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Ten Things that Anthropologists Can Do to Fight the West African Ebola Epidemic

This article is part of the following series:

Like other anthropologists who have woken up mid-career and found the countries where they’ve lived and worked awash in mass deaths (and let’s be real… that’s quite a lot of us), my initial response to the Ebola outbreak in West Africa was to hope that the experts had the situation under control, and bury my head in the sand.

Soon, the epidemic outpaced the global health response, and the calls for help grew more urgent, but anthropologists’ phones have stayed startlingly quiet. While leaders at the Centers for Disease Control (CDC), Médecins Sans Frontières (MSF), and the World Health Organization explained how factors like culture, weak governance systems, human behavior, and social organization made the outbreak unintelligible to the global health community, academics who work in the region like Danny Hoffman, Rosalind Shaw, Mats Utas, Chris Coulter, Mary Moran, Susan Shepler, Adia Benton, Mike McGovern, Sasha Newell, Gwen Heaner, and Marianne Ferme, not to mention anthropologist from the global south like Sylvain Landry Faye, have remained untapped as resources for understanding and creating innovative new approaches to attacking the Ebola outbreak at its source.

Let me share one example from a recent phone call that I made to the New York City office of Doctors Without Borders:

SA: Hi. I’m a medical anthropologist with 14 years of experience studying healthcare, health systems, and humanitarian aid in Guinea, Liberia, and Cote d’Ivoire. I heard your director put out a call for help on Ebola on NPR today, and I really think I can help you.

MSF: I’m sorry, but we don’t work with medical anthropologists in general, except for under very rare circumstances. If you really want to help out Doctors Without Borders, you are going to have to go to our website to register as a volunteer. The process takes nine to twelve months, and even if we decide that we need your skills, we still won’t guarantee that you will go to the county where you have done research. But please understand that it’s extremely rare that we ever have a need for a medical anthropologist.

A more concerted engagement between anthropology and global health is needed to address the unique challenges of the Ebola outbreak. Anthropologist-physicians like Jim Kim, the current President of the World Bank, and Paul Farmer, who is opening four new hospitals in Liberia as I write, are both closely involved with the Ebola response in their capacities with the World Bank and Partners in Health. Other African and Western anthropologists have been hired singly, or on a consultancy basis, to bring an anthropological perspective to World Health Organization local assessments and MSF activities in Liberia. Many more anthropologists of West Africa are being invited to write commentaries on the current outbreak. But this does not go far enough.

In this article, I share a 10-point list of actions that anthropologists could take, right now, to improve the global response to the West African Ebola outbreak. Take notice, global health and national and international biosecurity communities. There exists an entire discipline of anthropology that is dedicated to connecting the global and the local, to understanding and mapping populations in crisis, and serve as interlocutors[1] between international institutions and local populations in this region.

1. Anthropologists can teach epidemiologists how to count the dead in West Africa. It is common knowledge that there is an enormous gap between counted Ebola deaths and actual deaths. In the space between, critical intelligence is lost concerning the patterning, movement, and expansion of the epidemic. Cultural anthropologists routinely work with local institutions to track morbidity and mortality in contexts that lack formal birth and death registration systems, public health infrastructures, or modern industrial burial industries. Two examples come to mind:

  1. In her ethnographic work on infant starvation in Bom Jesus, Brazil, Nancy Sheper-Hughes counted child-sized coffins to gather data on seasonal infant mortality related to malnutrition, starvation, opportunistic infections, and diarrheal diseases.
  2. In a forthcoming publication[2], Alex de Waal triangulated data on lethal mortality in the Darfur region of Sudan (tribal reports, UN mission reports, and UN incident reports) to generate improved analyses of lethal mortality patterns (see also de Waal 2014).

Novel ways of tracking the toll of Ebola can be generated quickly using ethnographic methods to collect data. But new partnerships between anthropology and epidemiology – and a greater tolerance for multi-disciplinary collaboration – are required to proceed.

