Ebola: How a People's Science Helped End an Epidemic - Paul Richards (2016)

NOTES

Introduction

1Properly Ebola Virus Disease, or EVD. I will continue to use the short form. Ebola is the name of a river in the Democratic Republic of Congo, and it was chosen to avoid the risk of stigmatizing the small town, 60 kilometres distant, where the first known outbreak occurred (BBC News Magazine, 18 July 2014).

2www.ibtimes.co.uk/ebola-discoverer-peter-piot-i-would-sit-next-infected-person-tube-1459154, 31 July 2014.

3A second countdown was completed on 17 March 2016, the day a further case cluster was reported in Guinea.

4 Douglas (1992).

5I owe the phrase to Daniel B. Cohen.

6Mauss (1973 [1935]).

7Durkheim (1995 [1912]).

8Schlanger (2006).

9There is better news on vaccines. One vaccine candidate has been shown to be promisingly effective (Henao-Restrepo et al. 2015) when deployed via ‘ring vaccination’ to protect those with high exposure to the disease (mainly family carers and medical responders).

10Hobart (1993).

11The archaism was probably deliberate. Upper Volta (the former name for Burkina Faso) was a stand-in for any remote part of Africa of little conceivable interest to the UK government.

12Dant (2005).

13Richards (1985).

14O’Carroll (2015).

1 The world’s first Ebola epidemic

1Hewlett and Hewlett (2008).

2Richards et al. (2015).

3Weber (1930), Tawney (1977 [1926]).

4Durkheim (1995 [1912]).

5For example Karan and Pogge (2015).

6As offered by the neo-Durkheimian sociologist Randall Collins (2004).

7Oosterhoff et al. (2015).

8Fallah et al. (2015).

9On the other hand, the less densely populated peri-urban fringes of the three capital cities proved to be rather fertile terrain for Ebola spread. Numbers of cases were significantly higher per head of population in peri-urban Freetown than in the inner-city slums, for example (author’s unpublished data).

10See the section on literature in the entry for Ebola Virus Disease in Wikipedia (en.wikipedia.org/wiki/Ebola_virus_disease#Literature).

11Patent US 20120251502 A1, ‘Human Ebola virus species and compositions and methods thereof”, filing date: 26 October 2009.

12As alleged in a report in the Iraqi newspaper al Sabaah (‘Daash Ebola transferred to Mosul’, 31 December 2014), citing an unnamed source.

13www.who.int/csr/disease/ebola/overview-august-2014/en/.

14Kamins et al. (2011).

15Recent work in Sierra Leone establishes that bat eating is quite common in some communities (personal communication, Roland Suluku).

16One of these stories comes from villagers on the Guinea border in Kissy Teng, who speak of an earlier case of a woman who showed Ebola-like symptoms and later recovered (fieldwork, March 2016).

17Gire et al. (2014).

18Park et al. (2015).

19Ibid., p. 1518.

20Ibid.

21As remarked by Bob Geldof.

22Stadler et al. (2014).

23Maxmen (2015).

2 The epidemic’s rise and decline

1Lovejoy (2005: 95).

2Fairhead et al. (2003).

3A system of indirect rule (rule through indigenous institutions) modelled on that prevailing in the protectorate of Sierra Leone was adopted by Liberia at the end of the first decade of the twentieth century as a framework for more effective administration of interior districts.

4For one account see ‘Womey massacre’ at en.wikipedia.org/wiki/Womey_Massacre.

5Baize et al. (2014).

6Focus 1000 (2014a, 2014b).

7Richards et al. (2015), questionnaire responses, survey data sets, December 2014.

8The first Ebola cases in Sierra Leone emerged (in March 2014) in two villages close to a crossing point on the Moa river at Nongowa, a small Guinean town important in the regional trade in kola nuts.

9When I visited Sandeyalu (Kissi Kama chiefdom) in 2002, shortly after the end of the civil war in Sierra Leone, schoolchildren in the village greeted me in French. English and Krio were languages they associated with their older siblings. Hitherto, they had known only refugee life in Guinea.

10Alldridge (1901: 215).

