The ABCs of SBC

SBC in the Mpox Response

• UNICEF SBC • Episode 10

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In this episode, Qali dives into the unfolding mpox outbreaks in Central and West Africa. With new patterns of transmission, rising child mortality, and deep-rooted stigma, frontline responders in DRC and Burundi are rewriting the old playbooks in real time. Join UNICEF SBC experts as they unpack what worked, what fell short, and how communities, digital tools, and gender-aware strategies are shaping the response. This episode unpacks the opportunities taken, missed, and what must be done to prepare better for the next outbreak.

Guests (in order of appearance)

  • Vincent Petit, UNICEF SBC Global Lead
  • Gaoussou Nabalom, SBC and Risk Communication and Community Engagement Coordinator, UNICEF Burundi
  • Norman Muhwezi, former UNICEF OIC Chief of SBC in Democratic Republic of Congo (DRC) Innovation Specialist


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The views and opinions expressed by the contributors are their own and do not necessarily reflect the views or positions of UNICEF or any entities they represent. The content here is for information purposes only.

The ABCs of SBC is hosted by Qali Id and produced and developed by Helena Ballester Bon in partnership with Common Thread.

Check out UNICEF’s latest publication on Social and Behaviour Change, Why don’t you just behave! For more information about UNICEF SBC, check out the programme guidance.

We care about what you think — you can share your thoughts on the podcast using this feedback form. For all other inquiries, please contact sbc@unicef.org.

Vincent:

We had a lot of uncertainties and unknowns when we entered the outbreak response phase. These were new strains of the virus, so what we knew about the virus was not necessarily accurate for this response. We quickly realized that we had multiple transmission pathways at the same time, so it means that different viruses would transmit by different types of behaviors at the same time, in the same provinces, in the same villages. Which made the segmentations of geographies in population much harder. Child mortality was actually through the roof, which was connected with these new strains, new transmission pathways, and we had a lot of stigma happening. Everything we knew about Mpox was challenged, and we had to learn again. You can't provide an efficient response to an outbreak if you don't understand what you're fighting.

Qali:

Welcome back to the ABC's of SBC. You just heard from Vincent Petit, UNICEF's Global Social and Behavior Change Lead, describing the challenges that the Mpox response faced during the latest outbreak and the impact on communities. Mpox is a viral zoonotic disease that has reemerged with new intensity in recent years, especially across parts of Central and West Africa. Once considered a rare and self-limiting illness, the latest outbreaks have presented new challenges, shifting transmission patterns, broader population exposure, and increasing mortality among children. According to UNICEF, as of mid 2023, the Democratic Republic of Congo alone accounted for over 80% of global Mpox deaths. So in this episode, we're delving into Mpox- the opportunities taken and missed in the response in the Democratic Republic of Congo and Burundi. We'll be asking what happens when the data is incomplete, trust is broken, and the most vulnerable are overlooked, and how can social and behavior change efforts help us all to do better next time. We will be joined by three experts to help guide us. Vincent Petit UNICEF's Global SBC lead, Norman Muhwezi, UNICEF's, SBC, and Innovation Specialist in the DRC. First, let's hear from Gaoussou Nabalom, UNICEF's, SBC and Risk Communication and Community Engagement Coordinator in Burundi on why evidence is so critical and how it all starts with trust.

Gaoussou:

Data are very crucial to the Mpox response in Burundi. And we need to make sure that we are not, let's say, recreating the wheel. We know that there are at the country level, some organization who used to work with the communities. And have built a good relationship in term of confidence with these communities. And it is important to, to make sure that all the activities that we are conducting we are considering the needs at the community level, but also take the opportunity of this existing relationship to make sure that we can have the data that we need to move forward in the process.

Qali:

When stigma enters the data, it doesn't just hide the truth, it creates new blind spots. And in a crisis, what you don't see can hurt the most. But in an outbreak, like Mpox, was any data on stigma being collected and couldn't stigma also distort the same data? Let's go back to Vincent.