2. Anthropologists can systematically observe, report on, interpret, and explain local perspectives on the Ebola epidemic response. This is the most expected function of anthropologists, and it is, indeed, the function for which we are most often employed. In order to get past distorting reports of unreasonable local populations, disinterested local medical professionals, and “blaming the system,” anthropologists are able to make sense of local ideas, beliefs, and behaviors in ways that are actionable. Three examples suggest themselves:

  1. When residents of West Point, the Monrovia, Liberia ghetto, are told not to touch the bodies or corpses of individuals who have shown symptoms of Ebola, is it acceptable for them to use cheap plastic market bags instead of latex gloves?
  2. How can a neighborhood-based quarantine systems work in a way that doesn’t increase local contagious risk?
  3. What are the financial costs to poor populations who are asked to call in to Ebola hotlines, and are those costs bearable under current conditions of food shortages and economic crises? If the costs are not bearable, what communication systems can be put into place to facilitate “ground-up” communication with regional, national, and international systems

3. Anthropologists can detect emerging health risks in the “noise” around Ebola. Consider the following: On September 12th, the WHO reported that a black market had emerged for Ebola survivor’s serum. Anthropologists have developed sophisticated ethnographic approaches to track black market flows, and are skilled at making visible invisible connections between donors and dealers, buyers and healers. We can also work in partnership with local institutions to seek out emerging public health threats that are arising in concert with Ebola, and craft swift and effective responses.

4. Anthropologists can identify local health capabilities and latent social structural capacities for emergent Ebola responses. As #3 suggests, the people who live in Ebola affected regions of West Africa are tremendously innovative and inventive. In fact, one of the most extraordinary outcomes of this current epidemic has been the resilience of local populations under extreme systemic stress and perceived mortal threat. Rather than focusing on “culturalist” issues like Ebola-denialism, funerary practices, news of violence against aid workers, and labor strikes, anthropologists are sensitive to the fact that the populations in Ebola-affected regions are, in fact, human, and that they are inventive, adaptive, able to respond to impending threats in their environments, and deeply clannish – they love, they provide care, and they are, above all, concerned with the well-being of their families and communities.

For example, ethnographer, religion scholar, and development consultant Gwen Heaner noted in a recent personal communication that Pentecostal and Seventh-Day Adventist networks of pastors in Liberia remain untapped as potent allies in the fight against Ebola, while the CDC has already reached out to mainstream churches. At the same time, Pentecostal and Seventh-Day Adventist pastors are implementing strict protections against Ebola by banning touching during church activities. They support their actions with the New Testament verse 1 Timothy 5:22: “Do not lay hands upon anyone too hastily and thereby share responsibility for the sins of others; keep yourself free from sin.”

5. Anthropologists can convene university-based multi-disciplinary study groups that include undergraduate students, graduate students, and faculty to track the epidemic in real time, focusing on the sociological, economic, political, and cultural aspects of the outbreak. These groups can serve as sites for education and advocacy, fundraising, original research, and coordination in local communities across Europe and the United States. Using very few resources, they can serve as clearinghouses that link scholars with prior experiences of Ebola (e.g., Uganda, Democratic Republic of the Congo) or other epidemic containment efforts with academics and practitioners who are involved in the current effort.

6. Anthropologists can share their networks of local contacts with global health experts who are trying to coordinate a response. Anthropologists who work in coordination with local communities often have close, long-term personal and professional relationships with research assistants, community members, and private and public sector leaders. Increasingly, it appears as though a coordinated local response will be required to slow the pace of the epidemic. In sharing our networks informants, friends, and colleagues with local health professionals and international aid organizations, we can facilitate the development of bi-directional communication across local, national, and international institutions.

