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Paul Richards

February 10th, 2020

Self-quarantine for infectious diseases needs flexible public authority

0 comments | 18 shares

Estimated reading time: 6 minutes

Paul Richards

February 10th, 2020

Self-quarantine for infectious diseases needs flexible public authority

0 comments | 18 shares

Estimated reading time: 6 minutes

Quarantine as a method of preventing the spread of infectious diseases is often viewed as a form of state control. But self-quarantine by affected communities has a long history, as seen in West Africa during the 2014–15 Ebola epidemic, and by farmers in China in response to the 2020 coronavirus. Such action at the local level requires innovative organisation, allowing for a flexible approach to public authority.

Tawovehun (pseudonym) is an isolated Mende-speaking village in northern Moyamba District, central Sierra Leone. Ebola Virus Disease struck the village in July 2014, when a sick visitor arrived, seeking a cure at the hands of a relative, a noted local herbalist. The man died, but so did the herbalist and about 20 other people. These were mainly family members who visited the herbalist on her death bed. Tawovehun and a neighbouring village were quarantined by the army and humanitarian agencies provided food. The outbreak quickly subsided and by November was gone.

‘Family turn around’

The rapid end to the outbreak, however, was not a product of externally imposed quarantine alone. There is a second story here, of internal self-quarantine. This second story is encapsulated in the name given by the people of Tawovehun to the Ebola sickness in the Mende language – bonda wote. This means, literally, ‘family turn around’. Normal social interaction should be suspended.

The outbreak occurred during the pre-harvest months when farm households spend most of their days on the upland rice farms. Each farm was well-provisioned for a temporary period of isolation.

The upland farm supplies the local staple for family consumption. In and among the rice on the main part of the farm other food crops are also planted, and some are harvested as early as June-July to alleviate rainy-season food shortages. Every farm has a farm hut, where the family gathers when they are not at work. Some farmers build elevated sleeping huts to protect their crops at night. Villagers explained that it was easy enough, in an outbreak commencing in July, for them to retreat to their farms and stay there until the outbreak subsided.

Ebola infection chains were ended more quickly in districts with large numbers of subsistence farming households. Where more households were dependent on markets and trade, outbreaks lasted longer.

More than a subsistence option, however, was needed for self-quarantine to contribute to ending Ebola. People also had to recognise that the disease was spread by human contact, and that as a result it might be necessary to break important local commitments to visiting the sick and expressing sympathy through touch. As the local name for the disease suggests, families had to ‘turn around’.

Those closest to the sick continued to stand by their loved ones, and some died as a result of their devotion to nursing parents, children or siblings. But others could keep their distance. The safest strategy for those without direct obligations to the sick was to retreat to the farm and wait for the threat to pass.

It helped that family self-isolation was an already established seasonal practice in farming districts. Local public authorities – village and section chiefs – not only allowed it; in some cases they recommended it. Several times I heard local leaders state that ‘we should do what our grandparents did in the days of smallpox – isolate ourselves in the farms’.

In short, there was a helpful revival of what the anthropologist Mary Douglas terms ‘isolate social ordering’. This is where strong authority mandates or approves high levels of social and physical distancing of the rank-and-file.

Historical self-quarantine from plague to coronavirus

In the current epidemic of new variant Coronavirus Disease in China villagers appear to believe they have the authority to cut off their settlements to reduce infection risks. This is interesting in that it runs counter to the popular perception outside China of the state as the sole arbiter of societal action. It is perhaps best explained as state tolerance of (or perhaps even welcoming of) such action as a necessary contribution to infection control.

Self-quarantine was also a widespread but under-reported phenomenon in the Ebola outbreaks in Upper West Africa in 2014–15. Its importance has been lost in a debate about quarantine that generally sees it as state-imposed action, and an assault on human rights.

Perhaps the best-known historical example of self-quarantine comes from the Derbyshire village of Eyam, and a plague outbreak there in the years 1665–66. This is typically described as an example of noble altruism. The villagers sealed themselves in, and for the most part perished, in the hope of sparing neighbouring settlements the disease. An evolutionary theory of altruistic sickness behaviour has even been termed the ‘Eyam hypothesis’.

A paper by Whittles and Didelot (2016) re-examines the evidence, using a mathematical modelling perspective, and comes up with new findings. The altruistic explanation is based on the assumption that about three quarters of the Eyam villagers were infected and died. Whittles and Didelot present convincing evidence that the actual death rate from plague was much lower (37%). This opens up the possibility that self-isolation might have been a survival strategy.

The protagonist of Daniel Defoe’s A Journal of the Plague Year (a novel written in 1722) debates whether to flee London during the plague of 1665 or to stay put. He reasons that if he runs away he might only run into another outbreak triggered by the people around him madly trying to leave the city. Similar reasoning may have underlain the willingness of Eyam villagers to stay put, even if put into the language of self-sacrifice by their Rector.

Human-to-human infection (as distinct from rodent-to-human infection) may have been underestimated for plague. The data modelled by Whittles and Didelot suggest that plague in Eyam was transmitted by rodent-to-human and human-to-human contact in a ratio of about 1:3. Where human contact is the greater risk, staying at home might seem a better option; running away risks intensifying contact with people of unknown disease status.

The situation Whittles and Didelot reveal is much closer to the Ebola infection scenario experienced in Tawovehun, where all transmission was human to human, and people were protected by the idea of local separation and self-isolation (‘family turn around’).

Two further circumstances were as important in Eyam as they were in Tawovehun in ending infection. Both are essential aspects of isolate ordering – subsistence needs to be secured, and there must be strongly enforced controls to reduce instances of human contact.

In Tawovehun, villagers had food in their farms, and family heads made their members stay put, supported by the chiefs. In Eyam, the Duke of Devonshire provided food, and the Rector, William Mompesson, provided strong leadership in the village. Church services continued but in the open air, with families maintaining a distance from each other. Burial had to be carried out by family members. This meant that although infection continued, it was confined largely within families and may have burnt out quicker. Whittles and Didelot calculate there were 443 survivors, about 63% of the total population.

Self-quarantine as temporary public authority

Self-quarantine can be an important tool for ending epidemics, but it requires an organised attempt to cultivate isolate ordering as a mode of temporary public authority. Previous experience of isolate ordering during times of difficulty is an asset but, in epidemics, ritual innovation is also a very important tool for adaptation. Burials with families attending at a distance are an example from Ebola-affected Sierra Leone. The open-air church services in Eyam with families standing apart counts as another instance of ritual plasticity helping to shape an effective epidemic response.

This brings to light the importance of the part played by informal as well as formal leadership. In Eyam, the previous Rector, Thomas Stanley, had been deposed for refusing to conform to the liturgical reforms of the Restoration government, but nevertheless cooperated actively with his replacement, William Mompesson, to persuade people to follow the strict rules of self-quarantine. Ebola self-quarantine in Sierra Leone was sometimes pushed forward by chiefs (established figures of public authority) at odds with their people or with the national authorities. Effective public authority during epidemics is not always stamped with popular approval or the official seal of the government of the day; the test of isolate ordering in epidemics is whether it works.

Photo: ‘Ebola response: UK constructing treatment centre in Sierra Leone’ by DFID, Staff Sergeant Tom Robinson RLC is licensed under creative commons (CC BY-NC 2.0).

About the author

Paul Richards

Paul Richards

Paul Richards is an anthropologist with many years of research and residence in West Africa, and in Sierra Leone in particular. He is currently an adjunct professor at Njala University.

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