Ebola: How a People's Science Helped End an Epidemic - Paul Richards (2016)
Chapter 3. WASHING THE DEAD: DOES CULTURE SPREAD EBOLA?
Few were quite as blunt as the Australian minister for immigration and border protection, Peter Dutton, who justified an entry ban imposed on visitors to his country from Upper West Africa on the grounds that ‘West African … funeral rites make those travellers an unacceptable risk’.1 But he was not alone in implying that local cultural practices had turned an outbreak into an epidemic. A Ugandan doctor evacuated from Sierra Leone to Germany with Ebola, and a survivor of the disease, commented that ‘many locals seem unwilling to break with age-old customs such as communal dining [eating from a single plate] … [As infection mounts] people learn lessons. Unfortunately that takes a long time.’2
It was widely presumed that Ebola was spread because people in Guinea, Liberia and Sierra Leone stubbornly adhered to dangerous traditional beliefs. This led the international Ebola response to seek help from anthropologists, presumed to be experts in understanding culture, and thus (it was also presumed) well placed to help persuade people to abandon harmful ‘age-old customs’. Maybe, for example, anthropologists could help stop people washing dead bodies, or collectively eating rice from a single plate?
But this was to put the problem the wrong way round. People do not bury bodies because they want funerals. They want funerals because they have a dead body. Washing a corpse in an Ebola epidemic is a very dangerous practice. But it also turns out that epidemiologically safe burial is unsafe from a social and spiritual perspective. An unwashed body thrown in the ground in a body bag3 is likely to leave in its wake a great deal of social disquiet. The issue is both to prevent the washing, and to address the social disquiet.
The first part seems easy. The government of Sierra Leone made the washing of corpses a criminal offence, punishable by two years in jail. Liberia imposed cremation. But draconian approaches only added to social disquiet. Perhaps unsurprisingly, it was after the law against washing bodies was passed that response agencies began to refer to ‘hidden bodies’ and ‘secret funerals’. People were taking the law into their own hands. Death laid upon them a higher moral imperative. The problem, as the anthropologists tried to convey, was that staying safe in an Ebola epidemic cannot be attained without also addressing the social challenges of death. As will be shown, gaining recognition for this point of view was hard. A key conceptual difficulty had to be overcome concerning what, exactly, we mean by words like culture, tradition and belief.
Is culture a cause (of anything)?
There are many definitions of culture, but by and large anthropologists use the word to refer to shared values, patterns of behaviour and material artefacts, transmitted through learning, and deployed in social interaction. The notion of a culture is a useful descriptive device.
However, it is problematic to imply that a group of people is the outcome of its culture. It is certainly true that anthropologists, at times, tend to imply that cultures are causal in more than just a metaphorical sense, as when, for example, they speak of ‘acculturation’. This usage implies that an individual cannot perform as a member of a group until a common set of rules has been internalized. But in such cases it might be better to speak of acquiring a culture much as one acquires a language. I speak English, but it is not the case that English causes me to speak. The culture is the product of people acting as a group, and not the other way round.4
The distinguished anthropologist Clifford Geertz did more than most to promote ‘culture’ as a quasi-causal variable useful in organizing large bodies of descriptive anthropological data (something he referred to as ‘thick description’). For Geertz, there was (for example) no such thing as universal common sense. Common senses vary from society to society, since contexts differ, so Geertz5 finds it convenient to bring common sense under the rubric of culture. What he seeks to say by this move is that much of what passes for ‘common sense’ is not universally shared but applies only within a specific setting. Polar bears are dangerous animals, but it makes little sense to be scared of polar bears in a tropical forest.
When the Hewletts wrote their pioneering book on the anthropology of Ebola outbreaks, they wanted to find a way of making their account as accessible as possible to undergraduate students of medical anthropology. So they made use of the concept of culture, which was a word familiar even to beginner students of the subject. But they were aware of the trap of assuming that culture was equivalent to ‘tradition’, and determined a ‘fixed’ response to the disease. In fact, their evidence was that when people in east and central Africa were first threatened by this new and unprecedented danger, they were highly flexible in the way they went about selecting explanations.
