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Chapter 7
BIOCULTURAL MODEL FOR HIGH MORTALITY RAPID KILLING EPIDEMICS
Anthropologists have a reputation for writing detailed ethnographic descriptions and the
previous four chapters follow in this tradition in terms of providing details of how local
people in Uganda and Congo reacted to deadly Ebola outbreaks. While maybe not
particularly good at it, cultural anthropologists are also interested in explaining human
behavior. Ethnographic descriptions are interesting but we also want to understand why
people behave the way they do—in this case, how can we explain human behavior during
high mortality, rapid killing epidemics like Ebola?
Chapter 2 introduced a few anthropological theories that influenced our selection of
methods. The cultural models and clinical medical anthropological approaches indicate
that how we think and feel dramatically influences our behavior. The structural violence
approach suggests that global and local political-economic structures and institutions are
prime factors that help explain human behavior. But while each theory explains part of
the puzzle, each has limitations an cannot explain certain behaviors, such as the common
feeling of fear and the desire to flee during an outbreak. This chapter develops a holistic
and integrated biocultural model that we think helps to explain human responses to
epidemics such as Ebola.
The biocultural model is presented and applied to data from the Congo and Uganda.
The final part of the chapter examines how the biocultural model fits or does not fit other
cross-cultural studies of epidemics.
A Biocultural Model
The previous chapters provide a starting point for understanding human responses to high
mortality epidemics. A few commonalities emerge from the outbreaks, some of which are
listed below.
1. fear and panic after observing the rapid death of several individuals
2. desire to flee infectious areas —individuals, villages, hospitals
3. sorcery cultural model used to explain early cases
4. epidemic concept and control measures as deaths continued
5. national or international political economic origin stories
6. fear of Euro-Americans
7. washing and touching the body as part of burial ritual
8. rapid spread of information, including rumors and misinformation
9. population density (e.g., urban versus rural) influences how many health workers are
infected
10. availability of resources influences transmission (e.g., in hospitals)
The aim of the model is to try to understand the relationships between some of these
patterns.
The biocultural model is grounded in recent developments in evolutionary theory. We
find evolutionary theory useful for several reasons. First, it focuses on individuals rather
than groups. Natural selection is measured by the reproductive fitness of individuals not
groups. This means individuals (men, women, children) are active agents in their cultural
and natural environments. Cultural beliefs and practices exist, but they can be
manipulated, added to or discarded by individuals given their particular political,
economic, or natural environment. Second, contemporary evolutionary theory is
biocultural. Most anthropologists are familiar with the biological (genetic) aspects of
evolutionary theory, but few are familiar with evolutionary approaches to culture
(described in more detail below). The culture concept described in Chapter 1 is alive and
well in evolutionary theory. But more importantly, recent evolutionary approaches
emphasize the interactions between biology and culture; rarely is human behavior the
result of only genes or culture; behavior is mutually constituted. Third, evolutionary
theory enables us to incorporate other contemporary theoretical approaches, such as
cultural models and structural violence. These approaches are not inconsistent with an
evolutionary approach, although their proponents may suggest otherwise.
The biocultural model, illustrated in Figure 7.1, is a heuristic, rather than a predictive
model; this means the model is used to generate discussion and hypotheses rather than
making specific predictions. The arrows going every which way are indicators of a
heuristic model. According to the model, human responses to EHF can best be
understood as the result of interactions between biology, culture and ecology.
Evolutionary psychology is the branch of evolutionary theory that has attracted the
most attention and controversy, and why most anthropologists think evolutionary
approaches are genetic. EP’s are interested in identifying biologically based (i.e., genetic)
universals of the human mind that evolved during the environment(s) of evolutionary
adaptation (EEA) and continue to shape human behavior. The EEA is the huntinggathering period of human history; this way of life characterized over 90% of human
history, farming is actually a relatively recent innovation. For instance, humans today
desire foods with plenty of salt, sugar and fat because foods with these items were rare
and important for survival in the EEA. They are biologically based desires that continue
to influence dietary decisions. We do not have the desire for more fiber because this was
common in the EEA. EP’s view the human mind as containing specific modules that
evolved to solve re-occurring problems in the EEA. According to EP’s, some of the
modules of the mind that evolved in the EEA and are biologically based include: sexual
jealousy, language acquisition device for children, attachment in children and kin
recognition. Current research emphasizes identification of the universal behavioral
modules while their biological bases (i.e., specific genes or location in brain) are often
assumed.