7. Anthropologists can provide training, coordination, and qualitative data analysis to support to local Liberian, Sierra Leonean, and Guinean teams who try to use local information to design effective interventions. Much of the social and cultural analysis that has emerged from the Ebola epidemic has been fragmented, anecdotal, and sensationalized. This need not be the case. Working remotely from academic centers in the West, anthropologists can work in collaboration with local research teams based in NGOs, at Ministries of Health, and with the WHO to systematically gather, analyze, and report upon real-time data regarding the social and cultural conditions that are impacting the Ebola outbreak. This information can then be factored into real-time decisions about public health strategies like mass communication campaigns, treatment center access, infrastructure development priorities, staffing allocations, and material and human resource investments.

8. Anthropologists can take the lead in generating innovative solutions to the global health community’s mass health communication challenges. As a community, we can come together to publicly “brainstorm” strategies and interventions. We can offer counter-interpretations of current events, alternative readings of histories, and refined analyses of systems challenges in order to more precisely isolate actionable areas for improving the Ebola response. Under the rubric of the AAA, we can organize a National Task Force on Ebola, create opportunities for scholarly exchange, debate, and reports through the coming AAA conference, and use the AAA national platform to maximally engage national anthropological resources.

9. Anthropologists, especially through the leadership of the American Anthropological Association, the European Association of Social Anthropologists, or the World Council of Anthropological Associations, can advocate more strenuously for a “seat at the table” for the social sciences to contribute to the Ebola effort. As individuals and as an Association, anthropologists can reach out to our colleagues in government, public policy, public health, and medicine to remind them of the unique social and cultural challenges that Ebola poses, and identify missed opportunities that have resulted from failing to integrate the social sciences into a truly robust, multi-disciplinary response. A far more sophisticated understanding and operationalization of culture and human subjectivity needs to be integrated at every level into the global response to this epidemic, or – as current projections suggest – the possible human toll will rival those of genocides. Present approaches are failing, and the current devastation of the economic and medical systems in these countries, and the existential threat confronting their national food security, emerging economies, and post-conflict democratic political systems, needs to be monitored and responded to as carefully as the growing case counts reported daily in the international media.

10. Anthropologists in the U.S. can increase pressure on Congress to provide funding for NSF RAPID Research Grants for Ebola research, and for all other basic social science research that seeks to engage with real-time emergencies. Presently, in the United States, there are few robust mechanisms for funding emergency anthropological research, or partnerships between anthropologists and other disciplines, in order to address critical human health issues. NSF RAPID Research Grants are an exception. These grants are designed to bypass a lengthy process of external review in order to facilitate the accelerated development of research projects in emergency situations. Within NSF’s cultural anthropology section, however, NSF RAPID Research Grants are funded in the same pool as conventional NSF senior, NSF CAREER, and graduate student dissertation (DDIG) proposals. A dedicated funding line should be established that commits national resources to rapidly drawing upon anthropological knowledge and research in global emergencies at the NSF, at the CDC, and in the Department of Homeland Security. Moreover, anthropologists should be encouraged to draw upon all of the resources that can facilitate their research in affected regions.

Sharon Abramowitz is an assistant professor of anthropology and African Studies at the University of Florida. She is the author of Searching for Normal in the Wake of the Liberian War (University of Pennsylvania Press 2014) and co-editor, with Catherine Panter-Brick, of Medical Humanitarianism: Ethnographies of Practice (University of Pennsylvania Press 2015). She served as a Peace Corps volunteer in Cote d’Ivoire from 2000-2002, and has been working on mental illness, gender-based violence, post-conflict reconstruction, humanitarian intervention, and post-war health system transitions in Guinea and Liberia since 2003.

Acknowledgements:

This piece was reviewed, and greatly improved, by Lauren Carruth, Gwen Heaner, Michael Herzfeld, Arthur Kleinman, Emily Mendenhall, Sarah McKune, Mary Moran, and Noelle Sullivan. Thanks, as always, for your generous comments and keen insights.

