'A Perfect Storm' A case study of how the Ebola response played into conflict dynamics in Sierra Leone

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‘A Perfect Storm’

A case study of how the Ebola response played into

conflict dynamics in Sierra Leone

Author: Cathrine Barklin Bachelor thesis

Subject: Peace and Conflict Studies 12 credits

Spring Semester 2020 Supervisor: Ane Kirkegaard Word count: 13905

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Abstract

Between 2014 and 2016, West Africa was struck by the largest ever Ebola epidemic. In Sierra Leone, the outbreak occurred only about a decade after the end of an eleven-year long civil war, which left the country with little capacity to contain the virus. While many have investigated the crisis that the Ebola outbreak caused West African countries, few have turned their attention directly towards the response to it. Following that line of thought, this case study explores how the Ebola response carried out by local, national and international actors played into conflict dynamics in the aftermath of the Sierra Le-onean civil war. By applying the theoretical perspectives of ‘the fortified aid compound’ and ‘dependent agency’, I argue that the response embodied a militarised approach and that it was insensitive towards local customs, which showed in shifting acts of compliance and resistance by beneficiaries. Lastly, by applying the theory of ‘protracted social con-flict’, I argue that conflict dynamics from the civil war were amplified by the Ebola re-sponse to some extent. The study concludes that future rere-sponses to epidemics, particu-larly in conflict affected settings, should consider potential negative effects connected to response structures and measures to a greater extent.

Key words: Civil war, Ebola Outbreak, Humanitarian Response, Protracted

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List of Abbreviations

APC – All People’s Congress

AFRC – Armed Forces Revolutionary Council

ECOMOG – Economic Community of West African States Monitoring Group ECOWAS – Economic Community of West African States

EVD – Ebola Virus Disease ETC – Ebola Treatment Center HDI – Human Development Index

IFRC – The International Federation of Red Cross and Red Crescent Societies INGO – International Non-Governmental Organisation

MSF – Médecins san Frontiéres OCB – Operational Centre Brussels PSC – Protracted Social Conflict RUF – Revolutionary United Front SDB – Safe and Dignified Burials SLPP – Sierra Leone People’s Party

TRC – Truth and Reconciliation Commission

UNAMSIL – United Nations Mission in Sierra Leone UNMEER – UN Mission for Ebola Emergency Response WHO – World Health Organization

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1 Introduction

The Ebola Virus Disease (EVD) outbreak in West Africa from 2014-2016 has been re-ferred to as a ‘perfect storm’, where the combination of dysfunctional and underfunded national health systems, distrust in authorities, slow response by international actors and insensitivity towards local customs has been used to explain the crisis it eventually evolved into (Farrar & Piot 2014, Harman & Wenham 2018:362). The outbreak is the largest Ebola epidemic ever recorded with more than 28,000 cases and 11,000 deaths registered between 2014 and 2016 in Sierra Leone, Liberia and Guinea (MSF 2016:4). Because the size of the outbreak has been ascribed more to social and political factors than biological, it brought along wide-ranging of discussions on what should be learned from it. Writing in a time where the Covid-19 pandemic has spread rapidly across the globe, it will be relevant to look back at the Ebola outbreak in West Africa, to see what lessons can be learned in response to viral diseases.

1.1 Research Aim and Research Question

In the case of Sierra Leone, the Ebola outbreak occurred approximately a decade after the end of a protracted civil war, which left the country with a low response capacity, insuf-ficient health personnel and infrastructure, and thus directly dependent on international assistance to contain the virus. While previous research has exposed many of the issues related to Ebola outbreaks in conflict affected settings, this paper will add a new theoret-ical perspective, aiming not to look at how the outbreak played out in a conflict affected setting, but how the response carried out by various local, national and international ac-tors played into the conflict dynamics present after the civil war in Sierra Leone. Follow-ing this line of thought – and focusFollow-ing on a particular set of INGOs, the Sierra Leonean state and local level actors – I seek to answer the following research question:

How can the theories of ‘the fortified aid compound’, ‘dependent agency’ and ‘protracted social conflict’ help us understand the Ebola response in Sierra Leone from 2014-2016 as playing into conflict dynamics in the aftermath of the Sierra Leonean civil war?

The question will be answered via an exploratory case study, and the data consists of three official reviews from organisations that played a large role in the response in Sierra Leone together with two interviews with staff employed by organisations during the response. To examine how the response played into conflict dynamics from the civil war, I formu-late three theoretical propositions. Firstly, to characterise the architecture of the response and discuss agency of beneficiaries I apply the theory of ‘the fortified aid compound’ as formulated by Duffield (2010) together with the theory of ‘dependent agency’ as defined by Anderson & Patterson (2017). Secondly, to analyse how these response-related issues played into conflict dynamics from the civil war, I use the theory of ‘protracted social conflict’ as defined by Azar (1978) to connect the two. Consequently, the response be-comes the unit of analysis.

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1.2 Research Problem and Relevance to Peace and Conflict Studies

This study is relevant to Peace and Conflict Studies because it seeks to explore how re-sponse to health issues could play into conflict dynamics, emphasising that conflict situ-ations permeate societies as a whole. Because Peace and Conflict studies also deals with the international spectres of conflicts, it is relevant to investigate the interplay between national and international factors concerning the Ebola response, which this paper seeks to contribute to. The case of the Ebola response is an interesting unit of analysis because it was initially approached as a health emergency, but tragically evolved into a humani-tarian crisis in West Africa.

1.3 Disposition

Firstly, a background chapter will outline conflict dynamics identified from the pre-war, civil war and post-war contexts in Sierra Leone. The chapter will also briefly describe the main events and concerns related to the Ebola outbreak and response in the Sierra Leone and include a short review of the discussions emerging after the outbreak. Afterwards, the theories of ‘the fortified aid compound’, ‘dependent agency’ and ‘protracted social conflict’ will be presented and linked to the research question. In the methods chapter I outline how the case study approach is used to analyse the data and reflect on the delim-itations of the paper. The analysis will be guided by the three theoretical propositions defined in the methods chapter using the selected data. Lastly, a concluding discussion will debate to what extent the theoretical propositions were beneficial for looking at how the response played into conflict dynamics and discuss implications of this study, relevant for further research.

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2 Responding to an Epidemic in the Aftermath of War

In the following I outline the historical context to the civil war in Sierra Leone, to identify which conflict dynamics have been recognised by scholars and thus can be relevant to look for when analysing the Ebola response. First, I briefly outline the pre-war context, secondly the course of the civil war and thirdly issues defined in the post-war context. To make sure both internal and external factors to the Sierra Leonean context are included in the following, I use the conflict-mapping guide defined by Oliver Ramsbotham et al. (2011:89f), which includes country background, conflict parties and causes as well as the global, regional and national context of the war. The chapter ends by briefly describing the formal structure of the Ebola response in Sierra Leone, reviewing the literature emerg-ing from the West African Ebola outbreak and afterwards I position this paper in relation to previous research.