Which responses in EHF outbreaks might be explained by EP’s? Aspects of outbreaks
that are common to outbreaks in any culture or country, and responses that one might
attribute to “human nature” are most likely to fall under this evolutionary branch. The EP
approach suggests that regardless of whether you are in Nebraska or central Africa, that
once you hear about or see an epidemic it should evoke similar feelings and responses. If
epidemics are a re-occurring problem in the EEA, which is likely (bacterial ones more
likely than viral ones due to lower population density), behaviors that led to greater
survival and reproductive advantages over others would have be selected for and become
part of our evolved psychology or human nature. A few considerations from our study:
1. fear, anxiety and panic after observing the rapid death of several individuals
2. desire to flee infected areas—individuals, villages, hospitals
3. special efforts to protect children during an epidemic
4. care for biological family members more than neighbors or unrelated people
5. ability to identify sick from healthy individuals
An individual who became fearful and attentive after watching a few people die
relatively rapidly is more likely to leave more descendents than others who were not
afraid or not concerned. Observing a few rapid deaths of individuals over time evokes
fear. The desire to flee may also be part of our evolved psychology. Those in the EEA
who moved away from infected individuals and camps were more likely to leave more
kin behind than those who stayed close to the infected.
In Congo and Uganda, explicit protocols provided special attention to children. They
were viewed as particularly vulnerable especially as the deaths continued. EPs and other
evolutionists emphasize the importance of inclusive fitness, which is an unconscious
preference to assist biologically related individuals. Protecting your own children from
potential risk of death is a clear example of inclusive fitness. It is also not unusual in
outbreak situations that primarily immediate family members take care of the sick.
Families in Gabon that were trying to take sick family members down river to the
hospital did not receive any help from friends or others passing by. Those who share
genes with a sick individual have more to loose and are more likely to take the risks of
caregiving infected individuals. Another example of inclusive fitness influencing
behavior is when Ugandan survivors where more likely to be accepted by their families
than by neighbors. Family members are more likely to take the risk that their biological
relative is cured. But it is important to remember that spouses and in-laws are not
biological kin; the EP approach predicts more conflicts between spouses and in-laws than
among biologically related individuals, such as brothers and sisters. As mentioned in
Chapter 6, several Ebola survivors were abandoned by their spouses. In-law conflicts are
also predicted to increase in outbreaks. For instance, in Congo, the older brother of two
young girls died. When his in-laws came to help prepare for his funeral, the girls
proclaimed to the in-laws that, “this is not Ebola” and suggested it was sorcery. The inlaws responded “then you wash the body!” The two frightened young girls ran off. Their
mother washed her son’s body, became infected with Ebola and died. Families are not
stigmatized if they are accused of sorcery, but stigmatization occurs if a family
member(s) becomes infected with EHF.
Finally, many of the proposed features of human nature listed above assume humans
have the ability to distinguish sick from healthy individuals and evaluate levels of
severity of disease. It makes reproductive sense that individuals in the EEA who were
able to distinguish sick from healthy individuals and keep some distance from those that
were sick, especially those who were very sick, were more likely to survive and leave
more descendents than individuals without these abilities. Sickness was a re-occuring
problem in the EEA, as it is today, and those who were able to intuitively identify sick
from healthy were more likely to survive. Certainly, cultural knowledge contributes
substantially to this ability, but our experiences with children suggest that an
understanding of contamination comes early and easily in life.
Several of the biologically-based behaviors mentioned above may be not be unique to
humans. Inclusive fitness is a concern of any species and fleeing infected areas,
protecting offspring and identifying sick from healthy probably have higher primate
ancestry. Chimpanzees reportedly treat themselves with medicinal plants when they are
fill, and primatologists at Lossi indicated gorilla mothers kept their babies away from
gorillas that had died from Ebola and that the group fled their traditional foraging area
after several gorillas died. The adaptive problems continued in the EEA but humans
probably build upon an existing phylogenetic biology.
Evolutionary ecologists (EE), more precisely known as human behavioral ecologists,
are quite different than EPs. They view the mind as more flexible and designed in a
general way to enhance reproductive fitness and are interested in explaining human
behavioral diversity rather than human universals. From this perspective, humans
evaluate cost-benefit trade-offs in making decisions to optimize or maximize their
reproductive fitness in a particular social, demographic, or political environment. For
instance, a mother’s decision to care for her child suffering from EHF will be influenced
by the mother’s age, her child’s age, how many other children she has, their ages, and a
variety of other factors in her current environment. Questions an EE researcher might ask
to help to understand human responses during an outbreak would include:
1. Is the disease localized or widespread?
2. Is the outbreak in a rural or urban area?
3. How many people are available to help out?
4. What are the resources available (money, gloves, isolation supplies, medications)?
5. What ecological factors trigger shifts in the cultural models?
The nature of the disease will influence whether or not it makes sense to try and flee
the village. Urban verus rural settings tend to impact how many health workers are
infected and die in outbreaks. As mentioned in Chapters 4 and 5 Uganda was an urban
outbreak and Congo was a rural outbreak. Individuals who get sick in rural areas stay in
the village because the hospital is far away. They infect other family members and
individuals from other villagers who attend funerals. In urban areas, one sick person
brought to the hospital can infect the healthcare personnel and other patients in the
hospital; nosocomial transmission such as this, is often exacerbated by the severe lack of
such basic resources as soap, bleach, clean water and proper training for those involved in
the care of Ebola patients
The national and global political-economic setting influences the availability of a wide
variety of resources essential for control efforts. Finally, they would be interested in what
ecological conditions contribute to a shift in the cultural models. How many deaths does
it take for a shift to occur? What is the role of past experience? From an EE perspective
culture is simply one way humans adapt to diverse environments. Culture does not have
any special properties of its own.
