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Paul Richards And Esther Mokuwa On Lessons Learned During The Ebola Epidemic

Mar 16, 2018

When the Ebola virus spread rapidly throughout parts of West Africa in 2014, epidemiologists faced the challenge of containing a disease they knew little about. But their biggest blind spots were cultural and historical realities in Guinea, Sierra Leone and Liberia that should have been taken into account during the crisis. That’s according to anthropologist Paul Richards, who wrote about the topic in his recent book, “Ebola: How a People's Science Helped End an Epidemic.”

“Some of these projects, with all the best will in the world, they kind of mess up because they’re not really understanding the local social ordering,” Richards said in an interview with KGOU’s World Views.

Because of concerns about disease transmission, the World Health Organization (WHO), which coordinated the international response to the outbreak, created rules for disposing of the bodies of those who had succumbed to the disease. Richards’ colleague, Esther Mokuwa, explained that relatives of the dead were  upset when strangers came into their communities and prevented them from participating in the burial process.

They said, We can do it...Let them just give us the equipment. We can do it,” she said, paraphrasing what she heard from locals during the outbreak. “We can give respect to our fathers, to our mothers, because that is the only time that we have to give them their last respects.” In other words, locals were willing to change burial practices and wanted to be trained.

In November of 2014, WHO issued updated guidelines for safe burials, mandating the inclusion of family members and observance of local culture.

In many cases, communities had their own protocols because they had been dealing with the disease on their own before WHO stepped in. Sometimes, Richards said, they took matters into their own hands because they could not wait the four days it generally took burial teams to arrive, given the region’s hot climate. He and Mokuwa maintain that building on the local response would have been better than a top-down approach.

Much has been learned since 2014. Epidemiologists now know more about how Ebola spreads, and WHO recently developed a plan for accelerating drug development for future epidemics. WHO also commissioned an independent review of the Ebola response after criticism that the organization waited too long to declare a global health emergency. That report stated that WHO “was inadequately informed about cultural factors relevant to outbreak control.”

Mokuwa assists in a wide range of projects in West Africa, bridging the gap between foreigners and locals. Richards’ book contrasts most accounts of the Ebola epidemic by acknowledging local responses to the disease and countering the mainstream narrative surrounding the 2014 outbreak. 

INTERVIEW HIGHLIGHTS

Richards gives an example of overlooked social norms in Sierra Leone:

I tried to explain about, for example, kinship relations, the issue that the women move from their own village to their husband’s villages, but marriage is a process. It doesn't happen overnight. It's not you go and get married, and then you're married. It's something that happens over 30, 40 years. It's an obligation in return for the gift of a wife. You take responsibility for your wife's parents. So you have to do work, or send money and food, and so on for the in-laws, for the father-in-law, the mother-in-law. If you don't do those things, you're not completely married. So a Mende woman will often say, if you ask her, “Are you married?” she says, “Time will tell.” She doesn't know the marriage is yet complete because all the responsibilities have not been discharged. If you don't fulfill those responsibilities, you don't have the right to bury your wife. The body of the wife has to go back to the family, to the brothers, or the father, and they will arrange for the burial, which potentially means that the bodies are traveling from village to village. And if these are Ebola-affected bodies they could be very dangerous.

Mokuwa on how locals communicated crucial information as the epidemic spread:

The community themselves, we are watching each other. If somebody is sick they have to go and tell the chief, and the chief has to go and tell the task force people and so forth. So the community, also we are involved… If there's any new person in the community, or if I have a stranger I have to go inform the chief that my sister has come to visit me and so forth. If I don't do it there's a fine and so forth, or my neighbor will go and tell the chief what is happening…something like that.

