infectious disease

“It don’t take a semiotician…” Or, what we talk about when we talk about bush meat.

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This weekend, Newsweek published a relatively controversial article about the recent Ebola outbreak in West Africa. Here’s the cover:

chimp ebola

Let’s just say it’s not exactly an original piece of journalism either.

I found myself frustrated not only by the cover and the article, but also by the editor-in-chief’s condescending response to his critics:

Not exactly the kind of response you want from an editor-in-chief, right? I vented to Facebook friends about the magazine cover, the thin claims of the article and its editor-in-chief’s rude response to critical tweets. One of my friends pointed out that the magazine has been propagating race-baiting click bait for a while now. (Yes, I used the word ‘bait’ twice, and we, the scholars, have bitten). So it shouldn’t be surprising to see the old trope of apes standing in for black folks or sexually charged Grubb Street prognostications regarding ‘back door’ entry of Ebola into the US gracing its front pages. (As one tweeter noted, It doesn’t take a semiotician to see what’s going on here).

Nor is surprising to see ‘exotic foods’ as the site for the latest in what journalist Howard French calls ‘ooga boogah’ writing on the Ebola epidemic. As French recently wrote,

He has also referenced Chinua Achebe’s biting criticism of Conrad’s Heart of Darkness to bring attention to how Western media continue to write about Africa.

There are some pretty standard “Africa” tropes in the article, which incidentally, takes place in the Bronx: a Ghanaian interlocutor speaks with a “thick accent”; the “heat and stench… assault” the authors in a (Bronx) market. The authors seem to mock the irrational fears expressed by Donald Trump while also trafficking in them. But the article is mostly a superficial account that overstates what is known about the trade in bushmeat and the biological and public health implications of an unregulated industry. The scientific studies it cites are small and cautious about the implications of bushmeat traffic at the borders of the US. The experts to whom they speak provide their best guesses about the public health stakes of loose border controls. The article also raises as many questions as it answers:

1. What the heck are they talking about when they are talking about bush meat? While the scientific literature is clear about what they mean by bushmeat, the article seems to lump all kinds together. “Bushmeat” has become a catchall for every kind of meat that one might transport across international borders, including the mollusks, grasscutter and dried fish found in a variety of West African cuisine. None of these are culprits in the Ebola outbreaks. But the article also made me wonder about how I should think about the locavore/hunting-for-food lifestyles that are increasingly en vogue among a certain class of Americans. Should American hunters be worried about the animals they kill and prepare for eating? (Seems so.)

2. So, let’s say we want to focus on threats from current outbreak of Ebola, as the title of the piece suggests (but isn’t really done in the article, except to say that Ebola was not found among animals in one of the studies cited). Which animals are coming from Guinea, Sierra Leone and Liberia? How many of them are capable of harboring deadly viruses like Ebola?

3. By the authors’ own account, dining practices have already changed because of the outbreak. The authors can’t even find any bushmeat. Their Ghanaian source is telling them that it’s increasingly difficult to find bushmeat these days. Isn’t it worth explicitly noting that people’s fears might be prompting all kinds of rapid change? Now that we know that, might we ask what other kinds of change is possible: are hunters, butchers and merchants now handling bushmeat with greater caution?

I leave with Dave Chappelle’s hilarious bit on race and food:

On gender, the case data and why an anthropologist cares

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Last night, I was talking to a reporter with the Washington Post about gender and Ebola. She contacted me because she saw a tweet I wrote asking about sex disaggregated data for the outbreak. None of my ‘Ebola tweeps’ — some of them data wonks — knew of any good sources. I looked at the ministry of health updates and WHO data, but found nothing about sex or gender. It seems that much of what we hear, and much of what we know, is based on conjecture and speculation. Liberian President Ellen Johnson-Sirleaf apparently reported that 75% of the cases were women (I haven’t found the link but it’s one of the things that prompted the reporter to request an interview). It is not clear where these figures come from, but I suspect it is an educated guess related to who takes care of sick people at home and within health facilities, who deals with bodies in funerary rites, and other factors involving the differences between women’s and men’s daily practices. It might even be a hunch that frontline workers have communicated. I can’t be sure. But this article suggests that Ebola is affecting ‘breadwinners’; who are these people?

