Engaging Anthropology in an Ebola Outbreak

Case Studies from West Africa

in Anthropology in Action
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  • 1 University of Cape Town emilie.venables@brussels.msf.org
  • 2 Médecins Sans Frontiéres u.pellecchia@gmail.com

Abstract

The articles in this special issue demonstrate, through ethnographic fieldwork and observations, how anthropologists and the methodological tools of their discipline became a means of understanding the Ebola outbreak in West Africa during 2014 and 2015. The examples, from Liberia, Guinea and Sierra Leone, show how anthropologists were involved in the Ebola outbreak at different points during the crisis and the contributions their work made. Discussing issues including health promotion, gender, quarantine and Ebola survivors, the authors show the diverse roles played by anthropologists and the different ways in which they made use of the tools of their discipline. The case studies draw upon the ethical, methodological and logistical challenges of conducting fieldwork during a crisis such as this one and offer reflections upon the role of anthropology in this context.

The largest Ebola Virus Disease (EVD) outbreak in history severely affected the three West African countries of Liberia, Sierra Leone and Guinea during 2014 and 2015. As we write in March 2017 the region is still considered Ebola free since the last reported case was declared to be Ebola negative in March 2016. It appears that the epidemic had a drawn-out end phase, with multiple flare-ups observed in the three countries at the epicentre of the epidemic, but the articles in this special issue focus on the crisis period in 2014 to 2015. The effects of this outbreak went beyond the spheres of medicine and public health, raising geo-political concerns over security that were often framed through a global communication machine. As we discuss throughout this collection of articles, the outbreak drew global awareness to the sociocultural factors that can affect a health crisis such as this one.

The medical emergency within West Africa was embedded within sociopolitical dynamics, power relationships and cultural paradigms that concerned affected communities, NGOs and aid organisations, many of whom became entangled in a cross-border maze of reciprocal misinformation and rumours (Wigmore 2015; Wilkinson and Leach 2015). At times, despite huge efforts from different organisations working in West Africa, the daily realities of those most affected by the epidemic were overshadowed by the media focus on Western fears that the virus would spread outside of Africa’s borders. A weakened health sector, combined with wider structural issues such as conflict and political instabilities in the region, then poor post-war infrastructural systems in Liberia and Sierra Leone, made it difficult to contain the virus and ensure the identification and clinical management of those who were infected. An awareness and understanding of sociocultural beliefs and people’s daily, lived experiences – often through an anthropological lens – thus became paramount.

With this backdrop highlighting the interplay of local and global practices, politics and narratives, the authors of the articles in this special issue demonstrate, through grounded ethnographic fieldwork, how anthropologists and the methodological tools of the discipline became a key approach for grasping and untangling the complexities of such an event. The authors’ contributions – and the themes that they raise – span across the three countries most affected by the EVD outbreak: this collection follows the trajectory of anthropological involvement in the crisis response using case studies from different points during the outbreak. Manca’s article is a technical account of the importance of health promotion when planning and implementing Ebola-related interventions. She shows how her experiences as a health promoter with an anthropological background helped her and her team implement messages and communication strategies that were culturally relevant to the intended beneficiaries. Pellecchia and Minor’s articles examine how communities reacted to government-introduced policies to curtail transmission in Liberia and Sierra Leone, whilst Venables’ work focuses on the experiences of EVD survivors and the ongoing challenges they face after recovery.

The use of anthropological fieldwork in the case of an EVD outbreak is not new, as we discuss in more detail below (Hewlett and Amola 2003; Hewlett et al. 2005; Hewlett and Hewlett 2008), but during the recent West African outbreak, the body of anthropological work produced was far greater than in any of the previous, smaller outbreaks. From early in the crisis, as soon as they could be mobilised for the emergency response, anthropologists and other social scientists from different organisations and institutions began to offer insight, recommendations and evaluations of the Ebola response on the ground and through online networks and forums. This information sharing continues today with workshops, publications, meetings and the ongoing collections of resources. This body of ‘social science intelligence’, as the authors of a Lancet correspondence piece termed it (Abramowitz et al. 2015), demonstrates the contribution that anthropologists can make to such public health crises, but at the same time we must recognise that recommendations can be difficult to implement and scale up and that anthropological involvement in such a context is not without its challenges or critiques. This input from social scientists changed practice on the ground through offering recommendations relating to ‘safe and dignified burials’(Abramowitz and Omidian 2015; Richards 2014), community engagement, the development of health promotion materials as well as a richer understanding of culture and practices across the region and their interaction with health policies and systems. In brief, anthropologists – along with other actors, such as those working in the fields of mental health and community development – explored and attempted to strengthen the links between communities and organisational actors through providing an in-depth analysis of the situation on the ground.