2.1 Pre-war Context

When Sierra Leone gained independence in 1961, it is argued that the postcolonial state emerging from British rule was never democratically reconstituted (Kieh 2005 in Wong 2012:85). The decades that followed were characterised by political and economic crisis. During the British colonial (from 1808) and protectorate -rule (from 1896) in Si-erra Leone, tribal chiefs were deliberately diffused into political power for the British to gain infrastructural advantage on e.g. resource extraction and diamond trade – and also as part of the trans-Atlantic slave trade before it was outlawed in 1833 (Wong 2012:84f). Despite initial efforts of the democratically elected Sierra Leone People’s Party (SLPP) to develop a more liberal and democratic system, the party lost their popularity because their rule turned increasingly authoritarian and corruptive (ibid., 85). The party staged a military coup in 1967 after losing elections (ibid., 85), and the following decades leading up to the civil war were characterised by political and economic crisis. Tunde Zack-Wil-liams defines the post-dependence era in Sierra Leone as a “failure of a democratic ex-periment” (2012:3). In 1978 Sierra Leone became a one-party state led by the All People’s Congress (APC) government, and according to Zack-Williams, the usage of authoritarian measures - such as introducing a permanent state of emergency to supress political oppo-nents - kleptocracy and neglect of southern regions, combined with an economic crisis that resulted in aid dependency were some of the main factors preparing the ground for the outbreak of an eleven-year long civil war (ibid., 17). It was also highlighted in the Truth and Reconciliation Commission’s concluding report that before war “government accountability was non-existent” (TRC report 2004 cited in Zack-Williams 2012:71). In 1993, before the outbreak of the war, Sierra Leone scored second lowest on the Human Development Index (HDI), which “combines indicators of real purchasing power, educa-tion and health” (United Naeduca-tions 1993:10).

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2.2 Civil War 1991-2002

Perhaps the term ‘civil war’ will fall short in defining the complex fabric of various re-gional and international actors who eventually became part of the war in Sierra Leone, but for the sake of simplicity, it will be phrased as such. The civil war was characterised by various and changing military factions. The national army was splintered which e.g. resulted in involvement of private mercenaries, and regional and international military interventions eventually became part of the eleven year-long war.

The war officially began when the rebel group Revolutionary United Front (RUF) entered Sierra Leone from Liberian border areas in 1991, and it is argued that they en-joyed support from the regimes of Liberia, Côte d’Ivoire, Burkina Faso and Libya (Zack-Williams 2012:21,13). RUF claimed to fight as part of the widespread discontent with the APC leadership, but their legacy from the war remains their brutal means of fighting that indiscriminately targeted civilians (Abdullah 1998:204,227). In 1992, a group of army officers seized government power from the APC, allegedly because of dissatisfaction with authoritarian rule, declaring their intention to end the war (ibid., 204). Another coup in 1997 was carried out under the name Armed Forces Revolutionary Council (AFRC), in-cluding elements from both RUF and army officers (ibid., 204). The AFRC was, however, driven out the same year by forces from the Nigerian-led Economic Community of West African States Monitoring Group (ECOMOG) – a peacekeeping force set up by ECO-WAS during the Liberian civil war – so that the former government could return (Zack-Williams 2012:25,130). In 1999, the Lomé Peace Accord was signed by president Kabbah and RUF leader, Foday Sankoh, but due to a subsequent coup by RUF in 2000 increasing the state of chaos (Zack-Williams 2012:55), the United Nations Mission in Sierra Leone (UNAMSIL) was formed by March 2001. It was the biggest UN peacekeeping mission at the time, wherein the British military played a large role (Zack-Williams 2012:65). John Hirsch argues that during war, the country was “caught between the divergent regional interests of the local actors and the narrowly compartmentalised policies of the major western powers” (2001:145), explaining e.g. that the US and France sought to leave the war, while the UK felt obligated to stay as part of the UNAMSIL mission (ibid.). In 2002, the civil war was finally declared over. Apart from political power, many have argued that economic incentives i.e. related to diamond fields played a large role. One example is how private mercenaries were offered cash and mining concessions (Zack-Williams 2012:30). The war cost 70,000 lives and displaced 2.6 million people, more than half of the population (Okano 2019:1).

2.3 Post-war Issues

Many of the issues identified during the post-war period in Sierra Leone can be traced back to the pre-war context. These especially include problems with authoritarian forms of governance, rural marginalisation, low standards of living and dependency on interna-tional aid and interventions resulting in non-sustainable solutions.

Clare Shelley-Egan and Jim Dratwa underlines that distrust in authorities were exacerbated after the end of the civil war (2019:14). A part of post-war efforts in Sierra

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Leone was to re-establish a decentralised system of governance because the centralised system had supposedly contributed to the conflict (Jackson 2005:51). The centralised sys-tem of governance in Sierra Leone has often been connected to rural marginalisation em-anating from ill-functioning service delivery (Zack-Williams 2012:43f). According to Amadu Sessay et. al., low living standards in Sierra Leone were exacerbated by eleven years of war, where “thousands of war victims were mired in poverty and unimaginable suffering” (2009:69). Though slightly improving between the pre-war and post-war era, the HDI score remained low in global comparison. In 1990 the score was at 0.270, and in 2005 it was at 0.346 (UNDP 2019) – in the same year, 81 percent of the Sierra Leonean population belonged to the category of multidimensional poverty (University of Oxford 2010), which includes people “below income poverty line”, “people in severe poverty” and people living “near poverty” (UNDP 2015:6f). Andreu Solá-Martín further argues that even though the international UN peacekeeping mission were successful, the subse-quent peacebuilding initiatives had not been effective in addressing root causes of the conflict (Solá-Martín 2009). Additionally, marginalisation of youth (Ekundayo-Thomsen 2012), chiefdom-level governance including legacy of colonial indirect rule (Fanthorpe 2005), and war trauma including from sexual violence (Africa Renewal 2020:161) have also been addressed as part of post-war issues in Sierra Leone, but will not be directly dealt with through this paper, because these issues were not found to be part of the re-sponse from the data reviewed.

Even though the formal peace agreement officially ended the war, the years fol-lowing it were affected by conflict, health facilities were inadequate, and Sierra Leone remained dependent on international aid. Thus, the country Leone was ill-equipped to deal with the imminent epidemic (McPake et al. 2015).

