On the 8th August 2014, The World Health Organisation (WHO) declared an Ebola epidemic (Biruk, 2014). The location of this epidemic primarily being Guinea, Sierra Leone and Liberia, all located in West Africa. Ebola Virus Disease (EVD) is a severe, often fatal illness in humans; the virus is transmitted to people from wild animals e.g. fruit bats, and then spreads in the human population through human-to-human transmission (who.int. 2015). Nearly a year on since Guinea found its first case; there have been 23,406 suspected, probable and confirmed cases of the diseases and a total of 9,457 deaths (cdc.gov, 2015). The 2014 Ebola epidemic is the largest in history. Not only is this outbreak the largest, but also the most complex and far reaching, with patients found in Nigeria, Senegal, Spain and the USA (who.int, 2015). But why has this outbreak been so dramatically different to previous outbreaks in other African countries such as Uganda (Hewlett and Amola, 2003) and Congo (Hewlett and Hewlett, 2008)? This essay will argue that although culture and local traditions have played a part in failure to contain the disease spread, it would be naïve to assume that this is the entire story. There are wider structural issues at play which has meant the West African countries affected have been left in a vulnerable position which this virulent disease took advantage of.
Since it’s emergence in 1976, Ebola has been unequivocally associated with foreign origins, and undisputedly linked to Africa. Phrases spread across newspapers such as; ‘A Killer on the loose in the rainforest’ (Jones, 2011) have entrenched in western minds an association between this violent disease and African life. Public discourse on the 2014 outbreak has been characterised by cultural essentialism and the rhetoric of blame and the spread of the disease and failure to control it placed at the feet of the sufferers themselves.
Understanding culture is indeed essential for understanding disease patterns, however there is a vast difference between understanding cultural contexts and stigmatising them (Hewlett and Hewlett, 2008). Over the past year, popular discourse on West African culture has shaped minds and feelings and led to an increasingly ethnocentric portrayal of the Ebola outbreak and a narrative which presumes one way of life is superior to another (Hewlett and Hewlett, 2008).
Sub-Saharan Africans have been subject to an extensive history of colonial exploitation, and they continue to deal with the political and economic fallout (Hewlett and Hewlett, 2008). In the 21st century colonial rule has been replaced by an influx of development programmes, which have arguably weakened countries, and failed to reduce impoverishment and exploitation (Escobar, 1999). When international communities react to the delayed response of the West African governments by labelling them failures (Moran and Hoffman, 2014), their simplifications dissocialise the nature of this epidemic (Farmer, 1999). Put simply, disease is indeed biological in its expression but it is determined and experienced socially (Farmer, 2009). This has implications for the success and or failure of disease control programmes, as is evidenced by the 2014 EVD outbreak.
A Clash of Cultures
During the 2014 Ebola epidemic, culture has found itself designated a risk factor (Jones, 2011). Global media news outlets, online discussion forums and general discourse is littered with phrases blaming local customs and practices for the continued spread of Ebola in West Africa. Countries affected have been labelled ‘unknowable from outside and nonsensical from within’ (Moran and Hoffman 2014:1) thus narratives of ignorance and backwardness have developed to blame sufferers themselves for their misfortune (Batty, 2014).
The West has bemoaned the persistence of what it views as irrational beliefs in conspiracy, sorcery and superstition (Biruk, 2014), views are eerily similar to those held by Levy-Bruhl who argued individuals in such traditional societies held a pre-logic mentality (Ogunniyi, 2007). The belief that traditional custom is an obstacle is not new, one of the UN’s first papers on development in the 70s painted ancient philosophies and old institutions as public enemy number one for development, pushing for their disintegration (Escobar, 1999). This rhetoric has been exacerbated during the 2014 Ebola outbreak and the focus on cultural differences has directed attention away from larger forces at play, hindering the success of disease control programmes.
There are two traditional practices that have come under particular scrutiny, burial rites and consumption of bush meat. From the outset, the World Health Organisation identified local behaviours associated with burial rites as hugely important in the fight against Ebola transmission and amplification. Global media outlets were flooded with images of the dead being taken away from their families in body bags whilst West African funeral traditions such as ‘the love touch’ were sensationalised (Richards and Mokuwa, 2014) as primitive and wrong (Biruk, 2014).