The final evolutionary approach illustrated in Figure 7.1, is evolutionary cultural
anthropology (ECA). ECA researchers use the definition and concept of culture (as
presented in Chapter 1) to point out that culture exhibits the characteristics required for
natural selection: 1) production of variation, 2) competition and fitness effects of cultural
variants, 3) inheritance (i.e., transmission) of cultural variants, 4) accumulation of
modifications. For instance, during EHF outbreaks, individuals within a culture can have
several ideas (e.g., herbal, biomedicine, sorcery), or cultural variants, individuals select
and utilize one or more of the ideas (i.e., some of the ideas are acted upon and become
the “phenotype” where selection takes place) which leads to individual variability in
survival. Those who survive transmit this knowledge to future generations and new
knowledge about EHF is added to existing knowledge about epidemics in general.
Although cultural transmission differs in significant ways from genetic transmission it
should be possible to understand some of the evolutionary features of culture. Most
studies to date try to identify and describe the nature of cultural transmission
mechanisms. Some ECA researchers are population geneticists who point out that genetic
mechanisms can produce genetic maladaptation. For instance, if parents in West Africa
are heterozygous for the sickle-cell trait (i.e., carry genes for both normal and sickleshaped red blood cells), they have a 25% chance of producing a child who inherits only
their sickle-cell genes, which usually leads to the death of child before age 15. If genetic
mechanisms produce maladaptation, it seems reasonable to hypothesize that cultural
mechanisms could produce maladaptive patterns as well. The suggestion that culture has
its own features and can lead to maladaptive behaviors does not sit well with the EEs and
EPs.
The mechanisms identified by ECA research are briefly described in Figure 7.2.
Humans have different mechanisms to learn because it does not make sense to learn
everything by trail and error; it is more efficient and leads to greater reproductive fitness
to learn from parents (vertical), friends (horizontal), leaders (one-many) or from all of
those around you (group). If everyone else is doing it, it is likely to be adaptive. Some
mechanisms lead to the conservation of culture while other mechanisms lead to rapid
culture change. Vertical transmission and group effect are most likely to be important in
stable environments while horizontal and one-many transmission are likely in rapidly
changing environments where individuals need regular updating. Vertical transmission
was common for most of human history, but horizontal transmission is more important
today in our rapidly changing world.
Researchers have demonstrated that many aspects of kinship and family organization
are a result of demic diffusion (movement of people with their beliefs), vertical cultural
transmission and group effect rather than adaptations to natural or social environments, or
cultural diffusion (Hewlett et al. 2002). These researchers would hypothesize that cultural
models for illness are linked to spread of particular groups of people and the people’s
conserving those beliefs as they moved. For instance, beliefs in sorcery and epidemics
spreading with the “wind” are common in sub-Saharan Africa, and are probably linked to
the expansion of Bantu-speaking peoples about 2000 years ago. ECA researchers would
focus on these features of the EHF outbreaks:
1. cultural models; sorcery, epidemic, biomedical
2. fear of Euro-Americans
3. washing and touching the body as part of burial ritual
4. rapid spread of information, including rumors and misinformation
5. national or international political economic origin stories
All of the above elements are socially transmitted and learned. The first three are
likely to be transmitted via vertical and conformist or group mechanisms. This means
they are highly conserved, slow to change, and individuals are likely to have strong
emotions attached to them. Obviously, individuals can modify and adapt in unusual
circumstances influencing survival, but people will have strong feelings about them.
Africans have a long history with whites and local people have cultural models or
schemas developed as a result of these repeated interactions. In a similar way, local
people have developed epidemic control measures due to repeated occurrences of
epidemics. Both types of information are socially learned, often via vertical and group
transmission.
Information spreads rapidly during outbreaks; information about the contexts of Ebola
deaths and arrival of foreigners, travels like wildfire—long distances within hours. This is
called horizontal transmission in Figure 7.2. Cultural knowledge or information comes
from friends and neighbors and can have “epidemic” qualities. Horizontal transmission is
common where individuals need to be updated frequently. The last type, one-to-many
transmission was rare for most of human history but as social stratification and
technology such as the radio, TV, internet were developed, it became particularly
important. These forms of transmission can lead to rapid culture change and greater
conformity of beliefs.
The last item is linked to niche construction. The concept of niche construction
(Lalande, Odling-Smee and Feldman 2000) is a recent conceptual contribution to ECA.
