Africa’s Custom-Made Cures

Emerging Infectious Diseases, Vol. 9, No. 10, October 2003, Atlanta With less than 1,200 deaths since the first known outbreak in 1976, Ebola is a relatively small player in the world league of infectious diseases. Still, Ebola’s mysterious origins, its high fatality rate (between 50 and 90 percent), and the sheer horror of its manifestations ...

Emerging Infectious Diseases,
Vol. 9, No. 10, October 2003, Atlanta

Emerging Infectious Diseases,
Vol. 9, No. 10, October 2003, Atlanta

With less than 1,200 deaths since the first known outbreak in 1976, Ebola is a relatively small player in the world league of infectious diseases. Still, Ebola’s mysterious origins, its high fatality rate (between 50 and 90 percent), and the sheer horror of its manifestations (patients often bleed from multiple orifices as their internal organs disintegrate) have earned the virus a top spot on the list of new bugs that bear close watching. As with most viruses, a few mutations could launch the virus from its remote outbreaks in Africa onto a destructive global odyssey.

Teams that contain Ebola outbreaks in Africa often find themselves battling more than just the virus. They’re also up against forces that defy mobile labs, protective suits, and rubber gloves: namely, unhygienic traditional healing methods, unsafe funeral rites, or patients’ deep-seated fear of just visiting a clinic. During an outbreak two years ago in Gabon, disputes over burial practices became so heated that international teams felt compelled to withdraw temporarily from a town where the epidemic was still raging.

But while outbreak fighters at the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), or the international nongovernmental organization Médecins Sans Frontières can relate many such episodes, the medical community has yet to systematically investigate the local beliefs or misunderstandings that fuel them. Recently, however, Barry Hewlett, an anthropologist at Washington State University, and Richard Amola, a medical official at the Ugandan Ministry of Health, teamed up to study the cultural context of Ebola among the Acholi, the ethnic group hardest hit by a devastating 2000-01 outbreak in northern Uganda. They reported their findings in the cdc’s flagship monthly journal, Emerging Infectious Diseases.

The Acholi were aware of Western biomedical explanations for the disease, the authors note. During the outbreak, some victims took antibiotics or antimalarials to try to cure themselves. But once the epidemic had raged for more than a month, another theory took hold among the Acholi. Residents started classifying the scourge as two gemo, which means "epidemic illness." Gemo are bad spirits that sneak up on many people simultaneously, perhaps as punishment for not respecting the gods.

Interestingly, gemo triggered a range of Acholi containment procedures — from quarantining patients and marking their homes to limiting everyone’s movements — that also made sense from a biomedical perspective. These procedures have been around for a long time, and it is unclear whether the Acholi adopted them from the British during colonial rule or whether they discovered their usefulness independently. In any case, Hewlett and Amola conclude that traditional beliefs aren’t always bad; in fact, they may jibe with what Western doctors would order.

Conversely, Western healthcare professionals who don’t understand local customs can make matters worse. WHO workers, for example, believed that Ugandan Ebola patients shunned hospitals because they feared they might be buried in the emergency cemetery near the local airfield, not in their village’s burial ground. Not so, Hewlett and Amolo discovered. Burial at the edge of the village was part of standard gemo protocol, and if families had been allowed to witness their loved ones being interred at the airfield, the problem could have been averted.

As fascinating as such details may be, a study published nearly three years after the last victim was infected has limited practical value. The authors can’t offer much guidance to the doctors and health authorities who will deal with coming outbreaks, because such epidemics (possibly spurred by new, different viruses) may occur among diverse ethnic groups in different countries. And one can hardly expect health authorities to dispatch anthropologists to catalog each and every cultural and medical belief across Africa.

But detailed anthropological studies like these may well become useful in another way. At a recent symposium near Washington, D.C., organized by the National Institute of Allergy and Infectious Diseases, Ebola researchers reported several promising findings, including two vaccines and a candidate drug that reduced mortality from the virus in monkeys. Sooner or later, one of these products must be tested in the real world. A profound understanding of how local cultures deal with the disease, and how a vaccine or drug would fit into their spiritual worldview, will then prove essential.

Martin Enserink is a staff writer for Science magazine.

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