Ebola, Cultural Responses, and the Funding Gap

A few weeks ago I linked to a handful of academic works on Ebola outbreaks past and present. This week, as I round out my job as a high school teacher, I ran my sophomores through a couple of days on the virus and ongoing outbreak. In looking for accessible readings that deal with the cultural and political aspects of the West African Ebola outbreak, I’ve found Amy Maxmen’s reportage at National Geographic really interesting. In particular, I assigned excerpts from two of her articles that are worth highlighting here, if only to quote them in contrast to the Hewlett and Amola piece I linked to before about locally-rooted traditional responses in Uganda that contained the 2000 outbreak there effectively.

The first piece is from March and depicts the challenges of contact tracing in towns where people don’t want to be kept in isolation or taken to clinics from which they may not return. The second, from January, gives a thorough overview of how cultural traditions in the affected countries have enabled Ebola to spread, and outlines efforts to find culturally acceptable burial methods in order to help contain the outbreak:

In the three countries hit hardest by Ebola, preparations for burial typically are carried out by community members who handle the dead with bare hands, rather than by doctors, morticians, and funeral home directors. People were unwilling to have those practices casually tossed aside. That worked in Ebola’s favor. As death approaches, virus levels peak. Anyone who touches a droplet of sweat, blood, or saliva from someone about to die or just deceased is at high risk of contracting the disease.

To health authorities, the solution was simple. With so much at stake, science eclipses religion: Risky rituals must end.

“People were expected to go from one end of the spectrum to the other; from washing the bodies by hand, dressing them, and holding elaborate ceremonies, to having a corpse in a body bag and no goodbye,” says Fiona McLysaght, the Sierra Leone country director for a humanitarian organization called Concern Worldwide.

Of particular interest to me was the flexibility of such rituals, to which many who have done fieldwork can attest. As Paul Richards says in the article, “burial rituals were flexible… the spirits are totally practical!” The lede to the article is a story about a family that is trying to bury a pregnant woman who died – they want to remove the fetus according to tradition, but healthcare workers won’t have it. The solution? They found a ritualist who said that a reparation ritual would correct any problems caused by burying the woman without following customary rituals.

The idea of flexibility in ritual has been around for a while. Many rituals were only recent codified, and so many “requirements” and “customs” can be molded to fit what’s needed and what’s available. In my own line of work, Tim Allen’s argument that the traditionalist response to the ICC intervention in northern Uganda essentially invented universal Acholi reconciliation rituals where there hadn’t really been any before comes to mind.

Anyways, digression over. Back to Ebola.

After assigning these articles and discussing them with my students, yesterday I saw another article by Maxmen on the topic of Ebola, this time on the wide gap between money being donated to the cause and money being paid to frontline medical personnel. From Newsweek:

Hundreds, if not thousands, of nurses and other frontline staff fighting Ebola have been underpaid throughout the outbreak – and many remain so today. The lack of pay is not simply a matter of corrupt officials stealing donor money, because so-called “hazard pay” was issued through direct payments to frontline workers starting in November, then electronic payments to bank accounts and mobile phones beginning in December. The problems appear to be twofold: first, Sierra Leone’s national health system has been so underfunded for so long, that it was a monumental challenge to document all of the country’s care workers and set up payment distribution channels to them. Second, it turns out that relatively little money was set aside for local frontline staff within Sierra Leone’s health system in the first place. In fact, less than 2% of €2.9bn ($3.3bn) in donations to fight Ebola in West Africa were earmarked for them. Instead, the vast majority of money, donated from the taxpayers of the UK, the US and two-dozen other countries, went directly to Western agencies, more than 100 non-governmental organisations (NGOs), and to the UN.

[…]

When I visited Kenema Hospital in February, graffiti on one wall of the Ebola isolation area read: “Please pay us.” By then, nurse Kabba had cared for more than 420 Ebola patients, and had lost several friends. She had not received most of the €80 ($92) weekly allowance she’d been promised since September. Nurses around the country were in similar positions. “We hear about money pouring in, but it is not getting to us,” Kabba said. “People are eating the money, people who do not come here. We are pleading nationwide, we have sacrificed our lives.”

When I spoke with Kabba’s boss, District Medical Officer Mohamed Vandi, he acknowledged that his health force had been sorely neglected. “I am not hopeful for the future,” he said. As Ebola ebbed, world leaders had begun to make promises about improving fragile African health systems. Vandi looked on sceptically. “If we could not get support when the virus was here, I wonder how we could get it when the virus is gone?”

The whole article is well-worth reading, as it outlines how international agencies tried to implement payment programs isolated from corrupt government officials, but also bypassed numerous nurses. There’s also a strong critique of international NGOs’ tendency to do everything on their own rather than improve the state’s existing (and weak) healthcare infrastructure. For those studying aid, development, and public health, there’s worthwhile stuff here.