Furthermore, the consumption of bush meat was pinpointed as dangerous by early health campaigns (Wilkinson and Leach, 2014), eventually leading to a ban (Wilkinson and Leach, 2014). Arguably this was worsened by western stereotypes about rural African life (Moran and Hoffman 1999) where generalised images of mud-hut villages prevail (Jones, 2011) and Africa’s increasingly high rate of urbanisation is ignored. This misguided focus on bush meat in fact denied local people vital sources of protein and their livelihood, which did nothing to aid local trust (Wilkinson and Leach, 2014). The international communities lack of understanding with regard to the cultural context that this catastrophe has taken place in has not helped efforts to contain the disease (Hewlett and Hewlett, 2008).
Disease control efforts are limited by playing into stereotypes of powerlessness, passivity and ignorance (Escobar, 1999). International journalists have created a discourse of power (Hewlett and Hewlett, 2008, Hall, 1992), which limits the ability of western aid programmes to build upon local knowledge and practices. Refusal to bring loved ones to hospital or quarantine zones is portrayed as ignorant, rather than understood as an action carried out through fear (Batty, 2014). Stereotyping West African’s actions as ignorant, homogenises them in an historical fashion (Escobar, 1999), and can do nothing to help the disease control efforts. This sort of cultural essentialism and anxiety can lead to cultural racism (Grillo, 2003), further alienating the community that needs help the most.
By stigmatising behaviours and strong-arming local populations into halting traditional practices such as bush meat consumption and burial rites, disease control efforts and international organisations have missed opportunities to develop trust within the community (Hewlett and Hewlett, 2008). Pinpointing burial rites as nonsensical and dangerous is unfounded and unsupported by anthropological fieldwork, which demonstrates the contrary, that people are flexible and knowledgeable (Richards and Mokuwa, 2014). For example, Wilkinson and Leach (2014) highlight how an anthropologist was able to broker discussions in one community affected by Ebola to ensure safer burial practices. In Kissi, a poor neighbourhood on the outskirts of Freetown, a mother and her unborn foetus succumbed to Ebola. Traditional belief stipulates it is forbidden to bury a mother and her unborn child, but health workers deemed it too risky to remove the foetus. Rather than ignore families and bury the mother, discussions revealed that this transgression could be overcome with a reparation ritual. There was no need to upset the family and no risk imposed on health workers. This is a prime example of how understanding cultural tradition rather than blaming it works better in the fight to control Ebola.
Furthermore, medical anthropologist Dr Alain Epelboin has outlined how outbreak control protocol can be made more culturally sensitive without diminishing its effectiveness. Studies in Uganda and Congo found that there are three main aspects of disease control efforts which have angered and upset local populations; burial or cremation, quarantine zones and body bags. Dr Epelboin suggested small changes to all three (Hewlett and Hewlett, 2008). During the Ugandan outbreak 2000-2001 families were often upset that their loved ones were kept in body bags before burial, the impersonal nature of the bags contrasted from their belief that burial is a hugely personal time in ones life (Hewlett and Amola, 2003). Dr Epelboin put forward that body bags could be developed with windows for loved ones to see their relatives face. Furthermore, in Congo 2003, Ebola victims were originally burned with all personal belongings to combat the spread of the disease (Hewlett and Hewlett, 2008). Anthropologists (Hewlett and Hewlett, 2008, Hewlett and Amola, 2003) noted that this served to alienate people and deprived them of their grief. To avoid this tension, international teams could alter burial guidelines, rather than ignore local custom. For example, by using bleach hand spray as the communal hand wash at a funeral services and placing victims and their belongings all in a coffin and bury a safe distance from living relatives integrates bio-medical guidelines for disease control into traditional services (Hewlett and Hewlett, 2008).
However, it would be naïve to assume that clashing epistemologies are solely to blame for the limited success of disease control protocols in West Africa. As Louis Pasteur once wrote, ‘The Microbe is nothing, the terrain, everything,’ (Farmer, 1999:37) and that is certainly never more true than when studying the context of disease in Africa. There are undoubtedly connections between local practices and beliefs and the spread of Ebola but there are significant structural forces at work, which have implications for disease control in West Africa, which have largely gone unspoken of.