The Ebola Virus

EVD is a haemorrhagic fever caused by a virus of the Filoviridae family, and often known as a ‘filovirus’. The virus was named after the Ebola River in former Zaire (now Democratic Republic of Congo) in 1976, where the first outbreak was recorded. EVD case fatality rates vary from 50 per cent to 90 per cent: in previous outbreaks, the number of victims did not surpass the hundreds, with the peak in Uganda in 2001. As of June 2016, when 42 days had passed since the last cases in Guinea and Liberia, the outbreak had caused 11,310 deaths out of the 28,616 cases reported worldwide (WHO 2016). Outside of the three countries most affected, cases of EVD were recorded in Nigeria and Mali, and also affected aid workers and medical staff from Europe and North America, but these cases were isolated and more easily contained.

Virologically, there are two main ways for EVD to transmit: through animal-to-human (primary) and human-to-human (secondary) contact. The transmission of EVD requires close contact – either with an infected person or with their infected bodily fluids, and together with the lack of curative treatment and high rate of death creates a very particular level of fear around it. Primary transmission of EVD is typically limited, with a single isolated incident capable of triggering an outbreak, and secondary transmission seems to be the mainstay of the outbreak dynamics. The understanding, containment and management of patterns of transmission are indeed key to outbreak control and many organisations, such as Médecins Sans Frontières (MSF), follow the ‘six pillars’ when trying to curtail the spread of an outbreak (WHO 2014). The typical emergency health response has focused on the isolation and care of suspected and confirmed cases in designated health-care facilities such as Ebola Management Centres (EMCs);1 case finding and contact tracing in communities through surveillance and close follow-up; health promotion and community engagement; non-Ebola health-care and safe burial rituals (Calain and Porcin 2015) as well as psychosocial support. As Pellecchia’s work in this issue and elsewhere discusses, other containment interventions such as mass quarantine and community-enforced isolation (distinct from the clinical isolation of positive Ebola cases) have also been implemented by different actors, outside of the isolation within an EMC (Rothstein 2015; Pellecchia et al. 2015).

The absence of a proper treatment or vaccine for Ebola – or even a high level of care and palliative care in some cases – make case investigation and contact tracing fundamental cornerstones of the intervention in an unprecedented global health emergency such as this one. A vaccine trial in Guinea was shown to ‘offer substantial protection against Ebola virus disease’ and showed high protective efficacy and effectiveness, and further research studies are ongoing (Henao-Restrepo et al. 2017: 516). Ebola is transmitted through contact with body fluids, which also constitutes a safety challenge for medical workers and caregivers: debates are ongoing within the medical community about how to manage Ebola patients appropriately in the light of all the difficulties and constraints the virus poses. Almost all of the organisations that intervened in West Africa eventually adopted the model of a central EMC and outreach activities of health promotion and surveillance as well as, in some cases, focusing on non-Ebola care.

The recent EVD epidemic clearly leaves many technical, medical and psychosocial questions around care and support unanswered, as well as questions that the authors of this special issue pose about the role of anthropology in such an outbreak. As this special issue attempts to show, public health cannot ignore the social and political aspects that local communities and response organisations alike produce and reproduce during such a crisis. The input of anthropologists was a crucial part of the Ebola response for many organisations, and they were involved in ensuring that all the pillars were understanding of community needs and relevant to the local population.

The Varied Roles of Anthropologists in an EVD Epidemic

What kind of contribution can anthropology make in an epidemic such as the Ebola epidemic in West Africa, and what are the specific roles that anthropologists can play, in the field or within the academy? Which analytical frameworks can inform practical recommendations made by anthropologists to wider actors involved in health promotion, community outreach, treatment of patients and survivor support? In other words, what is the role of applied anthropology in an emergency response and what combination of theory, critical view and practices is necessary for it to be of benefit? It is these very issues that support the arguments in the following articles and govern the minds of the anthropologists working and providing recommendations during the recent EVD outbreak.

This collection of articles demonstrates the range of roles played by anthropologists in Guinea, Liberia and Sierra Leone, including their work as health promoters, researchers and NGO advocates (Abramowitz 2014). These roles are not mutually exclusive, and many anthropologists found themselves holding interchangeable roles and positions which were not always easy to manage; an awareness of their varying roles, and the tensions between them, are highlighted in the articles that follow. Anthropologists found themselves conducting research studies on the epidemic itself as well as the local and international response to it; working as health promoters on community-outreach strategies or practically engaged in project implementation through activities with NGOs and civil society organisations. We cannot claim to speak for all anthropologists working within the Ebola response, as every person in the field was linked to a different organisation, set of guidelines and code of conduct. We believe many of the issues faced by anthropologists in the field – or those offering input from afar – are similar and shared across the countries most affected by the epidemic.