11Not to be confused with Koidu, the commercial centre of the diamond district of Kono.

12Hoku = Aku (we greet), the name by which (Nigerian) Yoruba people are often known in Sierra Leone. Lapa derives from Dutch (lappen - pieces [of cloth]). This is presumably a linguistic relic of Dutch cloth traders based at Cape Mount in the mid-seventeenth century.

13The town was hugely damaged during the war, and even today is but a shadow of its former self. Many Guinea traders abandoned their large houses in Koindu and relocated to the Guinean side of the border. This helps account for the large recent rise in the population of Gueckedou.

14Currently, the road reaches Pendembu, about twenty-five kilometres from Kailahun.

15Villagers interviewed in Kisi Teng chiefdom in March 2016 claimed the first case of Ebola (in Sokuma) pre-dated the reported origin of the epidemic in Guinea in December 2013. This suggests that more remains to be discovered about the origins of the epidemic than has so far been reported. But there seems little doubt that cross-border networking, by Kissi villagers, by Mandingo and Fula traders, and by local medical practitioners, played a significant part in the early spread.

16Interview with paramount chief of Jawei chiefdom, May 2015 (see Chapter 6).

17Ibid.

18Henao-Restrepo et al. (2015).

19www.who.int/csr/disease/ebola/situation-reports/en/.

20Hewlett and Hewlett (2008).

21Ministry of Social Welfare et al. (2014).

22Abramowitz et al. (2015).

23Mogelson (2015).

24O’Carroll (2015).

25CDC (2014).

26MSF, Liberia, 20 January 2015, Sierra Leone, 24 January 2015.

27Scarpino et al. (2014); see also Weitz and Dushoff (2015).

28Richards et al. (2015).

29Fithen and Richards (2005).

3 Washing the dead

1The Australian, 6 November 2014.

2Interview by Associated Press, 4 December 2014.

3‘Dumped like an animal’: Women’s focus group, Fengehun, Kakua, December 2014.

4The interested reader is referred to the excellent analysis by Kuper (1998).

5Geertz (1983).

6Durkheim (1995 [1912]).

7Ibid., p. 218.

8Berger and Turow (2011).

9Kuper (1998); Douglas (2004).

10Durkheim and Mauss (1963 [1902/03]).

11Mauss (1973 [1935]).

12And how is the bucket carried?; see Van der Niet (2009).

13Richards et al. (2015).

14Women elders, Peri-Fefewabu, Gaura chiefdom, Kenema District, a village with direct experience of Ebola cases, December 2014.

15From the field report of Fomba Kanneh, Bo-Gaura, Kenema District, December 2014.

16Picton (2000).

17Nuijten et al. (2009).

18Nuijten and Richards (2011).

19Mokuwa (2015).

20These voices (to be analysed below) were eventually heard via the Ebola Response Anthropology website. Some later burial teams were then recruited and trained locally. An example is the burial team in Kamajei chiefdom, trained in a nearby chiefdom headquarters, Mano (interview with the town chief, Mamawa Tarawali, in Mogbuama, Kamajei chiefdom, 27 March 2016).

4 Ebola in rural Sierra Leone

1Sterne (2003).

2McFeat (1972); Brooks (1995 [1975]).

3Douglas (1986).

4Gustav Holst, Seven Parts Songs for Female Voice, Chorus and Strings, Op. 44.

5Cumulative confirmed Ebola cases in Sierra Leone at 24 December 2015 were 8,704. About half of these were recorded in urban areas.

6Richards (1986).

7Summaries of questionnaire responses and transcripts of focus group sessions are available in the form of appendices to eight reports written for the Social Mobilization Action Consortium (SMAC) funded by UK Aid, and posted to the Ebola Response Anthropology Platform website (www.ebola-anthropology.net).

8Gender does not appear to be a significant variable in explaining variations in responses to these two questions.

9The differences between the answers to the two questions are statistically significant at the 95 per cent confidence level.

10Senehum-Buima, a forest-edge village in Gaura chiefdom, December 2014.

11The difference is statistically significant, according to the Fisher exact test, at the 95 per cent confidence level.

