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Washington State University
CAS Connect October 2014

WSUV anthropologists: Cultural knowledge crucial in Ebola battle

Husband-and-wife team describes previous outbreaks, reactions to disease

The virulence of the virus itself is just one reason why the ongoing rampage of Ebola across West Africa and beyond is now considered the worst outbreak ever of that deadly disease.

The other factors have everything to do with human behaviors and cultural practices—the things that anthropologists study.

Bonnie and Barry Hewlett
Bonnie and Barry Hewlett

Those anthropologists include Barry and Bonnie Hewlett, a husband-and-wife team at WSU Vancouver. They have worked with the World Health Organization in containing previous Ebola epidemics in Africa.

In a recent talk on campus, they said this outbreak of Ebola is also fueled by West African people’s long-standing mistrust of their own governments, as well as actions of foreign powers and international aid organizations.

Take the terror of the incurable and mostly misunderstood disease. Now add the local landscape of poverty, political corruption, war, widespread death, and strangers from overseas appearing in whole-body hazmat suits. Is it any wonder the locals are gripped by their natural human instinct to fight or flee?

That’s exactly what happened in the American colonies and the young nation in the 1700s and 1800s during historic outbreaks of diseases including cholera, yellow fever and typhus, Barry Hewlett said: Authorities were slow to catch on and catch up with the outbreak, while citizens tended to deny it was real, to head for the hills and to blame “outsiders.” During the Spanish flu epidemic of the early 1900s, he said, even some of the doctors fled.

Panic and misunderstanding over disease “have been right here,” he concluded. “The ‘outbreak narrative’ in the U.S. is not different.”

The Hewletts are co-authors of a 2007 book called Ebola, Culture and Politics: The Anthropology of an Emerging Disease. They were asked by the WHO to figure out why people flee the hospital, the ambulances and the health workers trying to save them.

‘You want to touch’

Barry Hewlett gave a quick primer about Ebola itself. It was first identified in 1976 in what’s now called the Democratic Republic of the Congo (then Zaire), but the virus may be much older than that, he said. The death rate is somewhere between 70 and 90 percent. The “reservoir” of the disease is very likely bats.

Ebola resembles HIV in that it is transmitted through bodily fluids including blood. Unlike HIV, it attacks “every cell,” not just the immune system, Barry said. Also unlike with HIV, the fluids that spread Ebola include saliva and sweat.

The symptoms start out just like “a bad flu,” he said. “That’s why it’s so difficult to identify.” A diagnosis requires sending blood samples to an extremely secure, specialized laboratory. Meanwhile patients are contagious when they start presenting symptoms, he said; at that point, chances are, they only have a week to 10 days left to live.

Of course, when patients start presenting symptoms, their family and loved ones are naturally drawn to comfort and care for them.

“If you have a loved one, you want to touch. You want to care,” said Bonnie Hewlett. “Imagine you’re told not to touch them.”

That’s how Ebola starts spreading through whole families — although, Barry Hewlett pointed out, the disease tends to be “biased” against women, with more fatalities among females than males.

Next in line to get sick are health workers who don’t have the luxury of super-sanitary conditions to work in, he said. And in the end, families want to bury their dead in traditional, respectful and loving ways; this too involves plenty of touching and handling.

“This is how it amplifies,” Hewlett said.

Widespread poverty

Larger factors contribute to Ebola’s current epidemic. Previous outbreaks that the Hewletts have fought were among forest people in central Africa, whose villages were relatively homogenous, isolated and not very populous; the current outbreak is more urban, spreading through cities in the coastal nations of Liberia, Sierra Leone and Guinea. The affected people are incredibly diverse, speaking many dozens of different languages, and they’ve suffered years of civil war, resulting in widespread poverty and lack of public health infrastructure including clean water and sanitation.

“Disease thrives where poverty is,” Bonnie Hewlett said.

The people living under those conditions may catch the news — that they are being blamed for spreading the disease through their own ignorance or backward cultural practices — and react with hatred and suspicion, Bonnie Hewlett said.

Some continue to believe that the disease is sorcery, but that impression is starting to fade with evidence, she added. Sorcery usually means something perpetrated by one individual upon another; the current situation is now proving too widespread, fast-moving and linked to physical contact even for people who believe in sorcery to conclude that that’s what this is.