Some species, including humans, modify natural selection pressures within their
environments by creating a niche (e.g., burrow, nest) that produces a separate
constellation of selective pressures (the constructed niche creates its own set of
problems), which may or not enhance the reproductive fitness of individuals. Over time
the niches and the consequences of the selective pressures are inherited. This is a
potentially important contribution to ECA because culture increases the ability of humans
to construct niches. House types, hospitals, how people make a living (e.g., huntergatherer, farmers, urban-industrials) are examples of how cultures construct niches. The
structure and organization of a hospital influence temperature, exposure to others and a
variety of other forces that individuals try to adapt to. Hospitals are culturally constructed
and create their own ecologies that humans must adapt to. They are socially transmitted,
so fall within ECA, but they also contribute to the ecology or niche that humans try to
adapt. Clan organization; education, political, economic structures and institutions; and,
technology and artifacts are part of the culturally constructed niche that humans we try to
adapt to. This helps to explain how culture is both in our minds (e.g., knowledge,
information) and “out there” in the environment.
Integrating aspects of the model
We have described the various part of the model and the components of an EHF outbreak
that are likely to fall into each of the three evolutionary approaches. Figure 7.3 places
some of the items discussed above into the three evolutionary approaches. But the real
value of the model is the emphasis placed on interactions between the various
components. To understand human responses in an outbreak it is necessary to understand
the interactions between human nature, culture and ecology. A few examples of these
interactions follow.
Fear is part of our evolved psychology but it is mediated by culture and ecology. We
felt safe participating in EHF outbreak control efforts because we had particular
information that made us feel secure. We still felt fear, especially when we were
physically close to Ebola patients or their relatives, but our cultural knowledge mediated
those feelings. Ecology also interacts with fear in that it is the ecology that evokes the
fear—observing or hearing about high mortality, rapid deaths—but if infected individuals
are far away or if individuals have the resources to flee, the feelings of fear are
diminished.
The success of EHF media stories is also an example of the complex interaction
within the model. Information about an unexplainable high mortality, rapid death disease
generates fear anywhere in the world. The one-to-many transmission of information
characteristic of the media, enables the rapid transmission of information to large
numbers of people at the same time. Depending upon the story, it can amplify or decrease
human fears. But often news commentaries, such as the following, amplify the fear.
A killer is on the loose in the rainforest, striking silently and without
warning…beginning of terror in Central Africa…Soaring fever, wrenching pain,
blood seeps from every opening, (the victim) suffers a horrible death, his insides
are liquefied.—CNN Presents “Return to the Hot Zone”
We hear so many news stories about Ebola because they build upon human nature. We
have an evolved propensity to be fearful and attentive to diseases that are mysterious and
cause high mortality. Ecology also plays a role such as when Americans were captivated
with Preston’s best-seller, The Hot Zone , because it described outbreaks of an Ebola
cousin, Reston, in the Washington D.C. area. Proximity, access to resources, access to
other knowledge (e.g., if one is an infectious disease specialist) all influence how an
individual responds.
In locations where outbreaks are taking place, the evoked fear also activates other
mechanisms of cultural transmission to acquire the best and most up-to-date information
possible. Information is power during an outbreak. Individuals usually try to acquire
updated information in two ways. First, individuals regularly share and transmit
information with friends and neighbors (horizontal transmission). A problem with this
type of transmission is that information changes quickly and can be exaggerated or
amplified. This is how rumors start. Second, people start to organize groups to meet,
share stories and information and make decisions about control efforts. Again, ecology
can mitigate interactions between biology (fear) and culture (information). Access to
resources, distance to infected individuals, AND cultural institutions will influence where
and how the information is transmitted (e.g., to clan members, neighbors, hospital staff,
and community, etc.).
Two other features of an evolutionary biocultural approach need to be emphasized.
The model can be useful for understanding EHF responses of groups and individuals.
Every individual’s circumstances will vary—the cultural information they have, access to
resources, past experiences, age and gender, all influence an individual’s response to
Ebola. The ECA approach also implies that individuals will try to develop innovations to
respond to the outbreaks. Similar to the concept of mutation in genetics, many of the
innovations will not be useful or could lead to decreased reproductive fitness. Individuals
tried a variety of innovative treatments during the outbreak most apparently doing little,
with the exception of the one woman in the Village of Grass who cured several patients.
Stigmatizing and ostracizing of victims or family and health care workers associated
with them are common in outbreak situations. As mentioned in Uganda, survivors are
often referred to as “the Ebola people”. Stigmatization is likely due to interactions of EP,
EE and ECA. EP suggests that humans are ably to distinguish sick from health and that
when several deaths occur fear and the desire to flee are common. Culture builds on these
propensities and develops criteria or culturally defined traits to determine in and out
groups and how long they will be stigmatized.
