Curtis Abraham
FROM THE ARCHIVES
In 1996, Gabon in central west Africa experienced two outbreaks of Ebola hemorrhagic fever, one of world’s deadliest diseases. A total of 91 people were infected and 66 died. The numbers involved were small compared with previous outbreaks in the Democratic Republic of the Congo and Sudan, but what happened in Gabon marked a turning point in the global fight against infectious disease.
As Ebola began to take a grip, teams of American and French aid workers arrived in the affected areas. Despite good intentions, their efforts to help did not go down well. Lack of coordination between the two groups meant that Gabonese villagers had to contend with two sets of outsiders coming through their villages taking blood samples twice and asking the same questions. Worse still, the researchers seldom reported back to the local people, arousing deep suspicion that they were up to no good. On two occasions, the situation became so tense that the aid workers had to be evacuated in the face of armed resistance from locals.
According to medical anthropologist Barry S. Hewlett of Washington State University, Vancouver, the root of the conflict in Gabon lay in a lack of understanding of local history, perceptions and practices. The World Health Organization (WHO) took a similar view, and in 1997, it revised its guidelines for responding to Ebola to take into account “specific cultural elements and local beliefs”. A decade on, experts including Hewlett, who has been working with the WHO, now argue that this approach should be far more widely adopted. They are calling for a total rethink about how Western aid agencies deal with epidemic diseases. The problem, they say, is that public health officials involved in international development are turning a blind eye to indigenous strategies for disease control and prevention. Yet, they believe that recognizing and exploiting these offers the best hope of combating disease in Africa and beyond.
This may sound like common sense, but it is a radical proposal. The popular perception of African medicine is based on Hollywood images of leopard-skin-clad witchdoctors reciting magical incantations to the beat of throbbing drums. These may be stereotypes but the belief that it is rooted in witchcraft, sorcery and black magic runs deep. So it is hardly surprising that many health professionals, including western educated Africans, consider African medical practices to be worthless at best, and even potentially harmful.
Such a view was propagated by some of the 20th century’s most famous ethnographers and is still being restated by some modern anthropologists. Yet, it is far from the truth, according to medical anthropologist Edward C. Green, a senior research scientist at the Harvard School of Public Health. He and others have found that while traditional African attitudes to mental illness are largely based on superstition, most indigenous ideas about infectious disease are not. In fact, these have much in common with modern western medicine.
Green, who has spent two decades working in sub-Saharan Africa, says that “indigenous contagion theory” consists of three naturalistic explanations for the outbreak and spread of disease. First, the idea of “naturalistic infection” or “indigenous germ theory”, proposes that microorganisms -- described as small insects or tiny worms -- are the immediate cause of many diseases. “Mystical contagion” or “pollution” denotes a belief that people become ill as a result of contact with or contamination by a substance or essence considered dangerous because it is unclean or impure. Finally, the notion of “environmental danger” recognizes that elements in the environment including the air can cause or spread illness. The way these ideas are expressed may seem mysterious and exotic to outsiders but says Green, once you decode the non-Western idioms, symbols and metaphors, the parallels with Western medicine are clear. What’s more, indigenous theories lead to strategies to limit infection similar to those used in Western medicine.
This is what Hewlett has found too. Between August 2000 and January 2001, he conducted the first systematic medical anthropological field study of an Ebola epidemic in northern Uganda. With a total of 425 cases and 224 deaths, it was one of the largest outbreaks since the disease was first identified in humans in 1976. At first, the Acholi community responded as they would to any normal illness, giving sick people a combination of western medicines such as antibiotics and local herbs to treat their symptoms. They also used several practices that may have increased the spread of disease, such as cutting to insert traditional medicines and their usual funerary rites of washing and dressing the body and “love touches”. However, by early October, people began to realize that this was no regular illness. They reclassified the outbreak as “two gemo” (bad spirit), their way of recognizing it as an epidemic illness and instigating a special protocol to bring it under control.
Two gemo requires patients to be quarantined in houses at least 100 metres from others, and marked with poles of elephant grass. Any village where there is infection is similarly marked. The sick are cared for either by a survivor of the epidemic or an elder. The Acholi recognise that pregnant women and young children are particularly vulnerable and these groups are especially advised to stay clear of patients. Everyone is encouraged to limit their movements, if possible staying indoors and not moving between villages. Food consumption is restricted to fresh cattle meat, which should not come from another village. There is no dancing or sexual activity. Any patient who becomes well, must remain isolated for one full lunar cycle. Anyone who dies is buried by his or her carer at the edge of the village.