The Bigger Picture
Addressing clashes between disease control programmes and local traditions is just one of many factors contributing to the limited success of Ebola outbreak protocols. The 2014 outbreak exposes a number of issues within the political economy of health and illness in the 21st Century, and brings to light the failings of quick fix solutions (Biruk, 2014) and poorly contextualised programmes. When asking why the 2014 Ebola outbreak starkly shadows previous epidemics, it is important to examine access to resources, levels of infrastructure, political stability and international policies, which all contribute to an individual’s experience of disease (Hewlett and Hewlett, 2008).
When designing disease control programmes, the outbreak should be contextualised within the countries own history and reality. A strikingly important aspect of West African history is the role colonialism has played in shaping its present and future. Colonialism has affected the political and economic status of West Africa and created a legacy of discourse that instigates a dialogue of ‘West vs. The Rest’ (Hall, 1992). The scramble for Africa took place in the late 19th and early 20th centuries (Mudimbe, 1988), and was characterised by what American and European colonisers thought was a struggle between the ‘rational’ west and the primitive traditional Africans (King, 2002). To justify conquest colonial discourse construed populations as degenerate based on their racial origins (Bhabha, 2013). Creating a cultural hierarchy, which to some extent persists today. Thus rather than acknowledge western models of disease control have failed West Africans, the responsibility is laid at the feet of the untreatable and their local customs (Farmer, 1999, Hobart, 1993).
Africa has undoubtedly experienced a long history of colonial exploitation; admittedly local histories do vary but the overwhelming result of this exploitation is that little trust remains between the previously colonised and colonisers (Biruk, 2014). From a medical point of view, the arrival of western medicine and western practitioners to African countries was parallel to the violent introduction of Africa to western control and capitalism (Biruk, 2014). There exists a history of health workers acting against the best interests of African people, therefore can it be a surprising that even today those suffering from disease are reluctant to follow western medical advice with regards to disease treatment and control?
In South Africa mining companies employed medics to ensure black men remained fit enough to work, forcibly overseeing vaccinations and medical procedures. The mid-19th century saw French colonisers justify violent removal of indigenous people from their homes on the basis of yellow fever policy, however white merchants were left alone. Finally, Ugandans were forcibly moved from their homes in the 20th century to control Tsetse fly (Biruk, 2014). When we take this into account, and the numerous clinical trials that have failed in Sub-saharan Africa, AZT and Torvan (Tilley, 2011), it would be wrong to blame unwillingness to participate in disease control protocols on ignorance or cultural backwardness.
Colonialism can be implicated in distrust of western medical practices; it can also be implicated in the persistence of poverty and poor infrastructure in West Africa (Jones, 2011). Development programmes often stipulate that corruption is to blame for high levels of poverty in Africa, and that corruption is endemic to African culture (Jones, 2011). However this culturally essentialist view, fails to recognise the legacy that a faulty colonial handover left. For example, when the Belgians left Congo in 1960, only 6 indigenous Congolese men were college graduates (Jones, 2011). Colonial regimes did not include indigenous people in the process of building or maintaining infrastructure. Thus when indigenous Africans regained their land back they had little information on the industries that had been developed by westerners.
In the 20th and 21st centuries the result of this rocky history with colonialism is evident. Guinea, Liberia and Sierra Leone are three of the poorest countries in the world (Wilkinson and Leach, 2014), their GDP’s stand at $6.1 Billion, $1.951 Billion $4.1 Billion respectively (worldbank.org, 2015). Their rich natural and human resources have been extracted for international elites and foreign profit (Wilkinson and Leach, 2014). The result is talented medical practitioners leaving the country (Biruk, 2014) and compromised health systems which all rely on the aid industry, a sector increasingly subject to corruption. Even prior to the Ebola outbreak and 10 years of civil war their health infrastructure was one of the weakest globally; For every 1000 people Guinea has 0.1 doctors, Liberia 0.014 and Sierra Leone just 0.022 (Wilkinson and Leach, 2014). Today the presence of nurses or drugs cannot be assumed and Ebola hotlines and services often go unmanned for days (Abramowitz, 2014). When this is combined with poorly built roads, limited public transport and intermittent electricity supplies it is unsurprising these three countries were unable to halt the spread of Ebola regardless of cultural traditions. The significance of good infrastructure for disease control programmes can be seen when examining nearby countries Senegal and Nigeria. Both had individuals infected with Ebola, and both were declared free from Ebola in 2015. Their success demonstrates how an intact African health system is capable, if the resources are there (Moran and Hoffman, 2014). However, the resources are not there in Liberia, Sierra Leone and Guinea, which have been characterised by histories of war, state collapses and corrupt governments for decades (Moran and Hoffman, 2014).
