In 1995 and 1996, Gabon in central west Africa experienced two outbreaks of Ebola haemorrhagic fever, one of the world鈥檚 deadliest diseases. A total of 91 people were infected, of whom 66 died. The numbers 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 way diseases are handled in poorer countries.
As Ebola began to take hold, American and French teams of medical aid workers arrived in the affected areas. Despite good intentions, their attempts to help did not go down well. Lack of coordination between the groups meant that, as well as coping with the outbreak of a deadly disease, local people had to contend with two sets of outsiders coming through their villages taking blood samples twice and asking the same questions. Worse still, the aid workers seldom reported back to the villagers, arousing deep suspicion that they were up to no good. The breakdown in trust was so complete that six years later, when another outbreak of Ebola swept through a neighbouring area, international medical teams faced fierce armed resistance and had to be evacuated on two occasions.
According to medical anthropologist Barry Hewlett of Washington State University in Vancouver, US, 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 鈥渟pecific cultural elements and local beliefs鈥�. That was not enough to prevent the violence in 2001, but over recent years the WHO鈥檚 new agenda has been implemented by researchers and aid workers, including Hewlett.
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Now, a decade on, they believe the approach has so much potential that it should be far more widely adopted. They are calling for a total rethink about how western aid agencies and African health ministries deal with disease outbreaks. The problem, they say, is that western public health officials involved in international development have been ignoring the fact that indigenous people have their own strategies for disease control and prevention. Combating disease in countries in Africa and elsewhere could be much more successful if only they would recognise this fact and find ways for traditional ideas to complement western ones.
This may sound like common sense, but it is a radical proposal compared with standard practice. The popular perception of 鈥淎frican鈥� medicine has not moved much beyond Hollywood images of leopard-skin-clad witch doctors reciting mystical incantations to the beat of throbbing drums. Of course this is a stereotype, but the notion that the medicine practised by rural people in African countries is rooted in witchcraft, superstition and black magic runs deep. So it is hardly surprising that many health professionals, including western-educated Africans, consider rural medical practices to be worthless at best, and even potentially harmful.
This view was propagated by some of the 20th century鈥檚 most famous ethnographers and is still being restated by some modern anthropologists. Yet it is far from the truth, says applied medical anthropologist Edward Green of the Harvard Center for Population and Development Studies. He and others have found that while traditional attitudes to mental illness contain strong elements of superstition, most ideas about infectious disease do not. In fact, they have much in common with modern western medicine.
Green, who has spent two decades working in various countries in sub-Saharan Africa, groups traditional ideas into what he calls 鈥渋ndigenous contagion theory鈥�, which has three main strands. First, people recognise that microorganisms 鈥� usually described as small insects or worms 鈥� are the immediate cause of many diseases. They are also well aware that people can become ill as a result of contact with or contamination by certain substances. Finally, there is a recognition that elements in the environment including the air can cause or spread illness. The way people express these ideas may seem mysterious or strange to outsiders, says Green, but once you get used to the non-western idioms, symbols and metaphors, the parallels with western medicine are clear. What鈥檚 more, knowing how diseases are caused leads to traditional strategies to limit or prevent them that are also similar to western ones.
This is what Hewlett has found too. In 2000, he conducted the first systematic medical anthropological field study of an Ebola outbreak among the Acholi people 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 community responded as they would to any normal illness, treating sick people with a combination of western medicines, such as antibiotics, and local herbs. They also used several practices that may have increased the spread of disease, such as cutting the skin to insert traditional medicines and carrying out traditional funerary rites, which involve washing and dressing the body and 鈥渓ove touches鈥�. However, three months on people began to realise that this was no regular illness. They reclassified the outbreak as , meaning bad spirit, their way of recognising it as a grave threat requiring a special protocol to bring it under control.
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 outbreak or an elder. Pregnant women and young children in particular are advised to stay clear of infected people, and everyone is encouraged to limit their movements, if possible staying indoors and not travelling between villages. Food consumption is restricted to fresh cattle meat, which should not come from another village. There is no dancing or sexual activity. Anyone who gets better must remain isolated for a 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 measures, the Acholi effectively contained the outbreak and saved many lives long before the WHO and national aid teams arrived on the scene. The incoming medical professionals even managed to incorporate the word gemo into posters and music as part of their health education campaign. 鈥淥ne reason the programme worked so well was that it was in many ways consistent with indigenous epidemic control measures 鈥� isolation, suspension of greetings, dances, public funerals,鈥� says Hewlett. 鈥淓ven 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.鈥�
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 the 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, though less formalised than those of the Acholi, and included isolation of the sick, special protection for children, and efforts to educate the whole community about how to deal with the risks.
By familiarising themselves with the local ideas, symbols and language used to cope with the disease, Hewlett and his colleagues were able to help international medical teams such as the Red Cross deal with the outbreak and assist the WHO in devising a more effective response programme based on culturally sensitive control strategies. Even then, a total of 143 people were infected with the virus and 129 died.
Hewlett鈥檚 experiences in 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 project to combat HIV/AIDS in Burundi, the World Bank is tapping into the different local practices used by the Tutsi and Hutu peoples to tackle the disease. By identifying and encouraging those that work well, the World Bank aims to help families and communities provide better support for 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 the US Congress pledged $15 billion to fight global AIDS under the President鈥檚 Emergency Plan for AIDS Relief , it decided to adopt a model developed primarily in Uganda to try to limit the spread of AIDS in sub-Saharan Africa. The approach aims to promote risk avoidance and reduction by encouraging abstinence and delayed sexual debut in young people, monogamy and fidelity among adults, and the use and availability of condoms for people at greatest risk of infection. ABC 鈥� Abstain, Be faithful or use a Condom 鈥� as it became known, began to reduce HIV infection rates in Uganda in the late 1980s, with more recent successes in Kenya, Ethiopia and Zimbabwe.
Its great strength is that it targets all sectors of a 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 gay men, intravenous drug users and prostitutes. Even so, the use of ABC as part of PEPFAR has been 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 until marriage. Many people in African countries view this as a subversion of the ABC message to create a 鈥淕eorge W. Bush model鈥�. The policy has also been criticised by the US Institute of Medicine, which argues that it limits the funding available for other, more effective measures (快猫短视频, 7 April, p 4).
PEPFAR provides a cautionary tale. It is not enough simply to recognise that traditional medicine has something to offer; aid agencies also need to win the trust of 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 healthcare providers on the ground. At the moment, he says, the biomedical fraternity exudes cultural chauvinism and professional prejudice. 鈥淲estern medical science has long dismissed African indigenous medical theories as superstitious gibberish, unworthy of serious consideration,鈥� he says.
鈥淭he biomedical fraternity exudes cultural chauvinism and professional prejudice鈥�
Green wants to see less western medical ethnocentrism and a bit more humility and understanding. Hewlett points out that most healthcare workers in Africa are not even aware that communities 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 poor 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 programmes that are failing to deliver because they ignore indigenous medicine. Local disease control strategies are often low-tech, cost-efficient, culturally acceptable and highly effective. If progress can be made simply by recognising and using them, surely that is not difficult medicine to swallow?