12Richards et al. (2015).

13Oosterhoff et al. (2015).

14Numbers were sometimes lower in smaller villages, where all available adults were interviewed.

15There was one missing answer.

16Bo-Gaura, all groups.

17Bawuya, female youth.

18Peri Fefewabu, various youths.

19Bawuya, female youth leader.

20Richards (1986).

5 Burial technique

1Bawuya, Kori, youth group. A similar practice - the ‘washing’ of widows - is described in detail in Ferme (2001) for a Mende village in Wunde chiefdom.

2WHO (2014b).

3Foindu, Yoni, youth group.

4Ibid.

5Male elders, Bo-Gaura, Gola forest.

6Mogbuama, Kamajei.

7Moyamba Junction, youths.

8Peri Fefewabu, youth group.

9Mobai, Kamajei, male elders.

10Bo, December 2014.

11Male, age twenty-one, Bo, December 2014.

12I owe the notion of the ‘invention of ignorance’ to the title of a book by Mark Hobart (1993).

13WHO (2014b).

14Parsons (1997).

15Ibid., Abstract.

16For example: ‘The Ebola outbreak in West Africa has claimed the lives of over 9000 people largely due to a combination of poor health care infrastructure in affected countries, traditional beliefs and cultural practices, including the consumption of bushmeat and certain burial rituals that have amplified transmission’ (Karan and Pogge 2015).

17But on occasion, Ebola survivors did speak about harassment: ‘they … come with guns to threaten us, and when you are diagnosed to have Ebola, they arrest you. That alone makes you to be depressed, and not for the disease but [because] of the forces surrounding [you]. The entire family [is] looked at negatively.’ (Ebola survivor, interviewed in Bo town, December 2014.)

18Several times I heard the comment that the slow process of ending Ebola infection pathways in Sierra Leone owed something to local political in-fighting.

19Ebola survivor, female, age thirty, Bo, December 2014.

20Ebola survivor, female, age twenty, Bo, December 2014, younger sister of the person cited above.

21Lamontagne et al. (2014).

22Hewlett and Hewlett (2008).

23Cohen (2014).

24Foindu, Yoni, Tonkolili District, youth group, December 2014.

6 Community responses to Ebola

1Geertz (1983).

2Focus 1000 (2014a, 2014b).

3The account was given to the author by Paramount Chief Musa Ngombuka Kallon II, of Jawei chiefdom, in an interview in Daru on 22 May 2015.

4Enquiries (March 2016) in Kpondu, a village in Kissy Teng chiefdom, close to the Guinea border, suggests this may have been the first place in Sierra Leone with an Ebola outbreak. People here date the first case to March 2014. The village schoolteacher compiled a record as events unfolded, and recorded over twenty cases up until August 2014, after which there were no further cases. A young man who survived the disease told us he was taken to the ETC in Gueckedou (Gegedu) in Guinea because the facility in Kailahun had not yet been built.

5The date in my field notes is 25 May 2014, but it is not clear whether this was the date on which Nurse M. travelled to Daru or the date she first became ill. An article by Abdul R. Thomas, in the Sierra Leone Telegraph, 28 May 2014, cites a radio interview by Brima Kargbo (government Chief Medical Officer) as stating that ‘Three people of the same family have died of the deadly Ebola virus in Sokoma village, Kissy Teng chiefdom. The first victim was a female herbalist who has frequently been travelling to Guinea. The herbalist died three weeks ago … The Ministry of Health was informed on 22nd May’ … Seven other suspected cases were also reported, after they had attended funerals. Nurse M. appears to have been infected when these subsequent cases were brought to the Koindu Community Health Centre. Sokoma is the neighbouring village to Kpondu. Villagers in Kpondu claimed their own village was first infected.

6The Njala-Giema case is currently being followed up by an Njala research team. We were told (23 February 2016) that there were eighty-nine Ebola cases in all (twenty-one survivors) in a period beginning in early June 2014. Located on the road from Daru to Joru skirting the northern margins of the Gola forest, Njala Giema is a typical compact, medium-sized, somewhat isolated Mende forest-edge village. Transporters found ways to bypass the village, which ran short of salt as a result. Ebola cases represented between a quarter to a third of all adults. Every residential quarter had infections. It seems probable most adults were high-risk contacts. Infection transmission may have been ended by isolation and quarantine, perhaps combined with some element of acquired immunity (O’Carroll 2015).