So the Hewletts preferred not to talk about culture as such but about ‘cultural scenarios’. In the case of the Ebola outbreak at Gulu in northern Uganda, they discovered that the Acholi people had three basic models of disease, and applied them according to the nature of the evidence. Two of these scenarios relate to Acholi beliefs in spirit forces; a third approximates to epidemiological understanding. But as noted above, there was no clear explanation of what causes the epidemiological model to be chosen, except by some process of elimination. Apparently, the Acholi have a preferred order of application, because it was only when the first two models failed to explain the facts of the Ebola outbreak that the Acholi turned towards the epidemiological explanation.
Elsewhere the Hewletts use the notion of cultural scenarios both to explain why some people resist Ebola safety controls, and why others apply them. This works the notion of ‘cultural scenario’ too hard. It explains too little by trying to explain too much. A remedy to this dilemma is to recognize that culture is effect, not cause. It is Acholi experience of and response to a range of diseases that shapes their cultural scenarios, not the other way round. What the Acholi have learnt is that there are such things as epidemic diseases. Ebola and other epidemic diseases have caused the Acholi to elaborate segmented disease models, because Ebola and other epidemics do not fit the other models they have elaborated to explain other (non-epidemic) diseases.
We can apply the same thinking to the notion that funerals ‘cause’ Ebola in Upper West Africa. There is no doubt that processing the body of a dead person for burial is a major Ebola infection pathway. But to emphasize symbolic aspects at interment over techniques of body-handling results in flawed explanation. The cause of infection is washing the body – a technique of the body. Body-washing has ritualistic associations, but is primarily a practice associated with the work of the undertaker. It prepares the body for the funeral ceremony, much as one might prepare for a wedding by shaving or dressing nicely.
Nursing of the sick is an equally dangerous technique of the body, but would not so readily be described as a ritual. Insisting on rolling up body-handling processes under a single label – ‘traditional ritual’ – risks lopsided explanation, in which a continuous process – caring for the sick to the point of their final departure – is deemed purely practical in its first part but purely cultural in its second.
Insisting (as we ought) on a unified explanation for a continuous process reveals the problem. If it is stubborn to wash the dead then it is stubborn to nurse the sick. To insist otherwise blames the victim. Courageous refusal to abandon loved ones normally elicits admiration, not blame. So commentators on the Ebola epidemic, whether in Australia or elsewhere, ought to avoid stigmatizing West Africans for no other reason than that they care for their loved ones.
A better approach is to accept that rites are outcomes, not causes. Ebola prevention, whether involving the agency of local people or international responders, requires safer techniques of the body. But these techniques can be developed only by those who know what they are intended to achieve. ‘Safe burial’ as mandated by governments, and performed by trained and equipped teams from outside the community, splits apart technique and its social purpose. Better, therefore, to follow the approach suggested by local interlocutors – train us to do the safe burial, because then we can reintegrate burial within a wider social field.
If so, how could this be done? Techniques of the body serve an end. Neither a rite nor a technique stands on its own; both are embedded in a field of social relations and practices of social interaction. It is by addressing the dynamics of this social field that solutions to the dilemma of ‘secret’ and ‘super-spreader’ burials can be found. Better rites, and better technique, will result if the process of change is driven by societal considerations. But to get to a point where the practical implications of such an approach can be found, a journey is required, both through some aspects of social theory (in the remainder of this chapter) and through empirical evidence (the ethnographic details in Chapters 4 and 5).
Rites and techniques
Durkheim, Mauss and other members of the school of social science in France in the first half of the twentieth century, formed around the journal Année sociologique, saw clearly through some of the confusions and difficulties just outlined. To them, ‘ritual’ was group activity performed in a sacred register, not a cultural model, scenario or programme to be implemented. The rite was an expressive form of collective action serving to generate and recapitulate shared emotions. These feelings were then invested in sacred symbols.
Sacred symbols (totems) served as memory aids to rekindle group commitments, thus leading to the misapprehension that the symbols are causal. An observer of one of these ritual events might suppose that the flags, banners, pictures, masks and totems ‘caused’ the collective response. But this leaves out the fact that first the symbol had to be forged by investing it with group energy. Symbols are artefacts, and behind every artefact energizing techniques of the body can be discerned.
