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

Chapter 6. COMMUNITY RESPONSES TO EBOLA

Ebola control is predicated upon six key factors: identification of the virus, extraction of the patient, application of safe nursing techniques, tracing and quarantining of close contacts, and safe burial. A major issue for epidemic control was whether or not communities could change their approach to care of the sick and burial of the dead. This meant the population had to rethink familiar and established techniques of the body – in both nursing and in handling the dead – to prevent transmission of the virus.

Addressing the first three factors depended in large part on resources brought by the international Ebola response. These included mobile laboratories, testing procedures, telephonic and transport equipment to report cases and safely transport patients, and purpose-built Ebola treatment units, and medical and logistical personnel to deploy these items. The tracing and quarantining of contacts and safe burial, however, raise a large number of social issues. The international response did not bring, by and large, personnel or resources to deal with social issues, since these are often highly contextual.

For Sierra Leone, UK Aid recruited British National Health Service volunteers, and units from the British army. The Americans and French governments did likewise in Liberia and Guinea. Such people had transferable skills, and could learn quickly and train others in how to address the biosafety, logistical and human security aspects of the epidemic. It would not, however, have made much sense to bring volunteers from the UK Department of Social Security (for example), because expertise in the management of social issues depends on local knowledge. So a question was how was this local knowledge to be mobilized.

Social mobilization was needed to create an environment in which biosafety control measure would be accepted and enhanced. Was there expertise to address these kinds of social challenges? The social sciences are less strongly supported relative to other areas of scientific knowledge formation globally, but especially in Africa, where sometimes politicians equate social investigation with political opposition. Much necessary social knowledge is locked up in the heads and practices of people in communities, and remains largely undocumented. Perhaps nowhere was this more true (as pointed out above) than in the case of burial. How, then, given a dearth of documented, evidence-based information, was a social response to Ebola to be organized?

Given that Ebola was a new disease in the region it was assumed by those coordinating the response that a priority would be to supply information. International responders displayed little confidence in the capacity of local populations to learn quickly about biosafety risks for themselves. This chapter will argue that too much emphasis at the outset of epidemic response was placed on messaging. However, the international responders were ignorant of how an epidemic of Ebola would play out, since this was the first time such an event had occurred. Some of the messaging was wrong, and undermined the confidence of communities in what they were being told. More attention, it will be argued, might usefully have been paid to the concept of local knowledge, and specifically the question of how experience is formed in the face of unprecedented circumstances. In this regard, the scholarly community, where a large part of writing on the region has been dominated by anthropologists, historians and others trained in the tradition of the humanities, was not well set up to support the Ebola response, having for the most part operated on the basis that local knowledge was cultural knowledge, in the sense defined by Geertz.1 People’s science was not its strongest suit.

The present chapter will suggest that in the event there was an effective community push-back against Ebola, based not on culture but on a capacity for rapid evidence-based local learning. This was in effect a people’s science of Ebola control, and depended on assessing biosafety risks freed from prior cultural assumptions. The purpose of the chapter is to suggest that this local empiricism was a significant factor in ending the epidemic, to explore how it worked, and to propose that agencies charged with coordinating Ebola response should in future more fully embrace the possibility of rapid local evidence-based learning, and figure it into their thinking about epidemic control.

Messaging: a false start?

In September 2014, as the big international push against Ebola got under way, WHO produced a document entitled ‘Key messages for social mobilization and community engagement in intense transmission areas’. This set the agenda for Ebola control based on what the document calls ‘the messaging approach’.

This approach, the document explained, is ‘driven by the need to be empathetic, action oriented (promoting specific preventive behaviors) and focused on the informational and emotional needs of people and communities’. Some of the supplied messages were models of concise, accurate information: ‘Ebola enters your body through your mouth, nose and eyes, or a break in the skin. To catch Ebola you must touch the body fluids of a person with Ebola and then with dirty hands touch your eyes, nose or mouth. Bodily fluids include sweat, stools, vomit, urine, semen, vaginal fluid and blood.’ Others were perhaps more dubious: ‘Ebola is spread to humans from animals like bats and monkeys. People can catch the disease touching or eating a sick or dead animal,’ though it was correctly added ‘that now Ebola is in the human population it is being spread from human to human’. But nothing was said about how the informational or emotional needs of the population had been assessed, how empathy was to be acquired, or how specific preventive behaviours were to be promoted.