2.4 Responding to Ebola Virus Disease in Sierra Leone 2014-2016

EVD was discovered for the first time in the Democratic Republic of Congo (former Zaire) in 1976 near the Ebola river (CDC 2020a), but the West African Ebola outbreak from March 2014 to June 2016, primarily affecting Guinea, Liberia and Sierra Leone, is the largest and deadliest ever recorded (CDC 2020b), where a few cases were also rec-orded across international borders (Shelley-Egan & Dratwa 2019:4). Ebola has a mortal-ity rate of approximately 40 percent, making it very deadly in comparison to other viral diseases. It is spread through bodily fluids, implying high risks for anyone in contact with infected persons (MSF 2016:4). The symptoms cover “sudden onset of fever and fatigue, muscle pain, headache, and sore throat, which can be followed by vomiting, diarrhoea, rash, and in some cases internal and external bleeding” (Patterson 2018:83). During the West African Ebola outbreak 74 percent of the transmissions were between family mem-bers, (CDC 2020c). Contact tracing, social distancing, quarantine, safe burials of bodies, healthcare training for workers, distribution of personal protective equipment (PPE) were some of the measures taken to contain the virus (MSF 2016, IFRC 2018). In Sierra Leone, the country with the highest number of cases, the response was compiled of both interna-tional, national and community efforts (DuBois et al. 2015:17), where the first mentioned

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constituted a great part of both funding and the health and humanitarian intervention. Thus, my research question investigating ‘the response’ includes these intimately linked components. The structure of the response changed over the course of the outbreak, but eventually consisted of a National Ebola Response Centre (NERC) headed by president Koroma, which coordinated the response and 14 District Emergency Response Centres (DERCs) serving as ‘command-and-control hubs’ (Ross et al. 2017:3). The Sierra Le-onean military was deployed in May 2014 i.e. “as a security measure to assist with con-frontations between communities and health workers” (ibid., 17), and eventually also as guards for treatment centres and burials. Emma Ross et al. stress that “interviewees re-ported that in certain sensitive areas soldiers carried guns, but these were not loaded” (ibid.). After the UN Security Council declared the EVD outbreak a security threat, the UN established its first mission related to a health emergency in September 2014, the UN Mission for Ebola Emergency response (UNMEER), to upscale the response and support national efforts (Ross et al. 2017:5, Global Ebola Response 2020). A UK civilian-military taskforce – Operation GRITROCK - also joined the response in September 2014 to lead the international operational response (Ross et al. 2017:5). The operation included com-mand and control, engineers, logisticians and intelligence personnel (ibid., 19). The tech-nical components of the response were run through pillars led by the Ministry of Health with support from international organisation representatives – the efforts included local and international NGOs and community groups (ibid., 16). International actors and staff primarily took coordinating roles – though medical staff was imported - while it typically was local nationals who engaged directly with communities and beneficiaries (Kirkegaard 2020).

2.5 Previous Research: Ebola and Conflict

The following will review the literature that has sought to explain how the Ebola outbreak in West Africa, including specifically Sierra Leone, evolved into the crisis it did. Re-searchers tend to agree that the size of the outbreak cannot solely be understood through biological factors, because structural and social factors were important to understand the development of it. While these cannot be separated entirely, the first part will look at the international factors discussed, while the latter part will look at national and local condi-tions.

Charles Silver presents the case of the Ebola outbreak in Sierra Leone as “a clear testimony to the fact that overreliance on international assistance, particularly in times of health emergencies, can sometimes have devastating consequences” (2016:20). In 2013, 24 percent of Sierra Leone’s health expenditures came from donors and 61,1 percent was paid by patients themselves, while inadequate funding led to shortages in health personnel (ibid., 16). For example, Ross et al. (2017) argues that it was unusual how the World Health Organization (WHO) did not manage to mobilise necessary assistance to national governments in the beginning of the outbreak, emphasising that this would have been their role at the time. She argues that the ‘international community’ in general was too slow to respond and argues that “the window of opportunity to contain the outbreak

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through conventional control approaches closed, and the outbreak became a humanitarian crisis” (ibid., 2). WHO’s late reaction has been criticised widely (Cortart et al. 2017:17), and their reluctance to act e.g. showed when the outbreak was not declared a Public Health Emergency of International Concern even though the first case was suspected eight months earlier (MSF 2016:3). Emphasising how global power imbalances were revealed during the course of the response, Shelley-Egan and Dratwa has criticised the interna-tional ‘outbreak narrative’. This, they consider “emphasised local-level poverty and cul-tural and ecological practices as the major factors of causation in the epidemic” (2019:3), which they believe “obscures fundamental political, cultural, historical and ecological determinants of the outbreak” (ibid.). An issue also posed is that to the ‘international community’, those regions affected by the virus was a secondary concern to the potential risks of a spread across international borders (ibid., 3).

The national factors explaining the crisis evolving from the outbreak are generally related to ill-functioning infrastructures, low trust in state authorities, low amount of health professionals and lack of investments in health systems in the aftermath of the civil war in Sierra Leone (McPake et al. 2015, Patterson 2018:85, Silver 2016:15). Between 2008 and 2016, Sierra Leone had less than 0.5 skilled health professionals per 1,000 pop-ulation (Eurodad 2018:20), and a Eurodad report stresses the issues that Sierra Leone had been dependent on foreign loans from e.g. IMF, whose loan conditionality has affected health spending in many low-income countries (ibid., 22). Silver underlines that gener-ally, the health sector in Sierra Leone was “not financigener-ally, logisticgener-ally, or technically equipped to respond to the Ebola outbreak” (2016:18). Barbara McPake et al. has com-pared the case of the Ebola outbreak in Uganda in 2001 to the case of Sierra Leone be-cause the two countries were at a “similar distance from national conflict” at the time of an outbreak in 2001 to emphasise how Sierra Leone had not been able to re-establish effective governance entirely in the aftermaths of war, which partly made coordination with international organisations difficult (2015:6f). The study also experienced that Uganda had established a higher level of trust in hospitalising, which was not the case in Sierra Leone that had to rely on “government hospitals, affected by all the problems of weak governance and depleted resources” (ibid.,7). The issue of mistrust both towards the government and implementing organisations has also been addressed as a negative factor for the course of the outbreak by Cordelia Coltart et al. (2017:14f). McPake et al. further stresses that the issues of “lack of decentralised authority within the health sector” were addressed in the aftermath of the war but not fully implemented at the time of the outbreak, and that provision of public services generally had not recovered (2015:6).

In terms of response practices, community engagement has repeatedly been ad-dressed as crucial to containing the virus, because it resulted in local legitimacy of the response and cultural sensitivity towards e.g. burial practices, but it is also agreed among scholars that because this was introduced too late in the response it had serious negative effects (Cortart et al. 2017:15, Silver 2016:20). Ilona Kickbuschand K. Srikanth empha-sised that “this comes as no surprise to health promoters but is not yet the model followed when dealing with infectious disease outbreaks” (2016:75). Adam Kamradt-Scott et al. has emphasised that civil–military cooperation in health in relation to the Ebola outbreak

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in West Africa work well in response to the outbreak, but that the involvement of military still is “controversial and raises questions about their effects on humanitarian principles” (2016:105).

2.6 Positioning the Paper

Reviewing the literature, it is agreed that the Ebola outbreak in West Africa, and also specifically in Sierra Leone, evolved into the crisis it did because of both internal and external factors, where the internal factors are primarily ascribed to the destructions from civil war. This paper will follow the line of thought presented by e.g. Silver (2016) and McPake et al. (2015) that sees the Ebola response as a crisis situated in a ‘conflict af-fected’ country. However, it is the response itself which becomes subject of analysis for this paper, and not the ‘fragile’ setting it was situated in. Some of the same ‘lessons learned’ will be concluded in the coming analysis but based on different data, representing an organisational point of view. While some empirical findings will be done, and the paper will be able to zoom into the selected organisations’ own perception of the response, the contribution of this paper primarily lies in perceiving the response from a new theo-retical perspective. By drawing lines directly from response measures to conflict dynam-ics from the civil war, the response will be seen in a new light, which hopefully can gen-erate new analytical perspectives for future epidemics responses.