Durkheim’s own work drew on early ethnographic accounts of Australian danced rites such as the corroboree.6 From these accounts he came to understand that dance, as an expression of sacred ceremonial concerns, is not the implementation of a specific choreography; the choreography emerges from the dance. Where spontaneous dancing is based on schooled capacities for movement and gesture, patterned responses – specific styles – are likely to emerge. Durkheim’s famous description of a corroboree perfectly captures the idea: ‘passions so heated and so free from all control cannot but help spill over, from every side there is nothing but wild movements … [but then] gestures and cries tend to fall into rhythm and regularity, and from there into songs and dances’.7
It would be truer in such cases to say that collective action assumes patterns, not that the pattern causes the action. The dance is entrainment, a capacity belonging to what has been termed ‘the rhythmic brain’.8
Arguments imputing causal powers to cultural schemes have been extensively criticized by anthropologists of a Durkheimian persuasion.9 In the Durkheimian account cultures, symbolic systems and institutions arise from collective action. Sometimes organization is an emergent property of spontaneous performance; in other cases it may be consciously planned. But in every case culture is the product of organization, not the other way round. The Durkheimians argued, with much evidence, that collective values and material transformation were ‘co-produced’. As Durkheim and Mauss put it, the taxonomy of people is the taxonomy of things.10
The body was a unique reference point in the articulation of the world of people and things. At times, the body was marked or modified to convey this articulation. Group identity – conveying some messages about who could, or should, do what to whom – might literally be marked on the face in terms of scarification. Today we are more likely to do the same thing through clothes. But either way the body is an important medium for apprehending our organizational concerns.
And yet body science has been rather slow to develop, especially as an aspect of the social sciences. It was left to Marcel Mauss to explore the understanding that behind observably different techniques of the body are to be found different social contexts and modes of organization.
Understanding techniques of the body
Those who today read Mauss’s seminal essay of 193511 might initially be a little disappointed. It seems little more than a list. But in seeking to be exhaustive it guides us to look at areas we might have missed. Fashion draws attention to itself, so we might have spotted the social significance of clothes without prompting. But would we so easily have paid attention to ‘rubbing, washing, soaping’, or cleaning of the teeth?
Mauss’s paper was a manifesto. It itemized areas of attention. First in the list was sexual (gendered) division of techniques of the body (not only, he adds, division of labour by gender). Variation of techniques of the body with age, classification of techniques according to efficiency and transmission of techniques of the body by teaching and training round out his primary list.
He then gives a secondary list arranged according to the phases of life, and moments of the day. ‘Techniques of adult life’ start with ‘techniques of sleep’ which in typical Maussian manner he denies to be ‘something natural’. He knew this was not the case because during the war he had learnt to trust his horse enough to risk the unnatural act of falling asleep in the saddle. A mountain climber, he had also taught himself to sleep when roped vertically.
Predictably there is a section on ‘Techniques of care for the body: Rubbing, washing soaping’. The French (or rather the Gauls), he claims, perhaps rather dubiously, were the first to use soap. Doubtless, the British were rather late to get the habit. Mass-produced, affordable soap became common only after Lord Leverhulme devised a way to ship and process large amounts of palm oil from western Africa, and the bar of Sunlight soap was born. The date of the first emergence of ‘native soap’ made from the same ingredients (palm oil and ash) in the West African palm belt is unknown. It is not likely to be recent.
But Mauss is less interested in the origins of techniques of the body than in what we can learn from social variations in use. No technique of the body exists in a social vacuum. The point of his analysis is to establish that techniques of the body vary across social groups, countries and regions, and that these variations relate to differences in the way people are organized to perform mundane, universally necessary, activities in significantly different ways.
Everywhere people wash, but not everyone washes the same. Some go to the stream, others tip a bucket over their heads. In part, the variation is a matter of context (is there a stream?) and ancillary equipment (is there a bucket?).12
Ebola response offers an illustration. Safety protocols advise families waiting for an ambulance to set aside a drinking cup for the sole use of the patient, and to fill it by pouring, but not touching (see Chapter 6). But how many households have the necessary items to implement this advice?
An inventory of forest-edge villages close to where the first Ebola spillover occurred suggested that not every household owned a bucket.13 Assigning to a single patient extended use of a cup might similarly tax some household equipment inventories. Shortage of containers is an aspect of extreme rural poverty making nonsense of ‘safe nursing’ protocols. So issues concerning how people wash their hands, handle soap, clean their teeth and drink are of great importance in addressing the infection threat from Ebola.