After my conversation with the reporter, I decided to look more carefully for data that might provide some clue about transmission and infection patterns as they relate to gender. I worry that because we have so little numerical data beyond these cases and their location (or maybe it’s just not available for public consumption?), however, the numerous consultants deploying to the region run the risk of basing many of their decisions about containing the epidemic on speculation and conjecture. Apparently, MSF has some anthropologists on staff now; I am hoping that the anthropologist has the willingness and foresight to not only provide fine-grained analysis of social and cultural practices that place people at risk (our work tends to be valued for being arcane, esoteric), but also to mine the numerical stuff for other clues. Perhaps s/he can suggest better ways to slice and dice the numbers.

But back to the original question: Why does gender matter? It might not at all. But my sense is that we might not know whether it does or not if we don’t have sex disaggregated data to look at how the epidemic has developed over time. And we don’t just need gender data for the cases, but for the health workforce, hospital cleaning staff and the like. This is how messages get targeted. This is how people follow contacts, trace movements, contain patients. Knowing how people do the work that they do, where they do it, and under what context they may be at risk for infection, is paramount as the new infections and cases show no sign of slowing.

On the off chance that war doesn’t change everything: more on Ebola

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I’m trying not to make my commentary about the current Ebola outbreak about representation, but I’ve been a bit troubled by the political analyses accompanying the epidemiological and health systems ones. Specifically, I want to talk a bit about how Liberia’s and Sierra Leone’s civil wars have been deployed by these analysts to understand the response to the outbreak and how explaining existing tensions requires some deeper knowledge about local context.

Laurie Garrett’s recent opinion piece on CNN and her appearance on Melissa Harris-Perry’s show are both examples of this kind of minimally informed political analysis. There is nothing unique about her stance, I suppose. We see this sort of “war changes everything” or “war happened, therefore…” logic quite a bit. But because she is such a well-respected journalist — I loved The Coming Plague in college and became interested in public health because of that book — I think it’s worth discussing here. As much as I have admired her work, I am beginning to see how her analysis, combined with a reputation for producing compelling journalistic accounts of global health problems, may successfully reproduce the tropes that make for interesting and juicy news, but may not help the cause.

One reason it is useful to understand the context is that even reading newspaper editorials requires some knowledge of existing tensions and conflicts. Yesterday, Garrett tweeted a link to an Awareness Times editorial, focusing (in her short Twitter allotment) on the ignorance of a “very important citizen” who underestimated the threat of the disease publicly. While this may very well be one of the points the editorial was making, I think Garrett’s tweet might be missing the point. It helps to know that the Awareness Times is a paper through which Sylvia Blyden, who has been very vocal and critical of the government response to Ebola from very early on, is communicating her disapproval of the government response to the epidemic.

It is also helpful to know that she has ruffled some feathers on many political matters. According to another Facebook friend, Blyden traveled to the Canada some months ago to collect donations for protective gear to help stop Ebola from spreading. Sylvia Blyden’s critique of this “very important citizen,” therefore, must be understood as a critique of the official response to the disease and elites’ repeated claims that rural people are uneducated and ignorant when it comes to assessing their risk for disease. Rather than simply demonstrating ‘ignorance’ of an elite class, then, she is also criticizing complacency and inadequacy of official response. She is disparaging their assessment of rural people.

In her CNN opinion piece, Garrett reminds of us all the backlash against health workers within these Ebola affected communities. She recounts the story of the woman with Ebola whose family removed her from the hospital and was “brought to a traditional healer.” “Brought to a traditional healer” is usually code for ‘culture’ and ‘tradition’, which tend to be, well, euphemisms for ‘backwardness.’ But any medical anthropologist or most undergraduates who have taken an introductory medical anthropology course, for that matter, knows and understands that an individual’s therapeutic itinerary is often related to perceived efficacy. Put more simply, folks’ quest to get better often means looking in multiple places for cures. In the case where biomedicine can’t get the job done, or you’re seeing people enter hospitals and not coming out, where would you go?

Certainly these protracted conflicts have done their damage, but it has been noted that some of the causes of the war were, indeed, the perceived failures of the state and the mistrust engendered in the late 1970s and early 1980s. These were tales told to me by older politically involved individuals whom I encountered during fieldwork in the mid-2000s. One friend, an anthropologist currently in Liberia and who lived in Sierra Leone before and during the war, described how people use the war to explain current problems, when she had observed the same misfortune and problems those years before the war. She wrote, “I remember driving along the Kamakwie road with someone who was saying what a shame the war had destroyed the road. I said, actually, this is pretty much exactly what the road was like before the war too.”