Richards on how burials could have been better handled:

The initial response was that the international community would train safe burial teams. So they were given protective gear to wear, and they were taught how to handle corpses safely so that they were not a risk to other people. The training was good, and the equipment was effective. But they recruited people and trained them in towns, and they brought them out into the country. So what the people in the villages said was, “We don't know these people, and if you're burying someone you should really have a social relationship with that person.” You know the consequences of their death. And then they said what Ester's just said: Why don't you train our local people? Because they saw that the people they recruited in town were very similar in terms of educational background and so on and so forth. It was just that they were strangers, and they were not locally intimate with the people. They said if there had been local people they would have done it much more respectfully and carefully. They would have communicated with us. We would have been able to devise some kind of local burial ceremony. Even though we couldn't actually handle the corpse, we could have all done it together. We could have prayed together and so on so forth.

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TRANSCRIPT

Cruise: Esther Mokua and Paul Richards, welcome to World Views.

Richards: Thank you.

Mokua: Thank you.

Cruise: Well, you both are researchers and experts on many development issues, but one of the issues that you have recently investigated is the Ebola outbreak in Africa, specifically in Sierra Leone and the neighboring area. And, for our listeners they may not remember entirely what happened, we're talking about an outbreak around 2014 that started in that area and then did begin to spread. A number of casualties, many many more infected. Can you give us a little bit of a reminder of what the situation was?

Richards: Okay. The epidemic first broke out in Guinea, in an area bordering Sierra Leone and Liberia. So it quickly spread over the border. So that was the end of 2013. It was spreading more or less undetected until the middle of 2014, and then it was reported by the governments in the region, the three governments, Liberia, Sierra Leone, Guinea, and the World Health Organization then declared a public health emergency of international concern in August 2014. By that stage it was obvious that there was going to be a full blown epidemic. The cases were doubling every week. And international alarm bells were sounded. One or two passengers infected with Ebola got on international flights and ended up in the United States or in Europe. So the epidemic peaked in all three countries in the later part of 2014. Numbers started to decline from the beginning of 2015, and control measures were intensified. So the epidemic then ended towards the end of 2015.

Cruise: What sort of control measures are we talking about here? What was done that finally was able to kind of get this all under control?

Richards: One of the first things that happened was that local communities mobilized against the disease. They were assisted by the authorities and by some international responders right from the beginning, but there was a big pushback in some of the earliest affected rural areas because there hadn't yet been any international agreement that there was an Ebola epidemic. A lot of people doubted, even in the capital cities they were denying that there was the epidemic, or that the disease was in the region. All sorts of fanciful theories flew around about... it, it was germ warfare experimentation by international governments, or it was a political rouse to affect election results and so on. So it wasn't really being taken seriously until the middle of 2014 by the national governments and by the international responders. So all the early response came really from local mobilization. Then from the middle of 2014 international resources started to be mobilized to protect against the further spread of the epidemic. And that meant that agencies like Medecins Sans Frontieres (Doctors Without Borders) came in and built what are called Ebola treatment units, which are a kind of bio-safe facilities that cut off people who were infected with the disease with, cut them off from the rest of the community. And low, and national quarantine measures were introduced. So the military forces became involved in the later part of 2014. There's still a big dispute as to which strategies worked and what contributed. [00:03:52] I personally think, and our own research shows, that the local responses were often very effective and should have been continued and built upon. But the international community thought otherwise, and they came in and implemented forcible quarantine measures for example using military agents. So there's still I think a debate about how the epidemic was ended, and it could be that it was just a natural burn out, because we don't yet know about acquired immunity. There's no strong data. There's some suggestions that people that were in contact with the disease develop natural immunity without developing symptoms, but it's very unclear as to how significant a factor that is. But if it was widespread it could have led to an actual burnout of the epidemic. So the curve of the epidemic started to fall early in 2015 and now people have more or less forgotten about it internationally and I'm afraid locally, as well.

Cruise: Well, and Esther, Paul mentioned some of these rural communities and community organizations that got together. What sort of things were they doing? What was the community response?

Mokua: Well they had community... Paul, what's the name?

Richards: Um, taskforce.

Mokua: They had a local task force. Since we are doing the burial and sending people, that they should not be in contact with... we are telling them what not to do during Ebola, that if someone is sick they should report... the community themselves, we are watching each other. If somebody is sick they have to go and tell the chief, and the chief has to go and tell the task force people and so forth. so the community, also we are involved.