The mutuality of rites and techniques
There is more to Mauss’s argument than simply to direct our attention to parts of social life we barely think about, such as who owns, or shares, a toothbrush.
The real point of his list of body technique is clear only when we return to the ways in which we classify people and things. I know one household (my own) where sharing a toothbrush and putting fresh paste on it are important signs that a marital quarrel reducing the parties to silence is about to be ended.
A funeral is an event rich in this kind of co-production; it addresses the technical problem of safely returning the body of the deceased to the ground, while at the same time resolving the social issues that the departure of the deceased has occasioned.
As will be shown in more detail later, an Ebola-mandated safe burial is problematic because in addressing a biosafety challenge it rides roughshod over the social issues. A funeral disposes of a corpse but it is also the occasion on which quarrels or debts are finally extinguished.
In rural Sierra Leone the partner will speak, in public, to the deceased wife or husband for one last time, with the onlookers, led by pastor or imam, urging that forgiveness be sought or offered. Perhaps more surprisingly, it is also a moment to settle outstanding debts: ‘One person will enter the grave to receive the body sent down by two people. They will ask all present if the deceased has to pay anyone. If someone answers, the family will pay that person the amount owed. This debt must be settled before the person is buried.’14
To wash a corpse, to help dig a grave and to carry the corpse are important expressions of social obligations. To do one’s duty brings about that indefinable quality of well-being known as ‘blessing’. To try to evade such responsibilities risks social collapse, and being haunted by the spirit of the dead. For example, a youth leader angrily expressed concern that the spread of Ebola disease has introduced a very bad practice in their communities: ‘We no longer do things in common. Even when your relative died, you do not see the body, neither the grave. We are not allowed to perform [a] ceremony, [and] we do not sympathize with others.’15
Banning funerals, we may infer, has destroyed social accountability. Each pre-Ebola funeral proclaimed the importance of such accountability by setting up a bucket from which mourners could wash off the mud from the grave (unless they did so, further deaths would follow) and into which they threw a pebble to signify attendance.
Of course, there would be no way of knowing who had thrown which pebble, but the total number of pebbles would give the bereaved an ample token that they were not alone in their grief. The community had stood shoulder to shoulder, and the pebbles proclaimed it.
To disrupt this complex articulation of body technique and social life by abrupt and uncompensated material changes – to forbid washing, to impose cremation, to burn the grave cloth instead of giving it to the last child – throws the system of social dependencies out of balance at a moment of extreme vulnerability. Maussian theory indicates that ways need to be found to allow rites and techniques to co-evolve.
Washing the body
With the bucket safely arrived in the picture, we can now explore the scope of the technical field it heralds – namely, washing the body. This is one of Mauss’s list of unexamined techniques of the body about which we might want to know more in comparative terms. It will lead us towards the bugbear of Ebola response – washing of corpses.
Washing is a daily mundane activity. It helps us clean off the dirt and stress of work, and aids sleep. Small children, and very frail old people, are washed; others wash themselves, except if sick or injured, when (typically) marriage partners or very close companions will help.
The observer will quickly note quite a lot of variation in the modalities of washing, dependent on local resources and preferences. Variables include location and climate, whether the water comes to the house or a person washes at pump or stream, whether water is heated (something reflecting the availability of labour and fuel), and (in cases of ill health) on the type of sickness (the body may need to be steamed or cooled).
The field worker’s notebooks are starting to fill.
Specific protocols and sub-routines for special body parts (for hair, eyes, teeth) will inevitably attract further attention, as will the vast array of ancillary technologies and specialist trades associated with washing. An army of craft producers prepares calabashes, buckets, ‘sapo’ (scrubbing materials) and soap, storage containers and drying materials, and builds shelter from the elements and screens for privacy, on and up to the plumbers and other specialists who sort out the en suite bathroom plumbing, piped water and blocked drains.
But little of this ancillary technology will make sense without first specifying the locally accepted or preferred body washing routines. I am of a generation in which British tourists had to have the concept and purpose of a bidet explained to them; even at that, usage outcomes might be quite variable.
Washing also attracts a vast array of secondary cultural attachments, none of which actually causes washing, unless your mother is exceptionally determined. This includes entire complex families of emotional and normative associations (‘Johnny, you will wash your hands, or get no supper’, ‘you will sleep better if you wash first’, ‘cleanliness is next to godliness’).