But it’s still understandable that they would fear clinics, hospitals and the special isolation units where Ebola sufferers are treated or only quarantined. During a previous outbreak in Uganda, Bonnie Hewlett said, patients disappeared into tiny isolation units that were covered with tarps; their families watched them go in and never come out again.

“They thought the health workers were in the body parts business,” she said.

Transparency — literal and figurative — makes all the difference. See-through plastic means the families can see and communicate with their loved ones in isolation, and one huge trust issue has been resolved.

Turning the corner on Ebola will mean working in genuine partnership with local people and putting their own knowledge and wisdom to work, Barry said. Bonnie added that she only hopes the developed world has the patience to see the whole problem through.

“My biggest fear … is that we’ll grow fatigued and we’ll close up our hearts and our wallets,” she said.

Fight against ebola now needs a social front

If medics in space suits inspire dread, then imagine the fear stoked by the arrival of foreigners with guns

The Acholi people called it gemo—a bad spirit that arrived suddenly, like an ill wind—and they had strict protocols to deal with the deadly sickness that followed. Patients were quarantined at home and cared for by a gemo survivor. Two poles of elephant grass were erected outside, as a warning to other villagers to stay away. Dancing, arguing and sex were forbidden, rotten meat was to be scrupulously avoided, and those recovering had to remain isolated for a lunar month. Those who succumbed were buried at the edge of the village.

It took the skills of a trailblazing anthropologist, Professor Barry Hewlett from Washington State University, to discover that the Acholi, an ethnic group in northern Uganda, had their own rather effective method of dealing with Ebola. He inveigled his way into a World Health Organisation team tackling an Ebola outbreak in 2000, furnishing the first, in-depth anthropological analysis of how communities regard this killer in their midst. Ebola may be classed as an emerging disease, but the Acholi, he found, may well have been battling it for a century.

Recently, Professor Hewlett revealed his dismay at how the current outbreaks in Guinea, Liberia and Sierra Leone were being handled by the international fraternity, whose urgent, well-meaning containment efforts were leaving scant room for the beliefs, customs and sensitivities of locals. Others in his field have voiced similar concerns. Professor Melissa Leach, from Sussex University, has pointed out that remote communities associate past epidemics with the sudden arrival of masked white foreigners bearing syringes and body bags.

Strangers in space suits came to take the blood of sick children — then the children died. Corpses were zipped up, kept behind curtains and then burnt before relatives could check that their loved ones were passing intact to the afterlife. Lurid rumours arose of a western trade in body parts; efforts at disinfecting villages were misconstrued as deliberate contamination.

Cultural norms

Such misunderstandings explain why Ebola containment teams, lacking the peace offering of a cure, have been met with hostility—and worse. Tragically, eight health care workers, officials, and journalists were murdered a fortnight ago in Guinea, their bodies thrown into a septic tank. Even when outsiders are welcomed, a slender grasp of cultural norms can lead to perilous knowledge gaps. The Acholi, for example, refer to certain cousins on the father’s side as “brothers”, a factor that is crucial to tracing contacts of the infected. Meanwhile, the epidemic grinds on in exponential abandon, thriving in the chaos caused by panic, fear, shattered domestic health infrastructure, and a laggardly international response. The number of cases is expected to surpass a million by the end of this year.

We have now reached a point where it is very hard to envisage every infected person—at least those in the three most ravaged countries—being treated solely in hospitals or clinics.

While the first response has understandably focused on the scientific, social engagement now needs to be stepped up. Containment will rely on securing the goodwill of terrified communities; indigenous healers, sometimes labelled witch doctors, may need to be courted for their influence rather than sidelined for their superstitions.

This social dimension is especially important as the likelihood of military involvement ramps up. It is becoming clear that only armies have the logistical capability of erecting field hospitals at anywhere near the rate that patients are filling them. If medics in space suits inspire dread, then imagine the fear stoked by the arrival of foreigners with guns. We must hope that medical anthropologists, an unseen and un-heralded battalion in disease containment, will now make the difference as we try to chase away the gemo.