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3 Three theoretical lenses

In the following, I outline the arguments of the theories 1) ‘the fortified aid compound’, 2) ‘dependent agency’ and 3) ‘protracted social conflict’. The first two are used to char-acterise the Ebola response in terms of response ‘architecture’ and relationship between aid workers and beneficiaries, and the ‘protracted social conflict’ theory is used to connect the crisis during the response with conflict dynamics seen in the aftermath of the Sierra Leonean civil war. Three separate propositions formulated on the basis of these theories will be presented in the methods chapter and used to guide the analysis.

3.1 The Fortified Aid Compound

To investigate the ‘aid architecture’ of the Ebola response in Sierra Leone, I apply the insights from Marc Duffield’s theory of ‘the fortified aid compound’ (2010). Because Duffield seeks to explain some of the general trends in contemporary humanitarian oper-ations, including consequences of integrated missions between military and humanitarian work, it will be relevant to my analysis, which e.g. touches upon the military involvement during the Ebola response.

Using the analogy of an archipelago - separating itself from its surroundings - Duffield argues that the segregation of aid workers and beneficiaries has been both aimed for and normalised during the past four decades (2010:457). This manifests in fortified aid compounds existing behind “walls and razor-wire fence” separating aid workers from the surroundings they work in (ibid., 468). While this is evident in the physical architec-ture, it also manifests in the social architecture of aid. The separation of aid workers and beneficiaries has according to Duffield sprung from outlawing local engagement, fre-quent staff rotations and integrating missions, where humanitarian workers and military personnel operate side by side (ibid., 462,471). An example of an integrated mission he e.g. experiences in the UN mission in South Sudan (UNMIS), which he believes has brought the “architecture of war into the city” (ibid., 465). Moreover, an ‘arms-length’ have emerged between international organisations and beneficiaries, where local engage-ment usually is outlawed to local staff and NGOs (ibid., 469). A shift from a more volun-tarist approach in the 1970s to an increased politicised form of aid Duffield categorises as ‘new humanitarianism’ (2014). The consequences of ‘protecting’ humanitarian work-ers from beneficiaries eventually results in a “fortified aid compound [that] resonates with a deepening North/South divide. It is an architecture of pacification and occupation” (Duffield 2010: 471). Relevant for analysing a response that consisted of both national and international actors, Duffield further distinguishes between national and international staff, emphasising that “while those on international contracts are able to move and cir-culate, local aid workers, like beneficiaries, are also immobile onlookers trapped outside the archipelago’s magical space of flows” (ibid., 457). He also underlines that interna-tional staff typically hold diplomatic status which will be “linked by exclusive and secure means of air and road transport, [because] fortified aid compounds interconnect to form a spatial archipelago of international aid” (ibid., 467).

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I suggest that the theory of ‘the fortified aid compound’ will be relevant for look-ing at the architecture of the Ebola response in Sierra Leone, not only the physical but also the social architecture. This will reveal what role the military involvement had for the understanding of the response and further disclose to what extent aid workers and beneficiaries were separated – not only physically but also in decision-making processes. This will this include an emphasis on whether the response measures taken were sensitive towards local culture and practices in the targeted communities.

3.2 Dependent Agency

While Duffield’s theory of ‘the fortified aid compound’ represents a structuralist view of humanitarian aid, the ‘dependent agency’ theory defined by Emma-Louise Anderson & Amy S. Patterson places itself within a “structure-agency” linkage (2017:8), to emphasise that one can “simultaneously act and be dependent” (ibid., 2). The theory will be used to uncover the agency beneficiaries had during the Ebola response in Sierra Leone.

Anderson & Patterson focus on how different types of agencies in the actions of beneficiaries can “cause donors to rethink projects or to limit demands in specific con-texts” (ibid., 8). They emphasise that structuralist approaches tend to undermine agentic behaviour and instead only focus on powerful Western actors, especially with foreign aid programs on the Africa continent (ibid., 6). Where Duffield identifies an “architecture of pacification”, Anderson & Patterson explore “opportunities in dynamic aid architecture” (ibid., 33), perceiving structure and agency as mutually constituting on a continuum (ibid., 8,3). Like Duffield, they recognise that within the field of foreign aid, this will occur in unequal power relationships between donors and beneficiaries, but that agency is never static and can change over time (ibid., 8f).

According to Anderson & Patterson, ‘dependent agency’ is expressed either in acts of compliance, extraversion or resistance ‘below the line’ (2017:30). Compliance to foreign aid programs are usually seen as a way of reinforcing unequal power-relations, but it can also be seen as “local agents’ desire to never burn bridges” (ibid., 11). Extra-version, they say is when dependent agents deliberately emphasise the portrayals of pov-erty and economic dependency to gain economic support (Anderson & Patterson 2017:11). Resistance ‘below the line’ is characterised as “foot-dragging, stretching the rules, using euphemisms, and redefining the issue”, which will expose whether dependent agents really oppose foreign aid programs (ibid.,81). Anderson & Patterson further stress how the aim of sustainability in foreign aid programs are often undermined by relying on volunteers who cannot work unpaid indefinitely, and underline that volunteers quitting can be a form of illustrating agency (2017:12).

While the theory of ‘the fortified aid compound’ mainly focuses on structures of aid work, the theory of ‘dependent agency’ is useful for looking into some of the dynam-ics existing within these structures. Because volunteers constituted a large part of the re-sponse, the perspective concerning sustainability will be useful for the analysis.

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3.3 Protracted Social Conflict

To investigate the relationship between the above described theoretical frameworks and the post-war dynamics in Sierra Leone I use Edward Azar’s theory of ‘protracted social conflict’ (PSC). To apply the PSC theory to the contemporary case of the Ebola response, I complement Azar’s own writing with Ramsbotham’s (2005) ‘tribute’ to the theory.

Azar developed the theory of PSC because he experienced that conflict categories tended be divided into civil wars or international wars, recognising that further nuances were needed (Azar et al. 1978:45). The theory is developed for defining conflicts with “no distinguishable point of termination” (ibid., 50) and characterised by a “blurred de-marcation between internal and external sources of conflict” (ibid., 395) in the Post-World War II era. The four PSC prerequisites defined by Ramsbotham are: communal content, deprivation of human needs, authoritarian governance and international linkages (2005:114-116). Communal content is referred to as identity groups which are “racial, religious, ethnic, cultural and others” (Azar 1985 cited in Ramsbotham 2005:114). Ex-emplifications of PSCs include the Arab-Israeli, India-Pakistan and Ethiopian conflicts (Azar et al. 1978:50), which contains clear ‘ethnic’ distinctions between conflict parties. Azar underlined that it is “how individual interests and needs are mediated through mem-bership of social groups” (Ramsbotham 2005:115). Deprivation of human needs is tied to both political and ‘developmental’ types of security. Azar stresses that “peace is devel-opment in the broadest sense of the term” (Azar 1985 cited in Ramsbotham 2005), em-phasising that ‘human development’ has close relationship to a ‘state of peace’. Addition-ally, the issues of authoritarian governance are linked to political inequality, meaning that the state apparatus is often dominated by one social group, which will generate income and wealth inequality and thus lead to “physical deprivation” (Azar & In-Moon 1986:395-397). Finally, international linkages are tied to “political-economic relations of economic dependency within the international economic system” as well as political-military link-ages of cross-border interests (Ramsbotham 2005:116). Like Duffield and Anderson & Patterson, Azar sees global structural inequality as a colonial legacy (Azar & In-Moon 1986:396).