Furthermore, the student of technique, now thinking comparatively, will eventually conclude that the experience of washing is well nigh universal (except for maybe hermits and religious ascetics) and that it lasts a lifetime, and beyond.
Understandably, the desire to wash the body at death seems irresistible, to wipe away the signs of life’s last struggles, and to prepare the corpse for its last journey. It is a natural reaction on the part of survivors, many of whom will have daily assisted the deceased to wash through the best part of a lifetime. It readily takes on symbolic or ritual associations. But the primary impulse is to wash the body for one last time. What could be more normal and practical?
This is borne out by the fact that we now know, from comparative anthropological work on Ebola, which highlights washing of corpses because it is a major infection pathway, that corpse-washing is found right across the African continent, and perhaps across the entire planet.
What the Hewletts write about body-washing among the Acholi would be very similar to what an ethnographer of the Mende in Upper West Africa might write. The Acholi are a Nilotic cattle-keeping people, the Mende of eastern Sierra Leone are forest rice planters, with hardly a cow to be seen, except on a butcher’s hook. They are separated by a distance as great as the distance of London from Freetown. And yet accounts of Acholi and Mende washing of corpses are almost identical. This is not some kind of bizarre cultural ritual, as some Ebola responders seemed to imply, but a normal end to a human life.
For Marcel Mauss techniques of the body were integral to the articulation of social and material life. The body was not just a tool of human performance, but also a tool for the generation, and regeneration, of social life. How the body articulates social and material dimensions of human existence bears further scrutiny. An example of this co-production of the social and material may help illuminate some of the specificities, as far as life in rural districts of Ebola-affected Upper West Africa is concerned.
Throughout the region the basic staple is rice. Households and communities are shaped around obtaining rice and eating it. In Mende thought, rice is synonymous with eating. I used to marvel at my research assistant, who ate every item of food on offer as we went on our daily survey rounds, and would then return home in the evening to say he had eaten nothing all day. He meant he had not yet eaten rice.
Closely observing how farmers select suitable rices enables us to trace out especially clearly the relation between techniques of the body and the cooperative social relations underpinning productive activity in a typical village community.
Some rices are deliberately introduced from elsewhere. They come with a recommendation, perhaps from a friend, community leader or merchant. In the language of neural network engineers, this is ‘supervised learning’.16 But West Africa also has its own rice – African rice. This is a distinct species (Oryza glaberrima), closely related, genetically, to a plant that grows wild in swamps and marshlands across the region. West Africans have gathered this wild rice for millennia.
Handling gathered grain led to spillage, and the rice planted itself around the homestead. Later, these handy patches of self-planted rice types were further selected for deliberate cultivation. The plant was changed by this selection into one better suited for farming. For example, selected types were less likely to shatter (lose seeds from the panicle) when handled for harvesting. A cultivar had been shaped by human practices. This was a product of unsupervised learning.
Later, the slave trade introduced rices from both East and South Asia. These were seed types which merchants, and even governments, had had a hand in promoting, thus products of supervised learning. But they grew alongside the local African rices, often in the same field, owing to mechanical mixing at harvest, and thus gene flow took place between products of both supervised and unsupervised learning. A number of distinctive farmer rice types began to emerge.
How were these farmer hybrids made? The available evidence suggests via crossing in farmers’ fields.17 For a spontaneous rice hybrid to arise there must be natural gene flow. Gene flow between rices is ten times higher in-field than between fields.18 Thus for an inter-specific farmer hybrid African rice to emerge the African parent must be growing in the same field along with an Asian rice.
To understand these selection processes requires an account of the details of the techniques of the body deployed in rice seed harvesting and post-harvest processing, and how these activities are socially organized. Selection of seed for planting begins at harvest, and continues in storage (though rats may at times deselect what the farmer has reserved).
Who selects the seed to save? The rice harvest in a typical West African rice zone village is a distributed social event – it happens over a period, and the workforce varies. This is because the activity needs labour, but this is generally not paid, except in rice. The harvesting team will be mixed group of relatives, dependents and friends of the field owner (both men and women). The standard technique for harvesting deployed in many communities, even to this day, is to collect the panicles one by one, using a small knife, or sliver of sharpened bamboo. Reaping – bunch harvesting with a sickle – is found in some communities, but is a recent introduction.
