Recent years have seen major global investment in epidemic preparedness and response. The World Health Organization’s new guidelines for health emergency preparedness (WHO 2017), extending the ambit of the 2005 International Health Regulations, have accompanied growing commitments to centralised planning, surveillance, modelling and prediction capacities, funding and insurance instruments, drug and vaccine research and development, rapid response teams and more. This refreshed global model for techno-managerial epidemic control emerged in the aftermath of the major 2014-2016 West African Ebola outbreak – in a spirit of ‘never again’. The COVID-19 epidemic, likely to spread to African settings amidst intense China-African interactions, invites this global model to be put to the test – now invigorated further by China’s forceful state-supported outbreak control measures. But how applicable is this emergent global/Chinese model to African settings? What insights emerge from African experiences with Ebola virus disease and response, as highlighted by local populations’ and anthropologists’ engagements with them (Abramowitz 2017)?
Ebola may have fostered some relevant national and local preparedness. In Sierra Leone, for instance, the national committees set up for the Ebola response are now meeting regularly to plan for COVID-19; the 117 Ebola hotline has been reactivated; local health workers have set up WhatsApp groups to spot and share case information, and communities are arguably more used to public health measures and quarantines. However, the Ebola experience also brings stark warnings about the applicability of standardized, top-down response models (and new Chinese versions), showing the crucial importance of attuning them to the complex, historically-embedded, social and political realities in diverse African settings. These warnings can be highlighted briefly in relation to four issues.
Quarantine and social isolation
The assumed Chinese model of top down, centrally-managed lockdown is to some extent illusory even in Hubei province; rather, emerging evidence shows how social isolation and quarantining of COVID-19 cases is enacted in diverse ways by myriad grassroots workers within China’s decentralised ‘grid management’ system (Zhong and Mozur 2020). Yet there is no doubt that these are state-sponsored actions embedded in Communist party social control and public health practices extending back to the Cultural Revolution era. Resistance to such efforts is kept below the radar for good reason.
Experience with Ebola suggests that in most African settings, centralised state control is less likely to be effective, and more likely to generate mistrust. State-driven quarantines have a history linked to colonialism, and their contemporary reproduction invokes memories of repressive state practices. Thus the three-day Ebola emergency lockdown in Freetown, Sierra Leone in 2015 echoed the repressive smallpox campaigns of earlier decades. In the city’s dense slums there were angry confrontations with police as hungry residents took to the streets to find food and keep up the social interactions vital to their livelihoods (Maxmen 2015). In contrast, community-led quarantines in many villages and towns drew on a range of public authorities and institutions, from village and paramount chiefs to youth and women’s leaders (eg. Richards 2020), meeting social and economic needs more flexibly and pragmatically. These were a key part of family and community-led efforts now acknowledged to have been vital in turning the epidemic around (Richards 2016). There is a danger that if central state authorities attempt to co-opt or graft onto such community efforts, they will be compromised or undermined. Ebola experiences suggest the value of appreciating community efforts and the diverse social relations they draw on (Wilkinson et al 2017).
Embedded understandings and anxieties
While global epidemic response efforts are framed by biomedical understandings of viruses and disease, they encounter diverse local meanings embedded in experiential knowledges and socio-cultural logics. In Guinea, Sierra Leone and Liberia, Ebola was a novel phenomenon entering settings where some health afflictions carry explicit names and aetiologies, while others are categorised by their effects (eg. ‘fever’), vulnerable social groups, or precipitating circumstances (Fairhead et al 2008). Symptoms often overlap, and causes, whether social or ecological, are uncertain and need to be worked out, drawing on experience and trusted specialists. Public health interventions, by contrast, acted in a risk averse and conservative way against what was seen as a clear and dangerous infectious threat, admitting suspected cases into Ebola Treatment Centres and enacting ‘safe’ burials. This created confusion and many villagers, unsure what precisely was being treated, withdrew their family members and eschewed burial teams. It took patience, respectful dialogue and learning amongst both villagers and health workers to develop aligned understandings of infection risk – what Richards (2016) terms a ‘citizen science’ of Ebola – and co-develop socially appropriate interventions.
With COVID-19, we can expect a similar need for such learning and accommodation, less because this is a novel syndrome and more because of its overlapping symptoms and presentation with familiar fevers, coughs and colds. It will be particularly challenging for health workers and local populations alike to distinguish it, and thus know when and how to respond. Rapid, mobile diagnostics, if and when they become available, will surely help. But Ebola’s lessons suggest that respectful discussion and messaging built around local disease categories will also be important.
Ebola also reminds us, sharply, that epidemics and their responses are social and political phenomena that involve much more than ‘disease’. They evoke (and can be harnessed to incite) broader, and historically-embedded, aims and anxieties whether linked to political-economic relations, foreign intervention, conflict or social control. Thus some West African populations interpreted Ebola and response efforts as fabrications of foreign or governmental agencies variously seeking political power, genocide or land dispossession. They reacted accordingly, sometimes with violence (Wilkinson and Fairhead 2016). Such fear and distrust reflected lived histories and memories of inequality, conflict and intrusive foreign intervention amidst structural violence (Leach 2015, Wilkinson and Leach 2014). Yet they were often framed, problematically, by external agencies in terms of local ignorance, rumour, misinformation to be corrected, or pathological exhibitions of resistance or reticence (Fairhead 2016, Abramowitz 2017).