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Understanding Ebola

The latest issue of African Studies Review includes a commentary from Adia Benton and Kim Yi Dionne titled “International Political Economy and the 2014 West African Ebola Outbreak.” It’s available for download here for the next month, and I think it’s well worth a read. In the piece, Benton and Dionne outline the domestic and international response to the Ebola outbreak that has caused so much damage in Guinea, Liberia, and Sierra Leone, but they also place the outbreak is a much wider context, looking at the setting in which this outbreak is taking place and looking at the outbreak in relation to past events. They even lay out the relevance of problems in the region as recent as the Mano River War and structural adjustment and as far back as the slave trade and colonialism. With this background in mind, they state:

[W]e should expect that ordinary people navigating an epidemic would be suspicious of the motives and directives not just of their governments, but also of local agents implementing health interventions on behalf of their governments. It should not be surprising that these suspicions could further antagonism toward governments.

In describing the response to the outbreak, Benton and Dionne provide a survey of attempts and failures from the weak response of a broken healthcare infrastructure to the inaction of the international community – led by a dismissive WHO. What’s really important, though, is their emphasis on how the international community responded to the crisis only when it began to threaten the West itself. We all saw this when Ebola became huge news as it arrived in hospitals in Dallas and in the streets of Manhattan, and faded out of the news cycle once those threats abated. Discussing the UN’s decision to create an emergency committee to focus on the outbreak, the authors write that “the resolution adopted at the end of the emergency meeting stated that ‘the unprecedented extent of the Ebola outbreak in Africa constitutes a threat to international peace and security.’ The security paradigm—and particularly one in which threats from West Africa were spreading to the West— therefore colored U.S. and European responses to the ‘crisis.” Kim Yi Dionne gave a talk at Yale earlier this year in which she talked about and around the issues discussed in this article. One thing she brought up that I found fascinating that isn’t discussed in the article is the role of “culture” in spreading disease. In particular, how many stories cite West African burial practices, belief in witchcraft, or mistrust of outsiders as cultural reasons that Ebola has spread. In relation to this, Dionne referred to the work of Barry Hewlett and Richard Amola, whose report on the Ebola outbreak in northern Uganda in 2000-2001 outlined a very different role for culture to play:

In early October, residents began to realize that this outbreak was more than a regular kind of illness and began to classify it as two gemo (two [illness] gemo [epidemic])…Gemo is a bad spirit (type of jok that comes suddenly and causes a mysterious illness and death in many people within a very short period of time). Gemo reportedly comes like the wind in that it comes rapidly from a particular direction and affects many people, but the wind itself does not necessarily bring it…Once an illness is identified as gemo, a protocol for its prevention and control is implemented that is quite different from the treatment and control of other illnesses.

When an illness has been identified and categorized as a killer epidemic (gemo), the family is advised to do the following: 1) Quarantine or isolate the patient in a house at least 100 m from all other houses, with no visitors allowed. 2) A survivor of the epidemic should feed and care for the patient. If no survivors are available, an elderly woman or man should be the caregiver. 3) Houses with ill patients should be identified with two long poles of elephant grass, one on each side of the door. 4) Villages and households with ill patients should place two long poles with a pole across them to notify those approaching. 5) Everyone should limit their movements, that is, stay within their household and not move between villages. 6) No food from outsiders should be eaten. 7) Pregnant women and children should be especially careful to avoid patients. 8) Harmony should be increased within the household, that is, there should be no harsh words or conflicts within the family. 9) Sexual relations are to be avoided. 10) Dancing is not allowed. 11) Rotten or smoked meat may not be eaten, only eat fresh cattle meat. 12) Once the patient no longer has symptoms, he or she should remain in isolation for one full lunar cycle before moving freely in the village. 13) If the person dies, a person who has survived gemo or has taken care of several sick persons and not become ill, should bury the persons; the burial should take place at the edge of the village.

As they reflect, “From a biomedical perspective, this protocol constitutes a broad-spectrum approach to epidemic control.” The Acholi response to Ebola varies widely from other groups’, but it is a response rooted in both history and culture. There are a lot of facets to epidemics and responses that only emerge with on-the-ground research and observation with local interlocutors. Benton and Dionne’s call for more research into the Ebola outbreak and the response to it is an important one to heed.

Their commentary is just one of a number of academic attempts to understand the Ebola outbreak and call for more investigations and responses. One that I found really informative and interesting was Cultural Anthropology‘s collection on Ebola. Another one is the blog of a development worker in Liberia, Codex Lector (HT Rachel Strohm for this link).

Two Ethnographies of Conflict

I’m peaking my head over the books to give a brief glimpse at two really incredible books that I read recently. In a course on insurgency, the state, and political consciousness, I’ve had the chance to read two ethnographies that present really interesting approaches to studying conflict: Danny Hoffman’s The War Machines and Sharika Thiranagama’s In My Mother’s House. I’ve wanted to read the former for a couple of years, the latter I hadn’t heard about until I picked it up. Both are new books which hopefully haven’t slipped under everyone’s radar (and if they have, now you have no excuse!) – they’re well worth your time if you’re interested in how conflict shapes society and vice versa.

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