Where Duffield deals with the architecture of humanitarian aid, the PSC theory developed by Azar can be used for seeing the Ebola response in a historical perspective where issues during the response are perceived in the light of conflict dynamics from the civil war. The theory is appropriate for not only looking at national factors but simulta-neously international structures as leading to the humanitarian crisis evolving during the response.

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4 Methodology

This chapter will outline the methodological approach of the study. Firstly, I will elabo-rate on the design of the case study, secondly describe the selection of data, thirdly de-marcate the case, and lastly present ethical considerations and outline delimitations con-nected to the study.

4.1 Research Design

This study is an exploratory case study, as it seeks to explore the kinship between the Ebola response and conflict dynamics in Sierra Leone. As shown above, though many researchers have seen the severity of the Ebola outbreak in Sierra Leone in the light of the consequences suffered from warfare, they tend to approach the civil war and the sponse as two individual pieces of history. Thus, the exploratory component of this re-search is the attention to the response as potential amplifier of ‘historical’ conflict dy-namics. To analyse the response and potentially link it to a ‘protracted social conflict’, I follow the case study guidelines proposed by Robert K. Yin (2018). Yin emphasises that the case in a case study should not be thought of as a sample but “the opportunity to shed empirical light on some theoretical concepts or principles” (2018:38). To operationalise the research question, I structure the analysis by three theoretical propositions based on the theories outlined above, one analytical strategy proposed by Yin (ibid., 168). This will allow for analytical generalisability (ibid., 37), and the propositions are formulated as follows:

1) The fortified aid compound: The humanitarian and health response to EVD in Sierra Leone embodied a militarised approach, encouraged separation of aid workers and beneficiaries and were not sensitive to local cultures and practices. 2) Dependent agency: During the EVD response in Sierra Leone, beneficiaries were

able to practice their agency in a dependent donor relationship by either comply-ing to, becomply-ing extravert towards or resistcomply-ing response measures.

3) Protracted social conflict: Conflict dynamics related to communal content, dep-rivation of human needs, authoritarian governance and international linkages, were evident both during the civil war and the EVD response.

After having chosen a suitable analytical strategy, the theory will be linked to the data by “pattern matching”, one relevant analytical technique suggested by Yin (2018:175). The theoretical propositions include predicted patterns, which will be compared with empiri-cal patterns from the data (ibid.). During the analysis, the propositions will not be ac-cepted or rejected directly, but used to nuance how and to what extent the response played into conflict dynamics. The response changed and developed over time due to learned experiences and increased epidemiological understanding, meaning that it cannot be un-derstood as a delimited event.

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4.2 Data Collection

This study uses three reviews from organisations involved in the Ebola response in Sierra Leone and two semi-structured interviews with organisation staff employed during the response, as the primary data. This means that the data overall represents an organisa-tional point of view. The data collection is done based on the theoretical propositions, and the triangulation of data should help strengthen the construct validity (Yin 2018:43).

The review selection is based on the organisations’ different roles during the re-sponse and includes Médecins Sans Frontiéres (MSF 2016), International Federation of the Red Cross and Red Crescent Societies (IFRC 2018) and Oxfam (2015). MSF was primarily responsible for running Ebola Treatment Centers (ETCs), though not exclu-sively, IFRC primarily engaged with the safe and dignified burials (SDBs) and Oxfam worked with ”community mobilisation for Ebola prevention, case finding and referral, and public health engineering (PHE) interventions to support isolation and treatment of Ebola patients” (Oxfam 2015:5). The reviews evaluate the overall response in West Af-rica because the aforementioned organisations also worked in Libera, and some in Guinea, during the outbreak. For the analysis, I have therefore only included the parts where the reviews explicitly discuss the case of Sierra Leone or trends that were experi-enced in all the countries. The reviews discuss the organisations’ overall effort and are not focused on any specific measures of the response. The Oxfam and MSF review were published during the response, while the IFRC review was published two years after the end of the outbreak, resulting in different temporal perspectives.

Additionally, two semi-structured interviews with organisation staff working dur-ing the response are included, to gain a more informal perspective on the response. The first interviewee is Nuru Deen from Sierra Leone, who was employed by Ibis (later Oxfam IBIS) and worked as part of an education emergency team and other programs as the program and partnership lead during the Ebola response. Currently he works as an Influ-encing Lead for Oxfam in Sierra Leone. The second interviewee is Susanne Kirkegaard from Denmark, who worked as a country coordinator for the American organisation E-health (headquartered in Nigeria), whose primary tasks were to establish a ‘911’ call cen-tre during the response. Where Kirkegaard had only lived in Sierra Leone a few years before the outbreak, Deen had lived there all his life and were thus able to reflect on actual linkages between the civil war and the Ebola response qua his experiences but also polit-ical insights. These interviews I categorise as ‘elite interviews’, meaning that the target group has a specific professional position, from where specific information about the re-sponse can be gathered (Harrits et al. 2012:150). The theoretical propositions were used to guide the semi-structured interviews, and special attention was paid to ask open-ended questions allowing for multiple issues to be explored during the interviews, also some that were not prepared for (Rapley 2011:315). The interviews were conducted as video and phone call respectively, meaning that some data might be lost e.g. facial expressions and interview setting (Irvine et al 2012:89). In Appendix 1, I have outlined the interview guide used for both interviews, to make sure that the questions were able to reflect the topics investigated (Harrits et al. 2012:150).

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Additionally, the following sources have been used to complement and triangulate findings from the primary data: A press release from Oxfam (2014); an interview with the former international director of MSF published in the Guardian (O'Carroll & Jones 2016); a working paper by Marc DuBois et al. (2015) describing how military was in-volved in the response; and two UNDP reports describing trends in HDI and multidimen-sional poverty in Sierra Leone.

4.3 Demarcating the Case

The case investigated is the Ebola response taking place in Sierra Leone between March 2014 and March 2016, limited to the perspectives presented in the reviews of MSF, IFRC and Oxfam and the two interviews (Deen 2020, Kirkegaard 2020). As outlined in the background chapter, the response was carried out by both national authorities, local and international NGOs like MSF, IFRC and Oxfam, international organisations like the UN and WHO and British military. Thus, my analysis of ‘the response’ includes these inti-mately linked components. Furthermore, this paper is ‘theory-testing’, meaning that the conclusions will be delimited to the propositions based on the selected theory connected to conflict dynamics.