Instructions predominated: ‘Pay your respects [to the dead] without touching, kissing, cleaning or wrapping the body’, ‘Call the toll free number to arrange [for] the body to be picked up’, ‘the house, latrine and person’s room must be disinfected by trained staff’, ‘do not care for a sick person at home’, and ‘soiled clothing and bedding are contagious and must be burnt’. That there would be practical difficulty in responding to these instructions was clear from some of the alternatives then offered. One was to ‘contact your local community leader’ if the toll-free pick-up call received no answer. Whether the local leader would have any clear idea about what to do, unless specifically trained, remains unsaid.

Another option recognizes that getting a person to a treatment facility might be impractical. In this case, ‘if you provide care’ (a statement flatly contradicting a previous injunction not to engage in home care), patients were to be isolated in their own space, one person, preferably a survivor, was to be assigned as nurse, and copious liquids were to be provided, in a vessel used only by the patient. Advice was also given on how to improvise protective clothing, with plastic bags to protect the hands, and raincoats worn back to front. But resource constraints are not mentioned, and it is these that determine whether an interesting suggestion becomes an effective technique. Community members might well have asked who would supply the plastic bags and reversible raincoats, or whether the response agency would supply replacements (for burnt clothes and bedding), or what happens if the items are left unattended for a few days to allow the virus to die. Such questions were neither anticipated nor answered.

The document closes with a section on ‘what can you do to stop Ebola in your community’. Of six items, three involve speaking with someone to pass the message on, two require the volunteer to educate someone, and one requires contacting a local leader ‘to devise ways to inform and engage the community’ (more messaging).

This approach to reducing infection expected communities to pass on information and instructions. How well did such an approach work?

Messages, conveyed by radio, poster and loudspeaker van, were received over much of Sierra Leone. This was confirmed by two studies undertaken in late 2014 by Focus 1000.2 Surveys covered the Freetown area and eleven districts. There was a degree of urban bias, since sampling was weighted towards enumeration areas with larger populations. Village-based surveys in December 2014 showed, however, that the messages had also been clearly received even in remote, off-road, forest-edge villages.

Direct impact of messages on Ebola infections is harder to pin down. Ebola continued to spread and increase in Freetown and surrounding districts in the last three months of 2014, despite intense messaging. At the same time, cases fell in the east and south, in more remote locations where exposure to the main medium, radio, was perhaps rather limited. Kailahun District, the area first experiencing Ebola in Sierra Leone, had its last case on 4 December 2014. It is worth repeating that the epidemic declined first in areas where it first began.

Kailahun District is an especially interesting case, because here there is evidence of decline in infection prior to the major international response. Initial messaging in Kailahun concerned only the risks of forest spillover and bushmeat consumption. At the same time Kailahun provides firm evidence that communities devised effective local responses, including modes of inducing compliance with the demands for behavioural change, once the first shock of the disease had been overcome. This points to a neglected element in Ebola response – the rate at which local learning took place.

Ebola in Jawei chiefdom: a case study in local learning3

Kailahun District was the epicentre of the Ebola epidemic in Sierra Leone. Jawei chiefdom, in Kailahun District, had the highest number of Ebola cases in eastern Sierra Leone excepting Nongowa chiefdom, the location for the Kenema ETC, which took patients from all over the country (see Figure 2.5 in Chapter 2).

The first confirmed case of Ebola in Sierra Leone occurred in late May 2014.4 The victim was a nurse-midwife (MK) working at a community health centre at Koindu, Kissy Teng chiefdom. She had been called to treat a case of Ebola in Guinea, without knowing the risk it posed. The disease arrived in Jawei chiefdom a few days later when Nurse M., trying to reach Kenema hospital, found herself too ill to continue and was admitted to the clinic in Daru.5Hearing of her arrival, the wife of the paramount chief hurried to Nurse M.’s bedside, to offer sympathy and help. The two were childhood friends, born in the same village (Njala Giema, Upper Ngebu section, Jawei chiefdom).

The paramount chief of Jawei chiefdom, Chief Musa Kallon, and other local authorities in Kailahun, were warned by the government about Ebola in March 2014. This was immediately after the Guinea outbreak had been identified as Ebola, but before the disease came to Sierra Leone. This early warning focused on risks of consuming bats and monkeys. But Chief Kallon already had some idea about viral infection risks because he had trained (at Serabu) as a nurse, then as a dispenser, and finally in Freetown as a laboratory technician. He was familiar with Lassa fever, another zoonotic viral disease, which also regularly affects villagers in rural Sierra Leone, and he knew some of the staff of the Lassa fever research unit at Kenema hospital.

On the day in question, however, the chief had been called to Freetown for a meeting. In Freetown, a journalist phoned him to tell him that Ebola had reached Daru. Chief Kallon then called home, to notify his family, and the town chief in Njala Giema, warning of the dangers of touching patients or bodies of Ebola victims. The warning came too late. M. was already dead, and Aminata, the chief’s wife, and several staff of the Daru clinic had been infected.