Works Cited:

de Waal, Alex, Chad Hazlett, Christian Davenport, and Joshua Kennedy. “The epidemiology of lethal violence in Darfur: using micro-data to explore complex patterns of ongoing armed conflict.” Social Science & Medicine (2014).

Scheper-Hughes, Nancy. Death without weeping: The violence of everyday life in Brazil. Univ of California Press, 1993.

Notes

 

[1] I send a credit to Dorothy Hodgson for her unique understanding of the term “interlocutor.”

[2] In forthcoming edited volume Abramowitz. S. and C. Panter-Brick, Eds. (2015) Medical Humanitarianism: Ethnographies of Practice. University of Pennsylvania Press.

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29 replies on “Ten Things that Anthropologists Can Do to Fight the West African Ebola Epidemic”

That transcript from MSF is very telling… Maybe we should begin to refer to ourselves as something other than medical anthropologists when we interface with organizations like MSF. How about sociocultural systems analysts? (Or I also like sociotechnical systems analysts.) Medical anthropology has a vexed status with most physicians, who are just as likely as sick people to be medical anthropology’s object of analysis, but who can deny the insights of a systems analyst? The first step to getting a place at the table might just be dropping ‘anthropology’ — the word, not the work.

I work as an anthropologist in Sierra Leone since 2006. From mid July I have sent my applications, assessments and recommendations to WHO. Sometimes I get a standard reply, but most times no response at all. We see the very obvious mistakes they have made from the onset of the epidemic. We can easily predict the reaction of the public to the approach. We know what needs to be done, we can build the bridge between government and the people, we could have ended this epidemic two months ago. Their approach made the epidemic to grow out of control. The epidemic now has a very complex dynamic epoch r needs

While I respect the intent and obvious concern motivating this essay, I have to disagree with some of the points being made here. I’ve worked with, observed, interviewed, and consulted for staff working within “global” health at the CDC and WHO, and I can attest that they aren’t quite as clumsy when it comes to culture as they are assumed to be in this piece. Most of them are very interested in working with medical anthropologists to improve international response and to understand how local cultural systems may affect the transmission of disease. Not only do they fully understand that local cultures are part of “situational awareness” during an outbreak, but they also requested my aide in better understanding their own institutional “cultures” in order to improve collaborative responses in the field. All steps in the right direction.

If we’d truly like to collaborate with those working in public health, then we need to better understand what they do and how they do it (i.e. treat them like a local culture and pay attention to how they frame their jobs). The teams responding now are working to support local responders. They are not able to dictate or to make unilateral decisions. Rather, they are listening to and taking the lead from local experts. They are negotiating with MoHs and various government bureaucracies (there and here). As often as possible, they try to make sure that local responders take on the role of team lead.The CDC and WHO folks see themselves as there to work, to collaborate with local teams, and to weigh in, to help whenever and however they can. As much as possible, health communications are designed with locals who have an intimate understanding of the area. The trouble is that this situation caught everyone by surprise and no one was prepared to escalate the response. The outbreak is different than a “routine” Ebola outbreak and in coping with scant resources and staff over widespread areas, there is little room for “systematic” collection of data on local customs or beliefs. It’s more of a “all hands on deck” type of response. Medical anthropologists are there, working with teams. As pointed out above, the WHO has a network of medical anthropologists set up for this. And whether or not we agree it’s enough or not, it’s a positive step in the right direction.

Why don’t they want medical anthropologists without MDs or training in epidemiology to respond directly? Because we would only be at risk and/or in the way. In other words, in this situation, we’re a liability. Even those trained in medicine or epidemiology typically receive intense special training in order to be “deployable” in such situations. Of course MSF is not going to rely on medical anthropologists without an MD or an MPH. At least not right now.

This is not to say that collaboration is not possible and a bio or med background is necessary (I don’t have one, and they listened to me). At one point, many years ago now, I was in discussion with folks at the CDC to help set up a network of medical anthropologists (similar to the WHO’s) that they might activate whenever our particular sets of expertise were needed. A general lack of interest on *our* part eventually scuttled the nascent interest on theirs.

