Responses to Ebola outbreaks, including the 2013–16 West African outbreak and the current outbreak in Democratic Republic of Congo, often serve to reinforce existing inequalities among affected populations. Frequently failing to understand local dynamics, international response teams have further marginalised those most deprived under current hierarchies. With no sign of containing the most recent epidemic, effective efforts at control and treatment must learn to challenge practices that exacerbate social exclusion.
Ebola responses are highlighting chronic problems with public authorities and multiple inequalities in public health assessments and disease-control responses. Our team’s research has explored the implications in a number of articles and briefings which highlight the uneven experiences of affected communities and regions, as well as differences between international and local practitioners.
With respect to the 2013–16 epidemic in West Africa, the problems were extreme, and apparent to anyone who cared to notice. A basic statistic underlines the point: the estimated amount spent on Ebola was 150% more than the annual government budgets of the three most affected countries combined. Why was that? Was it because West Africans are particularly precious? That seems unlikely.
More probably, it is because West Africa is situated relatively close to Europe, and the populations of affected countries have close connections with both Europe and the United States. There were serious concerns about infection spreading to rich countries. Significantly, Liberian Americans were diagnosed with the disease in the US, as well as Nigeria. Unsurprisingly, containment was the priority, and protection of international humanitarian staff shaped events on the ground. Indeed, unprecedented steps were taken. Unlike previous Ebola epidemics, the West African epidemic was categorised as ‘a threat to international peace and security’, and triggered a Security Council response that was comparable to a humanitarian intervention in genocidal circumstances. A military deployment was legitimised, essentially to contain the epidemic to the region.
In Sierra Leone, a very expensive operation by the British military involved deploying hundreds of personnel. Many were based offshore on HMS Argos, with some being helicoptered into Freetown on a daily basis, while others were based on shore in protected locations near the site of the treatment centre that they helped to construct and run in Kerrytown, at the edge of the city. They worked closely with staff from Save the Children. However, the centre took so long to complete that the worst of the epidemic was over by the time it was effective.
Noteworthy, too, is that attempts were initially made at Kerrytown to provide care for infected expatriates in a separate space to Sierra Leonean citizens. Differentiating the quality of care proved predictably controversial; it was eventually agreed that they could be treated together. However, the number of Sierra Leoneans coming forward for treatment was small. The lack of adequate communication was a persistent flaw in what was happening, and rumours about the Kerrytown centre abounded, including the possibility that it was being used to collect body parts. The situation was not helped by the fact that infected expatriates were, in practice, evacuated to their home countries.
Upcountry, Médecins Sans Frontiers (MSF) and other NGOs were on the front line in the official treatment centres, working with Sierra Leonean colleagues. It was a terrifying situation, and concerns about becoming infected were acute. Speaking to some of those involved, it is clear that the situation in mid-2014 was harrowing and involved making deeply troubling choices about who might have a chance of survival. It was decided that it was too dangerous to attempt intravenous rehydration of infected people arriving in crowded ambulances at Bo and other large treatment centres. Instead, those sent there were triaged and the infected segregated and quarantined – such that relatives could not access them to administer intensive individual care (including oral rehydration). Most patients died quickly, and were then buried in ways that set aside local customs, thereby preventing infection from corpses.
Most independent assessments of international engagement with Ebola in West Africa have been highly critical. Evaluations of the role of the World Health Organisation are scathing, and MSF, which was instrumental in calling for military deployment, has openly expressed doubts about whether it was the right thing to do. Overall, there is a prevalent view among analysts that neither the soldiers nor the international humanitarian aid workers were particularly influential in containing the epidemic until late in 2014 – even if they were helpful in treating the last recorded cases once intravenous rehydration eventually became widespread clinical practice (reportedly with advice from a Ugandan medical team with experience from the 1999/2000 Gulu epidemic), and more treatment centres with enough trained staff became operational.
So, what worked? The answer is far from certain. Acquired immunity may have been a factor, and probably also the behavioural responses of the population. In the public health world, the latter is usually referred to as ‘community mobilisation’, but that term is misleading. It suggests that social changes are externally directed, and it begs the question of what is meant by ‘community’. In Sierra Leone, like everywhere else, communities are far from homogeneous or cohesive – and they have contested hierarchies. Here, too, inequalities are a crucial factor in assessing events, in so far as there is evidence.
It has been suggested that, in many parts of the country, paramount chiefs were key. These chiefs are a legacy of British indirect colonial rule and were rehabilitated with support from the UK government after Sierra Leone’s civil war. The argument has been made that they took responsibility for quarantining and reporting patients. That was probably the case in some circumstances, but to equate claims made about (or by) paramount chiefs with pervasive experiences across the country is absurd. Our research shows that chiefly authority is variable, and location specific.
In places in which we carried out fieldwork, notably Ribbi Chiefdom, there were many surprises. To begin with, far more people reported having had Ebola than was officially recorded. Moreover, the majority of people were treated by their families in secret. Everything was done to hide what was happening from the paramount chief, and information from the radio and from educated friends and relatives was used to protect those looking after patients, and to bury those who died. Intensive oral rehydration was attempted from the outset by relatives (something that could not be done in the overcrowded treatment centres due to a lack of carers), and the majority of those with suspected Ebola survived. Eventually, it became known to the paramount chief that secret treatment and burials were occurring, and the Sierra Leonean army was sent to punish the population. Many people were severely beaten. Nevertheless, people are proud of how they acted in a mutual way towards one another, and side-stepped hierarchies associated with controlling them. They successfully prevented loved ones being taken away to die with strangers.