A workshop for health workers was taking place in Daru on the day Nurse M. was admitted to the local hospital. She was a well-known figure in her profession, and many of the participants came to her bedside to sympathize; in all twenty-seven of these visitors became infected and died. The people of Njala Giema failed to heed the chief’s warnings about burial, and sixty-eight persons later died in this village as a result of participating in preparation of the corpse.6

Chief Kallon tried to get his subjects to suspend normal burial practices, but rumours persisted that Ebola was a political ruse. The chief was known to be a personal friend of the president, and was said to be involved in a plot to reduce opposition votes. Ebola denial was especially strong in Njala Giema, where one of the strongest deniers later died of the disease.

In Freetown, the chief gained permission to leave his meeting early and travel back to Daru. Three days later Aminata herself started to show symptoms. Away that day in Segbwema, a small nearby town, Chief Kallon returned home that evening, and asked for his wife, but she was too ill to come. Chief Kallon insisted she go to Freetown for help, but she died before the journey could be arranged.

The chief decided to put himself in quarantine after he contacted Joseph Bangura of the Tulane University Lassa fever programme, based in Kenema, who told him he suspected it was Ebola. His daughter Jenneh, who had nursed her mother, also became infected and died. Ebola was confirmed and the chief continued a self-imposed quarantine for a total of forty-two days.

At that point Chief Kallon told me he might have become too discouraged to continue, but reminded himself he was descended from warrior stock; ‘all is not lost; I go nowhere and fight for the chiefdom I love’. Allowing no one to come physically close to him, he arranged the recruitment and training of fifty-two young men from all parts of the chiefdom, as an anti-Ebola task force. The job of this force was to teach villagers about the disease risks, find the sick, and raise the alarm. It also supplied recruits as surveillance workers, contact tracers and members of burial teams.7

Bye-laws were drafted to regulate local movement, and task force members blocked roads. The rule became that if the village chief did not know a visitor that person would be prevented from entering a village. The message was ‘no roaming, stay at home’. Even children did not go out to play. Chief Kallon made ‘a noise’ about Ebola wherever he could, including on the radio, and with agencies such as Médecins sans frontières, who supplied buckets, chlorine and other items.

As the rains were now heavy the chief equipped his force with raincoats and boots. He also paid for his team to go to Kenema, where the virologist, the late Dr Sheik Umar Khan, taught team members how to dress and undress safely using personal protective clothing.8 People with Ebola were now moving into Daru from outlying districts so local teams sometimes had to bury bodies four or five to a grave. Remarkably, none of the task force volunteers got the virus.9

Denial persisted for some time. People avoided Chief Kallon in his compound. On one occasion, a small crowd assembled at his house, on hearing a rumour that his dead wife had appeared to him in a vision. They had hoped to force him to confess that Ebola did not exist. ‘But how could they still think Ebola was a plot, since this implied I had killed my own wife?’ Task force members were also shunned, and some driven from their homes. The chief housed those who were stigmatized at his compound.

As a result of task force work in identification of cases, contact tracing, movement restrictions and safe burial, infection numbers in Jawi chiefdom began to decline. It was at this point that people began to realize the measures worked, and the rumours began to abate.

The chiefdom experienced 184 Ebola deaths 25 May–28 July 2014, but infection was already ending ‘due to the efforts of brave indigenes’ (Awareness Times, 29 July). Paramount Chief David Keili-Coomber of Mandu called for these local ‘best practices’ (by-laws, contact tracing and burial teams) ‘to be replicated in other parts of the country’ (Awareness Times, 31 July, see text box, p. 137). The first outside responders wisely attached themselves to these local initiatives.10 In effect, communities had begun to think like epidemiologists, and epidemiologists (in providing timely and relevant advice to local agents) had begun to think like communities. An evidence-based people’s science of Ebola control had begun to emerge.

I asked Chief Kallon what lesson needed to be retained from this experience: his answer was ‘learn from earlier mistakes. The denial syndrome was a big problem. We need to learn how to get politics out of Ebola, or similar national emergency responses. People need to understand that some problems affect us all, and are bigger than tribe or party.’ He added that the downward curve of the epidemic response reflected growing recognition that the issue was a threat to all – Ebola is a disease, not a party political ruse. But this wisdom should be documented for the future. The story of the Ebola epidemic, he thought, should be taught in every school, so that no Sierra Leonean school child ever forgets.