COVID-19 and its response can also be expected to evoke broader anxieties, in this case shaped by intense historic China-Africa relations intensified by China’s recent economic emergence, globalisation, investment and Belt and Road Initiative. African experiences of Chinese intervention are hugely varied, both positive and negative. They extend back to the Cold War and geo-political support for key African regimes. Recent economic and infrastructure interventions have been boosted by health-related ones, including China’s strong support for the West African Ebola response and the new African Centre for Disease Control. Interpretations, anxieties and related discrimination will surely not simply stereotype COVID-19 (negatively) as a ‘Chinese disease’ or (positively) as a ‘Chinese response’. The diversity, nuance and historicity of sentiments and anxieties needs to be appreciated. But they must be taken seriously and not written off as ‘rumour’, in order to attune messages and responses in ways that suit political-economic and historical contexts and build, rather than undermine, trust.
Challenges in controlling Ebola were magnified by so-called ‘weak’ health systems. The outbreaks in both West Africa and in North Kivu, Democratic Republic of Congo during 2018-2020 unfolded in places where decades of underinvestment in health staff, services and facilities had been compounded by conflict. This created serious problems both of capacities for epidemic surveillance and response, but also of engagement with local populations who distrusted and sometimes shunned formal health services that had been of little use to them. Major injections of external resources for Ebola could not immediately address these long-term issues, and created their own problems: the narrow Ebola focus undermined still further the availability and use of health services for other conditions such as malaria and maternal health, while fuelling competitive ‘Ebola economies’ that fed into factional rivalries. In North Kivu, citizens have wondered why Ebola was prioritised over other health issues in an already so limited health system, and their mistrust has been exacerbated as resources and finance scaled up, generating further contestation amongst already fragmented local political authorities (Ripoll et al 2018).
In the aftermath of Ebola, broad-based health system strengthening and trust-building have become central priorities in global and national epidemic preparedness, and rightly so. Yet these efforts remain far from complete. Meanwhile COVID-19 is generating a massively resourced response – both in China’s centralised state-supported hospitals and public health services, and in some of the biggest global donor pledges in epidemic history. COVID-19’s epidemic economies promise to be even more intensive than Ebola’s, and in African settings, even more disruptive.
Engaging with the politics of epidemics and response
It is no surprise that both in West Africa and DRC, some of the biggest challenges to global and state-led Ebola responses were in areas of political marginalisation and opposition. For it is here that anxieties and clashes of all these kinds – over quarantine, understandings of disease, deeper political-economic relations, and health system resources – could so easily come together, and fuel each other. Such aspects of the Ebola experience remind us how easily both epidemics and responses to them can become politicised, confounding the assumptions of techno-managerial models.
This is likely to play out too for COVID-19, albeit in diverse ways according to setting, and nuanced by the characteristics of the disease and response plans. Arguably the politics will be even sharper given the geo-political context of China in the world, and the unprecedented level of global attention and resources accorded to COVID-19. Tracking how these unfolding politics play out, in a way that can inform unfolding responses, is a key task for anthropologists and other social scientists, bringing Ebola’s echoes to inform efforts that are more sensitive, contextually attuned – and perhaps more likely to be effective.
Abramowitz, S., 2017, Epidemics (Especially Ebola). Annual Review of Anthropology, 46, 421-445.
Fairhead J. 2016. Understanding social resistance to Ebola response in the forest region of the Republic of Guinea: an anthropological perspective. African Studies Review 59:7–31
Leach, M., 2015, The Ebola crisis and post-2015 development. Journal of International Development, 27, 816–834
Maxmen A. 2015 In Sierra Leone, quarantines without food threaten Ebola response. http:// america.aljazeera.com/articles/2015/2/19/in-sierraleone-quarantined-ebola-survivors.html (accessed 12 October 2016)
Richards, P. (2016). Ebola: How a people’s science helped end an epidemic: Zed Books Ltd.
Richards, P. (2020) Self-quarantine for infectious diseases needs flexible public authority. https://blogs.lse.ac.uk/africaatlse/2020/02/10/self-quarantine-infectious-diseases-ebola-coronavirus-public-authority/, accessed 10th February 2020
Ripoll, S.; Gercama, I.; Jones, T. and Wilkinson, A. (2018) Social Science in Epidemics: Ebola Virus Disease Lessons Learned – Background Report, UNICEF, IDS & Anthrologica, for the Social Science in Humanitarian Action Platform SSHAP. https://opendocs.ids.ac.uk/opendocs/handle/20.500.12413/14160
Wilkinson, A., M. Parker, F. Martineau, M. Leach, 2017, ‘Engaging ‘communities’: anthropological insights from the West African Ebola epidemic’, Philosophical Transactions of the Royal Society B 2017 372 20160305; DOI: 10.1098/rstb.2016.0305. Published 10 April 2017
World Health Organization, 2017. A strategic framework for emergency preparedness. Geneva: WHO.
Zhong, R. and P. Mozur, 2020,’To tame Coronavirus, Mao-Style Social Control Blankets China’, New York Times, February 15th, https://www.nytimes.com/2020/02/15/business/china-coronavirus-lockdown.html, accessed 20th February 2020
Melissa Leach is a Social Anthropologist with long-term ethnographic experience in West Africa, and Director of the Institute of Development Studies at the University of Sussex, UK. She co-led the award-winning Ebola Response Anthropology Platform and is currently co-leading the Social Science in Humanitarian Action Platform (www.scienceinaction.org) and a Wellcome Trust Collaborative award on Pandemic Preparedness: Local and global concepts in tackling deadly diseases in Africa (@anthro_prepare).