4.4 Ethics

All data apart from the two interviews conducted, is publicly available, and thus the eth-ical concerns of this paper are connected to the interviews. As emphasised by Deborah Court & Randa Abbas, an interviewer is not a “passive recorder of others’ stories” (2013:486) but can influence the course of an interview together with the interviewee. Therefore, I paid specific attention formulating open-ended questions, but it should not be disregarded that the questions can suffer from “bias due to poorly articulated ques-tions” (Yin 2018:114), because I was interested in specific aspects of the response. Fur-thermore, an ethical consideration is that I did not have extensive previous knowledge of the Ebola response in Sierra Leone and neither the country background, meaning I had to rely on colleagues’ insights and material available online. Investigating the case from a distance makes me an ‘outsider researcher’, meaning that sub-contexts not found in the background material as well as cultural nuances might be lost (Court & Abbas 2013:485).

Before the interviews, the interviewees consented to usage of their names and occupation in the paper, and the exact quotes and references to the interviewees from the paper were sent to them before hand-in. The interviewees have now corrected and ap-proved all the quotes used in the paper. Most of the references to the interviews are fur-thermore presented in quotes, aiming to avoid misinterpretations. However, I take full responsibility for possible misunderstandings.

4.5 Delimitations

Specific weaknesses related to using documents are “reporting bias” and “biased selec-tivity” (Yin 2018:114). The reviews are done by the organisations’ own review units, meaning that there is a great chance of reporting bias, so it should generally be

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acknowledged that the data used solely represents an organisational point of view of the response. Even though the reviews were based on many interviews with staff, Ebola sur-vivors and community members from targeted areas, the reviews themselves are eventu-ally an expression of the organisations’ view on the response. It is likely that these larger organisations included can express the opinion of general ‘lessons learned’ but going over the reviews it also became clear that disagreements had persisted in between organisations during the response. The interviewees had both been employed by organisations during the response, but their interviews were used to hear their personal opinions of both soci-etal and political elements of the response. Lastly, as shown when reviewing the literature, many aspects of post-war issues and the Ebola outbreak in West Africa are relevant to approach, but this study is limited to the ones defined in the above. Because this study deals with how the Ebola response played into conflict dynamics, the focus is largely put on the ‘negative’ aspects of the response, while it should of course be acknowledged that many of the initiatives taken, from both local, national and international actors, were vital for eventually ending the outbreak.

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5 Response – Part of the Problem?

Now, to answer the research question on how the Ebola response played into conflict dynamics from the civil war in Sierra Leone, the theoretical propositions outlined above will be examined. Firstly, to investigate which issues were present during the Ebola re-sponse, I look into the ‘architecture’ of the response using the theory of ‘the fortified aid compound’. Afterwards, to examine the relationship between aid workers and beneficiar-ies during the response, I use the theory of ‘dependent agency’. To see how the response played into conflict dynamics from the civil war through a historical perspective, I use the theory of ‘protracted social conflict’.

5.1 The Fortified Aid Compound

The following will argue that the response practices embodied a militarised approach and were essentially securitised. Furthermore, especially in the beginning of the response, aid workers and beneficiaries were separated, and the latter were excluded from all spheres of decision-making and thus the response became insensitive towards local customs. Is-sues described in relation to ‘the fortified aid compound’ were evident in the practices of the response, even though, according to data, less so in the physical architecture.

The data showed no specific signs of physical fortification, as predicted by theory. The architecture of the response primarily consisted of the Ebola Treatment Centers (ETCs), which were temporary facilities of tents, some in old barracks, set up both within and outside communities (Kirkegaard 2020). However, though the physical architecture did not show fortification characteristics, other militarised elements were embodied in the response, illustrating the separation of aid workers and beneficiaries. Both the Sierra Le-onean and the British military worked as an integrated part of the Ebola response in Sierra Leone, and DuBois et al. conclude that “through the deployment of international military forces and the imposition of coercive control measures by the governments of Guinea, Liberia and Sierra Leone, the response was essentially securitised” (2015:38). This line of argument resembles Duffield’s account of South Sudan, while DuBois et al. argue that in regards to the Ebola response “the West African ‘battleground’ more closely resembled integrated approaches in Afghanistan than, for example, the aid response in South Sudan” (DuBois et al. 2015:38).

While the data showed no significant signs that the physical architecture of the response was fortified, the implementation of the aid architecture was not always well received by beneficiaries. According to one interviewee, it was not “conflict-free” to es-tablish ETCs in and outside communities, because people were afraid to have many in-fected people placed near their homes (Kirkegaard 2020). Some ETCs were even placed in the middle of slums to avoid possibly infected people to move further than necessary, and especially in the beginning of the response, conditions for treatment were generally primitive (Kirkegaard 2020). Some communities with high number of infections were forcefully closed, so that people were not allowed to move outside a marked area:

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Red tape was put up, and if you lived inside that zone you were not allowed to leave – often with police and military patrols around. Many were dissatisfied because you cut people off, who have to go out and make money to be able to buy food for the same day […] this created conflict-prone situations, where riots easily could emerge (Kirke-gaard 2020)

The quote shows one example of how military were involved in response practices, and coercive means were further used in relation to contamination and transportation of per-ceived infected persons. Kirkegaard stresses that especially in the beginning, when the infrastructure of the response was primitive, people were driven across the country be-cause initially there were only two established ETCs, and she describes that “if you did not have it [EVD] when you entered the truck, you certainly had it when you got out, 10 hours later […]. It has not always been voluntarily [to enter transportation trucks]” (2020). In Oxfam’s review they describe how one of their tasks was “promoting confidence in the health system when it had been badly shaken by the coercive nature of the state’s response to the epidemic” (Oxfam 2015:55), emphasising that the forceful measures taken were counter-productive for containing the virus. Though the British military mainly took logistical roles during the response, it is clear that organisations knew how involvement of international military was not considered optimal to the general public. In their review, Oxfam mentions that they received a lot of attention because they requested military as-sistance for logistics in a press release in October 2014 (Oxfam 2015:46):

It is extremely rare for Oxfam to call for military intervention to provide logistical sup-port in a humanitarian emergency. However, the military’s logistical expertise and ca-pacity to respond quickly in great numbers is vital. The military mission must be under civil coordination. (Oxfam 2014)

In the summer of 2014, before international efforts had manifested its assistance in re-sponding to Ebola in West Africa, MSF further recalls how “A call for military assistance was first discussed but not made public” (MSF 2016:5). In September 2014, MSF did officially request military assistance but specifically related to biohazards (MSF 2016:5). In IFRC’s review the establishment of UNMEER is related to Ebola being approached as an issue of security: “On 18 September 2014, the United Nations Security Council de-clared the EVD outbreak a threat to peace and security […] The EVD response continued to be destabilized by a state of panic and confusion arising from resistance by communi-ties” (IFRC 2015:9). The fact that the UNMEER mission was the first-ever UN mission with related to health emergencies, falls in line with Duffield’s argument that humanitar-ian aid has increasingly been securitised, but should also be seen in the light of the unpre-ceded size of the outbreak. It is further noticeable that the minister of defence was ap-pointed chief executive of the NERC (Dubois 2015:21). However, both interviewees in-terpret this as sign of the response being politicised and not necessarily increasingly mil-itarised (Deen 2020, Kirkegaard 2020).