Outside of West Africa, there are international forces at play that have limited the success of disease control programmes. Poor communications and delayed responses from international agencies meant that the first joint action meeting failed to take place until a further three months had passed (Wilkinson and Leach, 2014). The reason for this was not Liberian failures but poor internal organisation at WHO and substantial funding cuts. In 2011, the WHO lost $1 billion and 300 jobs (Wilkinson and Leach, 2014). This took place parallel to a policy shift towards combating non-communicable diseases and has meant that the agencies core outbreak response team was been dismantled (Gostin and Friedman, 2014). The World Health Organisation now has a budget one third of the Centre for Disease Control. With funding and resources limited, the agency does not have the capacity to implement unique and specifically designed disease control programmes.
The importance of a specialised and unique disease control programme cannot be emphasised enough. For example the Uganda 2000-2001 Ebola outbreak took place in vastly different circumstances to the current West Africa outbreak. Excellent health infrastructure pre-existed the Uganda outbreak due to increased government funding for HIV/AIDS response, the outbreak occurred in an urban area with numerous hospital, paved roads and electricity (Hewlett and Amola, 2003). Finally, the outbreak existed in an area dominated primarily by one ethnic group (Hewlett and Hewlett, 2008), WHO intervention was successful and peaceful. However in Congo, 2003, the outbreak took place in a different scenario. Infrastructure was weak, the outbreak area was home to several ethnic groups and there were few healthcare facilities in the vicinity (Hewlett and Hewlett, 2008). The WHO’s success in Uganda led to the same policy being implemented in Congo and Gabon in 2002 (Hewlett and Amola, 2003). Far from peaceful, outbreak control programmes were characterised by locals chasing away health workers with spears and refusal to move family members to medical units (Hewlett and Hewlett, 2008). The social landscape affected by Ebola in West Africa is even more complex than these previous outbreaks. Guinea alone has 24 ethnic groups, Sierra Leone, 20 and Liberia 16 (nationsencyclopedia.com). Not only does the current outbreak affect three different countries, it affects dozens of different ethnic groups, each with their own unique histories and trajectories. Implementing non-specific disease control programmes will ultimately fail, international organisations need a nuanced understanding of each and every epidemic, and not a one size fits all protocol.
Towards A More Nuanced Approach To Disease Control
There are three key factors that need to be taken into account when asking why the Ebola outbreak in West Africa has been so prolific. Firstly, the cultural landscape of the countries affected is complex and varying, a detailed understanding of the people affected by Ebola is needed in order to develop open dialogue, trust and effective practical measures on the ground. Blaming local customs and attempting to remove traditions only serves to alienate the community. Secondly, disease control measures will inherently fail if they do not take into account the wider political economic state of a country. Providing resources and manpower is only effective if the country has infrastructure capable of distributing it. Guinea, Liberia and Sierra Leone have some of the poorest health care systems in the world and a hugely unstable political past, which has implications for disease control. Finally, international health development organisations that often implement guidelines for global practice on disease control must be careful not to homogenous communities or impose ethnocentric medical views upon others. To this tune there has been an increasing call from the anthropological community to help realign the current discourse surrounding the 2014 Ebola epidemic, and future events that may arise. A need exists to integrate western medical programmes more efficiently with local cultures (King, 2002). In addition there is a requirement to ensure international communities and organisations understand epidemics in terms of short and long-term circumstances (Herring and Swedlund, 2010). Finally, we must work towards an increasingly critical perspective on emerging diseases, asking how large scale forces have effects on individuals globally in our increasingly interconnected world (Farmer, 1999).