Why disease epidemics need input from anthropology
- The people who resist Ebola precautions have reasons for their suspicions
- Strategies assuming everyone thinks and believes the same way won’t work
- Health crises need social science input, like the online network begun for Ebola
The Ebola epidemic in West Africa has been fundamentally social, spreading through people’s networks, and affecting those caring for the sick and dead. Much has been written about the social resistance to control strategies, but previous Ebola outbreaks show that local people draw on a wealth of knowledge to devise control strategies that are effective and that break with social and ritual norms. Evidence from this outbreak also shows adaptive behaviours occur rapidly.
Ebola hit urban Monrovia, Liberia, with full force in July 2014. By early September, communities were organising task forces for neighbourhood surveillance, and families were planning how to deal with sick loved ones.  Using plastic bags as makeshift personal protective equipment (PPE) was a local innovation that diffused rapidly though social media and word of mouth. 
In Sierra Leone, villagers are now familiar with Ebola transmission pathways and many have changed their care practices.  People report sickness and death to village chiefs or helplines, and generally comply with measures such as quarantine and safe burial practices. Unlike during the first months of the crisis, most Ebola alerts are now dealt with quickly and smoothly. Bodies are buried, cases investigated and most quarantined houses receive food rations.
Yet some aspects of control efforts remain problematic. Resistance, at times violent, continues in Guinea. In Sierra Leone, an upsurge in cases followed when residents of a fishing community scattered to evade quarantine. Records show low but persistent resistance: hiding of sick people, suspect cases going ‘on the run’, illicit medical care and bodies being washed before relatives call burial teams.
The reasons for such incidents are not well understood and are often dismissed as selfishness, stubbornness or the result of deeply ingrained traditional culture. But dismissing them or framing them in ‘cultural’ terms amounts to a misdiagnosis, and it limits the scope for understanding and working collaboratively with people who are at risk.
To be effective, the response system needs to recognise how local groups respond and organise to contain an epidemic, and to support these groups. It must also address fear and distrust.
Mistrust and assumptions
Social science and anthropology can help to recognise how behaviours reflect culture and politics. This applies as much to the culture of the response mechanism as it does to the culture of local people.
As this outbreak has shown, mistrust and assumptions can damage interactions between response workers and communities. Officials might assume ignorance on the part of rural people, while marginalised populations might suspect officials of ulterior motives — their suspicions sometimes reinforced by evidence of misappropriated Ebola funds.  Community outreach workers in Sierra Leone have complained anecdotally that one of their biggest challenges has been people not taking them seriously, because they thought they were just out to make money.
Indeed, there is much that can look suspicious: ‘volunteers’ who are paid a stipend; conflicting messages that at first emphasised bushmeat and certain death from infection, but then avoiding body contact and seeking hospital treatment; and clumsily applied one-size-fits-all solutions.
Take the example of a blanket policy in Sierra Leone that all burials have to be conducted by burial teams. Some villagers interpreted this ‘safe burials’ rule as meaning the authorities were claiming all deaths were from Ebola. A policy borne out of precaution was contested because it reached remote villages without a proper explanation of its rationale, and led to doubts about the disease.
Seen in this light, remaining resistance to Ebola measures may have less to do with traditional culture or ignorance than with inconsistencies that breed distrust.
So social science offers insights that can strengthen short-term epidemic response. It can also offer long-term perspectives on the origins of local judgements.
Ebola has found fertile ground in West Africa because distrust and suspicion are rooted in a history of exploitation by elites and ‘outsiders’ — for slaves, land or minerals. Such logic cannot be easily undone. But being aware of it allows better understanding of how some interventions (such as trials that require blood samples) may be misinterpreted, so that negative reactions (such as accusations of blood theft) can be avoided.
This is often as simple as taking extra time to explain things fully. There is much to be said for slowing things down, taking time to coordinate messages and activities, and being humble about past mistakes.
Draw on a wider network
Bringing social science perspectives into an emergency response is tricky but possible. A network formed during this epidemic — the Ebola Response Anthropology Platform and the Ebola Anthropology Initiative listserv — has crowdsourced knowledge and provided advice on subjects ranging from the design and ethics of clinical trials to tools to support community-led Ebola action.
This initiative taps people with a range of expertise — not just medical anthropologists — who would not be the usual ‘go to’ names or disciplines in a disease outbreak. So it complements short-term research and field deployments, which are more common. Including anthropologists on scientific advisory committees is another way of bringing in such expertise.
The Ebola outbreak has shown the value of anthropology, and has created an opportunity to bring social science insight into health emergency operations. Behaviour change and control strategies need not be based on everybody thinking and believing the same — that is unlikely to ever be achievable. Instead, responses need to be organised around meaningful collaboration from the beginning, in ways that involve local people and diverse knowledge.
Annie Wilkinson is a postdoctoral researcher at the Institute of Development Studies (IDS). She has conducted research on Lassa fever and Ebola in Sierra Leone and is on the steering group of the Ebola Response Anthropology Platform. She can be contacted at [email protected]
This article is part of our Spotlight, Managing health crises after Ebola.
References Sharon A. Abramowitz and others Community-centered responses to Ebola in urban Liberia: the view from below (Ebola Response Anthropology Platform, accessed 7 April 2015)
 Elizabeth Cohen Woman saves three relatives from Ebola (CNN, 26 September 2014)
 Paul Richards and others Village responses to Ebola virus disease in rural central Sierra Leone (Ebola Response Anthropology Platform, January 2015)
 BBC News Sierra Leone audit claims Ebola funds unaccounted for (BBC, 13 February 2015)