Monday, November 10, 2014

Biology and Culture in the Treatment of Ebola

We are starting to make progress against Ebola.  But those who believe it is because we have developed new treatments or vaccines, would be wrong.  We are still struggling to find the right treatments, and still doing research on an accelerated time table to try and find vaccines for this rapidly mutating virus.  Rather, we are making progress because we are fighting the disease using basic principles of public health while paying closer attention to the cultural aspects involved in both the spread and the control of the disease.  In a study done in “Emerging Infectious Disease” in October of 2003, during an earlier Ebola outbreak, Barry Hewlett and Richard Amola explained how the local population in Northern Uganda both explained and treated Ebola using local beliefs and customs and the wisdom of traditional healers.  Contrary to Western biases, the authors found a great deal of pragmatism and flexibility in the local healer’s approach and found that local cultural and religious norms could have a positive effect on the control of an outbreak.  The local healers led efforts, which appear to pre-date Western influence in Uganda that are very much in keeping with modern methods of infection control.

“When an illness has been identified and categorized as a killer epidemic (gemo), the family is advised to do the following: 1) Quarantine or isolate the patient in a house at least 100 m from all other houses, with no visitors allowed. 2) A survivor of the epidemic should feed and care for the patient. If no survivors are available, an elderly woman or man should be the caregiver. 3) Houses with ill patients should be identified with two long poles of elephant grass, one on each side of the door. 4) Villages and households with ill patients should place two long poles with a pole across them to notify those approaching. 5) Everyone should limit their movements, that is, stay within their household and not move between villages. 6) No food from outsiders should be eaten. 7) Pregnant women and children should be especially careful to avoid patients. 8) Harmony should be increased within the household, that is, there should be no harsh words or conflicts within the family. 9) Sexual relations are to be avoided. 10) Dancing is not allowed. 11) Rotten or smoked meat may not be eaten, only eat fresh cattle meat. 12) Once the patient no longer has symptoms, he or she should remain in isolation for one full lunar cycle before moving freely in the village. 13) If the person dies, a person who has survived gemo or has taken care of several sick persons and not become ill, should bury the persons; the burial should take place at the edge of the village.”

Yet during that earlier outbreak in 2003, the traditional healers’ approaches to disease control was assumed to be destructive to the enlightened Western approaches.  It was assumed that the local traditions contributed to the spread and that those local beliefs and approaches had to be challenged and discarded. 

In the current outbreak, the same cultural arrogance, and belief in the Western approach being the only acceptable approach, may have initially hindered early progress on disease control.  As an example, one of the factors that is believed to have contributed to the spread of Ebola has been the local burial practices.  Muslim burials in West Africa, are traditional and involve a ritual washing of the dead, a practice that Muslims and Jews have in common (as is true for many practices of Muslims and Jews).  In addition in some cultures of West Africa, during the funeral, touching the face of the dead is also done as a way of showing their love.  Yet research has also shown that people are willing and ready to modify those burial practices if the changes are done with respect for beliefs and the involvement of local religious leaders. 

A new protocol that has been instituted by the World Health Organization addresses these burial practices but does so in a way that respects the cultural and religious beliefs of the mainly Muslim and Christian communities that are now being affected so severely by the disease.  As reported in the New York Times,

“The new protocol emphasized that burials needed to be safe, but also dignified, taking account of religious and cultural sensitivities to build trust in communities where some people have accused burial teams of spreading the disease. Inviting the bereaved to be involved in digging the graves of relatives and offering Muslim families an alternative to ritual washing of the dead, a practice that could involve lethal exposure to the virus, “will make a significant difference in curbing Ebola transmission,” the W.H.O. said.”

Alpha Kamara, a journalist who lives in Sierra Leone in a piece published in USA Today describes this interface between religious faith and medical care quite eloquently from a Christian prospective quoting the book of Joshua.  He states:

“Joshua 1:9 reminded me that although God can be everywhere, Ebola cannot.  God can command.  Ebola cannot……. Ebola is a virus.  We react to it.  But we can control our reactions.”

He goes on to states his thanks to OXFAM, the World Health Organization, UNICEF, and Doctors without Borders who have done so much for the people of Sierra Leone.  Those organizations are at the forefront of caring for people in both a scientific and a culturally and religiously sensitive way.

Without the trust built through protocols that respect beliefs, and the attention to the cultural issues in health care, the work of worldwide health organizations and protocols such as this new protocol for burial practices would not be as successful and would not be able to decrease the spread of the disease as it appears to be doing.  Without the blending of science, faith and culture, we could not vanquish this virus.  If this were a pure biologic approach that did not incorporate local religions and cultures while respecting local leaders it would not have the kind of success that is needed. 

Medicine, wherever it is practiced, must start with trust and respect for the patients and their beliefs.  That includes understanding and respecting their cultural and their spiritual selves as well as their biology.  Without that starting point, the best biologic research and treatment in the world, will never be as successful as it can be.