In August 2017, a man who had recently traveled by shared taxi from the central highlands of Madagascar to Tamatave (via Antananarivo) died after a brief illness. Soon after his death, an additional thirty-one people who had come into direct or indirect contact with this man became sick and four died. By November 22, 2017, 2,348 cases and 202 deaths from plague were reported throughout the country. No new cases of confirmed bubonic plague have been identified since November 8. But, since the disease is seasonal in Madagascar, prevention and response activities are expected to continued through April 2018 and the World Health Organization (WHO) is advocating for a longer-term strategy to be put in place. At present, Madagascar’s Ministry of Public Health and the WHO are leading the response, which is organized around four major activities: surveillance, community response, case management, and communication. This global health mobilization is reminiscent of what was seen in West Africa from 2014 to 2016 in response to the Ebola virus disease (EVD) epidemic. This epidemic, the largest of its type ever seen, rapidly infected almost 30,000 and killed over 11,000 people, mainly in Guinea, Liberia, and Sierra Leone. This was the first time that EVD had threatened major urban areas. It was also the first time that anthropologists were involved in such large numbers at all stages of the response, particularly to help ensure that public health interventions were locally relevant. Will the collective social science experience acquired during the West African Ebola epidemic be engaged to address the current plague outbreak?
While the social sciences are rarely included in emergency interventions, anthropologists have been increasingly mobilized by the WHO in Ebola outbreak response efforts since the 2000–2001 epidemic in Uganda. Some of their experiences and lessons learned are relevant to outbreaks of other diseases, as well as to future epidemics of EVD. Similar to EVD in West Africa, the Madagascar plague outbreak is threatening densely populated urban areas. In contrast to Ebola, though, plague is treatable with antibiotics if detected early enough. However, many of the same barriers to control exist for both diseases: avoidance of patients by some health workers; resistance to contact tracing and safe burials; overreaction of the media; fear of medical interventions; conflicts between biomedical and lay representation of illness, and more. Anthropologists with expertise in hemorrhagic fevers were hired by United Nations agencies to address these barriers soon after the outbreak was declared in Madagascar, and have built their present response on their previous experience. Beyond translating and sharing the knowledge of these skilled and experienced individuals, how can anthropologists collectively develop and improve their contribution to outbreak response?
The role of anthropologists in responding to EVD began with rapid qualitative investigations of the sociocultural factors that enable the spread of disease and limit the effectiveness of emergency response efforts. However, anthropology’s engagement with epidemic response quickly escalated beyond a mediating position between global health agencies, national response programs, and populations. During the West African EVD epidemic, anthropologists served as expert-advisors to national response coordinators and global actors like the WHO, and they also delivered trainings and implemented research projects. As a result, social science methods and knowledge were engaged to adapt messages and activities to specific contexts, acknowledge the perceptions and local knowledge of populations, show the limitations and controversial aspects of public health measures, and speak up against the overuse of “sociocultural factors” as a general explanation for the spread of epidemics, especially in connection with the pathologizing use of terms like “resistance” or “reluctance.” In the current plague outbreak in Madagascar, anthropologists are developing studies that explore funeral practices, therapeutic itineraries, and perceptions of health facilities, as well as the factors that influence trust and compliance related to public health measures.
Anthropology usually functions as a slow science, taking the time to listen, observe, analyze, and think about the data it gathers. Involvement with rapid emergency response efforts challenges this usual working process, as public health actors require rapid studies, drawing on strategies like KABP (Knowledge, Attitudes, Beliefs and Practices) surveys that—from the perspective of anthropologists—are often insufficient and require complementary, in-depth investigation to produce meaningful findings. Organizing effective epidemic response on the part of anthropologists also requires overcoming institutional and linguistic divides in the social sciences. During the West African EVD epidemic, French research and response efforts were focused mainly on Guinea and bordering French-speaking countries, while U.K. and U.S. actors worked largely in English-speaking Sierra Leone and Liberia. Efforts were also needed to translate anthropological insights into concepts and recommendations that were relevant for public health in addition to the social sciences. This often meant a discipline-specific focus on results translation and communication. In order to share relevant research in real time during the Ebola epidemic, anthropologists created dedicated social science platforms. This included the U.K.-based Ebola Response Anthropology Platform, the U.S.-based Emergency Ebola Anthropology Network, and the French/West African Réseau Ouest Africain Sciences Sociales Ebola. These experiences and efforts have led to the creation of new post-Ebola initiatives, such as the Réseau Ouest Africain Anthropologie des Epidémies Emergentes and the Social Science in Humanitarian Action Platform. As these continuing collaborations show, in post-epidemic times, social scientists remain interested in studying and writing about epidemics, although practical concerns such as funding and other research obligations have scaled down the involvement of many scholars.