Thanks to Theresa for these very insightful comments. I concur. While I certainly agree with Sharon Abramowitz’s assertion that anthropologists have valuable skills that could inform the ebola response, I also completely understand MSF’s reluctance to take on anthropologist volunteers without medical training at this particular point in time, as we would be a liability. As an anthropologist of global health (but without clinical training), I too find the current situation in west Africa heartbreaking and enraging, and feel the desire to volunteer to help with the response. But I also feel that if MSF or a similar organization were to take me on, the resources (human and otherwise) need to train and protect me would more likely hinder rather than help at this particular time.

Thank you Theresa for articulating such an insightful and important response. During the years that I worked for the CDC, I was lucky enough to be part of teams deployed to investigate “contextual” issues driving disease outbreaks through the use of rapid ethnographic assessments. Yes, I have an MPH but I worked with anthropologists who did not. The CDC has increasingly been interested in various social determinants of disease transmission and local responses to outbreaks, and after decades of efforts by anthropologists and other social scientists, rapid ethnographic assessments are becoming more accepted and acceptable, at least within the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB prevention (the domestic infectious disease unit—gasp, yes, there are domestic infectious disease outbreaks! And they should warrant far more attention from all of us than they do.). The folks who frequently engaged with our work and encouraged us on in our attempts to change institutional and methodological culture were always those working in public health, and never anthropologists outside of these spaces. Now, back in the academy, I realize that my time at the CDC was an extraordinary point in my professional career, and it will be a while until I am able collaborate in such an interdisciplinary way again.

An excellent and needed post that I hope does two things – encourages anthropologists to get involved in the issue, and helps organizations understand the value they bring to the table. Thank you for writing this.

As profound as some of the points raised in this essay are, I can’t shake the feeling of “oh we need to go help out those poor Africans who lack the academic expertise to direct or contribute to how the ebola crisis is being handled in their countries”

We discuss most of the items you describe with ethnographic examples in our book Ebola, Culture, and Politics: The Anthropology of an Emerging Disease.Anthropologists are doing several of the items you mention.

Ibrahim Fofana: I agree. The article smells a bit like you put it. Something unnerving about the manner in which article other[ises] the object of focus, somewhat undermining the tangential point the author is trying to make–that local knowledge is important in disease surveillance and control and anthropologists can help bridge the knowledge gap between the local and the global.

As a graduate student of cultural anthropology with a focus on medical anthropology, I have been intently focused on the current Ebola outbreak since early summer. It has been frustrating to see the crisis escalate while feeling that there are more culturally sensitive ways to approach the situation. This article provides insightful avenues for anthropologists at all levels to participate in the global response to this epidemic.

I do appreciate the sentiment of this article. However, there are a number of very profound problems with some of the issues she raises.

For example: She states “Anthropologists can take the lead in generating innovative solutions to the global health community’s mass health communication challenges” and suggests this can be done under the rubric of AAA. The problem is this: there is already a field called “health communications” that employs thousands of people. In Africa, indeed, it employes predominantly Africans. Why would the AAA (and, moreover, white US-based anthropologists) be in a better position to advise on health communication than African health communication specialists?

b) She states “anthropologists can provide training, coordination, and qualitative data analysis to support to local Liberian, Sierra Leonean, and Guinean teams who try to use local information to design effective interventions.” Except this: there are people out there doing this work. Why would American anthropologists be needed to provide training and communication? These jobs are already being done. Yes, they were not done efficiently in the beginning of the outbreak. But unclear how anthropologists could add value to this effort at all. Indeed, I am an anthropologist, and I would state unequivocally that academic anthropologists are the very LAST people on the planet I would hire to do training and coordination work at local level. If I wanted someone to do training and coordination, I would hire a training specialist or a coordination specialist. Not an anthropologist from a US-based university.

