Issues in Interdisciplinarity 2019-20/The issue of History in the 2013 - 2016 EVD epidemic

Introduction

The first outbreaks of the Ebola Virus Disease were in 1976 in the DRC and Sudan. The subsequent West African Epidemic reached mortality rates of up to 90%, more specifically in Liberia, Guinea, Mali, Sierra Leon, Nigeria and Senegal. The epidemic had devastating social, political impacts on the countries’ economies and healthcare systems.

The death toll by October 2015, 11,323, begs us to question methods employed to end the outbreak. Medical and biological sciences are needed to explain the origin and treatment of diseases, while understanding the cultural practices that prevented the containment of EVD requires anthropological perspectives. However, the history of these different disciplines is problematic in tackling the crisis, as scientific procedure tends to take precedence. We will therefore explore different disciplinary approaches to the 2013-2016 Ebola crisis, illustrating the benefits of interdisciplinary thinking.

Extension of the 2014 EVD epidemic in West Africa

Biology and Virology

Zaire Ebolavirus is one of the most virulent pathogens within the hemorrhagic fevers. The virus spreads through contact with bodily fluids. The incubation period is 21 days, during which the patient may inadvertently cause propagation. Symptoms are similar to other diseases found in West Africa such as malaria, Lassa fever and typhoid, resulting in frequent misdiagnosis.

Cases and deaths from April 2014 to July 2015 during the 2013-2015 outbreak. A total of 28, 646 cases.

Electron micrograph of an Ebola virusvirion

Its genome consists of non-segmented, negative-sense, and single-stranded RNA molecule. After contagion, the virus targets and weakens the immune system, specifically dendritic cells. In a study published by 'Cell Host & Microbe', research found that the VP24 protein on Ebola inhibits the production of antibodies. Toxins trigger the release of proinflammatory cytokine and nitric oxide, which damage the endothelial lining of blood vessels. Then, the repeated coagulation reduces blood supply resulting in fatal organ failure.

Immediate symptoms of Ebola

No cure exists for EVD, but in 2016 the rVSV-ZEBOV vaccine was found to be 70-100% effective.

Responses

1. Medical

The primary aim of medical practitioners was to interrupt transmission chains by quarantining patients. The EVD response privileged the work of scientists often overlooking social and cultural factors. Medical intervention was highly individualistic and included enforced quarantines, movement prohibition, traveller test points, and mandated cremation. Unsurprisingly, the effectiveness of such measures increased the stigmatisation surrounding the disease.  Medical practitioners used IgM ELISA tests, RT-PCR tests, biopsy samples and viral cultures to diagnose patients and limit the spread of ebola.

Ebola Pathogenesis schematic

VHF isolation precautions poster

While there were no approved treatments, supportive care like the one recommended by the CDC was applied to alleviate the patients' suffering. This included: oral rehydration therapy, intravenous fluids, oxygen therapy, treating other infections if they occurred, and disinfecting surfaces with (>70%) alcohol wipes. Conventional medicine was used to relieve the symptoms (high blood pressure, vomiting, fever and pain). Medical workers used experimental treatments such as immune serums, antiviral drugs and possible blood transfusions to impede the disease from victimising others. To provide relief, the doctors deployed in the infected areas set up treatment and isolation centres rather than search for a cure. Containment was the main concern so medical action was largely unquestioned.

Yet this approach was occasionally met with hostility for example when 8 health workers attempting to raise awareness about EVD in a village in Guinea were murdered. While historically very effective at minimising physical suffering, the massacre of health workers made it painfully clear that this historical authority is not universal. Therefore, medics must turn to anthropologists to understand the important cultural dynamics present in diverse African societies.

2. Anthropological Approach

Anthropological research illustrates how social and cultural factors contributed to the biological transmission of EVD during the 2013 West Africa outbreak and interfered with the corresponding medical response. Many of the affected countries suffer from poverty and the recent civil wars in Guinea, Liberia, and Sierra Leone left behind fragile health care systems and physician shortages regionally. The consequent challenged quarantine, ineffective alerts and pleas for assistance facilitated further infection.

An example of a hospital isolation ward

Understanding cultural practices in infected regions is integral to tackling the EVD crisis effectively. Cultural differences between health practitioners and locals was problematic in dealing with the outbreak. The WHO’s retrospective analysis of the outbreak showed locals feared how much western treatment contradicted traditional practices regarding the dying or diseased. Ancestral funeral rites such as sleeping next to an infectious corpse of the community and bathing in water used to rinse corpses were attributable to 80% of cases in Sierra Leone by WHO estimates. The stigma around these cultural practices drove families to hide symptomatic relatives, leading to infection of their households. Traditions of returning dying patients to their native village elevated the risk of transmission through cross-border movement.

Fear of physicians was another barrier to its eradication. In Guinea, rumours of health workers disinfecting a market contaminating people led to riots. Proving that health care responses require communication between medical practitioners and community leaders. A post-colonial reading of western aid sees imperialistic thinking that disregards customs. Doctors often see locals' apprehension of western medicine as backwards tradition and the work of well-respected African healers is disregarded. Biology failed to provide a complete explanation nor complete response to EVD epidemic. Anthropological research is needed to provide culturally-sensitive aid. Moreover, theology could further inform anthropology in local religious customs.

3. Theological Approach

Burials according to biomedicine and theology present contradictory practices. Biomedicine, a Western discipline, institutionalises quarantines in burials, whereas West African religious preach religious inquires into pathology during burials.

Burials are important in many West African religions, as the time for the deceased to enter the afterlife, join their ancestors, and overlook the living. Ill-performed rituals could trap the spirits in the living realm and taunt loved ones. Bodies are cleansed and foetuses are removed from pregnant bodies to uphold natural cycles and ensure the wellbeing of both alive and dead. Thus, religious procedures concerning remains are strictly adhered to. Disagreements over how burials should be performed have arisen during the outbreak because the meaning of burials diverges between biomedicine and West African theology. An example of this is, in Guinea, a burial was brought to standstill amidst disagreements between a Kissi family and the medical team on how to handle the remains. The body rotted as the dispute carries on, which risked further infections upon leakage. Meanwhile, another team in Guinea substituted old repatriation rituals for the foetus’ removal, and successfully buried the pregnant body to everyone’s satisfaction. This underpins the importance of theology in complementing biomedicine and anthropology to understand, manage, and quell epidemics like Ebola in West Africa.

Conclusion

The 2013-2016 Ebola epidemic captured the world’s attention, and experts from a diverse range of disciplines sprang into West Africa’s aid; with medics handling the majority of ailments, while anthropologists liaised with communities, and religious leaders encouraging cooperation.

Unfortunately, due to the complex lexicon, disciplinary boundaries, and historical paradigms behind these disciplines; their ideas diverge on many seemingly intuitive concepts like burials, and could not communicate effectively. An interdisciplinary approach bridging knowledge between disciplines in their interpretation of treatment, healing, and well-being, could converge the efforts with synergetic effects.

Healthcare spending in West African countries such as DR Congo falls short of other countries in the continent, and public finances may be better managed with insights from governance

A mathematical model of epidemics, which could disease control centres the amount of resources needed at given points in time and where to distribute them

Further disciplines may also be introduced, such as mathematical models of disease transmission, governance theories of public healthcare, and psychological perspectives on trauma. While each discipline has developed distinct metrics and criteria for what a good approach is, coherence could be achieved between these knowledge frameworks if differences are proactively reconciled.