Hewlett believes that by instigating these practices well before the WHO and national biomedical teams arrived on the scene, the Acholi effectively contained the epidemic and saved many lives. What’s more, the incoming medical professionals incorporated the two gemo concept into posters and music as part of their health education campaign. “One reason the programme worked so well was that it was in many ways consistent with indigenous epidemic control measures -- isolation, suspension of greetings, dances, public funerals,” says Hewlett. “Even the burying of victims at the airfield, while a bit dramatic for some, was consistent with burying gemo victims outside or at the edge of the village.”
In 2003, the WHO invited Hewlett and his team to participate in its early response to another outbreak of Ebola, this time in the Republic of Congo. When they arrived, they found that people in the affected areas had already identified the outbreak as an epidemic illness, using their term “opepe ekono”, and were taking their own measures to tackle it. These were similar to, but less formalized than those adopted by the Acholi, including isolation of the sick, special protection for children, and efforts to educate the whole community about how to deal with the risks. By identifying the local ideas, symbols and language used to cope with the disease, Hewlett was able to help international medical teams devise a more effective response program. In total, 143 people were infected with the virus and 129 died.
Hewlett’s experiences in both Uganda and Congo have convinced him of the benefits of incorporating indigenous medical practices into aid programs. The WHO is not alone in experimenting with this approach. As part of its AIDS project in Burundi, the World Bank is also tapping into the local practices used by Tutsis and Hutus to tackle the disease. By identifying and encouraging those that work well, the World Bank aims to help extended families and local communities give better support to people infected with HIV and anyone affected by the disease. Even the US government has been persuaded to exploit the power of indigenous medical knowledge, although the results have not been altogether successful.
In 2003, when congress pledged $15 billion to fight global AIDS under the President’s Emergency Plan for AIDS Relief (PEPFAR), it decided to adopt an African model to limit the spread of AIDS in sub-Saharan Africa. The approach, developed in Uganda, aims to promote risk avoidance and reduction by encouraging abstinence and delayed sexual debut in youths, monogamy and fidelity among couples, and the use and availability of condoms for everyone. ABC (Abstain, Be faithful or use a Condom), as it is known, has been effectively reducing HIV infection rates in Uganda since the late 1980s, with more recent successes in Kenya, Ethiopia and Zimbabwe. It works because it targets all sectors of the general population, unlike the prevention programmes previously adopted by aid agencies, which were based on the earliest US efforts to restrict the spread of AIDS among prostitutes, gay men and IV users. Even so, the use of ABC as part of PEPFAR has been surprisingly controversial. From the start, congress insisted that one third of the $3 billion set aside for disease prevention measures should be spent on sex education programmes that promote abstinence before marriage. Many Africans view this as a subversion of the ABC message to create a “George W. Bush model” and the policy has been criticised by the US Institute of Medicine because it limits the funds for other, more effective measures such as the distribution of condoms (New Scientist, 5 April 2007).
PEPFAR provides a cautionary tale. It is not enough simply to recognize that African medicine has something to offer, aid agencies also need to build a partnership of trust with the people they are trying to help. This is not always easy in an arena where political ideology and global business interests often play a role in shaping policy decisions. Despite this, Green, who helped persuade the US government to adopt ABC, believes that progress can only be made if there is a change in attitude among the medics on the ground. At the moment, he says, the biomedical fraternity exudes cultural chauvinism and professional prejudice. “Western medical science has long dismissed African indigenous medical theories as superstitious gibberish, unworthy of serious consideration.” He wants to see less Western medical ethnocentrism and a bit more humility and understanding. Hewlett points out that most health care workers are not even aware that Africans have their own successful ways of dealing with infectious diseases. He believes that Western medical experts should be trained to identify cultural beliefs and behaviors that enhance health, and to build on these to improve their approaches to disease control and prevention.
Nobody doubts that developing countries need outside help in their battle against infectious diseases, the problem is huge and they lack resources and infrastructure. As things stand, however, countless millions of dollars are being spent annually on donor-funded health programs that are failing to deliver because they ignore indigenous medicine. If progress can be made simply by recognizing and working with local disease control strategies that are low-tech, cost efficient, culturally acceptable and highly effective, surely that is not difficult medicine to swallow?