EE also plays a role because stigmatization and ostracism are relatively infrequent in
hunter-gatherer groups while they are common in sedentary populations (farmers, urbanindustrial). Hunter-gatherers live in intimate, mobile and flexible groups of 25 to 35
individuals. People move into or out of camp every day. We have lived with huntergatherers for years and observed a measles epidemic in the 1980s. Sick individuals were
isolated and people kept some distance from infected patients, but individuals were not
ostracized or stigmatized during the epidemic, in part because anyone who wants can
leave the camp and move to another camp. Farmers and urban-industrialists on the other
hand, are tired to the land and permanent structures; they are simply less mobile and
flexible. In a context where it is hard to move away, population densities are high and
strangers more common, stigmatism and ostracism may emerge as cultural strategies to
protect the family and minimize contact with potential sources of infection.
We want to apply the biocultural model to the film “Outbreak”. Most people reading
this book have not experienced an outbreak, but perhaps have seen this popular film
which has several of the features discussed with the biocultural model. Fear is obviously
generated by the unknown rapid killing disease. The scene featuring a African village,
with piles of burning bodies and corpses still dripping with blood serve to dramatize the
devastating effects of an Ebola outbreak.. Dustin Hoffman and his colleagues (in yellow
space suits) feel better protected from the disease because of their knowledge, technology
and access to resources (ability to fly from the infected area, use of protective gear).
Several other scenes show individuals trying to flee a high risk area in the U.S.; as when
three people take a pick-up truck, crash through barriers and head for the hills while
being pursued by military helicopters. Political and economic structures influence who is
able to flee.
Both within and outside of the infected town you observe people sharing information
about the killer disease—some of the information is correct, some is not. Most of the
story focuses on obtaining the correct information—what is the source of the infection?
People in positions of power have, and control secret information. Information is power.
The blame for the outbreak is placed upon the larger political-economic structures within
the U.S. There is also an effort to protect children as demonstrated when a mother thinks
she may have the disease, and the military truck comes to take her to quarantine. When
her children try to run to their mother to give her hugs and make her stay, their father
yells at the children to stop, and jumps up so they will not touch their mother as she goes
out the door.
Another reason we use the biocultural model is that other theoretical approaches can
be incorporated into it. This book is primarily about the cultural dimensions of EHF
epidemics, so the three theoretical orientations discussed—cultural models, clinical
medical anthropology and structural violence—fall within the ECA domain of the model.
But the political, economic, and historical aspects are part of the culturally constructed
niche that lead to other ecological structures impacting human responses to EHF.
In summary, proponents of all three of the evolutionary approaches discussed here are
interested in understanding interactions between culture and biology, but EP’s emphasize
universal biology, EE’s emphasize the natural and social environment, and ECA’s
emphasize the nature and structure of culture. Each approach asks somewhat different
questions and employ distinct methodological toolkits to address those questions, so it is
not surprising that at times there are conflicts between individuals affiliated with each of
the approaches; but we believe that these three approaches provide an opportunity to
examine human epidemics from a holistic and integrative perspective.
Cross-Cultural Studies of Human Responses to Epidemics
In this section we review anthropological studies of epidemics and compare them to the
outbreaks described in this book to see if the biocultural model is useful for interpreting
results from other studies. Studies reviewed include; Cross-cultural studies of epidemics,
field studies of non-EHF epidemics, reports from medical researchers on early EHF
outbreaks and anthropological studies of the most recent EHF fever outbreaks in Sudan
and Angola.
Cross-cultural and case studies of epidemics
Anthropologists who conducted research from the early 1900’s to the 1950’s occasionally
observed outbreaks of smallpox, cholera, measles, typhoid and other acute epidemics in
the field. None of these have a case mortality rate close to EHF, but they at least provide
some data about human response to epidemics. McGrath (1991) reviewed ethnographic
accounts from 229 cultures in an anthropological database called the Human Relations
Area Files (HRAF) and found six common responses to epidemics. By far the most
commonly reported response was flight or migration from the epicenters of the epidemic
(46% of cultures with epidemic data) followed by out of the ordinary kinds of therapies
and preventive measures, such as quarantine and isolation (24%), blaming or
scapegoating individuals, authorities or institutions (11%), resignation and despair (9%),
and ostracism of the ill or those at risk of becoming ill (9%). Based upon these
frequencies she hypothesizes a sequence of responses. At first groups responded to the
epidemic with existing regular therapies, from biomedicine to the use of healers and
herbalists. But as the deaths continue people shift to extraordinary therapies and
preventive measures. As the epidemic continues, flight, rejection of authorities, blaming
others and despair emerge.
All of the responses she finds in the cross-cultural record occurred in Uganda and
Congo. Her sequence of events from regular to extraordinary cultural actions is
particularly useful because this is precisely what we observed in both outbreaks—they
moved from sorcery and biomedicine to indigenous views of epidemic control. The high
percentage of cultures that responded with fleeing or migrating is consistent with this
being part of evolutionary psychology or human nature in the biocultural model.
