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October 11, 2016

Ebola: How a People’s Science Helped End an Epidemic

October 11, 2016
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Guest book review from Anita Makri, an editor and writer going freelance after 5+ years with SciDev.Net. (@anita_makri)anita-field-profile-pic_squarecrop

I’m sure that to readers of this blog the Ebola epidemic that devastated West Africa a couple of years ago needs no introduction (just in case, here’s a nice summary by the Guardian’s health editor). So I’ll cut to the chase, and to a narrative that at the time was bubbling underneath more familiar debates about responding to health crises – you know, things like imperfect governance, fragile health systems, drug shortages.

All of them important, but this narrative was new. It was about fear, communication and cooperation – the human and social side of the crisis (explored in a SciDev.Net collection I commissioned at the time). There was also an unsettling undercurrent to it – one that conveyed ‘otherness’ and ignorance on the part of West Africans, fuelled by reports of violence against health workers and of communities resisting expert advice against risky funeral rites.

_jpg_rgb_originalBut if you listened closely, you could just about make out the voices of anthropologists trying to dispel notions that these reactions were about exotic or traditional cultures. Paul Richards was one of those voices, and luckily he’s put together a rare account of evidence, theory and experience in a book that should trigger real reflection on how we can do better in handling similar crises (hint: more listening).

Ebola: How a People’s Science Helped End an Epidemic tells the story of the epidemic through the eyes of someone with intimate knowledge of the region and the rules that influence human interactions – very much an anthropologist’s perspective, not an epidemiologist’s. The book turns the mainstream discourse on its head, putting what Richards calls “people’s science” on an equal footing with the more orthodox science behind the international response. It captures how people and experts adapted to each other, falling into a process of knowledge co-production.

It’s something of a meandering read – you won’t be guided through the argument very neatly. But the narrative gems and fascinating anthropological insights more than make up for that. Chapter 4 had me at the first sentence: “This chapter offers an empirical analysis of the Ebola epidemic from the perspective of techniques of the body”.  You’ll get a metaphor involving “necromantic joyriding” in the chapter on burial technique, plus the occasional random observation (“the smartphone without contacts is not a phone”).

The structure comes in broad brushstrokes. After an introduction to the epidemic that leads to discussion of social knowledge, the book comes into its own as Richards begins to delve into culture, body washing techniques and the ritual of burial. He takes us through the sociocultural backstreets of the epidemic – different meanings of culture, how ethnic-linguistic affiliation relates to burial practices, the gap between social and medical norms, and the empirical evidence behind his main argument for local understanding and for co-production of knowledge between responders and communities.

The evidence he cites comes from focus groups, conversations, studies and journalistic or other articles. It’s a book rich in practical examples from extensive knowledge of the region, with theory to underpin observation.

It documents self-directed changes in people’s behaviour – using rehydration and improvising by using plastic bags ebola-responsewhen caring for sick relatives at home, for instance, changing burial rituals or restricting movement in affected areas. Richards shows how communities understood the disease in practical terms not communicated by official channels. One example is evidence that people grasped the risk involved in carrying vomiting patients for miles in a hammock – a common mode of transport in the region’s remote areas.

Towards the end he recounts how a chiefdom in Sierra Leone put together a task force to do epidemiological work like tracing the contacts of sick people. This, he says, reduced the number of disease cases before the international response was ramped up. Examples like this are key to his argument, though a bit short on the detail about what communities actually did and how.

At chapter 6 it all crystallizes into Richards’ main thesis: that local people learned about Ebola quickly based on their own empirical evidence (not the same as cultural knowledge, he says – a distinction that needs more explanation); and that the changes they devised managed to change the course of the epidemic.

Another message: that the international response suffered from limitations and flawed perceptions. Here’s a good line on that: “a contradiction between home nursing and no home nursing exists only in the straight-line space of a bullet-pointed official release”. And an example: models of how Ebola moves just don’t capture the network-like features of social relationships, like extended family – their main variable is residential proximity.

All leading to the point that Ebola epidemiology isn’t an exact science or only a medical science; it is also a social science. And this, to me, begs a conversation about how to adapt the response system so it can make better use of knowledge beyond traditional epidemiology; including what NGOs can bring to the table.

ebola-signs-and-symptoms-credit-tom-mooney-lshtmUltimately the two sides of the response converged, Richards argues, with villagers thinking like epidemiologists and responders thinking like villagers – for instance offering simple messages around practicalities of home care, like using coconut water where rehydration fluid wasn’t available. This “merged understanding” was crucial to controlling the epidemic, he concludes. Co-production of knowledge and co-evolution of response should be supported through institutional mechanisms.