A further issue he raised was the desirability of continuing the Ebola task force on a permanent basis. Burial ought (he suggested) to become a more sanitary process everywhere, with or without the threat of Ebola. The response teams in Jawei chiefdom were trained by section. Each of eight sections (Sowa, Mano, Kaio, Bobor, Upper Ngebu, Lower Ngebu, Upper Lumegeh, Lower Luengeh) has its own team. (Njala Giema, where so many deaths occurred at the outset, is in Upper Ngebu section.) The team members came from villages in each section. This ensured a social bond between those imposing Ebola control and the people affected by these controls. If local teams were recruited, trained and authorized to carry out ‘safe burial’ over the longer term, they would do the job ‘with respect’.

This would revive an older practice, the chief explained. In former times, young people volunteered to help with burial. The people who did the work of body-washing, carrying of corpses and digging of graves received social recognition in the form of token payments, small gifts, special food, and promotion in the sodalities. Their work was their own ‘gift’ to the community, in return for blessing. Thus, when there is a funeral, the first to be called out and recognized are the gravediggers and corpse-washers.

With the centrally based burial teams typical of much of the official Ebola response, village people sometimes had to wait four to five days for burial. With locally based teams (organized by chiefdom sections) there would be no delay. The local teams should do everything – the washing, wrapping, grave-digging and so forth. But they struggle for resources – for fuel and transport costs. Chief Kallon also asked that body bags should continue to be supplied, at least until the epidemic was officially declared over. Despite local social acceptance of ‘safe burial’, those who do the work still tend to be feared and stigmatized, even though none of the volunteers in Jawei had ever been infected. Attention thus needs to be paid to social consequences of stigmatization.

Figure 6.1 Chief Kallon flanked by members of his Ebola task force (Esther Mokuwa seated)

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The approach adopted in Jawei chiefdom later became the model for local Ebola response throughout Sierra Leone. Ebola bye-laws were introduced nationally from August 2014, after a conference of chiefs held in the eastern town of Mobai. The security services and other government agencies quickly began to support these local initiatives, so the organizational response resembled that of the army-supported civil defence forces battling the rebel Revolutionary United Front in the civil war in the 1990s. In the south and the east local Ebola task forces were often referred to as ‘Ebola kamajoisia’ (the name in Mende for special hunters, widely applied during the war to the local civil defence fighters). A more thorough study of task forces, and how they varied in capacity and impact from district to district, is currently under way. Task forces were initially successful at finding cases, reducing inter-village movement and imposing bye-laws. The Jawei force undertook ‘safe burial’ from the outset, having been trained and equipped before the national Ebola regulations took force. Few agencies were willing initially to build on this example, but later started to recruit and train burial volunteers from chiefdom task forces. Kamajei chiefdom was one instance where burial teams were village-based. Task forces were threatened with marginalization after the militarization of the Ebola response accompanying the international surge from November 2014, but paramount chiefs successfully petitioned State House not to exclude chiefdom task forces from the ramped-up response.

Burial teams (Chief Kallon thought) should also always include women (at least one per team, he suggested). But he admitted to some difficulty in persuading all the women of the chiefdom of his vision for safe and sanitary burial. He noted that he has no power over the Sande women, in matters belonging to their society domain.11 Techniques of the female body – notably matters relating to childbirth and sexual and reproductive health – remain exclusively under Sande control. This includes the knowledge of procedures to be followed when burying elders of the association. The chief thus acknowledged help from Esther Mokuwa, a member of the UK-based Ebola anthropology response platform,12 who visited Jawei chiefdom in December 2014 to work with Sande women on ‘owning’ the Ebola challenge (Figure 6.2).

A Liberian comparison

Sierra Leone was not unique in providing evidence that local responses were important in ending Ebola transmission chains. A case not dissimilar to the one just described has been documented for Lofa County, in north-western Liberia. Like Kailahun District, Lofa County is adjacent to the Ebola epicentre in Guinea, and an early focus for the spread of the disease in Liberia.

In November 2014 the United States Centers for Disease Control sent a team to Lofa County to investigate claims that infection numbers had begun to taper off. The team found evidence the trend was real, and concluded it had been triggered by an unusually effective cooperative relationship between chiefs, communities and international responders.13

The first cases of Ebola were reported in Foya, Lofa County, in March, and derived from cross-border infections in Guinea. There were no further cases in April/May, and Liberia hoped it had escaped. But cases began to rise again in June, triggering a more focused response. This included, from the outset, development of a comprehensive response strategy worked out in collaboration with local communities.

The strategy comprised changes in local practices of caring for the sick and burying the dead, the opening of a dedicated ETC in Foya, establishment of a hotline for reporting cases, commissioning of outreach teams, provision of rapid transport and safe burial, establishment of a laboratory for rapid identification, active case-finding, and training of community health volunteers.