Anthropology was not only able to offer its conceptual tools and knowledge to support the response within the three West African nations, but also, within the blurred boundaries of an emergency, discovered an object of study extremely dense with complex social significances that constitute a field of research in its own right. In some cases, anthropologists were torn between wanting to delve into a field of study rich in ethnographic potential whilst simultaneously needing to meet the practical and immediate requirements of an outbreak response such as developing health promotion messages or assisting with community mobilisation (Anoko 2015).

As stated above, Ebola is not new in the history of the anthropological discipline, and authors have previously written on such themes as health and sickness and the understandings and beliefs around the causality and treatment of EVD. The aforementioned works of Hewlett are pioneering in this sense, as his ethnography showed for the first time how the virus was both a social fact and a public health concern. The value of Hewlett’s milestone work lies in the balance between the search for a broader theoretical model to interpret the epidemic and the need to give practical feedback to support afflicted communities and response organisations. In searching for an ethnographic approach to EVD epidemic, the work of Epelboin et al. (2005) is also crucial as it deals with, amongst others, the communication of messages and their cultural meanings – topics of immediate relevance for health promoters.

Rooted in historical landscapes of colonialism and early forms of biopower, epidemics also constitute an important object of study for medical anthropology (Lock and Nguyen 2010) as crucibles of several levels of analysis (Dry and Leach 2010) that span from the impact of colonial medicine to the environmental disasters consequent to foreign exploitation of resources, and from clashes or encounters of local medicine with biomedical approach to the production of subjective identities through forms of biopolitics. Indeed, the views of Foucault lie in the background of these investigations in between anthropology, history and a genealogy of power (Foucault 1994, 2010, 2014). They recall that every phenomenon or crisis, whether provoked by human or natural causes, is embedded into, and always activates, forms of power that cannot be ignored even in the more ‘neutral’ medical humanitarian interventions. As Farmer (1999, 2003) reminds us, the political economy of epidemics is a macro-factor embodied in the ordinary lives of patients and drives behaviours, choices, fears and possibilities. We must consider such factors when engaging in applied anthropology on the ground.

As Calain and Poncin (Calain and Poncin 2015) argue in their recent article, medical anthropology can also offer an exploration of the divide between biomedical representations of EVD and other cultural understandings around the origin of the virus and the practices put in place to prevent its further spread, as seen in the work of Hewlett and Hewlett (2003, 2005, 2008) and Formenty et al. (2003) as well as more recently.

Parallel to this range of theoretical approaches and exemplified in all the articles in this special issue are the organisations engaging with anthropologists to assist with their work. Médecins Sans Frontières and Oxfam, along with many other NGOs and research and academic institutions, mobilised researchers and advisors on the ground throughout the crisis to assist with their work across the three most affected countries. This engagement has stirred up old debates including the study of clinical trials or experimental vaccines and the social and symbolic impact of a virus with no cure (Le Marcis 2015), and has created new fields of study, such as survivor identity, the differing humanitarian responses to outbreaks and the study of global public health governance itself. The EVD crisis highlighted the need for applied anthropologists to work in the field and offer their expertise through online platforms and the global sharing of experiences, but it also brought to light some of the challenges of working in an outbreak context. The authors of this special issue deal with some of these challenges, analysing them in light of their ethnographies and providing direction for practical actions that can drive humanitarian strategies and health-care policies if a similar outbreak situation should happen again.

The use of anthropologists in humanitarian aid and development organisations has been growing over recent years, with increasing emphasis on ensuring that any interventions and assistance are acceptable and relevant to the communities intended to benefit from them, and with their critical views on the narratives, politics and practices that the organisations implicitly or explicitly export over the terrains in which they operate. Aware of the risks run by the humanitarian discourse, its morality and its depoliticised connotations (Fassin 2012; Malkki 2015; Redfield 2013), anthropological engagement and critical analysis are key features of applied anthropology in this context. As we see elsewhere in Anthropology in Action, anthropologists can utilise their skills and training in different areas of study, with Ebola being just one of them. Anthropologists may be employed as consultants on a short-term basis or embedded within organisations in the long-term, but should share the dynamic methodological and theoretical specificity of the discipline acquired through training and experience.