McGrath also points out that human responses are generalized and that the responses,
such as fleeing, may or may not decrease infection. While one of the only cross-cultural
studies of epidemics, we disagree with McGrath’s interpretation of the data. She suggests
that human responses to epidemics are maladaptive because they lead to social disruption
and exacerbate the biological impact of the epidemic on the group. From this perspective
any human response that does not help bring the social system back into balance is
considered maladaptive. Bringing the system back into balance reportedly helps organize
a response effort and increases effective means to control the epidemic. Current
evolutionary theory indicates adaptation occurs at the level of individuals rather than
groups and most of the behaviors are clearly adaptive to individuals. Many of the
extraordinary measures taken, from ritual activity to epidemic control measures, can
enhance cooperation, information sharing and control of the epidemic. The study also
gives the impression that local peoples responses to epidemics are problematic. Nothing
is presented similar to the systematic epidemic control protocols found in Uganda and to
a lesser extent in Congo. This may be due to the limited ethnographic notes available to
her.
Although not a cross-cultural study, Fox (1989) conducted a historical study of human
responses in the U.S. from the 18th century and reports, like McGrath, a sequence of
responses. At the start of most epidemics many people, from physicians to politicians,
underestimate the severity of the problem. As the epidemic gains strength, fear and
anxiety develop and people respond to this fear by fleeing, denying or scapegoating
(blaming/accusing) the alleged carriers of the disease, especially people foreign to the
area.. In response to the fear and panic, business and government leaders collaborate to
establish control measures. He also points out epidemics are expensive and shortages of
healthcare workers are common.
Few anthropologists have conducted systematic research during epidemics. Coreil’s
(1989) study of an anthrax outbreak in Haiti, and Nichter’s (198x) study of a Kyasamur
forest disease outbreak in India are exceptions to this pattern. Coreil’s research illustrates
how local cultural models influence treatment decisions during the outbreak, and how
people are more likely to try virtually every available treatment concurrently even though
they may be conceptually inconsistent with each other. During normal illnesses, families
are more likely to use a sequence of treatment. Nichter’s extensive knowledge of the
people and cultures of southwest India enabled him to demonstrate how the disease was
interpreted as a moral transgression against local patron deities and how this
interpretation influenced health-seeking behaviors.
Table 7.1 synthesizes the cross-cultural studies mentioned above, the Uganda and
Congo data in previous chapters, and the biocultural model. The table lists common
features of human responses to epidemics and a sequence of responses.
Previous and recent EHF outbreaks
In this section we present three case studies of EHF with data on local peoples responses.
The first two case studies utilize epidemiological reports and popular accounts of the
outbreaks to get a sense of how local people responded. The last case is a recent and
preliminary description of research conducted by a medical anthropologist during an
outbreak in Sudan..
Yambuku, DRC (1976, 318 cases, 88% mortality)
The Yambuku outbreak was the first recorded emergence of Ebola, and the cause of the
outbreak was not known until 95% of the cases had already occurred. The index case
(first identified case) reportedly was a man traveling in the area who had become ill after
purchasing and eating fresh monkey meat. Once this person went to the hospital in
Yambuku, the outbreak amplified quickly within the hospital through nosocomial
transmission, largely due to the use of unsanitary needles as described in an epidemiology
report by Breman et al. (1978: 76).
Five syringes and needles were issued to the nursing staff each morning for use at
the outpatient department, the prenatal clinic and the inpatient wards. These
syringes and needles were sometimes rinsed between patients in a pan of warm
water. At the end of the day they were sometimes boiled.
International teams did not arrive until the end of the outbreak and the same report
suggests local responses contributed to the control (ibid)
The people in the community had already associated the mission hospital with the
epidemic and had stopped coming to the outpatient department. Several patients
with EbHF left the hospital for their villages in the second fortnight of September.
The hospital staff, themselves severely affected by the epidemic, closed the hospital
at the end of the month. This essentially stopped injection-transmitted disease and
the epidemic shortly terminated.
Our informal discussions with Dr. Karl Johnson, leader of the international response team
to Yambuku, are consistent with this report. Contrary to McGrath, the report and
Johnson’s verification suggest local peoples responses were adaptive.
Some of the best descriptions of local people’s responses in Yambuku come from
Ebola, a book by Dr. William Close (1995), father of actress Glenn Close and a
participant in the Yambuku response efforts. The book is a documentary novel; a story
based on actual events. The local explanation was that ancestor spirits were upset over
some transgression and sent magical poison darts (ndoki) to cause illness. Healers were
called to the hospital to try and extract the darts, while local people performed rituals
with drums, spears and guns to chase the ndoki away. Individuals accused of sending the
darts drank mbondo, a poison oracle containing strychnine which speaks the truth about
sorcery, in order to prove they were not the sorcerers sending the darts.