Cases rose from twelve in the week ending 14 June to 153 in the week ending 16 August, but declined to only four in the week ending 1 November. This (the authors remark) was the first example in Liberia of a successful strategy to reduce transmission in a country with high cumulative incidence.

The paper describes the creation of an effective environment for communities to come to terms with the disease. The authors note that ‘transparency in activities and engagement with the community were central to the response strategy in Lofa’. For example, the Foya ETC was designed without high, opaque walls, to minimize fear of and rumours about what was going on inside. Family members were permitted to visit, either to talk across a fence, or ‘inside a ward while wearing full personal protective equipment’. Those who died in the ETC were buried in presence of family members in grave sites marked with clear identification. In the communities, rapid transport of the sick and rapid safe burial ‘demonstrated that partners could quickly respond to requests for help’. During safe burials families ‘were invited to hold grieving ceremonies according to local customs in memory of the deceased’.14

Supervised and unsupervised learning

As noted in Chapter 3, computer engineers distinguish between two processes they refer to as supervised and unsupervised learning,15 which they apply to different approaches to tuning computational networks based on models of the brain. The distinction can also sometimes be usefully applied to community learning processes.16

What has so far been said about community learning in regard to Ebola comprises examples of supervised learning. The international response set parameters for local communities to acquire evidence and draw commonsense conclusions, with Ebola declining as a result of subsequent local behavioural adjustment.

This element of supervision is apparent in an eyewitness account given by Dr Gabriel Rugalema, who led a UN visit to Kenema and Kailahun districts in the early days of the epidemic.17 His team arrived in Kailahun town to encounter the District Health Management Committee, security forces and local leaders busy organizing a response, supported by MSF. A recently arrived Canadian mobile field laboratory was about to be assembled. Contact tracing was under way, though hampered by lack of transportation, a situation remedied by the temporary transfer of some FAO vehicles, at Rugalema’s request. Likewise, in the Daru case, Chief Kallon, through his medical contacts in Kenema, was in regular receipt of supervisory advice from infectious disease experts associated with the Lassa fever laboratory at Kenema hospital.

In short there was a strong local response to Ebola, but it was underpinned by international assistance. Scope for learning was shaped by these external inputs.

But in some cases a framework to guide the learning process was absent. One instance was the West Point slum in Monrovia. A nervous Liberian government, alarmed at the rapid rise in cases in a post-civil-war urban ‘ghetto’, settled by a number of ex-combatants, attempted, initially, to close off the area, perhaps mindful of its reputation not just as a slum, but as a home of former fighters.

Ringing West Point with troops created conditions for Ebola to spread further through the ghetto, but also induced some rapid local learning about how to tackle the disease. West Point residents had no other option than to take responsibility for solving a problem with which they had been incarcerated.

After visiting West Point, and then travelling more widely in Liberia and Sierra Leone at the height of the epidemic (November 2014), the journalist Luke Mogelson inferred that self-organized responses to Ebola were widespread in the region:

Regular West Africans, in the absence of rescue, by the world and by their own governments, which are among the poorest on earth, have proved remarkably adept at finding ways to live and to help others do so. Neighborhoods have mobilized, health-care workers have volunteered, and rural villagers have formed local Ebola task forces. Individuals who survive Ebola are usually immune to infection, and in many places they have become integral to stemming the epidemic. ‘Communities are doing things on their own, with or without our support,’ Joel Montgomery, the C.D.C. team leader in Liberia at the time, told me when I met him in Monrovia. ‘Death is a strong motivator. When you see your friends and family die, you do something to make a difference.’18

The anthropologist Sharon Abramowitz and colleagues19 provide further evidence that this unsupervised community-driven response was real and effective. They studied fifteen communities in Monrovia and its outskirts in September 2014, via focus groups organized with 386 community leaders, and ‘identified strategies being undertaken and recommendations for what a community based response to Ebola should look like’.20 ‘Communities were compelled to generate solutions of their own.’21

Leaders were clear about topics such as the need to restrict movement of strangers in and out of communities, the importance of quarantine, and the need to support quarantined households. ‘There was a strong community-based ethos informing control measures.’22 One focus group respondent is quoted as saying ‘as a community we keep watch over each other’.

