the money. I was unsure of essential support – whether material or social net- what she meant and what she had registered for until works such as survivor groups or associations – as I remembered a meeting I had att ended the previous without this label they would not be able to benefi t day in which survivors were going to be given cash from such resources. instalments by another NGO to help them buy essen- We must also consider the degree and kind of tial goods aft er they had been discharged from vari- support given to survivors, especially when think- ous EMCs around the city. These cash instalments ing about material or fi nancial assistance as well as were to be paid via a form of ‘mobile money’, which psychosocial or clinical follow-up. Providing eco- required the recipient to register a mobile phone in nomic or material support – whilst giving survivors order to receive the payment. She assumed that I was essential equipment or the fi nancial means to begin part of this service. to rebuild their lives and replace items that may Another time I was walking along the road to the have been lost when their homes were damaged by offi ce – the MSF offi ces were well known to people in the spraying of chlorine during disinfection – can be the community and there were oft en queues of people ethically complex and raise issues of dependency. waiting outside in the hope of picking up daily work Access to such support is also closely linked to sur- – when I was stopped by a man. His only words to me vivor identity and may be restricted to those who were ‘I’m a survivor. Do you have a job for me?’ He have been defi ned as Ebola survivors or who were was desperate to fi nd work, as he no longer had a job treated at specifi c health-care facilities, thus may not as a result of stigmatisation aft er being infected and be inclusive to everyone who defi nes themselves as spending time inside the EMC and had also realised a survivor, as discussed in more detail above. Chal-

40 | ‘Atomic Bombs’ in Monrovia, Liberia | AiA lenges with data collection and storage may also mean the initial ‘82 days’ mentioned above include what that some people are not listed as survivors, or their became known locally as the ‘90-day rule’, men ab- details may be lost, thus preventing them from ac- staining for an additional six months and Liberians cessing support available to others. requesting that men be quarantined in camps. The oft en confusing and contradictory information de- pended on the organisation that provided it, as well Stigmatisation of Male Survivors: as the access people had to information circulating in Understanding the Threat of the local and global media. ‘Atomic Bombs’ During my fi eldwork in Monrovia, I would re- peatedly hear anger and fear directed towards male Whilst the previous discussion highlights the issue of survivors as community members picked up on and stigma, at the time this data was collected, the main interpreted the WHO warning about the potential discrimination encountered by survivors seemed to sexual transmission of the Ebola virus through se- be aimed towards men because of the perceived risks men in ways that were meaningful to them, and that around sexual transmission of EVD. Interestingly, became stigmatising to others. Much of this fear was although there was also a potential risk of transmit- paralleled with a desire to protect themselves and ting Ebola through breast milk, these messages were those around them – especially women in their com- not picked up on in Monrovia, and instead the focus munities – from the unknown and invisible threat and indeed blame for transmission became linked to survivors were believed to bring. Whilst no inter- men. In one particularly heated FGD, a local religious viewee or focus group participant directly used the leader talked of male survivors as being ‘atomic term ‘rape’ or ‘sexual violence’, the discussions that bombs’ which were threatening the entire nation. took place during focus groups hinted at this threat In 2015, the WHO’s offi cial guidelines on the risk and referred to the ‘lack of control’ they felt men of sexual transmission of Ebola were as follows: would have when being discharged from an EMC, and would thus transmit the virus sexually to others. No formal evidence exists of sexual transmission, but sexual transmission from convalescent patients Focus group participants across Monrovia would cannot be ruled out. There is evidence that live Ebola oft en request separate ‘camps’ for men, saying that