Initially, aid workers and beneficiaries were separated in the Ebola response, as suggested by Duffield. One example of how Oxfam experienced the distance between aid

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workers and community members can be found in this quote, which illustrates disrespect between the two:

During the review visit, and through interviews, it was apparent that there were some staff attitudes that were disrespectful of CHC [Community Health Committee] mem-bers and ordinary community memmem-bers. For example, arranging a community meeting for nine o’clock in the morning when intending to arrive in the community at midday, or laughing at people who mistake Aquatabs for an Ebola treatment. (Oxfam 2015:54)

Reflecting on their own response procedures, Oxfam further recognises that “the action planning process tended often to be carried out in a mechanistic way, without engaging authentic and equitable participation from ordinary community members” (Oxfam 2015: 38), thus creating an unequal and distant relationship between aid workers and benefi-ciaries. These procedures fit with the observation that “encounters with aid beneficiaries now lack informality and spontaneity. They are structured, contrived, time-limited exer-cises”, suggested by Duffield (2010:469). Apart from the distinction between aid workers and beneficiaries, Duffield also distinguishes between national and international aid workers. The larger part of the hired staff and volunteers (who represented a significant part of the response teams), were Sierra Leoneans. To illustrate the ratio from MSF’s response in Guinea, Liberia and Sierra Leone there were: ”a total of 689 international staff from 70 countries, and more than 4,000 national staff, worked on 20 projects, run by OCB [Operational Centre Brussels], during the review period” (MSF 2016:19). One in-terviewee confirmed that Sierra Leoneans (and a large diaspora from the civil war return-ing to help durreturn-ing the EVD outbreak) were the only ones fit to engage directly with com-munity members, and also that many organisations would not send their staff to the field because of health and security risks (Kirkegaard 2020). Thus, international staff primarily overtook coordinating roles, but also medical since Sierra Leone had a deficit of health personnel at the time of the outbreak. This falls in line with Duffield’s armlength obser-vation, where local staff “do the bulk of the organization, they range from information gathering exercises [and] beneficiary training” (Duffield 2010:469). However, as will be emphasised below, the data shows that the success of the response was directly linked to it being local staff or volunteers engaging with community members.

Additionally, the MSF review found that international staff felt uncomfortable about disparities between national and international staff, because only the latter would be evacuated to another country with better treatment facilities in the case of infection (MSF 2016:20). This can be seen in the light of Duffield’s reflection on movement and space, when he experiences that international workers generally have more opportunities for movement during humanitarian operations. Another problem found in response re-views, also suggested by theory, is frequent staff rotations. International staff working as part of the MSF missions had an “average length of 36 mission of 36 days […] The max-imum duration of six weeks in the field was to minimise risks due to exhaustion and diminishing attention” (MSF 2016:19). MSF also experienced a high staff turnover within field staff, who they believed had been involved too little in designing clinical trials (MSF 2016:13).

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It is agreed and that sensitisation was underprioritized in the response, and that the positive results of it only started to show when community members were directly engaged. Oxfam concludes that “This was both more humane and more effective than an impersonal intervention carried out by strangers to the community” (Oxfam 2015:39). IFRC also describes how it was crucial to include volunteers from the targeted commu-nities in the response, to gain trust in the health information (IFRC 2018:25): “The situa-tion only began to change by the end of 2014, when the response became increasingly focused on the districts and started working closely with local officials and community leaders” (DuBois in IFRC 2018:9). The IFRC review further states that “Community en-gagement was a turning point in the epidemic control” (IFRC 2018:38), but it is also generally agreed in the data, that this engagement came too late (MSF 2016:12). The following quote illustrates how MSF did not see it as a part of their own tasks to make sure community members were engaged in the response, and it further demonstrates is-sues of communication existed on local as well as coordinating levels.

Due to an issue of resource constraints, and assuming that other actors would take care of the sensitisation, local communication was not a priority in this response. There is no doubt that stronger local communications would have helped to counter the many rumours, misunderstandings and false information that were circulating. (MSF 2016:18)

The failure to sensitise towards local cultural practices especially manifested with tradi-tional burials during the EVD outbreak. Ebola is contagious from dead bodies, and be-cause some burials rituals include washing bodies of deceased family members, many were infected with Ebola during burials (Coltart et al. 2017:11). Eventually Safe and Dig-nified Burials (SDB) practices were developed for funerals and successfully imple-mented, in which IFRC played a large role, but it is agreed that because the overall re-sponse was not sensitive to this issue from the beginning with, mistrust sustained all through the response. An unforeseen consequence of the response EVD survivors, staff and volunteers, especially those who had engaged with SDBs were exposed to “very dev-astating stigmatization by family and community members” (IFRC 2018:14).

It was a general strategy not to treat Ebola at existing hospitals – both because of transmission risks to other patients and because it would mean suspending non-Ebola related treatments (Kirkegaard 2020). However, the MSF review mentions that they still had to suspend some of their health activities, which they believed reflected that interna-tional staff did not feel working conditions were safe enough working in Sierra Leone at the time: “Obstetric care closed in August and paediatric activities in October, depriving the local population of essential services” (MSF 2016:12). Oxfam also “along with other agencies had to cut back to essential staff only in both countries” (Oxfam 2015:14), mean-ing that other programs were put on hold. One of the interviewees also stressed the prob-lem, that funding received for projects had to shift to the Ebola response (Deen 2020). Overall, the result of both the outbreak and the response was suspension of many non-Ebola related treatments during the response.

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In conclusion, the social consequences of ‘the fortified aid compound’ manifested in the Ebola response in Sierra Leone. Even though the response did not contain physical fortification characteristics in the facilities established, as suggested by theory, several coercive measures were used during the response. The response underprioritized sensiti-sation, especially in the beginning of it, which manifested in separation of aid workers and beneficiaries and resulted in negative outputs of the overall response.

5.2 Dependent Agency

Having looked at the ‘architecture’ of the response, the following part will look at the relationship between aid workers and beneficiaries. First, I argue that Sierra Leoneans receiving aid during the response were in a dependent relationship to especially interna-tional actors. Secondly, I argue that beneficiaries, by resisting to some and complying with other response measures, were able to perform agency in a dependent aid situation, and thus came to play an important and not passive role during the response.