Panicle harvesting allows off-types (rices that are morphologically different from the one planted) to be selected separately (and left in-field if not yet ripe). Off-types first survive selection at weeding, but only if the women of the farm (the experts in weeding) choose to leave them. I was once thrown out of a weeding party, because the women judged that as a man I was not percipient (or careful) enough to recognize immature rice among very similar grassy weeds.
Older food-insecure women, e.g. widows, often help with harvesting on the farm of a kinsman or in-law, and are rewarded by an allowance of what they harvest. Some might choose to involve themselves in sorting out the off-types that have been accidentally gathered into the bunches of rice waiting to be threshed. This is sometimes a necessary task since off-types may be harder to clean than the main variety. They might also choose to glean the freshly harvested field, and so keep any interesting off-types still ripening.
Thus the custodians of off-types are typically poorer, older, less strong women (and men) embedded within larger social units. Their existence becomes apparent from careful survey work on the composition of quarters, rather than through surveys of households, since many prefer to live independently, if they can. They comprise a class of farm helpers, rather than farmers, commanding less labour from others and with declining strength themselves.
If members of this group wish to plant rice for their own food security they have no capacity to fell the bush, or hire strong men as labourers. Thus they depend on ‘borrowing’ land that has already been cleared and cultivated, and is thus low in soil fertility. Such farmers are interested in any robust seed types that perform well on poor soil. In countries such as Sierra Leone and Guinea-Bissau, where farmer hybrids are particularly common, these rices have spread widely in areas of poor soils, or where other material constraints on farming have been experienced, such as isolation during times of war.19
What we get from this example is a sense of the manner in which techniques of the body, social organization and food security outcomes are co-produced. Particular configurations of body technique (e.g. panicle harvesting) and social values (e.g. opening up of spaces for widows to live independently, within the framework of the kin-group residential quarter rather than the household) go hand in hand. The specific forms of embodied technique, collective action and social organization have been co-produced, and largely through unsupervised learning. They are not consciously designed, but emerge through what people do.
Understanding of the co-production of techniques of the body and forms of social life is essential for a grasp of the challenges posed by Ebola. These are both social and medical. Responders have not always fully appreciated this intimate connection. Preaching against funerals (arguing that the Ebola problem is driven by a stubborn adherence to cultural norms) is potentially counterproductive, since it fails to take account of the larger social field within which funeral techniques (or cultural practices more generally) are embedded. ‘Safe burial’ is the major case in point.
In Sierra Leone burial teams were (at first) recruited, trained and equipped in towns. Once problems with transport had been overcome, the teams often performed with skill, dedication and courage. But all burials had to be treated as Ebola burials, and the busy urban-based burial teams had no social connection with those they interred. By November 2014 Ebola responders had become aware that there was huge resentment of ‘safe burial’, and the WHO mandated a new approach, based on ‘safe and respectful burial’. Religious leaders were attached to burial teams to lead prayers. But respect was an add-on, not integral to the co-production of techniques of the body and collective action.
A better approach would have been to embrace local participation, and to allow techniques and social meanings to co-evolve, as they did in the rice example discussed above. Collective action, social signification and safer techniques of the body would then march hand in hand. The argument is more fully elaborated in the following two chapers.
This chapter has outlined arguments for rejecting the idea that traditional culture caused Ebola Virus Disease to spread. Culture is epiphenomenal; it is a symptom, not a cause. Burials create pathways for virus spread, but so do several other, more mundane activities, not least practices of caring for the sick. So it is not helpful to distinguish ritual from practical aspects, and to invest the former with the sense of something exotic or bizarre. Both funerals and nursing are better viewed with a single explanatory lens – as techniques of the body. In turn, techniques of the body need to be understood as essential human resources in the co-production of material and social life. This provides us with a different analytical framework for assessing the problem of community Ebola response. In Chapters 4 and 5 it will be shown, by case study evidence from Sierra Leone, that where Ebola response initiatives – such as safe burial – were resisted or questioned this was not out of perverse adherence to tradition, but because imposed measures threatened the cooperative basis of social life. Communities argued strongly for training in safe burial, in order to adapt it to local social needs.20 Understanding material and social co-production – it is suggested – is an important key to effective Ebola response.