One of the most troublesome issues for practice, however, was a disconnection between messages about not touching, and the practical demands of dealing with a sick person. ‘We have heard the messages, but most people do not know how to praticalize them.’23 The authors of the paper note that caregiving in all its aspects demanded physical contact, but the public health messages regarding physical contact failed to take account of this reality. Some messages said ‘don’t touch’, others said ‘touch, but use rubber gloves’.24

Faced with this kind of inconsistent advice local opinion moved in its own direction, selecting quarantine as the issue over which communities might have the most meaningful influence. Abramowitz and colleagues sum up the community leader discussions on this topic:

it was apparent that [leaders] sought to position the community at the centre of the Ebola treatment response by managing the health and safety of quarantined families through food supply, illness surveillance and oversight, reporting, provision of medical supplies, and communication and information.25

International responders early on set their face against anything that would smack of ‘home care’ for Ebola patients, on the grounds that this would multiply the disease. The Monrovia focus groups offered a different perspective. Home care was a moral imperative, especially for women: ‘A broad subset of respondents – mainly women – reported that they would care for their sick family members on their own, and that they preferred to do so inside the home.’26

So there was a need to think through how home care might be made safer. Focus group members described a plan for isolating themselves with their sick family members and for providing the best locally available appropriate care they could offer, using available resources.

One woman is quoted as saying: ‘it will be impossible that my child or husband is sick and I refuse to touch them. I do not have the courage or heart to do that.’27 Another woman reported that she would find her own protective equipment, ‘using a raincoat [and] plastic bags on hands’, clearly referencing a widely seen news item regarding Fatu Kekula, the young Liberian nurse who had saved three members of her family, using bin liners for protection (see Chapter 5).28

Here, then, was a crucial impasse. A senior international Ebola responder told me bluntly that to advocate ‘home care’ would be unethical. The Liberian voices referenced by Abramowitz and colleagues imply that to deny the possibility of home care would also be unethical. If international responders resisted moving to support those who refused to abandon what they conceived to be their duty of care then endogenous ways of making home care safe were liable to be pursued.29 It is apparent that local responses to Ebola embodied an ineradicable element of unsupervised learning.

Changing technique: deliberation or dance?

The Ebola epidemic raised important questions for social science about how behavioural change is achieved. The crisis made apparent a need to return to debates about theories of change.

One approach to change – widely used by agencies working with communities – is based on notions of deliberative decision-making. Participatory rural development draws heavily on the deliberative approach. People meet and explore their problems. They listen to each other. Strategies are proposed. There is debate, disagreement and compromise. Agreements are made to act in various ways. Tasks are allocated, and change is effected.

This is the approach adopted for the community Ebola response in Sierra Leone, based on a set of guidelines for community intervention known as the CLEA Manual (Community Learning for Ebola Action).30

The manual states that ‘triggering is about stimulating a collective sense of urgency to act in the face of the threat of Ebola, and realize the realities of inaction or inappropriate action’. The natural milieu for deliberation, and for triggering changes in states of mind, is the workshop. The CLEA Manual proposed literally thousands of community workshops.

But there are reasons for wondering whether a deliberative approach – and changes of mind achieved through deliberative interaction – are the most appropriate means through which to approach changes in body technique.

The problem with Ebola is that a natural instinct to care through touching needs to be modified. Deliberation might ‘stimulate a collective sense of urgency’, but probably through activating conscious checks, including inducing a sense of fear. This might not be the most appropriate way to address the concerns expressed by the Liberian women community leaders quoted by Abramowitz.31

As indicated in Chapter 3, Marcel Mauss’s seminal paper on techniques of the body initiated a tradition of work on embodiment based on a rather different theory of change – namely, the Durkheimian notion that concepts, categories and mental representations are formed and fixed not through deliberation but through performative action. In particular, the Durkheimians were interested in performative action directed towards sacred ends through which social categories became fixed (or, on occasion, dissolved and formed anew32). In short, they were interested in ritual.

The theory of ritual has been mostly used by anthropologists to explain large-scale ceremonial events in ‘traditional’ society. An instance to which Durkheim himself often alluded was the Australian corroboree. But the approach can be equally well applied to large-scale ceremonial events in any society – for instance, celebration of religious holidays, presidential inaugurations or mourning the war dead. According to Wendy James, the subject of anthropology applies itself root and branch to the study of human beings as ceremonial animals.33 This explanatory edifice rests on theories of performance. The study of embodiment and movement is freed from asking unhelpful questions such as ‘but what does it all mean?’ The ceremonial animates. It leads on to the doing of many things, in which deliberation may play little or no part.

A performative approach finds little use for the idea that deliberation triggers a change of mind. In the specific case of Ebola the requirement is to find direct ways of doing (for instance, caring for sick people) that avoid infection risks, but that also avoid hamstringing care through inducing fear and hesitation.