7This was before emergency legislation required all burial to be carried out by official burial teams.

8Dr Sheik Umar Khan was the country’s leading Lassa fever specialist. Later he too caught Ebola, and died on 29 July 2014, a shattering and demoralizing loss, felt throughout the country and internationally.

9Interview by the author with task force members, Daru, 20 October 2015.

10See ‘How Kailahun District kicked Ebola out’, WHO December 2014, www.who.int/features/2014/kailahun-beats-ebola/en/.

11Jedrej (1974, 1976a, 1976b).

12www.ebola-anthropology.net.

13Sharma et al. (2014).

14A similar positive response to makeshift community treatment centres in Sierra Leone is reported by Oosterhoff et al. (2015). These were intended as temporary holding centres, but owing to the rise in the number of cases became alternatives to more distant ETCs, and were staffed by local workers, not all of whom were medically trained. But with workers recruited locally families could easily get information about a patient’s progress, and even at times see or talk to loved ones through the open-sided tents. This reduced fear of the disease and stemmed rumours about the hidden purposes of distant ETCs (e.g. fear of organ harvesting).

15Picton (2000).

16Richards et al. (2009).

1730 June and 1 July 2014.

18Mogelson (2015).

19Abramowitz et al. (2015).

20Ibid., p. 1.

21Ibid., p. 3.

22Ibid., p. 8.

23Ibid.

24Ibid., p. 9.

25Ibid., p. 11.

26Ibid.

27Ibid.

28Reported by CNN at http://edition.cnn.com/2014/09/25/health/ebola-fatu-family/index.html.

29CLEA (2014) Community-Led Ebola Action field guide for community mobilisers, Freetown, Community Mobilization Action Consortium (SMAC), GOAL and Restless Development.

30This point is now explicitly recognized in a very interesting discussion of ethical challenges raised by the West African Ebola epidemic by Calain and Poncin (2015).

31Abramowitz et al. (2015).

32Richards (2015).

33James (2003).

34A celebrated paper by the German sociologist Georg Simmel (1906) first proposed that secret societies, as a sociological phenomenon, were an organizational reaction to conditions of high external insecurity. Although Simmel’s paper is lacking in ethnographic detail, he mentions the existence of African secret societies, and may have had some knowledge of Poro and Sande from the well-informed descriptions of these sodalities in a book on Western Liberia by the Swiss zoologist Buettikofer, published in German in the 1890s (Richards 2015).

35Richards (2015).

36Douglas (2007).

37Douglas (1993).

38However, it is worth adding that dancing can offer a number of important back channels for communication. See, for example, Adam Zamoyski’s entertaining account of the dances and social occasions attached to the Congress of Vienna, where the post-Napoleonic future of Europe was negotiated, through which a number of informal diplomatic understandings were facilitated (Zamoyski 2001).

39Mogbuama, Kamajei, women’s focus group.

Conclusion

1This book thus differs from my earlier Indigenous Agricultural Revolution (Richards 1985), where crop selection by African farmers was shown to out-compete international crop science in local conditions. In this earlier case, both parties were rich in prior knowledge. The present case is one in which both parties started from positions of considerable ignorance.

2Richards (2015).

3Some of these issues are addressed in an important assessment of lessons learned from Ebola, Moon et al. (2015). This report flags but does not elaborate on the importance of community response.

4All three countries had completed the time period without cases for the region to be declared free of Ebola by 17 March 2016, the day on which a new case cluster emerged in southern Guinea traced to lingering infection in a survivor. Three new cases in Liberia were also linked to this outbreak. Rapid containment measures have been put in place, including ring vaccination among high-risk contacts. Other similar isolated cases are expected to emerge, probably mainly through sexual transmission, and these could ignite new infection chains where (as appears to have been the case just mentioned) ‘safe burial’ was neglected.