Ethics and Methodological Conundrums

The engagement of anthropologists in the EVD outbreak raised several ethical questions regarding the use of the anthropological discipline, its methods and their application. Although the articles do not directly address the issue of ethics, ethical dilemmas and questions underpin each author’s work. We have identified three main fields of ethical and methodological questioning, which we discuss in more detail below: (1) the position of the researcher within the ethnographic context they intend to study, (2) the relationship with the organisation or institution where s/he is situated and their ethical framework and (3) the compromises between theory, methods and praxis that inevitably the researcher has to make in a high-security context. Namely, how can we – writing as anthropologists – be true to our discipline, whilst working within a restricted, high-security context with limited access and strict regulations to control our movements (see also Brown and Kelly 2014)?

Reflexivity as a research tool to avoid biases between the researcher, his/her ethnographic environment and those being researched, has been shown to be an essential part of anthropological studies: the researcher must be very attentive to and aware of the emotional state of his or her informants, including an awareness of their fears, hopes and expectations. In West Africa, local communities and anthropologists were at potential risk of becoming infected with EVD, and in this sense, ethnography was also restricted by the physical hazards of being potentially contaminated or of contaminating others.

The fieldwork environment was, for many on the ground, an exceptional one, where the authors of these articles found that those involved in research were on the one hand reluctant to disclose their true feelings surrounding Ebola for fear of not being helped or assisted by NGOs or the government – or, on the other, may have overemphasised their situation in the expectation of receiving additional compensation or benefits, such as in the case of survivors (WHO 2015). Whilst reimbursements are often an issue in anthropological research, the Ebola epidemic heightened some of these ethical issues because of the numbers of actors working on similar issues and offering differing degrees of compensation for information.

Within the second category lies the delicate positioning of the anthropologist both in the role of researcher and, in several of the articles in this special issue, also as a representative of an NGO with its own set of codes and guidelines. As each organisation and institution has its own set of values, ethics and practices, we do not go into detail about the specific ethical challenges of working within the frameworks of particular organisations or institutions but wish to point out that values can clash and at times can be difficult to manage.

In addition, many anthropologists working for NGOs or research institutions must undergo an ethical review procedure for formal research protocols that are – in some cases – conducted by a professional board that does not necessarily have expertise in qualitative methodologies or ethnography. These institutional procedures require time, and, within an emergency context, the situation changes rapidly and research questions may shift in relevance before approval has been granted, as well as during and after the fieldwork process. In addition, working for any institution – NGOs, other international agencies, or in academia or research – raises the question of how the critical approach of anthropology can stay within the rules, confines and limitations set by these institutions to protect research participants, and in some cases to prevent the researchers themselves from coming to harm. The risks of impartiality cannot be overshadowed and the freedom of research might not be assumed, especially for those working in a heavily donor-dependent framework. There is an urgent need to streamline the process of ethical reviews in emergency situations in order to make investigations that have a potential public health benefit possible in emergencies whilst still maintaining ethical standards.

Methodologically, an outbreak poses obvious restrictions to classic ethnographic tools such as participant observation, causing researchers to consider the need to compromise. Anthropologists might find themselves frustrated by a dependence upon narratives collected through interviews, and may perceive tools such as focus group discussions reductive when they are accustomed to spending long periods of time in the field observing and participating in the minutiae of daily life. As Brown and Kelly (2014: 281) write, there are challenges of conducting fieldwork in an epidemic ‘in terms of the risk to the anthropologist and the coincidence entailed in “being there” when an outbreak occurs’. They also note, as we have highlighted above, how when working in an emergency setting, the ‘slow paced research methodology’ often associated with anthropology counters the immediate demand for action (ibid.).

It is not the aim of the authors to provide concrete answers to such dilemmas, but instead to highlight how the EVD epidemic, as any other field of anthropological study, represented a need and opportunity to reformulate the methodological, ethical, practical and theoretical challenges of working within a constantly evolving discipline.

Anthropological Networks and Resources for Ebola Beyond the Field

In addition to those working on the ground in Sierra Leone, Liberia and Guinea, large numbers of anthropologists from research institutions and universities provided remote assistance to the field through a range of online platforms in Europe, West Africa and the U.S. These included the Emergency Ebola Anthropology Network and the Ebola Response Anthropology Platform in addition to the francophone SHS Ebola Network.2 Such forums hosted spaces for online discussions and debate, created contact networks, and enabled access to reports and articles as they were published (as many immediate findings were not yet published in academic journals, these networks enabled the sharing of first drafts, recommendations and internal reports). The inputs provided by such resources were essential for anthropologists and other actors from NGOs, medical institutions and civil society on the ground who needed prompt in-depth information: the constantly updated efforts of anthropologists around the world enabled the sharing of online ethnographic resources and analysis on a variety of issues ranging from the sociocultural dimensions of EVD to the interpretation of local and global dynamics and narratives. This facilitated sharing is quite unique, and indeed other sectors, including clinical actors, could have learned from this rapid and participatory approach to sharing lessons learned.