Where, then, can the kinds of performative approaches to behavioural change required to beat Ebola be rehearsed and perfected? One answer is that the capacity to effect such change already exist in countries like Guinea, Sierra Leone and Liberia, through the performative skills inculcated in rural sodalities such as Poro and Sande. These can be seen as ‘workshops’ in which dance does the work of deliberation.

The sodalities evolved as a secure and confidential retreat in which small groups could organize around common interests, when beset by many enemies in a dangerous and fluid external world.34 The sodalities fostered a range of disciplines – from keeping secrets, to enduring pain and hardship, to ways of testing and weeding out spies. Meanings and agreements were danced out by the group, rather than proclaimed or documented.

Expressively, music and dance were thus a major part of the social dynamics of the sodalities. The techniques of the body manifest in dance were major accomplishments expected of both male and female members. An elder who stumbled and missed a beat in a dance might expect to be fined.

Masquerades were both an expression of the sacred values of the society, and a way of publicly expressing the collective power and organization of its members. Society songs sometimes preserved a complex oral record of the linguistically and thus socially mixed origins of its members.

An obvious fact about Ebola was that the super-spreader events were on several occasions the well-attended funerals of society elders. The ritual techniques of the body applied in the burial of these elders are neither known to, nor knowable by, non-members. Nor is it profitable for persons from outside the group to try to know them, since any attempt to penetrate these mysteries is met by group closure.

‘Messaging’ from non-members about body matters over which the sodalities claim control is wasted effort, since this causes the mechanism of secrecy to snap shut. A logical alternative is to get the members to develop a modified understanding from within.

When Chief Kallon needed to mobilize the women of his chiefdom to support the campaign against Ebola he had to turn to Sande interlocutors to spread the word. He had no power to instruct the women directly. Some were initially opposed to his strategies to cut Ebola infection chains. When I asked him what then happened, he remarked only that the Sande elders went into the bush and danced a solution.

Figure 6.2 The Daru Sande masquerade, and society elders

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A useful analytical account of the Durkheimian theory of ritual change applied to sodalities in Upper West Africa is provided in the work of the anthropologist Charles Jedrej on Sande ritual dynamics. There he explains that the Mende word hale (sometimes translated as ‘medicine’ but with multiple, apparently disparate meanings) works as a ritual separator. It dissolves old collective understandings, and allows for the reworking of taxonomic elements into new collective representations. According to Jedrej, Sande elders use hale as much to adapt to new challenges as to maintain a status quo.35

Two Sande elders accompanied Chief Kallon to a workshop at Njala (July 2015) on community mobilization against Ebola and other zoonotic diseases. The visitors from Daru listened patiently to a number of presentations covering deliberative approaches to Ebola control. Eventually, one of the elders asked to speak. Could we help her acquire the white personal protection suit, she asked. The answer was ‘yes’ (they cost only $25.00), but we wondered why. She explained that the Sande women had the idea to use the suit to create a dancing ‘devil’ that would teach the girls of the chiefdom about the Ebola hazard. At times, as Durkheim argued, dance may make more sense than deliberation.

Coda: expressing the need for change

In the Durkheimian tradition of analysis rituals are seen as expressive modes. Ritual action speaks to social circumstances, but does not dictate them. When social circumstances change then so will the rituals expressive of these circumstances. Rituals decay, mutate or erupt as social life demands.

Few in Britain who experienced it will forget the public outpouring of grief that followed the death of Diana, Princess of Wales, in a car crash. The entrance to her London residence was overwhelmed with offerings of flowers. There were so many that the rotting bottom layers of the pile began to cause a public nuisance. Something had to be done. Ritual composers were brought in to create a more suitable venue where public feelings could be vented.

This resulted, eventually, in an imaginative water feature in Hyde Park in which the public could walk barefoot, as somehow seemed appropriate to the memory of someone known as the people’s princess. The water feature is constantly on the move, like a stream.

Movement is an almost inescapable feature of most rituals. This is because rituals speak to transitions or renewals. Some take us on a journey. We exit the ritual a different person. Other rituals go round in circles. We begin again with renewed zeal.

Mary Douglas’s last book, Thinking in Circles, addressed the ancient literary form of poetry constructed as a ring.36 This was a generalization of her earlier work on the Book of Numbers in the Hebrew Bible,37 where she had suggested that an allegedly incoherent text was composed as a ring, and for a distinct sociological purpose.

The ancient and fractious tribes were drawn up, in the poem, in marching order, and the ring, decked at strategic points with various items of contested clan history, allowed variant versions to be collated across the ring. The entire ritual structure could be envisaged as rotating through time, carrying its competing claims forward as part of a single entity, like spokes in a wheel.