And that’s where Richards leaves it – the floor is ours. There are a few questions in the air. On the point of co-production, how do you institutionalise it? How do you address the tension between time needed for knowledge to co-evolve and the political pressures of responding quickly? More broadly, how generalisable are Richards’ observations beyond this epidemic? And, from a practical standpoint, how realistic is it to grasp nuanced anthropological understanding in real time?

I’m hoping for some ideas and conversation in response to this fascinating book.

 

7 comments

  1. Hi Duncan, I haven’t read the book yet but it sounds like an important one for epidemiologist to read in their training. Do you know of similar works that have been written on response to other epidemics? In particular, I appreciate this observation: quote: “models of how Ebola moves just don’t capture the network-like features of social relationships, like extended family – their main variable is residential proximity.” Your comment on the importance of more listening resonates with a blog my colleague wrote about her experience working with Ebola response in Guinea: “How we listened for the virus: the contribution of community engagement to the Ebola response” (http://www.blog.cdacollaborative.org/how-we-listened-for-the-virus-the-contribution-of-community-engagement-to-the-ebola-response/?src=fp2p) she talks about some of the questions you raise at the end of your post: “It can be hard to find the time to listen in a humanitarian emergency, when every second counts. This is true in natural disasters, where there is a singular event or series of events that requires rebuilding. It is even more true in epidemics, when disease is like a wildfire, unpredictable – when one tiny unnoticed spark can set off another blaze.” It would be interesting to compare experiences with practitioners currently working in Zika response/prevention.

    1. Hi Jasmine, I can’t speak for Duncan but I’m not aware of books sharing an anthropological perspective for other recent epidemics; which of course doesn’t mean there aren’t any! Happy to be pointed in the right direction. I agree that a forum to compare experiences and learn from sectors outside health would be a good step.

  2. I also haven’t read the book…but it seems there’s a lot about “understanding”, “messaging” and “communication”, but very little on language itself. Language being not just translation – which was probably crucial, but under-studied – but also the words that were used and the culture that is deeply intertwined with it.

    The aid community wasn’t communicating in local languages…which is one reason why there wasn’t communication.

    As we always did, we expected our local staff to translate; but translation is a skill, a profession. It’s like asking the guy who painted your house to paint the ceiling of the Sistine Chapel. It’ll be painted, but it won’t be the same. :-)

    But, at least translation is a pretty easy problem to solve.

    1. Good point about language, Aimee – though the book says a lot about culture and doesn’t really take the view of communication as one-way messaging (quite the contrary).

      1. Indeed, it can’t just be one-way translation. The point of having good translation is to communicate both ways. The organization I work with is doing that now – developing professional translators and interpreters…and translation tools and two-way communications channels…in languages that the Googles of the world don’t invest in.

  3. This perspective on an epidemic seems similar to what we found re responses to the AIDS epidemic in rural Malawi (Watkins, 2004, “Navigating the AIDS Epidemic in Rural Malawi”, Population and Development Review 30 (4), 673-705). http://www.blackwell-synergy.com/doi/abs/10.1111/j.1728-4457.2004.00037. The primary data are observational field journals in which local ethnographers wrote their recollections of conversations about AIDS that they overheard or participated in during the course of their daily lives. In their networks of friends, relatives, and neighbors, rural Malawians discussed a range of strategies of prevention. These strategies ranged from the abstinence, fidelity, and consistent condom use prescribed by international and national experts to innovative strategies of partner selection, divorce, and renewed religious commitment. The Malawi Journals Project is now publicly available at http://deepblue.lib.umich.edu/handle/2027.42/113269. There are now approximately 1200 anonymized journals, each about 20 typed pages, covering the period between 1999 and the present.

    1. Susan, the first link seems broken but I can access the Project material, thanks for sharing. I’d be interested to know if you’re aware of any efforts to take these observations more directly to the people shaping response in terms of policy and/or on the ground. With Ebola, for example, anthropologists were eventually listened to – that there was a specific need for their input on burial practices probably helped. And there was some organised effort to produce practical guidance during the crisis (e.g. this platform: http://www.ebola-anthropology.net/).

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