The book provides multiple descriptions what local people did to try control the
epidemic. At the suggestion of healers and chiefs villages put up bamboo poles with
protective objects on them and monitored all movement into or out of the village.
Communities did this during smallpox epidemics and when rebels fighting the
government were in the area. A villager explained to a priest “I hope Father that your
prayers and medicines will be effective, but as in the rebellion my people will be isolated
behind the same bamboo poles and fetishes that kept the sambas [rebels] out.” The book
describes several instances of priests and nuns from the hospital negotiating passage
through village barriers.
Also, as mentioned above, local people fled from areas of high risk for infection, such
as the hospital.
After the first nun died at hospital and local people thought it was ndoki…Within
minutes the hospital was practically empty. The patients fled in all directions, some
carried on the backs of relatives. Others dragged their sick into the forest and built
stick and leaf shelters near a stream, as they had done during the rebellion. There,
hidden from the dangerous spirits at the hospital, they would wait for the terror to
pass or die in isolation (Close 1995: 45)
It is also clear that local people modified burial practices to respond to the outbreak.
Elders mandated that burials of EHF victims take place the same day, without any of the
usual ceremonies or contacts with the family. Burials also took place outside of the
village rather than next to the family’s house.
Several stories in the book also suggest that physical contact was avoided even
though it was perceived as sorcery (ndoki). For instance, Close describes bodies around
the hospital that nobody wanted to touch or bury and indicates that sometimes it was even
difficult to get family members to bury a deceased victim.
Close does not provide much information about cultural models. We do not know
where the sorcery originated or the reasons people changed their burial practices. But
Close’s book provides evidence of actual behaviors taken by local people during the
Ebola epidemic.
Kikwit, DRC (1995, 315 cases, 81% mortality)
The Kikwit outbreak was one of the largest at the time and experienced the greatest
amount of media coverage, generating documentaries such as “Return to the Hot Zone”
by CNN, “Plague Monkeys” by the Canadian Broadcasting Corporation, and “The
Coming Plague” by Turner Broadcasting Corporation. It was an urban outbreak and like
Yambuku, a lack of resources coupled with unsanitary hospital procedures, dramatically
amplified the outbreak. Origin stories for this EHF outbreak were discussed in Chapter 3
and the local responses presented here are from Garrett (2000) and conversations with Dr.
Ali Khan, CDC epidemiologist at the outbreak.
Laurie Garrent is an incredible writer and provides emotive images of local people’s
suffering, the fear and anxiety experienced during the outbreak, and the politicaleconomic inequality that amplified the Ebola outbreak. Unfortunately, she does not
provide much information about local people. She indicates that local people explained
the outbreak as bad spirits or poison objects (landa landa) sent by the ancestral spirits,
but does not provide any detail.
Dr. Khan recounted the most common explanation people provided to him about the
early cases of the outbreak. A few days before the outbreak started, staff members had a
party at the hospital, but for some reason a few individuals were not invited. The omitted
staff members were angry and decided to seek revenge. They eventually found a sorcerer
to send poison to the hospital. (This is why the outbreak originates in the hospital). This
story is consistent with stories from Gabon and Congo where lack of sharing and
consequent sorcery are said to be the cause of early cases.
Garrett gives some indication that local people implemented a few of their own
control measures when she mentions a story of a village chief who quarantined two men
who carried an ailing woman into his village. She also provides evidence of stigmatizing
families of victims when she presents a story of a woman whose husband died from EHF.
The widow was attacked by neighbors and she eventually fled to a remote village with
her children.
Yambio, Sudan (2004, 17 cases, 41% mortality)
A relatively small outbreak occurred in southern Sudan in 2004. Dr. Armin Prinz, a
physician and medical anthropologist, was asked by WHO to assist in EHF research in
Yambio because of his knowledge of the language and culture of the Azande, the primary
ethnic group in the region. Unfortunately, he arrived at the end of the outbreak rather than
at the start. He was asked to try to understand how the index case became infected, why
people refused to be isolated in wards established by international teams, and why the
chief government nurse disappeared after surviving an infection.
He found that the index case traveled 30 miles and entered DRC to hunt for baboons.
It is customary for hunters to eat the internal organs of the animal raw or barely grilled
shortly after killing the animal. He retuned to Yambio, became sick after 5 days, and
went to the hospital. He infected the chief nurse at the clinic, while he survived the
infection, his wife and baby did not. The three aunts who had cared for the baby also
became infected and two died. The nurse was accused by his in-laws of selling the lives
of his wife, child and two sisters-in-law to a “Mami Wata.” Mama Wata is a mystical
figure, similar to a mermaid, and common to many parts of sub-Saharan Africa, who
aggressively approaches men to sexually tease them. She promises power and wealth in
exchange for the lives of family members that they have to present to her. (The cover of
the book is a painter’s rendition of Mami Wata). Before the outbreak had started, the
chief nurse was promoted to head of the clinic. This promotion aroused jealousy in
others, and it was rumored that he had obtained the promotion through a deal with Mami
Wata sacrificing his family members. He disappeared, in part, to garner evidence from
diviners that he was in fact, innocent (Prinz 2005).