Whether the poem was ever performed, perhaps as a ring dance, a widespread ancient artistic form expressive of social cohesion, is not known. But given Douglas’s description and analysis it is not hard to imagine it might have been.

This brings out one of the objectives that such a ritual performance can attain. By assembling disparate elements into a single experience, apparently contested or contradictory components can be shown to belong to a larger dynamic whole. The overall purpose outweighs troublesome contested or dysfunctional details.

Maybe this approach should have been tried by WHO, when composing its apparently contradictory advice on social mobilization for Ebola: ‘home nursing is forbidden’ and yet when ‘home nursing is unavoidable this is what you should do’. That which is forbidden is attached to the part of the ritual structure speaking of ambulances on paved city streets, and the reversed raincoat is reserved for villages at the end of the forest track. But both belong to the diverse, lively functionality of what people call ‘Mama Salong’ (Mother Sierra Leone, a ritual being frequently honoured in song and dance, not to mention public exhortations to avoid Ebola risks). A contradiction between home nursing and no home nursing exists only in the straight-line space of a bullet-pointed official release.

A general question arises, ‘does ritual composition offer solutions to practical problems’? Could the right kind of composer – poet, dramatist or musician – dynamize the search for safer techniques of the body. The answer is ‘yes, perhaps’, but only if we first fully understand the social problems to which the ritual must speak. Recall that ritual (and by extension music, poetry and drama) can only speak to underlying social reality; it cannot dictate it.38

First we can identify a negative example, an unnecessary performance. Village focus groups sometimes complained that ‘we do not even want an ambulance to come to this town, because we hate the crying of an ambulance’.39Why did the Ebola ambulance constantly sound its siren, even on remote country roads, where there were no other vehicles to stand aside? If (as information stated) nearly all were bound to die, then please don’t cause a noise.

A respectful quietness might have been more appropriate to the deadly reality with which people were coping. Switching off a siren when not absolutely essential may seem a small thing, but it is not a trivial matter to move with quietness and deliberation in the face of death. It shows understanding of local feelings, and from that empathy new patterns of cooperative action and interaction might evolve.

The ritual composer can also inject dynamism where it is sometimes most needed. At times Ebola risked turning emotions from fear to despair, and despair is a very corrosive emotion.

Here is how they do things on the Sierra Leone rice farm, when energy and purpose flag. The purpose of ‘ploughing’ rice on a Mende upland rice farm is to scatter seed and to dig it in and cover it against birds. This requires rapid ‘scratching’ with a narrow hoe, to break the crust of the soil and bury the seed, but not too deeply. The task is a major farming bottleneck, since it needs to be done quickly to stop the birds having a feast. The task group is a gang of men, sometimes a pick-up team of brothers or neighbours, but sometimes a regular work gang, supplying labour to its members on a by-turns basis, hoeing in the wake of a skilled broadcaster, with individuals competing to finish stints.

In the 1980s, when I several times took part in such work, a prudent field owner would sometimes also hire a three-man drum band. The Mende slit drum (kele) is able to ‘talk’, and so provides comments on the proceedings, mocking those who are too slow, praising those who do well. To facilitate back-breaking competition members of hoeing groups choose from two styles of hoe, a long-handled and a short-handled. The village blacksmith will generally adjust the handle and pitch of the blade to suit individual arm lengths. Task group members are sometimes as fussy about these adjustments as a concert violinist buying a bow.

Spurred on by the music, the team speeds through the field at accelerated pace. I timed and measured task group stints and found that 20 per cent more ground was covered, on average, when the band was playing than when it was not. But sometimes the women of the farm, who follow on later, to mend patches that have been missed, complain about this high-speed work. In the excitement of the ‘dance’ the task group has done its work clumsily. The women will also comment if the broadcaster was not up to the mark, throwing too much seed here, and not enough there. But everyone admires that rare breed of expert broadcaster who, for a suitable consideration, will spit rice from the mouth. This truly virtuoso attainment I never even attempted to learn. The result, of course, of all this danced effort is an abundant harvest.

In April 2015, the Kenema singer Ngor Gbetuwa kindly gave me a copy of his Ebola song. I soon discovered he is not the only one to sing about Ebola, and that Ebola-affected Upper West Africa boasts a considerable corpus of music intended to lift spirits and get bodies moving in new and safer ways. Of course, dancing bodies, for the time being, should not touch. There is, in fact, a new dance style, I am told, based on achieving this end – no small feat in crowded events. This encapsulates the argument of this book. If Ebola can so readily evolve its own new dance style, then we should not be surprised if local modifications to techniques of the body have helped end Ebola by spreading as rapidly as the elbow-knock has replaced the handshake as a greeting.