Vincent:

We rarely capture stigma in the data. Stigma is something difficult to measure, and when you ask about stigma to people, the answers are obviously extremely loaded and biased, but people would come to the health center to report their symptoms and are being listed as cases or not, would provide the occupation in a form. And when they showed this data over the first 30 or 40 weeks of the outbreak, you would see something very interesting. At the beginning, sex workers were the vast majority of people reporting cases at the health centers, and suddenly around week 10 to 15, the proportion of sex workers would decrease significantly, and the proportion of people without O Occupation -unemployed- would go up. And so you see two different curves, sex workers going down, sharply unemployed people going up sharply. And the statistical analysis shows that these are fully correlated. And when you look more closely at the point where these two cross is a moment when we started seeing many publications in scientific papers and in newspapers about the role of sex workers in spreading transmission, right? And so what this communication has done is basically driving sex workers underground. They have just started lying to the health centers about their occupation. And that's why you see so many unemployed people and so few sex workers when the situation was the opposite at the beginning. This is important, not just because it shows that sometimes our response contributes to the stigma on people who are already vulnerable, but if sex workers start lying on their occupations you can imagine there might be other consequences to that. They might be starting to think twice about getting treatment or reporting new cases, or talking to their peers about reporting new cases.

Qali:

The unintended consequences of the data we collect and how we respond to it can have massive implications in the DRC part of the response, blended digital with community feedback. Here's Norman Muhwezi,. UNICEF's, OIC, chief of SBC and Innovation specialist. For Mpox in this particular case. We collected data both online and offline.

Norman:

Online we use U report where people register our needs and are able to respond to messages free of charge. So in this particular case, what we sent out, what you'd call calls. To people in communities to tell us do they know how they can prevent the transmission? Do they know what to do if they actually start feeling sick or start seeing signs of mpox whether we would be able to take the vaccine if it is available to them. At the same time, we as well have teams of SBC consultants, SBC officers as well in the field that are able to collect information about. The most popular rumors, the most popular misinformation in the community, and the questions that are coming from the communities. And this was being tracked on a weekly basis. The other way we are collecting data is we have what you call U report communities, which would be the offline element of the platform in the sense that. That these young people in down communities that come together because they want to create positive change within their communities, and these young people are able to actually share information and also report using that platform that we created. And even those that do not have phones could inform their fellow of friends that have phones so that this information can come through.

Qali:

So digital tools gave people a voice. But it was the combination with community presence on the ground that brought those voices to life. Young people became fact-checkers, data collectors, and community mobilizers. It was a kind of on and offline community surveillance, but there was more to be done. Here's Vincent again to tell us why it's so important.

Vincent:

When you want to stop an outbreak, it means that you need to get ahead of the virus. And the only way to do that is what we call surveillance. So you need an effective surveillance, otherwise you're basically constantly in reacting mode. And surveillance is not just about tracking numbers, it's basically about understanding where the transmission is happening who is the most at risk, and how to stop further spread. In the case of Mpox, surveillance was pretty weak across countries. DRC is the place I know the most because that's where I was deployed. We only had 5% of the reported cases in DRC on an average month that were coming from non contacts, and that's extremely low. So does that mean that the rest of the cases were unknown to the response? That means that 95% of cases were. Coming from people that we weren't necessarily specifically monitoring. In cases like that, if you don't prioritize surveillance, then you're always playing catch up, right? Instead what we needed to do was to invest in real time community surveillance, which means door-to-door visits by community members households, skin checks, local reporting systems to try and identify the cases early and break the chains of transmission. And that was not happening. All of the strategies for response are based on contacts, so the vaccination is prioritizing the contacts. So you can imagine that when you only have so few contacts that are reported, it's very hard to vaccinate the right people, but it's the same for RCC responses. Countries like DRC are enormous. We're talking millions and millions of people, extremely hard to reach people. The operational costs of engaging communities and families is enormous and nobody can afford it. Not the government, not unicef, not the coalition of partners. So we need very precise surveillance so that we don't spread ourselves too thin and we don't spread the resources that we have too thin. But we target the people who are the most at risk.