Cruise: Because they know each other, and they know who is in their community...

Mokua: Yeah. They know who... yeah. If there's any new person in the community so the chief, or if I have a stranger I have to go inform the chief that my sister has come to visit me and so forth. If I don't do it there's a fine and so forth, or my neighbor will go and tell the chief... What is happening, something like that.

Cruise: So what was the response among some of these communities when the international community finally started acting? Was there some conflict there? Or what was their response?

Mokua: People, we are scared because, uh... let me say, most of these international people never went into the field. I don't have data on that, but from my own experience, when I went into the field I never saw foreign people in the community. The y  only hired these task force people, local people... people from another town coming into this. That one jalso brought som clash because people were telling me that why are they bringing people from outside to come and tell us this? why can't they take our local brothers? they know us. They know our language. For instance, if they were taking somebody...

Cruise: So it created some issues, and Paul, as you mentioned we have kind of... maybe forgotten isn't the right word, but we haven't paid much attention to this since the numbers decreased. What are the lessons that we should learn, perhaps some lessons about the interaction between the local communities and the international communities? But other lessons about how this sort of health issue spreads and how it's contained. What should we be thinking about today?

Richards:  I think those are the lessons that need to be to be learnt, and to some extent they have been learnt. I was listening to Dr. Anders Nordstrom, who was at the time the World Health Organization country director for Sierra Leone. He was speaking at a conference a few weeks ago that I attended, and he was very clear that the international community had not paid enough attention to local voices. They had not consulted enough. They haven't listened carefully enough. He said we were just telling these people what to do through megaphones, and we should have listened first. So I think that message has been accepted.

Richards: And if there were any further Ebola epidemics in Africa then I think they will be a lot better handled because these lessons have been learned. One lesson that may not have been learnt so well, because it relates to local social knowledge, is why you want to engage local actors in certain key activities. So burial was a very sensitive issue, and the initial response was that the international community would train safe burial teams. So they were given protective gear to wear, and they were taught how to handle corpses safely so that they were not a risk to other people. The training was good, and the equipment was effective. But they recruited people and trained them in towns, and they brought them out into the country. So what the people in the villages said was we don't know these people, and if you're burying someone you should really have a social relationship with that person. You know the consequences of their death. And then they said what Ester's just said: Why don't you train our local people? Because they saw that the people they recruited in town were very similar in terms of educational background and so on and so forth. It was just that they were strangers, and they were not locally intimate with the people. They said if there had been local people they would have done it much more respectfully and carefully. They would have communicated with us. We would have been able to devise some kind of local burial ceremony. Even though we couldn't actually handle the corpse, we could have all done it together. We could have prayed together and so on so forth. So that element that they were bringing outsiders and strangers... And often, because they were coming from outside, they were very delayed. And if you have someone who's died, and it's a hot climate, as you as you must understand, you cant wait three or four days for a burial team to turn up. So communities took their own decisions at that point, and maybe that actually spread the disease further, but it was because the thing was not being organized well enough at the local level. Where they did organise local burial teams it worked much better, and people cooperated. And they reported earlier, they got a death in the household and so on. But the alienation came because the people that came from 50 or 100 miles away were not known to the communities, and they were both afraid but there were also angry that they were not being involved in the response.

Mokua: And also the people they were telling me that they were young people. They were youths. And in Africa Africa out there saying it is an end up missing. Its a setup scene at age 70 so far so you have to give them declasse the rest of it. You cannot allow a youth, let me say a fifteen year old boy to just come and take part in that, in his funeral or something like that.

Cruise: Right... the need to be very sensitive to the cultural realities, and this very seriousness of the situation, and rituals and those sorts of things. So this is an issue, hopefully we do not experience an Ebola outbreak again, but hopefully we have learned some of the lessons there. And it seems like there's two things that occurred. We had a bit of a conflict between the international community and the local community, but it also sounds like there is a divide there between the rural communities and the city communities. It's very interesting that you pointed out that things were happening in the rural communities and people weren't believing that this was happening. Is that something that was the case with the Ebola outbreak but also the case with other issues, this divide with the rural land urban communities?

