The lead for a story on the Ebola outbreak is, by now, familiar: on the 22nd of March, the Guinean Ministry of Health declared an outbreak of Ebola, the first ever in the region. The virus has since spread through the countryside and across its borders: west to Sierra Leone, south to Liberia, and most recently, north into Senegal. Cases in Lagos and Port Harcourt, Nigeria have put countries across the region and beyond on high alert; as far away as Kenya, public health posters inform people about modes of transmission. With now almost 4,800 people infected and over 2400 dead, the WHO has declared the outbreak ‘an extraordinary event,’ and is demanding drastic attention from governmental and non-governmental aid organizations. As levels of hostility to foreign aid and health care workers rise and efforts to remove bodies and enforce quarantine become increasing violent, tracing contagious contacts has become all but impossible. Following the high-profile infection of foreign medical personnel, the news media have exploded with unsettling images of doctors in full body protective gear and residents running from police in riot gear attempting to cordon off neighborhoods. Twitter feeds and Facebook pages are rife with apocalyptic scenarios, rumors and blame for the failure to stamp out the spread of the virus.
From the perspective of social scientists working in the context of global health delivery and policy, there is much to say about the failures of biosecurity measures, the racist undertones of many media representations, and the histories of violence inscribed in weak health infrastructures and the misrepresented and poorly understood resistance to biomedical practices. However, what is worthy of note is that this commentary does not take place on the margins of policy, but rather is articulated in reports delivered by the WHO. As the outbreak continues to accelerate, it is clear that conventional tools of containment are failing; where transmission has slowed, it is mainly in areas where afflicted populations have put in place their own protective measures. With the hopes of garnering these community resources, anthropologists have been increasingly brought into the containment response and their ethnographic insights sought out. As in other emergency settings, the urgency for immediate action to control Ebola often runs counter to the demands of a time-consuming and slow-paced research methodology. The question remains: how best to bring ethnographic insights to bear on containment practices? When faced with the immediate public health demands of an outbreak, what does an anthropologist do?
We represent an anthropological team involved in an interdisciplinary project on another viral hemorrhagic fever endemic in parts of West Africa, Lassa fever (LAROCS). Coordinated by Charité Berlin, the project was set up to interrogate and intervene in the spread of the virus from rats – its primary reservoir – to humans. When the Ebola outbreak in Guinea was first identified, our colleague Almudena Marí Sáez was conducting ethnographic research in the area. She was asked to join two different Ebola containment interventions.
The first involved the Wild Chimpanzee Foundation Guinea (WCF), the Max-Planck Institute for Evolutionary Anthropology, and the Robert Koch-Institute, and aimed to identify the point of primary transmission and in so doing, shed light on the most likely animal reservoir for Ebola. The team worked in Meliandou, the site where the first or index case (a one-year old child who died in early December) was believed to have originated as well as two other locations with known wildlife densities. Building upon the working hypothesis that bats were the primary vector, Almudena gathered information about bat behaviors from the people who live with them (and sometimes consume them). Extending ecological investigations on species density and diversity through an detailed ethnographic description of bat-human relations, the team integrated perspectives on bat behaviours—roosting habits, feeding preferences—with anthropological insight into domestic spaces and practices—cooking, praying, food storage—illuminating the forms of proximity that create occasions for viral transmission.
Understanding the socio-material practices of hunting has been crucial. Almudena has documented the different tools and techniques used to handle, kill and butcher animals, as well as the ways in which game is distributed. She has sought to unpack the very concept of the ‘hunter’ – a designation that in this particular context entails the use of fetishes to assist in hunting and the social obligations that come with bringing meat home or to the market.
This kind of ethnographic work is intense, and its insights into mechanisms of primary transmission are still preliminary at best. However, even at this early stage, this attention to modalities of multispecies existence opens up new fields of investigation in outbreak situations, deepen understandings of primary-transmission, and provide richer accounts of the spread of Ebola across sites of encounter. The prevailing rumor that Ebola is not real, hinges on the fact is that these communities have been living with animals and in this environment “for centuries” and they never before have seen this kind of disease. The epidemic becomes linked instead to practices never before seen or out of context: disinfecting houses, erecting barriers, taking relatives to the hospital, from where they do not return. Disease becomes then a logical extension of the efforts of government officials and foreigners to keep them out of the forest.
As the outbreak continued to gain pace, Almuenda and Matthias Borchert, a clinical epidemiologist and the principal investigator of LAROCS, were asked to join a team led by the Guinean Ministry of Health and Médecins Sans Frontières to carry out an investigation into community perceptions of Ebola containment interventions. In particular, the question animating this intervention was why some groups had welcomed medical response teams while others had not. In-depth discussions with communities underscored the importance of funeral rites—key occasions of transmissions and the source of much public health anxiety. For the communities with whom we spoke, death is a journey, and for this journey one needs to be equipped with materials such as clothes that need to be washed and ironed before the coffin is closed. Critically, the dead person can also transport things for others in the afterworld. Attending a burial, even entering into physical contact with the dead body, is seen as an obligation not only to the living, but also to previously deceased kin.
