“African culture” – cute if you’re a tourist, catastrophic when you want to put a lid on Ebola, or so some international health experts and media coverage of the outbreak would have us believe.
Why do people persist with risky funeral rites, eat Ebola-harbouring bushmeat, and occasionally attack the very health workers sent to help, the news reports leave us wondering. What is the value of “traditional beliefs” when they are harmful: why can’t people just act more rationally?
The simple answer is; ask the communities. The growing number of researchers that do, find that people are acting as responsibly as they can in desperate circumstances. The lack of a properly functioning Ebola response and weak healthcare services has forced communities into rough and ready self-reliance. Faced with hotlines going unanswered, overcrowded Ebola Treatment Units (ETU), militarized quarantine areas, communities are actually looking for more information, not less.
“Communities will do the best they can given the resources they have, even if ‘un-cultural’, in moments of crisis in order to fight for a future,” a recent study exploring community responses in urban Liberia found. It noted community leaders want training so they can provide safe burials; young men are rallying to guard their neighborhoods against perceived threats; and some people, ill-advisedly, have improvised protection suits out of raincoats and plastic bags to nurse the sick.
They know, in theory, the best option is care in a hospital or ETU (although palliative care at home is tried first), the removal of sick individuals by health care teams, and proper burials. “But in the absence of open clinics and hospitals, residents are trying to assume responsibility for all aspects of healthcare in their local communities,” the study, Community-Centered Responses to Ebola in Urban Liberia, noted.
Remarkable resilience has been shown, that inadvertently can be a source of additional risk with such an infectious virus. Traumatizing decisions are made daily: do I abandon my child to die alone so the rest of my family can survive? Or, as one women quoted by researchers said: “It will be impossible that my child or husband is sick and I refused to touch them. I do not have the courage or heart to do that.”
Forget the fruit bats
The go-to-theory on Ebola’s origins, the link to bushmeat and deforestation, has been found to be an oversimplification. Nevertheless, people are aware of the messaging – whether accurate or not. In a study released this month in 25 villages in east and central Sierra Leone, the majority of respondents listed bushmeat as the main culprit in the emergence of the virus by a large margin – with body-to-body contact and the washing of corpses before burial as the main transmission routes.
Avoiding bushmeat (or game, as it is known in the rest of the world) has hurt rural livelihoods and this "inaccurate sensitization, which jarred with people’s experiences, [has been] met with suspicion”, a briefing paper by Annie Wilkinson and Melissa Leach of the Institute of Development Studies found. It is people-to-people transmission, not fruit bats, that is the problem.
The initial communication slogan was “Ebola is real” – few people now have any doubt. “But community health messaging is essentially failing to provide the kinds of ‘higher order’, practical information and training that communities are desperate for – ‘How do I manage a family of children, including infants and toddlers, in quarantine?’ ‘How do I transport someone to a hospital or clinic without promoting infection?’ … ‘What does my community do with an exposed and infectious body when the health teams do not come to collect it?’,” the Liberia study found.
Don’t insult
Fatou Mbow is a medical specialist working in Guinea, exploring the idea that when communities understand the disease, there is a better behavioral response. Working with the government and Save the Children, she holds question-and-answer sessions with groups most at risk – including healthcare staff, traditional healers and transport workers.
“The content of Ebola communication is really about do’s and don’ts, but it’s rare to see an explanation as to why, or to address what at times is the inconsistency,” she told IRIN. “You are told to come to the ETUs, but you are also told there is no treatment for Ebola; a big fuss is understandably made about corpses, but nobody explains why they are so infectious, more than with other diseases, so people are confused, at times suspicious.”
She finds “troubling” the novelty of her team’s work. The fact that “we didn’t start with this level of explaining is insulting”. She was asked by one snooty aid official whether communities can understand the science of Ebola, yet finds the questions raised in her meetings “completely rational”.
Cyvette Gibson, mayor of Paynesville, a sprawling suburb east of Liberia’s capital, Monrovia, admits that in the initial stages of the outbreak the “messages were unclear; we weren’t even sure if they were accurate”. Central government also ignored local authorities, limiting the reach of the communication strategy; the top-down approach further weakened its impact.
“Local government has a relationship with the community, information wasn’t reaching the local level because the right tools were not being used,” Gibson explained. “The thing is to continue dialoguing. I really feel that’s the only way this virus can leave us, if we deal with it at that local level.”
Ebola has exposed the crisis of governance in Guinea, Liberia and Sierra Leone; and the inadequacy of the international response. Local action and ingenuity cannot be a substitute for an effective epidemic control strategy. Communities dealing alone with the fear and confusion of the disease “are not empowered, they are desperate,” noted the Liberia study.
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