Richards: Well I think it's a long term issue in both Sierra Leone and Liberia. I don't know Guinea so well, so, but I think also there's evidence it is a problem in Guinea, particularly with the people that live in the forest, who are very remote from the capital ,  Conakry, and there are different ethnic background, and they tend to distrust everything that comes from the capital city. They were even at war with them in effect in the late 1990s, and the Guinea government was bombing the forest communities. So there was a lot of hostility in all three countries in rural areas to things that came from the capital, and that's kind of long term historical thing. The capitals have always been as it were somewhat predatory on the interior rural communities. And that's because of colonial, colonialism. These capital cities were gateways to French and British colonialism in the case of Guinea and Sierra Leone. You could say that the African American colonizers of Liberia were a sort of colonial group as well. So Monrovia has a similar relationship to the interior. And there's a lot of hostility and distrust, and it was recapitulated in the civil wars of the 1990s. And people would sit in the capital city, and they say Oh we hear rumors over radio that there's a rebel movement in the far flung part of eastern Sierra Leone or in northwestern Liberia. And then they say but you know this this is just, sort of, these local people they're always fighting each other. It's not serious and so on. And it took for several years before people in Freetown were serious about the civil war in their own country. And when Ebola started they said it's just the same thing all over again. It's coming from the same area. It's just these barbarians. Okay, you know let them get on with it. And that really was a problem, an internal problem. The international community probably didn't know well enough that they had to step carefully around that, that issue and build alliances with local communities. So it wasn't a good idea to be organizing everything from the city and trying to take it out. But when I've talked to people in the international response about why they did that then it was partly logistics, but it was also partly safety. So they were, they were worried about going into the interior because they didn't know really how Ebola spread and how dangerous it would be and so on. So they wanted to do the training in places that seemed to them safe. So they did it in the capital cities or the larger provincial towns, and that created, that fell into this trap that the city is often alienated from the rural areas, and those are sort of a legacy of historic, historical bitterness. In Guinea it became so bad that a team of Ebola responders were actually attacked, and some of them were killed by villagers because they were so hostile to the very notion of outsiders coming in and dealing with their problems, and forcing them into quarantine, and stopping them forcibly from burying their dead and so forth.

Cruise: Certainly very very tense issues there and a history. So you both have done research on Ebola outbreak, but you're also doing other research, particularly in some of these rural areas, and I wanted to give you a chance to tell us a little bit about that.

Mokua: We are doing research... We have been doing various research before Ebola came in. We are doing research with Gola forests. We are doing some economic baseline survey with the community and so forth. And also recently we are trying to do something about cocoa, the cocoa project wherein farmers have to do a plot farming, wherein they have a plot of land... I have my own land, you have your own land. We plant cocoa. After we've harvested our cocoa, we sell it to the project. So that's what is going on now. So, but, there's an issue over there. So I have to go and talk about the land issue, because most projects that go into these places to do agriculture activities, they are not doing well because of land issues. So when I go into communities I talk to local people and so forth... both men and women are talking to me that the land issue and so forth. So they've asked me to go back in January and really talk to the local people about the land issue. How are they going to manage, so that if ever they are trying to sell the cocoa, how best the women can also benefit from that. So I have to go there and do something. We are also doing some science shop with the community. Science shop is when you listen to the community because there are things that people know, or probably they don't know, so they're giving us their ideas. Like we are thinking about mosquito. Once we do a pilot and test in some villages... just simple pictures to show communities... to identify the mosquito that carries malaria. That's one we are now busy with.

Cruise: That's fascinating, and particularly you mention the role of women in some of these communities. That's been a trend, I would say in the last couple of decades, to focus on the importance of women in the communities and how they can benefit, because many of these issues obviously do affect women, affect women, as mothers. I would agree it's very important to talk with them and see how they are living and what experiences that they are having.