These kinds of insights underscore the fact that changing burial practices is not merely a mater of improving hygiene but also a disruption of the social fabric of kinship. Breaking these forms of contact with the dead is on a par with severing ties with the living – it implies a forced separation from the present as well as the past. Ethnographic attention to the concrete organization of burials and the social dynamics of morning rendered a further insight with potential epidemiological relevance: detailed ledgers of attendance offered a critical instrument for tracing inter-personal contacts.
The groundbreaking work in outbreak contexts of anthropologists such as Barry and Bonnie Hewlett, Julienne Anoko or Alain Epelboin has underlined the important role that ethnographic research can play alongside medical response teams and the affected communities. This role includes the development of burial practices that are safe but incorporate people’s deeply felt need to care properly for the bodies of their loved ones, or the attempt to take seriously rumors and expressions of distrust and use this appreciation to build relations of trust between response teams and afflicted communities. In this way, ethnographic work can help break down stereotypes – or, as Annie Wilkinson puts it, “the simple narratives that blame the epidemic on local people.”
In the context of an outbreak, anthropologists are often among the few professionals willing to ‘be there’. There were multiple occasions when Almudena and Matthias were the only visitors who could stay in the village long enough to speak to people and, critically, listen to their concerns. To contain this epidemic we must come to grips with dynamics of fear and obligations of care in a context where everyone is afraid. It is an anthropological truism, but this means seeing populations not as a stumbling block to halting the spread but as our only resource.
Almudena Marí Sáez is a postdoctoral fellow at Charité Berlin working on hemorrhagic fevers in Guinea and Sierra Leone. Her previous ethnographic work focused on maternal health and local medicines in Benin and Sierra Leone and on women’s participation in local politics in Mauritania. She and Matthias Borchert were supported by a research grant from the German Research Foundation (DFG BO3790/1-1).
Ann H. Kelly is a Senior Lecturer of Anthropology in the Department of Sociology and Philosophy at the University of Exeter. Her work centers on the pragmatic dimensions of public health research in Africa, with special attention to the built-environments, material artefacts and practical labours of experimentation in former British colonies. She is also a member of Somatosphere’s Editorial Collaborative.
Hannah Brown is a lecturer in the department of Anthropology at Durham University. Her research interests include economies of care, the management of epidemics, and human-animal health in Africa.
A very interesting piece and serious questions: thank you for publishing it.
I am curious to know more about the following: “where transmission has slowed, it is mainly in areas where afflicted populations have put in place their own protective measures.” How is this known? Is it possible to say more about these practices and “protective measures” of afflicted populations?
Thank you for your question.
Regarding the role of community-based measures/practices in slowing transmission, Almudena’s and Matthias’s original observations are drawn from their work in the area where the outbreak began. One of the earliest cases was that of a woman who had been carried to a health clinic by a number of community members, all of whom subsequently died. As the routes of infection became clear, people began to discuss and strategize their own protection, even if it was as simple as avoiding contact with the sick. Another example is from a neighboring village where a local chief insisted that the sick be placed in separate rooms and made sure that relatives wash their hands when entering and leaving the room. Since the summer this part of Guinea has had a significant drop in cases.
Other anthropologists who have worked in Sierra Leone recently or during previous outbreaks have pointed to similar practices of community-led protection including placing the sick in separate houses at the edge of the village and baring foreigners from entering (e.g. Melissa Leach, Paul Richards, Mariane Ferme, personal communications)
On the whole, it is clear that conventional methods of contact tracing, successful in Nigeria and Senegal, are no longer appropriate in the region. In response to some of the smaller local initiatives, the WHO has recently emphasized the importance of community-based measures (see conclusion 2):
Containment measures, including the identification of cases and the introduction of safe burial practices, are obviously more feasible when people are listened to and their concerns are integrated into control methods:
Home care is currently being pressed forward as the best way to curtail the epidemic, as traveling to overwhelmed clinics can lead to further spread of the virus.
Yet, introducing safe means of home care is a gigantic challenge, and one that requires giving serious considerations to the question of who will be doing the care (men/women, survivors), where the Ebola Care Units are to be located, and how to protect extended families from infection.
Needless to say, reaching for abstract generalities about the benefits or risks of ‘community involvement’ is dangerous in times of a public health emergency. It is imperative that we are critical about the robustness of our own anthropological understandings of disease transmission. But we must continue to pull together, compare and corroborate our insights in ways that can best support efforts to contain this epidemic.
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This is a fantastic piece and so clearly addresses two underlying issues that I have been facing in the way I think about and interact with the dominant US media present and represent Ebola. The first is the willful blindness to the role of love and compassion playing an unfortunately insidious role in facilitating viral transmission. The way you describe the role of funerals as ‘social fabric linking past and present’ is a much cleaner way. I also appreciate this final paragraph which explains why communities ought not to be ‘seen’ as blame-worthy or obstacles, but as crucial guides to innovating solutions.
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If I have to agree that Ebola has really emerged from bats,I should first understand why these bats have not infected my west African people from ages except now?Why didn’t the bats infect countries close to Congo(Zaire) where the first cases of Ebola emerged in 1976?
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