Two gemo requires patients to be quarantined in houses at least 100 metres from others, and marked with poles of elephant grass. Any village where there is infection is similarly marked. The sick are cared for either by a survivor of the epidemic or an elder. The Acholi recognise that pregnant women and young children are particularly vulnerable and these groups are especially advised to stay clear of patients. Everyone is encouraged to limit their movements, if possible staying indoors and not moving between villages. Food consumption is restricted to fresh cattle meat, which should not come from another village. There is no dancing or sexual activity. Any patient who becomes well, must remain isolated for one full lunar cycle. Anyone who dies is buried by his or her carer at the edge of the village. Hewlett believes that by instigating these practices well before the WHO and national biomedical teams arrived on the scene, the Acholi effectively contained the epidemic and saved many lives. What’s more, the incoming medical professionals incorporated the two gemo concept into posters and music as part of their health education campaign. “One reason the programme worked so well was that it was in many ways consistent with indigenous epidemic control measures -- isolation, suspension of greetings, dances, public funerals,” says Hewlett. “Even the burying of victims at the airfield, while a bit dramatic for some, was consistent with burying gemo victims outside or at the edge of the village.” In 2003, the WHO invited Hewlett and his team to participate in its early response to another outbreak of Ebola, this time in the Republic of Congo. When they arrived, they found that people in the affected areas had already identified the outbreak as an epidemic illness, using their term “opepe ekono”, and were taking their own measures to tackle it. These were similar to, but less formalised than those adopted by the Acholi, including isolation of the sick, special protection for children, and efforts to educate the whole community about how to deal with the risks. By identifying the local ideas, symbols and language used to cope with the disease, Hewlett was able to help international medical teams devise a more effective response programme. In total, 143 people were infected with the virus and 129 died. Hewlett’s experiences in both Uganda and Congo have convinced him of the benefits of incorporating indigenous medical practices into aid programmes. The WHO is not alone in experimenting with this approach. As part of its AIDS project in Burundi, the World Bank is also tapping into the {>>]DIFFERENT[<??] local practices used by Tutsis and Hutus to tackle the disease. By identifying and encouraging those that work well, the World Bank aims to help extended families and local communities give better support to people infected with HIV and anyone affected by the disease. Even the US government has been persuaded to exploit the power of indigenous medical knowledge, although the results have not been altogether successful. In 2003, when congress pledged $15 billion to fight global AIDS under the President’s Emergency Plan for AIDS Relief (PEPFAR), it decided to adopt an African model to limit the spread of AIDS in sub-Saharan Africa. The approach, developed in Uganda, aims to promote risk avoidance and reduction by encouraging abstinence and delayed sexual debut in youths, monogamy and fidelity among couples, and the use and availability of condoms for everyone. ABC (Abstain, Be faithful or use a Condom), as it is known, has been effectively reducing HIV infection rates in Uganda since the late 1980s, with more recent successes in Kenya, Ethiopia and Zimbabwe. It works because it targets all sectors of the general population, unlike the prevention programmes previously adopted by aid agencies, which were based on the earliest US efforts to restrict the spread of AIDS among prostitutes, gay men and IV users. Even so, the use of ABC as part of PEPFAR has been surprisingly controversial. From the start, congress insisted that one third of the $3 billion set aside for disease prevention measures should be spent on sex education programmes that promote abstinence before marriage. Many Africans view this as a subversion of the ABC message to create a “George W. Bush model” and the policy has been criticised by the US Institute of Medicine because it limits the funds for other, more effective measures such as the distribution of condoms (New Scientist, 5 April 2007). PEPFAR provides a cautionary tale. It is not enough simply to recognise that African medicine has something to offer, aid agencies also need to build a partnership of trust with the people they are trying to help. This is not always easy in an arena where political ideology and global business interests often play a role in shaping policy decisions. [>>]Despite this, Green, who helped persuade the US government to adopt ABC, believes that progress can only be made if there is a change in attitude among the medics on the ground. At the moment, he says, the biomedical fraternity exudes cultural chauvinism and professional prejudice. “Western medical science has long dismissed African indigenous medical theories as superstitious gibberish, unworthy of serious consideration.” He wants to see less Western medical ethnocentrism and a bit more humility and understanding[<<OK?]. Hewlett points out that most health care workers are not even aware that Africans have their own successful ways of dealing with infectious diseases. He believes that Western medical experts should be trained to identify cultural beliefs and behaviours that enhance health, and to build on these to improve their approaches to disease control and prevention.Nobody doubts that developing countries need outside help in their battle against infectious diseases, the problem is huge and they lack resources and infrastructure. As things stand, however, countless millions of dollars are being spent annually on donor-funded health programs that are failing to deliver because they ignore indigenous medicine. If progress can be made simply by recognizing and working with local disease control strategies that are low-tech, cost efficient, culturally acceptable and highly effective, surely that is not difficult medicine to swallow?
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