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Thoughts on Ebola

Posted by on Saturday, December 13, 2014 in Uncategorized.


Dominique Behague

{Thanks to Jonathan for the invitation!} I want to begin with a caveat: I should clarify that I am in no way an ebola or even infectious disease expert. But I do speak as an anthropologist with at least a few years’ experience in global public health and I would like to reflect a little bit on what ethnographers can contribute to the current crisis.

Ethnography, as you all know is generally defined as a methodological process – the study and systematic recording of human cultures — and a product, a piece of writing. Ethnography is also as an “attitude” or approach or analytical disposition that anthropologists claim no ownership over. Douglas Holmes and George Marcus have coined the term “para-ethnography” to recognize the many ways people, both expert and lay, nurture ethnographic sensibilities, especially when they come up against conundrums of life that they can’t explain with rational science. It is the sharing and widening of this para-ethnographic sensibility that I’d like to argue we need to foster more intensely in this crisis moment.

Paul Farmer, who, for those of you who don’t know, is a prominent physician-anthropologist at Harvard, published a piece on Ebola a few weeks ago in the London Review of Books after having just returned from Liberia. He argues that “Ebola is more a symptom of a weak healthcare system than anything else. But until this diagnosis is agreed on, there’s plenty of room for other, more exotic explanations.”  We’ve certainly seen a lot of talk in the media about the ‘cultural beliefs and behaviors’ associated with the outbreak; hunting and eating bush meat; taking part in strange funerary practices; the bizarre rituals of ‘secret societies;’ allegations of witchcraft, etc. He points the finger at anthropology itself in propagating this focus on cultural beliefs and practice – to quote, “an obsession with funerary rituals – the more lurid the better – was characteristic of anthropology from the 19th century and continues with us today…. Despite anthropologists’ fondness of recounting such practices, these rites are not suspected of having played a major role in outbreaks of Ebola in Congo, Uganda and Sudan over the last forty years.” He then considers epidemiological data to show that these are not plausible explanations for the levels of transmission we are seeing.

I think Farmer is both “right” and “wrong.” He is rightly concerned about the ways culture, cultural belief and local customs often become scapegoats in global health, targets of intervention itself.  Anthropologist Didier Fassin – who is also a physician and was once Vice President of Doctors Without Borders — has called this “culturalism:” that is, the tendency to attribute health problems to cultural practices; the view of “culture” as a key constraint to health, over and above structural or political determinants of health. Culturalism is politically convenient as it relieves governments, institutions and politicians of their responsibilities, while it also identifies a clear target and plan of action, one usually centering on educating the local population about disease transmission, hygiene, the need for quarantine, etc…

Culturalism is normative in public health: Several years ago while I worked at the London School of Hygiene and Tropical Medicine, I shared an office with a physician-epidemiologist who specialized in hemorrhagic fevers. At the time, he was about to embark on fieldwork in Angola and Congo where he knew teams of anthropologist were being employed to help negotiate with the local population. He came back excited and wanting more. He told me about how useful anthropologists had been in achieving a high level of compliance to disease control measures from the local population and as he sat in on interviews conducted by these ethnographers, he was taken with the way people opened up, disclosed their fears about witchcraft and the intentions of “the white man.” Though he was also very astute about the neo-colonial contexts in which rumors and mistrust grow, his publications, and his policy recommendations to key organizations like the WHO revolved around tackling mistrust with science and education campaigns. He was practicing “culturalism” – he wanted, perhaps, simplified take-home messages that sound feasible to stakeholders, funders, and politicians. This is not a gratuitous critique. Even in the absence of such institutional pressures to simplify, many of us in anthropology have struggled with the slippery slope of culturalism in our own work.

So, Farmer is right to critique this facile understanding of culture. But he is wrong because culture matters very much, especially if we rethink our notion of culture to be not about exotic stories that splash headlines, but the whole of how people make meaning of their world, how they engage in different forms of sociability, how they inhabit political positionalities, and how these positionalities, in Africa especially, are products of long-standing colonial encounters. The fact of the matter is, the question of whether and how hunting practices or close human-animal living or funerary rites may be a part of the epidemiological outbreak picture is still an open question and yet levels of fear, suspicion, even violent reactions to outreach workers are making epidemiological investigation very difficult. Even if funerary rituals turn out to not be epidemiological significant, the recent writings of anthropologist such as Catherine Bolten, Anne Kelly, Barry and Bonnie Hewlett, Almudena Mari Saez, Melissa Leach  – to name only a very few – have shown that measures to control the epidemic – barriers, quarantine, space suits, intervening on burial practices – break critical forms of sociability in communities that are already economically and socially fragile. These measures will always be interpreted by local populations against the backdrop of the power-relations that have permeated for centuries. These anthropologists also show that rumor, allegations of witchcraft that split communities, the desire to protect funerary practices, are well known to become more meaningful, more frequent, and more volatile, when communities feel threatened.

My physician-epidemiologist colleague from the London School is now at the forefront of a large multidisciplinary research team working in West Africa, with anthropology at its center. He has become a para-ethnographer par-excellence, and he is turning his attention to the politics of knowledge, to the apparatuses of intervention that local people rightly find distressing, to understanding the rationality in people’s so-called irrational responses. He is asking colleagues in major international organization to think seriously about their role in producing the rumors and expressions of mistrust that abound. In a blog-site, he was recently described to be one of the few from this Western apparatus who is willing to stick around in villages, long after others are gone, together with anthropologists, to listen to people’s concerns and fears. He takes a deep understanding of culture seriously, one that sees talk of witchcraft not as irrational and non-scientific, but as a potent commentary on long-standing rifts of power and oppression.

Farmer is making an important point; health systems are essential and health systems strengthening has traditionally been a second-tier priority in global health. But he should not be lured by the sound-bite approach with which he is trying to carve a much-needed policy-space for health system strengthening. We can’t just say it’s all about weak health systems and leave go-to sensationalizing culturalist explanations up to the media. As the size and geographical breadth of this current epidemic grows to unprecedented levels, into urban centres and the middle class for the first time, sparking fears that it will invade the very countries from which the contested white man comes, the politics of blame and the politics of the knowledge production about culture is bound to become even more inflammatory. For any disease control measure, this dimension needs to be addressed head-on and with full recognition of the moral and political positionalities at stake.

Dominique Behague is an Associate Professor at the Center for Medicine, Health, and Society (MHS) and the Department of Anthropology at Vanderbilt University.