These platforms and networks created a shared space of knowledge that demonstrated how quickly anthropologists can operate beyond the canonical spaces of the academy. However, what the contributions to this special issue show is that fieldwork and the participatory nature of the anthropologist’s role (even if limited by concerns over safety and security) remain the core methodological and analytical principles of a discipline able to respond to social complexities by not only giving answers but also asking questions. Moreover, the engagement of anthropologists and their teams on the ground recalled the role of the anthropologist not only as a producer of knowledge but also as a professional that can bring about change on the basis of such knowledge. Indeed, this collection of articles contributes to the debate on what form applied anthropology can take and in which direction engaged anthropology is possible. The authors show how a training and background in anthropology lends itself to making practical recommendations in a medical emergency, and that voices and experiences from the field are essential.

Integrating Anthropology into an Emergency Response

The Ebola epidemic in West Africa is a multilayered subject of study and intervention where sociocultural dimensions of health and illness, local and global explanatory models, different clinical strategies for protection and care entwine with the fluctuating positioning of communities, states and aid organisations, governance, power relationships, global inequalities and the historical heritages of colonialism and postcolonialism. Anthropologists endeavour to recombine the sectorial disciplinary subdivisions of medical, social and political anthropology in a comprehensive approach which is able, on the one hand, to inform humanitarian and development work with practical ideas to help reduce transmission and on the other remain grounded within an academic discipline. As we mentioned previously, the different roles played by anthropologists were often difficult to manage.

An important element of this work is to increase the uptake of anthropological findings and make them relevant and accessible to a wider – often biomedical – audience, and we emphasise the importance of an interdisciplinary terrain where epidemiology, ecology, medical sciences and anthropology can find a common ground to increasingly communicate and share experiences with each other. This process of operational and methodological metissage would work to comprehend the complexities of epidemics and seek to provide a socially sustainable and medically effective framework of good practice around the prevention and control of transmission and for surveillance, community engagement, health promotion and social mobilisation. Another key element to this approach is the involvement of local researchers and actors, whether medical, anthropological or from other disciplines, who understand the realities on the ground and can provide essential expertise and links to community networks. The intertwining of oft-distinct scientific domains (and in the case of this outbreak, overlaps with advocacy and communication networks) has the added benefit of providing a comprehensive analysis of epidemic phenomena that can explain its logic and generate recommendations for health policies and global politics.

In this mutual engagement of theories and practices, disciplines and methods, pragmatic solutions and structural political claims, humanitarian aid agencies and NGOs on the ground may emerge as privileged actors to integrate and involve anthropologists who in turn can offer a wealth of theoretical and practical experiences from within and beyond their own discipline. In doing so, they show how anthropology, with its analytical, critical capacity and ability to apply its findings practically, can be applied to the context of humanitarian intervention – in this case, the Ebola outbreak of 2014 to 2016. Rooted in the experiences of those who have contributed to this special issue, as well as those who have written about this relationship elsewhere, we believe there is the need for a critically engaged applied anthropology in such contexts, despite the practical, ethical and methodological challenges encountered.

Notes
1

Ebola Management Centres (EMCs) are also referred to as Ebola Treatment Units (ETUs). For the purposes of this special issue, individual articles use the term which was most commonly used in that particular context.

2

The SHS-Ebola network: Réseau Ouest-africain de Sciences Humaines et Sociales sur Ebola.

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Contributor Notes

Emilie Venables has been based in South Africa since 2009 upon completion of her MSc and PhD from the University of Edinburgh. She also holds an undergraduate degree in Social Anthropology from the University of Cambridge and an MSc in Development Studies from SOAS, University of London. Emilie is currently affiliated with the University of Cape Town in South Africa. E-mail: emilie.venables@brussels.msf.org

Umberto Pellecchia has worked as an anthropologist for Médecins Sans Frontières since 2012. He received his PhD in Anthropology of African Societies at the University of Siena, Italy. His main interests are the interplays between global inequalities and health in the field of African societies and migration. He has carried out fieldwork in Ghana, Italy, South Sudan, Egypt, Liberia and Malawi. E-mail: u.pellecchia@gmail.com

Anthropology in Action

Journal for Applied Anthropology in Policy and Practice

  • Abramowitz, S. (2014), ‘Ten Things That Anthropologists Can Do to Fight the West African Ebola Epidemic’, http://somatosphere.net/2014/09/ten-things-that-anthropologists-can-do-to-fight-thewest-african-ebola-epidemic.html.

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