How prevalent such procedures were across Sierra Leone is unknown. The unequal ways in which evidence in public health is assessed tends to ignore such insights from ethnographic fieldwork. Too often the result is that purportedly rigorous epidemiological estimations bear little relationship to the realities of daily life, with profoundly unhelpful effects when those estimations inform policy choices. In fact, the number of people who were infected and died from Ebola in Sierra Leone can only be guessed. The 3,955 deaths officially reported are based on data from the terrifying treatment centres, which people tried to avoid. As a precaution, everyone who was known to have died during the epidemic, irrespective of possible causes, were supposed to be buried by trained teams in large grave-yards. There are hundreds of such graves in the cemetery outside Bo town, most just marked with a number.
No information is available about how many of those buried outside Bo town had Ebola, but it is known that there were secret burials of people with Ebola-like symptoms in hidden places, close to homes in villages and towns, where relatives could mourn them.
Ebola requires families to make decisions that challenge moral norms. Do they hand loved ones over to foreigners to die and be buried in unknown places, or do they deal with infected people in morally appropriate ways – ways that are at odds with external demands and impositions? For many, this is not a choice at all. Social inequalities do not mean that hierarchies are unquestioned or go unopposed. On the contrary, they are likely to encourage the rejection of public authorities associated with political office in favour of public authorities grounded in mutual relations and moral probity. When it comes to matters of life and death, as in an Ebola epidemic, it is predictable, even inevitable, that leaders and systems associated with maintaining social stratification are ignored or subverted. Given the dreadful symptoms of the disease, the lack of trust towards outsiders, the history of exploitation, and experience of oppression, rumours and conspiracy theories are ways of trying to make sense of things. Those who most compellingly interpret events are unlikely to be government agents or aid workers, unless they engage very seriously with understanding local dynamics and communicate effectively in that context.
These issues are apparent in the shambolic situation unfolding in Ituri, North Kivu, and now South Kivu Provinces of eastern Democratic Republic of Congo. The current, ongoing Ebola epidemic is out of control, although its location in central Africa means that it is not considered a threat to international peace and security. If it was possible to have a global ranking for the importance of populations, the people living in this region would be very low on the list. It is a place of chronic insecurity, and where it is known that slaughter on a shocking scale has occurred. One telling statistic is that, during a few months in 1997, around 200,000 Hutu refugees under the protection of the UNHCR disappeared. Many are assumed to have been killed or fled westward, depending on which source is consulted. Nothing much was done about it.
Dealing with Ebola has reinforced experiences of deprivation and marginalisation. The initial response in the DRC was even more militarised than in West Africa. The Congolese army deployed armoured vehicles accompanied by soldiers, targeting the ill, sometimes tackling them to the ground and taking them away to unknown places. Contacts and contacts of contacts – ring vaccination – were treated in the same manner. The approach was aggressive and extremely poorly communicated. Public service announcements and fliers described bleeding from orifices, in French and garbled Swahili – languages few residents understood.
Ebola was also used as a reason to exclude the affected population from the national elections, encouraging rumours about the epidemic being a deliberate means of imposing controls to facilitate political oppression. Expatriates and staff sent from Kinshasa on high salaries in local terms were supposed to instruct and direct treatment, quarantine and the complicated vaccination procedure. That alone has provoked intense resentment.
Chiefs are again being promoted as a solution, but, it seems, to no useful effect. In practice, the WHO and international actors resolved to try and contain the epidemic in the affected provinces, and treatment has been very limited – not least because there is the threat of attacks from people convinced that the health workers are doing something sinister, or possibly even from resentful colleagues or side-lined locals. A WHO doctor from Cameroon was killed in Butembo hospital in April 2019 following the death of an Ebola patient, and suspicion has been directed at Congolese medics.
Only as infected people have crossed into Uganda and Rwanda has a new approach been necessitated. Now that there have been cases in urban centres, including Goma city, close to the Ugandan and Rwandan border, responses have escalated. There has been no Security Council Resolution, but the WHO in July 2019 categorised the epidemic as a public health emergency of international concern. This may be an appropriate development, but whether it elicits positive changes on the ground remains to be seen.
In local terms, vast amounts of money are suddenly being made available in Goma for foreigners and selected Congolese nationals. Consumption of the new resources is spectacular and highly exclusionary. City residents tend to view it all as a way that makes some become rich, and many of them remain sceptical that the Ebola epidemic really exists. Currently, there is little indication that the acute social inequalities of the region are going to be taken into account. As in Sierra Leone, it is probable that efforts at control (including the roll out of a new vaccine) and treatment will continue to make every effort to co-opt, exploit and reinforce existing hierarchies as much as possible. Given the political realities of the region, and the nature of the disease, it is a risky strategy.
Photo credit: Morgana Wingard