c) She says: “Anthropologists can share their networks of local contacts with global health experts who are trying to coordinate a response.” But which contacts would these be? Ministry of Health contacts? District Health Office Contacts? NGO contacts? Contacts with people that mobilize CHWs? Is the author suggesting that global organizations lack these contacts? That these networks just do not exist? Because this is simply not true. And if she means people at community level, its unclear how the act of knowing people in a village somewhere could possibly add any value to epidemic response. Because the people at community level who can and are willing to be mobilized for epidemic response will already be known by others, will already be acting, will already be mobilized. These people will have contacts already – local contacts – that far surpass anything a US-based anthropologist could ever provide.

I could go on. But will stop with just these three examples.

The main problem right now, it seems to me, is not that academic anthropologists aren’t being listened to. Its that academic anthropologists don’t listen. That academic anthropologists – even those writing on development and global health – fail to understand how international organizations work, how epidemic response works, how to add value, and how to work on a team. If you want a “seat at the table” then you have to understand the table. You have to have empathy for the table. You have to look at the problem the way the people sitting at the table look at the problem, and explain to the table what role you could play in the terms that make sense to them. You have to tell them how you add value you. You have to approach them with humility.

If US-based anthropologists want to help, the best way they can do it is by translating the epidemic to other Americans. By calming US-based panic. By translating the epidemic to Americans. Its where anthropologists add the most value.

“Its that academic anthropologists don’t listen.”

Thank you for this, Anne. Ethnographers often think, they should be the one to inform naive physicians on how to do their work properly. In fact, I never ran across a mandatory seminar for training anthropologists in tropical or international medicine – at least for self-protection during field-research. There are not many students of anthropology who share a sound interest in medicine – many foster romantic feelings about native treatments, homeopathy and the like. It is easy to meet students full of arrogance against so-called “restricted western mindsets” of biomedicine, citing some never properly validized sources on miracle cures of “shamans”. (But one can meet a lot of naivety and fandom for “alternative treatment”, accupuncture and homeopathy in doctors, too.)

However, it is not up to the doctors who sometimes risk their lives to make this intervention “culture-sensitive”. The very native soldiers of Sierra Leone impose curviews without proper training in “culture sensitivity”. Other native Africans already train their fellows in understanding Ebola, with great success. Otherwise we would see far more cases.

It is up to the anthropologists to organize and provide relevant information in a way, that target groups can understand them, if it really matters. However, efforts of anthropologists in tackling witchcraft-beliefs and magical therapies at the local level are extremely rare while literature abounds with ultra-relativism.

One comment on section 8:

“As a community, we can come together to publicly “brainstorm” strategies and interventions. We can offer counter-interpretations of current events, alternative readings of histories, and refined analyses of systems challenges in order to more precisely isolate actionable areas for improving the Ebola response.”

I share the spirit, but if this “organization” of anthropolgists in a higly competitive environment has so far totally failed to develop responses to witch-hunts, HIV, conspiracy-theories, anti-Semitism, Islamism, genocides – why would it now work with Ebola? If anthropologists so far failed to halt the expansion of “alternative treatments” in their own societies – why would they succeed in campaigning for biomedicine in West-Africa?
Anthropology can’t even boast proper training, working conditions and payment for the very own personell – how would they be able to organize to a level that they would improve the training of doctors and staff?

There will be a lot of Ebola-projects in anthropology for sure. If they are good, they are good and will be read. I contacted a research group of virologists and they instantly offered to organize a seminar session on witchcraft beliefs and conspiracy theories. Most of the time I meet far more interest from doctors for cultural aspects of diseases than from ethnographers for biomedicine.

Barry Hewletts interview by the way does not inform about anything not yet known, the message is “buy my book”. Which seems rather expensive for its 183 pages. One would expect the result of a WHO study to be published free and online. If the content matters, it could’ve been condensed by now. If it wasn’t condensed, it won’t make much difference in training personell anyway.

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