As emphasised in the background chapter, Sierra Leone had long before the Ebola outbreak suffered from economic crisis, and provision of many public services had not recovered at the time of the outbreak. In 2013, from the 187 countries the Human Devel-opment Report, Sierra Leone is ranked 183 and put in the category of “low human devel-opment” (UNDP 2014:162). The HDI score includes life expectancy at birth, mean years of schooling, expected years of schooling and Gross National Income (UNDP 2014:162), and why there are some pitfalls in using the HDI score as measurement of ‘development’ because it cannot encompass all nuances of human needs, it will be sufficient to show that Sierra Leone were strongly dependent on foreign aid at the time of the Ebola out-break. Deen (2020) further stressed that the Sierra Leonean economy is donor-driven, and that the majority of the funds for the response came from outside donors. The theory describes how the foreign aid field is a “dynamic arena” with “lack of unity in ap-proaches” (Anderson & Patterson 2017:10). This can be observed looking at the reviews, where there were several references to lack of communication and collaboration in be-tween the INGOs in the Ebola response, e.g. “heated discussions took place bebe-tween MSF and WHO/CDC on the subject of CCCs [Community Care Centers], with OCB remaining opposed” (MSF 2016:14), pointing to possible incoherent response from international or-ganisations. Additionally, the IFRC points to the fact that MSF warned the WHO that they should declare the outbreak an international public health emergency, which they did not do until 9 august 2014, though it was recognised already in January 2014 (IFRC 2018:9), indicating a general disagreement on the thresholds for declaring emergencies. Deen describes how dependency on international organisations slowed the response, partly because the Sierra Leonean government did not have an emergency plan that or-ganisations could respond to:

Both local and international factors actually influenced the government’s response. And aside, the government was cash-strapped and with their little or no experience in man-aging such epidemic, so they could not make any initiative on their own, and thus looked out to the international community to drive the process. And the international community were a bit slow to response, because they had these different categorical

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levels of classifying outbreaks[…] it was only when it reached that level, and this was way into the breakout, by then so many people were already infected. […] [and] the international community was a little reluctant because there was nothing to respond to, there was no plan, no nothing or road map from the government then. (Deen 2020)

Deen thus illustrates the complicated situation evolving from aid dependency. Aside from organisations own willingness to act, the organisations were dependent on state actors to allocate funding for the response. This is evident when IFRC emphasises how they were dependent on the publicity of the outbreak for support: “Although the EVD operations in both countries struggled to kick start due to lack of funding during the first months fol-lowing the appeals, the situation changed positively when the epidemics became more publicized” (IFRC 2018:18). This is also evident in MSF’s review, stating that the infec-tion of internainfec-tional workers was a “huge game changer” regarding internainfec-tional aware-ness (MSF 2016:15). DuBois et al. confirm that “delays caused by the early lack of insti-tutional funding were compounded by low public interest in the West, meaning that fund-raising efforts on Ebola did poorly” (2015:2020), in line with Shelley-Egan & Dratwa’s criticism sketched out above. It stands clear, that if the Sierra Leonean state system have had response capacity to react to the outbreak itself, it could have avoided the issues fol-lowing a delayed international reaction.

Having explained how and why Sierra Leone was dependent to the ‘international community’, it should now be relevant exploring what kind of beneficiary agency was present during the response. According to the theory, ‘dependent agency’ will appear in between donors and beneficiaries, but structure and agency will be mutually constituting and never static (Anderson & Patterson 2017:8). The theoretical proposition suggests that beneficiaries in Sierra Leone either complied with, was extravert towards or resisted the response measures ‘below the line’ by e.g. foot-dragging. As described, sensitisation had not been prioritised from the beginning of the response. MSF openly acknowledged that “OCB also underused local capacity in the affected countries” (MSF 2016:19), and that they were dependent on this both for discussing treatment but also for MSF’s own advo-cacy “to relay the issues directly from the field” (MSF 2016:18,19). As a consequence, a general trend from the data shows how the majority of community members targeted dur-ing the response were reluctant to comply with the guidelines put forward by the govern-ment and the organisations. However, when community members were integrated into communication and decision-making, the scepticism volatised to some extent:

At the initial stages, because of the panic, fear, denial and confusion among community members, it was difficult to reach some of the people who needed urgent support. How-ever, as more community outreaches were conducted by volunteers, and as community members gained more understanding of EVD, the situation started to change. They be-came more open, accessible and receptive; and many more of them were reached by the key EVD information. (IFRC 2018:25)

From the example, it stands clear that the success of the international organisations’ ef-forts was directly dependent on the active engagement and thereby agency of Sierra Le-oneans. The community engagement shifted gradually from resistant to compliant. Addi-tionally, Deen (2020) states that: “it was only when they started to use a community

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approach that they were able to contain the virus”. Reviewing the data, extraversion was primarily something performed by the organisations, when they had to advocate for action and funding from the ‘international community’, but this finding is of course related to solely using data representing organisational perspectives of the response. Not only re-sistance below the line, but also overt rere-sistance was evident during the response, espe-cially towards the coercive measures like shutting down communities, which created con-flict-prone situations. IFRC further stresses that “delayed recognition of the extent of the epidemic was compounded further by poor communications, political and cultural re-sistance by communities” (IFRC 2018:9), highlighting how a mixture of delayed response and insensitivity resulted in resistance. According to Anderson & Patterson, corruption is one example of ‘resistance below the line’. One interviewee describes how:

I can’t recall the exact amount, but a large part of the funds wasn’t really accounted for. The government received money which they use down the system international organ-isations put a lot of money into the response. You do not have time to do due diligence […] so the first and the best gets the contract. And in that way, money disappears with-out gaining anything from it” (Kirkegaard 2020).

Where “echoing the official stories” of foreign aid program are seen as a form of compli-ance (Anderson & Patterson 2017:55), I will argue that changing the narrative of it can be seen as a form of resistance below the line, which is not necessarily done consciously. Conspiracy theories were growing widely, especially in the beginning of the response. Kirkegaard (2020) mentions two examples of “Americans who put it [Ebola] into the ground water and a witch who shot down a plane with Ebola”. Furthermore, many e.g. refused to believe that Ebola should emanate from bats:

Local people have been eating these bats for centuries and have never experienced Ebola, and then having someone coming from nowhere to say that the primary source was a bat did not resonate with the locals and their experience. So, it took some time for people to understand and appreciate the scientific explanation of the outbreak, and there was this conspiracy theory floating around saying that a research lab in Kenema infected some bats that formed the sources of the breakout. (Deen 2020)

Further, it can be argued that instances of compliance in the response were evident when many volunteers joined the response. Both the reviews and interviews point to the fact that volunteers were a huge asset for the response: “The volunteers established strong links with the community and religious leaders, an approach which was paramount in marshalling the support and active participation of communities and ensuring an effective follow up of activities” (IFRC 2018:5). According to the IFRC review, 4,924 trained vol-unteers were reported in Sierra Leone by December 2015 (IFRC 2018:18), showing their vast presence in the response. One of the interviewees emphasised the fact that volunteers, especially young ones, everyday went to the frontline to risk their lives, acknowledging that “many of them are today a part of the death tolls” (Kirkegaard 2020). The interviewee observed that many young people, who had felt marginalised, suddenly were appreciated because of their efforts and innovative skills during the response (Kirkegaard 2020), re-lating their effort to agency in the response. However, the reviews also exposed some of

&apos;A Perfect Storm&apos; A case study of how the Ebola response played into conflict dynamics in Sierra Leone