virus can be isolated in seminal fl uids of convales- they wanted them to be put in quarantine for an cent men for 82 days aft er onset of symptoms. Evi- additional three or six months as a way of control- dence is not available yet beyond 82 days. There is ling and containing the virus. They imagined that no evidence of live Ebola virus in vaginal secretions. creating such a camp would be for the ‘good of the (WHO 2015) nation’, with people wanting to prioritise the collec- These guidelines also added that ‘all survivors, their tive rights of the country over the individual rights partners and families should be shown respect, dig- of Ebola survivors. nity and compassion’ (WHO 2015). The most recent, At times the ‘blame’ for sexual transmission updated guidelines (published as this article was be- seemed to shift towards women, who were told dur- ing writt en) provide more information and research ing public campaigns that they should not encourage into the sexual transmission of the virus: or entice their boyfriends or husbands into having sex with them as they would then be responsible if Recent data suggest that Ebola virus can persist in they became infected with Ebola. One memorable the semen of males for a year or more aft er acute radio show gave women the advice that they should infection, although it is not clear for how long the not wear clothing that could be considered ‘sexy’ in virus is still infectious. Although thought to be rare, case this encouraged men to want to have sex with sexual transmission of Ebola virus has been reported. Consequently, all EVD survivors and their sexual them. Even though publicly men were feared be- partners should receive counselling to ensure safe cause they were seen as the ones who could transmit sex practices until their semen has been determined the virus, this example shows how the blame was to be free of Ebola virus. (WHO 2016: 22) also shift ed towards women. These offi cial guidelines, however, became distorted, misconstrued and adapted by individuals who were understandably terrifi ed of becoming infected and Supporting Survivors wanted to minimise their risk of contracting Ebola as Whilst health promotion messaging from diff erent much as they could. Locally produced variations on NGOs and institutions across the region originally

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focussed on modes of transmission and the preven- sion, it is essential to involve not just the individual tion of Ebola, it became clear that messages needed to survivor themselves but also those that they are in a be changed and updated constantly. It was necessary sexual relationship with. fi rst to update and give out accurate health promo- tion messages about EVD in general but then to in- clude messages that went beyond classic prevention Conclusion to include messages about avoiding stigma and wel- coming survivors home when the epidemic shift ed. The nature and identity of Ebola survivors – and the One of the main challenges in trying to combat kind of care and support they require – continues to the stigmatisation experienced by survivors was change as we learn more about what it means physi- ensuring that people had access to accurate, timeous ologically and psychosocially to be a survivor. Health information through health promotion activities that promotion messages and information given out went beyond early messages about preventing the across the region need to be consistent – something transmission of the virus (such as hand-washing and which is challenging when scientifi c research into avoiding touch) to include information about the po- survivors, their health needs and the potential trans- tential risk of sexual transmission. While conducting mission risks are ever-evolving. Survivors, particu- fi eldwork, the editors of this special issue both no- larly men, were stigmatised and misunderstood due ticed how ‘connected’ Liberians living in Monrovia to a lack of accurate and consistent information given were to media news and sources of information, and out to local communities about the sexual trans- were oft en asked to defend or clarify stories that had mission of the virus. Survivors are in need of on- been reported in the local or international media, in- going support, but they also need assistance in set- cluding updated information about the sexual trans- ting up their own networks and associations which mission of the virus. This meant it was paramount can directly meet their daily needs. to stay ‘one step ahead’ and give accurate and up- to-date information before it became distorted and diluted or became damaging rumours. EMILIE VENABLES has been based in There are many diff erent ways that survivors since 2009 upon completion of her MSc and PhD need continuing support, and these will continue from the University of Edinburgh. She also holds an to develop and change as more is learned about the undergraduate degree in Social Anthropology from physiological and psychosocial eff ects of Ebola upon the University of Cambridge and an MSc in Devel- the virus’ survivors, not just in Liberia but across the opment Studies from SOAS, University of London. West African region. One of the main ways of off er- Emilie is currently affi liated with the University of ing people support is through survivor groups or as- Town in South Africa. sociations – groups of survivors who meet regularly E-mail: [email protected] to discuss their challenges and look for ways to help each other (Gortor 2015). These networks serve as a way of replacing social networks and ties that may have broken down as a result of Ebola, and such Notes groups have been set up in the three most aff ected 1. ELWA 3 was the local name given to the EMC due to West African countries. As many people fi nd them- its proximity to the ELWA hospital. selves excluded from their communities, they need to 2. PPE was commonly seen in media images of the fi nd new ways of receiving support and new groups Ebola outbreak, and refers to the personal protec- of people to interact with, hence the need for such tive equipment worn by healthcare workers coming associations. into contact with an infected person or their bodily The potential for sexual transmission is also an fl uids to prevent them from becoming infected. opportunity for providing counselling around HIV and STIs to survivors, their partners and their wider communities. Parallels between HIV and Ebola have References been discussed elsewhere, and much of the stigma surrounding Ebola is similar to that experienced by Arwady, M. A., E. L. Garcia, B. Wollor, L. G. Mabande, people living with HIV (Calmy et al. 2015; Paul 2015). E. J. Reaves and J. M. Montgomery; Centers for When considering the potential of sexual transmis- Disease Control and Prevention (CDC) (2014),

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‘Reintegration of Ebola Survivors into Their Lee-Kwan, S. H., N. DeLuca, M. Adams, M. Dalling, Communities: Firestone District, Liberia, 2014’, G. Gassama and T. Davies (2014), ‘Support Services Morbidity and Mortality Weekly, 19 December, 63, for Survivors of Ebola Virus Disease: , no. 50: 1207–1209. 2014’, MMWR Early Release 63, no. 50: 1205–1206. Calmy, A., E. Goermaere and G. van Cutsem (2015), Mate, S. E., J. R. Kugelman, T. G. Nyenswah et al. ‘HIV and Ebola Virus: Two Jumped Species But (2015), ‘Molecular Evidence of Sexual Transmis- “Not Two of a Kind’, AIDS 29: 1593–1596. sion of Ebola Virus’, N Engl J Med. doi:10.1056/ Christie, A. et al. (2015), ‘Possible Sexual Transmission NEJMoa1509773. of Ebola Virus: Liberia, 2015’, Morb Mortal Wkly Rep Paul, K. and P. K. Drain (2015), ‘Ebola: Lessons (MMWR) 64: 479–481. Learned from HIV and Tuberculosis Epidemics’, Deen, G. F., B. Knust, N. Broutet, et al. (2015), ‘Ebola Lancet 15: 146–147. RNA Persistence in Semen of Ebola Virus Disease Sprecher, A. (2015), ‘Handle Survivors with Care: Edi- Survivors: Preliminary Report’, N Engl J Med. torial’, N Engl J Med. doi:10.1056/NEJMe1512928. doi:10.1056/NEJMoa1511410. Thorson, A., P. Formenty, C. Loft house and N. Brou- De Roo, A. D., B. Ado, B. Rose, Y. Guimard, K. Fonck, tet (2016), ‘Systematic Review of the Literature on R. Colebunders (1998), ‘Survey among Survivors of Viral Persistence and Sexual Transmission from the 1995 Ebola Epidemic in Kikwit, Demographic Recovered Ebola Survivors: Evidence and Recom- Republic of Congo: Their Feelings and Experiences’, mendations’, BMJ Open 6: e008859. doi:10.1136/ Trop Med Int Health 3: 883–885. bmjopen-2015-008859. Gortor, W. (2015), ‘Liberia: Ebola Survivor Network World Health Organization (WHO) (2015), ‘Sexual Claims Growing Stigma’, Liberia News Agency, 6 Transmission of the Ebola Virus: Evidence and April, htt p://.com/ stories/201504070737 Knowledge Gaps’. .html. World Health Organization (WHO) (2016), ‘Clinical Harries, J. and S.C. Davies (2016) ‘Ebola Survivors: Not Care for Survivors of Ebola Virus Disease: Interim Out of the Woods Yet.’ BMJ 352: 178 Guidance’.

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