I am sure that if you asked any anthropologist who happened to work in Sierra Leone in the 1980s about changes, they would see little change on some issues, but radical changes in others. Because time has passed. Moreover, war does not affect everyone the same. During one of my first interviews for preliminary dissertation research in 2005, I remember a cousin of a friend telling me, “We were very comfortable during the war. We stayed in a nice little place on the outskirts of Freetown and were very safe.” Her story wasn’t exactly typical, but it was not unusual either for a specific class of individuals. If anything, we might ask how intervention has been naturalized under these narratives about ‘failed’ and ‘fragile’ states, as my friend Susan Shepler has said. It also appears to naturalize the outbreak and responses to it: “well, they’ve experienced so much in war that this can only breed distrust.” The distrust and suspicion were there all along, albeit expressed in other forms. I would argue, too, that if war has changed anything, the incredible influx of humanitarian interventions and aid workers during the war and its immediate aftermath — where outsiders and their local cronies seemed to benefit openly from others’ suffering — has also engendered suspicion that has helped fuel the backlash against local and international health workers.

On Ebola and the pathological movements of Others

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This morning, I woke up to two emails about the most recent NYT article about the Ebola outbreak in West Africa. Having worked in Sierra Leone on a range of health issues, I have been a recipient of these kinds of messages at least a few times a week. I’ll just comment on this article because it best articulates a number of trends that I am seeing in these articles.

From Guinea, Adam Nossiter writes:

Eight youths, some armed with slingshots and machetes, stood warily alongside a rutted dirt road at an opening in the high reeds, the path to the village of Kolo Bengou. The deadly Ebola virus is believed to have infected several people in the village, and the youths were blocking the path to prevent health workers from entering.

“We don’t want any visitors,” said their leader, Faya Iroundouno, 17, president of Kolo Bengou’s youth league. “We don’t want any contact with anyone.” The others nodded in agreement and fiddled with their slingshots.

Singling out the international aid group Doctors Without Borders, Mr. Iroundouno continued, “Wherever those people have passed, the communities have been hit by illness.”

What I find intriguing about this piece is that it’s one of the first to make explicit people’s mistrust of international health workers and their motivations. Implicit is, as Susan Shepler notes, a related mistrust of government officials and the perceived competence of government officials to manage an epidemic, have shaped local responses to this outbreak. Add to this that hospitals are widely perceived to be a place where people become sick or die — not simply in West Africa, but elsewhere, too — and we’ve got ourselves some moral panic. (It bears repeating, too, that Ebola was previously unseen in the region and looks like a lot of other endemic diseases in its early stages. Where I previously worked,  Lassa Fever, a hemorrhagic fever with which many Sierra Leoneans are familiar, was also endemic, raising questions for me about whether they used those lessons to address Ebola.)

So, back to the NYT. Young men are trying to bar MSF from their village. Yet, in the paragraph following this vivid description, the analysis falls back on pathologizing the movements of West Africans:

Health officials say the epidemic is out of control, moving back and forth across the porous borders of Guinea and neighboring Sierra Leone and Liberia — often on the backs of the cheap motorcycles that ply the roads of this region of green hills and dense forest — infiltrating the lively open-air markets, overwhelming weak health facilities and decimating villages.

In short, foreigners should move and have unfettered access to ‘Africa’, but these same (literally pathological) movements of foreigners — certainly not all white and Western, but at least symbolically so — are pushed to the background, while the usual movements of West Africans are pathologized. They must stay in their rightful place.

This is not to say that epidemics aren’t traveling “on the backs of cheap motorcycles,” but these young men suspect, as many others in the region do, that (1) the disease may also be traveling with the foreign health workers who move fairly easily across international borders and who are at greatest risk for contracting the disease; (2) that there was a slow and inadequate government response upon initial rumors of the outbreak; and (3) the arrival of Ebola to West Africa is not a simple matter of chance, porous West African borders, ignorance and ‘local traditions’, but one embedded in a range of biological, political, economic and cultural arrangements that have put entire communities at risk. These at-risk communities are having a hard time building trust with people who have failed to control Ebola.