Qali:

And some of the most at risk in the Mpox outbreak were women who were vulnerable in unique and often overlooked ways. Here's Gaoussou in Burundi again, we know that at the national level, women are responsible for example of caring. Children and at the beginning of the outbreak, we have something like 40% of the cases who are children.

Gaoussou:

So it was challenging when the kids are in the treatment center they have to be accommodated by the mothers. And they were. Challenges around how to make sure that the mother are not infected. And beyond that, how to make sure that the kids can still have some support from their mothers to cope with the situation. And we know that. There is no community case management right now in Burundi. So it's mean that children have to be in the treatment center. So if the women have to accompany her children there, it is a kind of loss of income because she can't work. So yeah, it was a a challenge, but yeah, I think it's still a challenge if I can say that.

Qali:

For many women, caring for others has meant putting themselves at risk. And too often the systems built to protect don't always fully see them. Let's hear from Norman in the DRC to see how they offered alternative forms of supporting their families.

Norman:

Last year I visited the province, Cassai Central the city called Kanga. And in Kanga I actually visited a women's group or community action cell. And these women have done impressively well in terms of setting up activities for themselves, income generating activities. So these ladies went ahead and actually hired a piece of land while they're planting maize where they're planting cassava. So through these income generating activities, able to go ahead and earn some funding that they can use to promote these good practices within their own communities. The idea here is that we are using seed funding to enable these women to actually go ahead and carry out activities that will enable them to earn some sort of income. The funding is always, of course, never enough and it'll not keep coming and coming. At some point that funding will store that is a more sustainable approach to doing community engagement than us trying to keep going and supporting. The more these activities are actually done, the better it is for the different communities. The other income generating activities that I wanna talk about is we actually as part of that in capacity building program you report to, we created a special version for young people that in IDP camps in internet displaced persons camps. So these young people were able to start some simple income judging activities like, cutting hair or baking bread or making soap. So these are some of the things that. We're pushing for, and to me, the more we push for these income general activities as part of our community engagement strategy, as part of engaging with young people it's something that is sustainable and something that can continue even when the initial funding has stopped.

Qali:

These sorts of activities recognize the long-term economic impacts and works to ensure these groups aren't left vulnerable after the attention and funding has moved on to the next crisis, but not all efforts met women's needs. Let's hear a sobering example from Vincent.

Vincent:

When you think about the role of women in these communities, which is to care for the household and for the children and all of that, that puts the pressure and the burden of following this advice on women. And it's unfair. But this is not one of the most damaging case, I would say. One that I was fairly worried about was about. One of the vaccines for Mpox, the LC 16 vaccine has an administration method that was used for smallpox in the past. Meaning it's through multiple puncture of the skin. It's a different type of implementation modality that has not been used for multiple decades. And the government of Congo was offered, large batch of this vaccine to try and curb the transmission, which sounds quite good when you think about it this way, the problem is that the vaccine is contraindicated for pregnant women. And so in the protocol for the runout, there was nothing about asking or testing for the pregnancy, right? And widespread pregnancy testing is very impractical in the context of DRC, to say the least. And also, women who are unknowingly pregnant may inadvertently receive the vaccine, right? Including vulnerable adolescent women in some of the high risk groups that w e were working with such as sex workers or women living with HIV women in camps and so on. There was also a doubt about the vaccine suitability for breastfeeding women because there was not enough evidence about the transfer of the virus from the vaccination site to the suckling child, basically. So there was a lot of unknown around how this particular type of vaccine administration method would be dangerous potentially for women. So when you remove from the equation breastfeeding women who are pregnant, women who might be unknowingly pregnant, it's already quite a large cohort of women that cannot be covered. And actually the risk of transmitting the disease to the fetus or the breastfeeding child is very high. So this is an example of, I think, a protocol that is not necessarily considering the risk for women. And in my honest opinion the best solution would probably have been not to vaccinate girls and adolescent girls and women with this type of vaccine.