Richards: It's interesting you say mothers because one of the things that Esther's work on the land issue is focusing on is women's status as sisters. And this is missed by the international community because we don't have a very strong lineage descent group or organization that people in Sierra Leone and Liberia have. And so a woman has land rights, but she has the land rights in cooperation with her brothers. Its not her husband's land. So often the woman moves to her husband's village, and she helps him work on his land, but she will never become the owner of that land. Her own land is in her brother's village. And if a big international agribusiness comes in, they want to sign a lease with people to lend them the land for 15 years, sometimes even 49 years. And they think they're doing the right thing by paying the rents to the men, and they think that somehow the women will benefit because the women will get the spillover from the money that the man had it has in his pocket because the woman is a wife. But in fact the man will probably be spending his money on his own children. And the woman will have her own dependents and her own commitments in her original village, which is where her land comes from. And so she should be sharing in the land rents that are given to her brothers, not not to her husband. No international agency or agribusiness has yet got its head around that issue or worked out some way that it distributes rental payments. So there's disgruntlement among the women, and they say we're not getting our share, but it's because of the kinship system and the lack of understanding in the international community of how that works. So one of our jobs is to kind of research that, and to find out why some of these projects, with all the best will in the world, they kind of mess up because they're not really understanding the the local social ordering.

Cruise: That's just fascinating, and again, another example of how important it is to really understand what is going on with people in these communities and that sort of thing. So Paul, I did want to ask you you mentioned that Ebola came to the United States. I believe we had a case not too far from here in Texas or at least a scare in Texas, as well as elsewhere. You actually talked to the CDC about some of this, advised the CDC. What was your advice to them? How did you suggest that the United States deal with this issue?

Richards: Ok, this was in, I think it was August 2014, so we're right at the kind of crux of the issue when the international community is now beginning to focus, and CDC was gearing up its response. It responded earlier, but now it was clear that with the declaration, international declaration of a public health emergency of international concern. That's a kind of technical instrument that is in the power of the United Nations to declare and then everyone has to pay attention. So it was at that point that my friend who was advising the president of Sierra Leone, an American Daniel Cohen... He and I were in daily contact over this, and he was supplying technical advice to the state house in Sierra Leone on how to interpret the molecular evidence and so on. And he'd been talking to me daily about social issues, so he was convinced that the social issues were missing from the understanding of the epidemic. And, because he works from time to time with CDC, he had contacts in CDC so he said can I arrange for Paul Richards to talk to a CDC group that are responsible for the Ebola response So we had a about an hour long Skype telephone conversation, and I focused on the social issues. I tried to explain about for example kinship relations. The issue that the women move from their own village to their husbands villages, but marriage is a process. It doesn't happen overnight. It's not there you go and get married and then you're married. It's something that happens over 30 40 years. It's an obligation in return for the gift of a wife. You take responsibility for your wife's parents. So you have to do work, or send money and food, and so on for the in-laws, for the father in-law, the mother in-law. If you don't do those things, you're not completely married. So a Mende woman will often say, if you ask her, "Are you married? She says. Time will tell. She doesn't know the marriage is yet complete because all the responsibilities have not been discharged. If you don't fulfill those responsibilities, you don't have the right to bury your wife. The body of the wife has to go back to the family, to the brothers, or the father, and they will arrange for the burial, which potentially means that the bodies are traveling from village to village. And if these are Ebola-affected bodies there could be very dangerous

Cruise: And in large number...

Richards: And in large numbers. So we had to we had to get. I mean, that's just one example of why the social arrangements of these communities really are crucial for understanding how to control Ebola. So it was examples like that that we talked about during that hour, and the CDC people thanked me at the end and they said well you know you've opened our eyes. We didn't know about these things because they're all epidemiologists. They knew about Ebola. They knew far far far more than I knew about Ebola, but they didn't know about the social arrangements that might affect the spread of the virus. So that information increasingly was sort of pumped in to the international response, and I think it got better and better as time went on, because they started to understand that there were these complex social issues that they couldn't just simply trample over or disregard. They had to work with the grain of what, the way that people are organized.

Cruise: Well, I could talk to you for hours. This is fascinating work that you're doing, but we really appreciate you spending some time with us.

Richards: Okay. Thanks. It's been nice talking to you.

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