People feared the isolation units because they did not trust international teams
members, in part, because of perceived suspicious activities. For instance, they did not
understand why isolation units had such large tarps around them that made it impossible
for a family members to see or visit a patient. Also, when these patients died, they were
put in a body bag and buried immediately, without the family being allowed to see the
body. Azande thought the international teams were faking the Ebola diagnosis to make a
lot of money through the sale of the patients body parts and/or blood.
Two of the issues identified by Prinz (2005) are common to most EHF outbreaks and
described in previous chapters: sorcery linked to accumulation of wealth, suspicion and
lack of trust in Euro-Americans. His work also demonstrates the anthropologist’s ability
to contribute in important ways to epidemiological research during outbreaks. Only his
preliminary findings are published and we look forward to further details.
Conclusions
This chapter tries to explain the Congolese and Ugandan responses to outbreaks by
presenting a biocultural model. Data from cross-cultural studies of epidemics and
published materials from other EHF outbreaks provide supplementary data to illustrate
the biocultural model and identify common patterns of human response to high mortality,
rapid killing epidemics like EHF.
The biocultural model for EHF has the following implications:
1. Researchers and health workers often mention human nature, such as fear, during
outbreaks, but few think to integrate human nature into response efforts in terms of
factors and forces that might increase or decrease evoked fear. This perspective also
emphasizes that we are all humans with similar feelings about certain
occurrences/happenings/events. Culture and ecology contribute to diversity in behavioral
patterns, but our long common human history contributes to sharing distinct emotions.
2. Likewise, researchers and healthcare workers seldom consider the importance of
inclusive fitness for local people. At a recent meeting Dr.. Pierre Rollin, a leading EHF
researcher at CDC, mentioned that few children died in the Kikwit outbreak because a
taboo existed for keeping children away from sick individuals. This is common in the
local epidemic response protocols described in this book because children are viewed as
being particularly venerable. The taboo reflects interactions between evolutionary
psychology (genes) and culture. Local people are correct as researchers indicate very few
children survive EHF, even the Sudanese strain where survival rates should be close to
50%.
3. With the arrows going every which way, the model emphasizes that very few
responses to EHF are due to just ecology, culture or biology. This book has emphasized
the importance of culture in shaping peoples feelings and responses, but as the model
suggests, culture is influenced by evolved psychology and specific local ecological,
political and economic conditions.
4. Since the model has an evolutionary framework, it assumes agency and individuals
actively engaged in manipulating their physical, spiritual and cultural environment.
Cultural models exist, but individuals can manipulate the models to adapt to their
ecological conditions. Individuals are always trying to adapt especially during outbreak
situations since survival is threatened. It is not surprising that contradictions in people’s
behavior and ideas are commonplace during outbreaks. People saying “no Ebola exists
here”, but at the same time, asking for bleach and gloves, or people explaining that
sorcery is the main cause of the illness, while refusing to touch an infected person, are
just a few examples.
The data from Congo, Uganda and other outbreaks, identify several common human
responses to EHF and other epidemics, listed in Table 7.1. The biocultural model can
help to explain why these behaviors exist and hopefully generate hypotheses for future
research.
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Table 7.1 Common cross-cultural responses to rapid killing epidemics
INITIAL CASES
USE FAMILIAR CULTURAL MODELS
--Biomedical, Indigenous, Chinese
--try treatments in sequential way
--underestimate seriousness of situation
DEATHS CONTINUE
FEAR AND ANXIETY
--persists for duration of epidemic but varies by perceived risk, access to
information, distance to infected, access to resources to prevent infection
FLEE
--most common response in cross-cultural literature
--avoid places of infection—individuals, villages, hospitals
--most rapid with hunter-gatherers
--can take place any time during epidemic
--usually individuals or small groups
COLLECT INFORMATION ABOUT NATURE OF EPIDEMIC
--rapid horizontal transmission of information
--group meetings to share information and make decisions to control
IMPLEMENT EXTRAORDINARY CULTURAL MODELS TO TREAT
--use combination of familiar treatments at same time, try novel treatments
--switch to epidemic cultural models
--isolate, quarantine infected
--close and monitor village
SCAPEGOATING
--especially foreigners or marginal groups
--linked to local, national and global political-economic history
STIGMATIZATION AND OSTRACISM
--survivors, family members of sick
CONFLICTS
--within families
--between groups
--can take place anytime during outbreak
Legends to Figures
Figure 7.1. The biocultural model
Figure 7.2 Mechanisms of cultural transmission and some of their properties.
Figure 7.3 The biocultural model applied to EHF outbreaks