A few weeks ago, I spoke to my colleague Declan Walsh, who was reporting at the epicenter of the Ebola epidemic. One thing that stuck with me was the rage he described toward many of the health workers trying to contain the outbreak.
It reminded me of something I witnessed in Germany during Covid. There, too, anger was often directed at those whose goal was to help. There were weekly protests against restrictions, some of them violent. A gas station attendant was killed when he asked a man to wear a mask.
So what is it about health crises and rage? Today my colleague Sheri Fink explains why anger at health workers is something many societies have struggled with for centuries.
Efforts to contain Ebola in the Democratic Republic of Congo did not begin well. Patients fled a treatment unit after community members set it on fire. Residents assaulted a burial team and forced the crew to turn over a coffin.
Reactions like this would be easy to chalk up to a poor understanding of how diseases spread. But unrest during epidemics is not about Ebola, Africa or education. It is something societies have struggled with for centuries, in rich countries and poor ones, in modern times and medieval ones. During the coronavirus pandemic, doctors, nurses and health officials around the world received not only applause and gratitude but also death threats. Patients denied that Covid existed even as they died of the disease.
Experts say outbreaks often elicit a contradictory mix of responses. First, people deny reality and put off behavioral changes that might slow the spread. Then they demand explanations, often blaming individuals, groups within society and, sometimes, doctors. Finally, people take action.
In the Democratic Republic of Congo, when armed community members remove a child from an Ebola treatment unit, “we may view that as irrational, illogical, kind of anti-science,” says Megan Schmidt-Sane, an American medical anthropologist who has briefed humanitarian groups fighting the current Ebola outbreak. “We know that this is about so much more than that. It’s about history and culture and politics and even just about how people love and care for others in their family who are sick.” Only when we understand these tendencies, she and other scholars say, can we navigate them.
Disease breeds distrust
Before the discovery that germs cause illness, humans searched for answers that might explain waves of disease and death. During the Black Death in the 14th century, Europeans massacred Jews, Catalans and others they accused of poisoning wells.
And even when scientific explanations came along, they still left people to fight over the science itself. Today, we can photograph the tiniest viruses and sequence their genetic codes, but considerable mystery and debate remain over how pathogens emerge, spread and kill.
Conspiracy theories about disease travel much more quickly now, but they have always been a part of outbreaks. Samuel Cohn, a professor of medieval history at the University of Glasgow, found that during cholera outbreaks in the 19th and 20th centuries, impoverished people in places as different as New York City and tsarist Russia “produced similar fantasies that accused elites of plotting to cull populations of the poor.” This mistrust led to the murder of medical professionals “and the ritualistic destruction of hospitals and medical equipment.” Sometimes the state is the party sowing blame. In the early 20th century, Ottomans accused Armenians of spreading typhus, and Nazis accused Jews of the same. And in recent years, conspiracy theories can travel the world faster than the disease itself.
There are some simple reasons people in the Democratic Republic of Congo are distrustful of hospitals in the current outbreak. The disease has no cure and acts very rapidly. Many patients have entered the hospital seeming not very sick but then quickly died, raising fears about sending relatives there.
But the Ebola outbreak is also just the latest shock after decades of conflict and suffering, state neglect, and colonial and postcolonial violence. Under Belgian colonial rule in the 20th century, officials confined people suspected of having sleeping sickness — a parasitic disease spread by tsetse flies — and experimented with toxic, arsenic-based treatments. Research suggests these types of efforts contributed to persistent medical distrust across multiple African countries.
“Both medicine and humanitarianism have been used” to advance outsiders’ interests, says Myfanwy James, a British assistant professor of international development at the London School of Economics and Political Science. “These deeply held suspicions actually are based on historical experience.”
Breaking through
In recent decades, anthropologists have tried to bridge the understanding between public health responders and the communities affected by deadly diseases. Many African countries now include anthropologists on outbreak response teams, says Julienne Anoko, a Cameroonian anthropologist who works on community engagement for the W.H.O.
Drawing on previous outbreaks, health workers in the Democratic Republic of Congo are now adapting burial practices to honor community beliefs while reducing the risk posed by infectious bodies. And after complaints, the entrance to an isolation unit was moved so that incoming patients do not have to walk past a morgue.
That work is painstaking; the results can be unsatisfying. And the broader challenge of containing the epidemic remains: Two months into the response, new Ebola cases are still growing faster than in any previous outbreak. More than half of those who contract the disease are dying without making contact with Ebola response teams.
But in places where health workers have been able to impart the true nature of the threat, more people are seeking help. They “accept the virus is killing them,” Anoko says, “and they are scared of dying.”
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