Qali:

So while some opportunities were taken to support women financially in the outbreak, in other respects, their needs were overlooked or not prioritized. Let's move on to system strengthening. Beyond the immediate crisis response was the program benefiting from past investments and seizing opportunities to strengthen systems and work towards preparedness. Norman tells us more about this.

Norman:

We are very big in DRC on building onto what we already have. The country is very big. The, it's very complex emergencies happen all the time, so it's really. Paramount for us to build onto what has already been done, not to keep starting new things every time. So the way we are supporting system strengthening is really mainly through these community action sales or the community engagement pillar and as well some of the work that is being done with U reporters and some of the work they're being done with web fact checkers. When the training is done, these people stay there. These people stay in communities and they can pass on the information to their friends, to their families and actually train other people. It's not that of all those 8 million people that we have, over 8 million people that have on the platform, over 250 communities, we have reached all of them in person. No. Some have been reached through word of mouth, some have been reached by their friends. Even right now, we are again going through these same structures, the same community action cells, the same young people to pass on this message about, not drinking dirty water because we have a big problem with cholera right now. Encouraging them to take their children to school when the schools open encourage them to actually go for vaccination. And this is possible only because we've been able to actually strengthen these systems and set up these systems to ensure that whenever there's an outbreak, whenever there's emergency, we can always rely on this structures to actually do our response.

Qali:

So not reinventing the wheel. Building networks and systems that can be tapped for the next emergency no matter what that is. We got a similar response from GSU who spoke about building a more resilient health system in Burundi. When we spoke to Vin Saul, he emphasized why investments in health systems alone won't do the trick.

Vincent:

The UNICEF office has been planning on supporting the payment, supervision, and deployment of many community health workers in Southern Kivu to start with. I don't remember the exact number. It's between 1,002 thousand. It's a project that obviously costs multiple million dollars and it is something that is highly needed. Because health workers are not often paid or not regularly paid in places like Eastern DRC, and so people were placing a lot of hopes on the impact that deploying additional health workers would have on the spread of Mpox . But if we don't plan for an efficient articulation and collaboration with communities, health workers won't be able to achieve their objectives. What we need for them to meet their targets is for local community members to work in their communities and lies with them, to report cases, to help spread their messages to the last miles. Going house to house, family by family, to contextualize the public health advice into these communities that have, as you can imagine their own social dynamics, their own cultural norms and so on. And so it's the proper articulation and yeah, working relationship and trust between paid, trained, deployed health workers. And community members that is gonna advance not just the outbreak response, but broader public health goals. The problem is that the community side of this partnership is very often overlooked. When I said that deploying a thousand health worker in the province is not gonna stop the outbreak. This is just one side of the coin. You need the other side for this to work, right? And you need the trusted relationship for this to work

Qali:

Too often, investments focus on infrastructure, not relationships that needs to change. But I guess my follow up question would be, is the other side of the coin working? This trust and collaboration with communities.

Vincent:

I would say that on the conceptual level, this collaboration between the primary healthcare system and the community system is definitely considered when it comes to investments, policies, and operationalization. The side of the primary healthcare system is prioritized, which you know, makes a lot of sense, especially from the health perspective. If you spend enough time on the ground, you very quickly realize that under investing on the community system side is making the whole mechanism fail.

Qali:

Mpox exposed cracks in the system, but it also revealed resilience. It showed how communities when trusted and empowered can help lead the way forward. The responses offered hard earned lessons that can be

Qali:

-Don't wait for a crisis to build trust.

Qali:

-Data must be local, inclusive, and used to adapt to the response.

Qali:

-Women and youth are not just beneficiaries. They are the backbone of surveillance and response.

Qali:

-Community systems are just as essential as health systems.

Qali:

Thank you for listening to the ABCs of SBC, where we bring you the people's stories and science behind the best of social and behavior change in UNICEF. If you would like to hear more about the good work being done on the mpox outbreak, keep an eye out for the next issue of Change Magazine, which will be focused exclusively on mpox and other public health emergencies coming out later this year. We'll be back soon with a new episode on community health delivery partnerships. Until then, catch up on past episodes wherever you get your podcasts. Take care.