Issues in Interdisciplinarity 2019-20/The issue of History in the 2013 - 2016 EVD epidemic

Introduction The first outbreaks of the Ebola Virus Disease were in 1976 in the DRC and Sudan. The subsequent West African Epidemic reached mortality rates of up to 90%, more specifically in Liberia, Guinea, Mali, Sierra Leon, Nigeria and Senegal.Centers for Disease Control and Prevention [Internet]. 2019. 2014-2016 Ebola Outbreak in West Africa. [cited 2019Dec5]. Available from: https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html The epidemic had devastating social, political impacts on the countries’ economies and healthcare systems. The death toll by October 2015, 11,323, begs us to question methods employed to end the outbreak.Boseley S. Ebola crisis – the story in brief [Internet]. The Guardian. Guardian News and Media; 2015 [cited 2019Dec5]. Available from: https://www.theguardian.com/world/2014/sep/25/-sp-ebola-crisis-briefing Medical and biological sciences are needed to explain the origin and treatment of diseases, while understanding the cultural practices that prevented the containment of EVD requires anthropological perspectives. However, the history of these different disciplines is problematic in tackling the crisis, as scientific procedure tends to take precedence. We will therefore explore different disciplinary approaches to the 2013-2016 Ebola crisis, illustrating the benefits of interdisciplinary thinking. thumb|Extension of the 2014 EVD epidemic in West Africa|188x188px|alt=|none Biology and Virology Zaire Ebolavirus is one of the most virulent pathogens within the hemorrhagic fevers.Zawilińska B, Kosz-Vnenchak M. General introduction into the Ebola virus biology and disease [Internet]. Folia medica Cracoviensia. U.S. National Library of Medicine; 2014 [cited 2019Dec5]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25694096 The virus spreads through contact with bodily fluids. The incubation period is 21 days, during which the patient may inadvertently cause propagation. Symptoms are similar to other diseases found in West Africa such as malaria, Lassa fever and typhoid, resulting in frequent misdiagnosis. thumb|Cases and deaths from April 2014 to July 2015 during the 2013-2015 outbreak. A total of 28, 646 cases. |alt=|129x129px|left thumb|Electron micrograph of an Ebola virusvirion|alt=|border|239x239px|none Its genome consists of non-segmented, negative-sense, and single-stranded RNA molecule. After contagion, the virus targets and weakens the immune system, specifically dendritic cells. In a study published by 'Cell Host & Microbe', research found that the VP24 protein on Ebola inhibits the production of antibodies.Servick K. Science. What does Ebola actually do? [Internet]. 13 August 2014. [Accessed 5 December 2019]. Available from: https://www.sciencemag.org/news/2014/08/what-does-ebola-actually-do Toxins trigger the release of proinflammatory cytokine and nitric oxide, which damage the endothelial lining of blood vessels. Then, the repeated coagulation reduces blood supply resulting in fatal organ failure.Wambani RJ, Ogola PE, Arika WM, Rachuonyo HO, Burugu MW. Ebola Virus Disease: A Biological and Epidemiological Perspective of a Virulent Virus. Journal of Infectious Diseases and Diagnosis [Internet]. 2015Jan26 [cited 2019Dec5];1(1):2–4. Available from: https://www.longdom.org/open-access/ebola-virus-disease-a-biological-and-epidemiological-perspective-of-avirulent-virus-jidd-1000103.pdfthumb|Immediate symptoms of Ebola |220x220px|alt=|left No cure exists for EVD, but in 2016 the rVSV-ZEBOV vaccine was found to be 70-100% effective.Henao-Restrepo AM, Camacho A, Longini IM, Watson CH, Edmunds WJ, Egger M. Efficacy and effectiveness of an rVSV-vectored vaccine in preventing Ebola virus disease: final results from the Guinea ring vaccination, open-label, cluster-randomised trial. The Lancet [Internet]. [cited 2019Dec8];389:505–18. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32621-6/fulltext Responses 1. Medical The primary aim of medical practitioners was to interrupt transmission chains by quarantining patients.Factors that contributed to undetected spread of the Ebola virus and impeded rapid containment [Internet]. World Health Organization. World Health Organization; 2015 [cited 2019Dec6]. Available from: https://www.who.int/csr/disease/ebola/one-year-report/factors/en/ The EVD response privileged the work of scientists often overlooking social and cultural factors. Medical intervention was highly individualistic and included enforced quarantines, movement prohibition, traveller test points, and mandated cremation. Unsurprisingly, the effectiveness of such measures increased the stigmatisation surrounding the disease.Pellecchia U, Crestani R, Al-Kourdi Y, Drecoo T, Van den Bergh R. Social Consequences of Ebola Containment Measures in Liberia. National Centre for Biotechnology Information [Internet]. [cited 2019Dec8];10(12). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4674104/#__ffn_sectitle  Medical practitioners used IgM ELISA tests, RT-PCR tests, biopsy samples and viral cultures to diagnose patients and limit the spread of ebola. thumb|left|Ebola Pathogenesis schematic |328x328px|alt= thumb|VHF isolation precautions poster |273x273px|alt=|none While there were no approved treatments, supportive care like the one recommended by the CDC was applied to alleviate the patients' suffering. This included: oral rehydration therapy, intravenous fluids, oxygen therapy, treating other infections if they occurred, and disinfecting surfaces with (>70%) alcohol wipes. Conventional medicine was used to relieve the symptoms (high blood pressure, vomiting, fever and pain).Ebola (Ebola Virus Disease) Treatment [Internet]. Centers for Disease Control and Prevention. 2019 [cited 2019Dec8]. Available from: https://www.cdc.gov/vhf/ebola/treatment/index.htmlOleribe OO. Ebola virus disease epidemic in West Africa: lessons learned and issues arising from West African countries. Royal College of Physicians [Internet]. 2015Feb [cited 2019Dec8];15(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4954525/#__ffn_sectitle Medical workers used experimental treatments such as immune serums, antiviral drugs and possible blood transfusions to impede the disease from victimising others. To provide relief, the doctors deployed in the infected areas set up treatment and isolation centres rather than search for a cure. Containment was the main concern so medical action was largely unquestioned.Davis CP. Ebola Virus Vaccine, Causes, Symptoms, Treatment, Contagious [Internet]. MedicineNet. 2019 [cited 2019Dec8]. Available from: https://www.medicinenet.com/ebola_hemorrhagic_fever_ebola_hf/article.htm Yet this approach was occasionally met with hostility for example when 8 health workers attempting to raise awareness about EVD in a village in Guinea were murdered.Phillip A. Eight dead in attack on Ebola team in Guinea. ‘Killed in cold blood.’ The Washington Post [Internet]. 2014Sep18 [cited 2019Dec8]; Available from: https://www.washingtonpost.com/news/to-your-health/wp/2014/09/18/missing-health-workers-in-guinea-were-educating-villagers-about-ebola-when-they-were-attacked/ While historically very effective at minimising physical suffering, the massacre of health workers made it painfully clear that this historical authority is not universal. Therefore, medics must turn to anthropologists to understand the important cultural dynamics present in diverse African societies.Obeng-Odoom FMB, Bockarie MMB. The Political Economy of the Ebola Virus Disease. Social Change [Internet]. [cited 2019Dec8];48(1):18–35. Available from: https://journals.sagepub.com/doi/full/10.1177/0049085717743832 2. Anthropological Approach Anthropological research illustrates how social and cultural factors contributed to the biological transmission of EVD during the 2013 West Africa outbreak and interfered with the corresponding medical response. Many of the affected countries suffer from poverty and the recent civil wars in Guinea, Liberia, and Sierra Leone left behind fragile health care systems and physician shortages regionally.Calnan M, Gadsby EW, Kondé MK, Diallo A, Rossman JS. The Response to and Impact of the Ebola Epidemic: Towards an Agenda for Interdisciplinary Research. National Centre for Biotechnology Information [Internet]. 2017Sep3 [cited 2019Dec7];7(5):402–11. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5953523/ The consequent challenged quarantine, ineffective alerts and pleas for assistance facilitated further infection.thumb|An example of a hospital isolation ward|192x192px|alt=|left Understanding cultural practices in infected regions is integral to tackling the EVD crisis effectively. Cultural differences between health practitioners and locals was problematic in dealing with the outbreak. The WHO’s retrospective analysis of the outbreak showed locals feared how much western treatment contradicted traditional practices regarding the dying or diseased. Ancestral funeral rites such as sleeping next to an infectious corpse of the community and bathing in water used to rinse corpses were attributable to 80% of cases in Sierra Leone by WHO estimates. The stigma around these cultural practices drove families to hide symptomatic relatives, leading to infection of their households. Traditions of returning dying patients to their native village elevated the risk of transmission through cross-border movement. Fear of physicians was another barrier to its eradication. In Guinea, rumours of health workers disinfecting a market contaminating people led to riots. Proving that health care responses require communication between medical practitioners and community leaders.Scott V, Crawford-Browne S, Sanders D. Critiquing the response to the Ebola epidemic through a Primary Health Care Approach. BMC Public Health [Internet]. 2016May17 [cited 2019Dec6];16(1). Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3071-4#ref-CR4 A post-colonial reading of western aid sees imperialistic thinking that disregards customs. Doctors often see locals' apprehension of western medicine as backwards tradition and the work of well-respected African healers is disregarded. Biology failed to provide a complete explanation nor complete response to EVD epidemic. Anthropological research is needed to provide culturally-sensitive aid. Moreover, theology could further inform anthropology in local religious customs. 3. Theological Approach Burials according to biomedicine and theology present contradictory practices. Biomedicine, a Western discipline, institutionalises quarantines in burials,Kinsman J, Angrén J, Elgh F, Furberg M, Mosquera AP, Otero-García L, et al. Preparedness and response against diseases with epidemic potential in the European Union: a qualitative case study of Middle East Respiratory Syndrome (MERS) and poliomyelitis in five member states. Bmc Health Serv Res [Internet]. 2018 Jul [cited 2019 Dec 2];18(528). Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3326-0 doi: 10.1186/s12913-018-3326-0 whereas West African religious preach religious inquires into pathology during burials.Fassassi A. How Anthropologists Help Medics Fight Ebola in Guinea [Internet]. SciDevNet [2014 Sep 24] [cited 2019 Dec 2]. Available from: http://www.scidev.net//global/cooperation/feature/anthropologists-medics-ebola-guinea.html Burials are important in many West African religions, as the time for the deceased to enter the afterlife, join their ancestors, and overlook the living. Ill-performed rituals could trap the spirits in the living realm and taunt loved ones.Anderson A. African Religions. In: Kastenbaum R, editors. Macmillan Encyclopedia of Death and Dying. 1st ed. New York: Macmillan Reference USA; 2003. p. 9-13 Bodies are cleansed and foetuses are removed from pregnant bodies to uphold natural cycles and ensure the wellbeing of both alive and dead.Maxmen A, Muller P. An Epidemic Evolves - How the Fight Against Ebola Tested a Culture’s Traditions [Internet]. National Geographic [2015 Jan 30] [cited 2019 Dec 2]. Available from: https://www.nationalgeographic.com/news/2015/01/150130-ebola-virus-outbreak-epidemic-sierra-leone-funerals/Manguvo A, Mafuvadze B. The Impact of Traditional and Religious Practices on the Spread od Ebola in West Africa: Time for a Strategic Shift. Pan Afr Med J [internet]. 2015 Oct [cited 2019 Dec 2]; 22(Suppl 1):9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709130/ doi: 10.11694/pamj.supp.2015.22.1.6190 Thus, religious procedures concerning remains are strictly adhered to. Disagreements over how burials should be performed have arisen during the outbreak because the meaning of burials diverges between biomedicine and West African theology. An example of this is, in Guinea, a burial was brought to standstill amidst disagreements between a Kissi family and the medical team on how to handle the remains. The body rotted as the dispute carries on, which risked further infections upon leakage.World Health Organization. What We Know About Transmission of the Ebola Virus Among Humans [Internet]. World Health Organization [2014 Oct 6] [cited 2019 Dec 2]. Available from: https://www.who.int/mediacentre/news/ebola/06-october-2014/en/ Meanwhile, another team in Guinea substituted old repatriation rituals for the foetus’ removal, and successfully buried the pregnant body to everyone’s satisfaction. This underpins the importance of theology in complementing biomedicine and anthropology to understand, manage, and quell epidemics like Ebola in West Africa. Conclusion The 2013-2016 Ebola epidemic captured the world’s attention, and experts from a diverse range of disciplines sprang into West Africa’s aid; with medics handling the majority of ailments, while anthropologists liaised with communities, and religious leaders encouraging cooperation. Unfortunately, due to the complex lexicon, disciplinary boundaries, and historical paradigms behind these disciplines; their ideas diverge on many seemingly intuitive concepts like burials, and could not communicate effectively. An interdisciplinary approach bridging knowledge between disciplines in their interpretation of treatment, healing, and well-being, could converge the efforts with synergetic effects. alt=|left|thumb|300x300px|Healthcare spending in West African countries such as DR Congo falls short of other countries in the continent, and public finances may be better managed with insights from governance thumb|A mathematical model of epidemics, which could disease control centres the amount of resources needed at given points in time and where to distribute them|alt=|none Further disciplines may also be introduced, such as mathematical models of disease transmission, governance theories of public healthcare, and psychological perspectives on trauma. While each discipline has developed distinct metrics and criteria for what a good approach is, coherence could be achieved between these knowledge frameworks if differences are proactively reconciled. References