Anthropologists’ involvement in outbreak response should not be limited to the beginning of an epidemiological event. More than one year after the last case of Ebola in West Africa, the biological consequences of the EVD epidemic have waned and yet the social disruption caused by the disease continues. Public health systems have been marked by the epidemic’s psychological and physical drain on health care workers, as well as fear of the disease and of its public health response. Population subgroups created during the epidemic (“at risk”, “suspected case”, “infected”, “survivors”) continue to impact current social representations, practices, and memory. Research conducted in the countries and communities that bordered this epidemic confirm that the social effects of Ebola occur even in the absence of epidemiological evidence—both before and after cases. Perceptions about the disease and how it was addressed remain, even in places that never experienced a single case. In affected communities, many individuals who received treatment for EVD still experience the social effects of the disease. Programs like the cohort study PostEboGui, which follows up with Ebola survivors in Guinea, highlight the specific physical, social, and psychological effects in individuals who were infected with the disease. These initiatives also provide us with a chance to explore how individuals experienced Ebola prevention and care during and after the epidemic, experiences that can be engaged to improve the adaptation of global public health measures to patient and survivor needs, population response, and local health service constraints.
The WHO has called for preparedness in order to strengthen rapid emergency response in the case of a new Ebola epidemic. While vaccines are being developed and national emergency response plans created, how can the social sciences best contribute and be ready to act rapidly and effectively when faced with a new crisis? What strategies should be engaged to develop useful, up-to-date, and relevant work in spite of institutional and linguistic divisions? And how can this be done with the funding limitations that are the reality of post-epidemic periods? Answering these questions during a time of calm, rather than waiting for a time of crisis, incites reflection on what it means for the social sciences to be prepared. Preparing a response means, at the very least, making in-depth knowledge about the social, economic, political, and cultural worlds of affected populations accessible. It also means developing in-depth research on the structural factors that affect response to epidemics, such as the significance of funeral rituals or the status of health professionals in health systems, to provide background knowledge for studies focused on the outbreak. While social scientists have primarily been called upon to contribute to national and regional epidemic work, research is needed to address global health policy as well. Social science preparedness also means developing theoretical frameworks beyond empirical studies, such as those that consider the social and ideological effects of an epidemic as the result of tensions between local and global dynamics. The rapid methodologies promoted by global health agencies must be critically addressed and discussed in order to achieve scientific validity informed by the in-depth knowledge acquired through comprehensive anthropological research. Preparedness for emergency studies should also include discussing the advantages and disadvantages of preparing mock-up research protocols, literature reviews, methodological guidelines, or focused policy briefs in advance of an epidemic.
On an organizational level, preparedness can mean keeping tabs on existing experts and expertise and establishing connections that allow the right person with the right skills to be mobilized at the right moment. Platforms such as the Réseau Ouest Africain Anthropologie des Epidémies Emergentes and the Social Science in Humanitarian Action Platform stand to help collate this information. Preparedness also involves identifying what types of expertise still need to be developed. For instance, should health professionals or epidemiologists receive social science training? Or should social scientists be trained in applied response to infectious disease? Should such training focus on emergency outbreaks or should they also concern epidemics that have become pandemics, such as HIV/AIDS or tuberculosis, in order to produce true social science experts in infectious outbreaks and public health response?
As these questions about preparedness are examined in relation to past experience with Ebola, they have has also been renewed over the last two years in light of other emerging epidemics. On October 20, 2017, an outbreak of Marburg virus disease was declared at the Uganda-Kenya border, and anthropological expertise has already shaped the response. With the involvement of anthropologists in response to different epidemics in diverse contexts, standard practices will continue to be refined. To translate individual experience into collective knowledge, support and engagement are needed at three levels: sharing of anthropological knowledge between scholars, including translation for public health specialists; transmission of that knowledge to junior scientists; and ongoing work to develop relevant methodology and theory. Anthropologists currently working in Madagascar, Uganda, and Kenya should be able to count on the support of their professional networks to contribute more effectively to ending epidemics, while retaining a critical stance toward the involvement of anthropology in emergency response.
This post grew out of the workshop “Populations Facing Ebola,” which was organized by the Institut de Recherche et Développement and the West African Network for the Anthropology of Emerging Epidemics and held in Montpellier, France on September 21, 2017. The participants included Kelley Sams, Alice Desclaux, Julienne Anoko, Francis Akindès, Marc Egrot, Khoudia Sow, Bernard Taverne1, Blandine Bila, Michèle Cros, Moustapha Keïta-Diop, Mathieu Fribault, and Annie Wilkinson.