The Nordic Africa Institute


Building trust is crucial for disease control

Gibriel Kabba, a swabber for the ministry of health, prepares to enter a house with protective clothing. Freetown, Sierra Leone in March, 2016.

Gabriel Kabba, a swabber for the ministry of health, prepares to enter a house with protective clothing. Freetown, Sierra Leone in March, 2016. Photo: World Bank

Date • 3 Apr 2020

Although often considered a theoretical science – compared to the practical field of medicine – anthropology saves lives. During the Ebola epidemic in West Africa in 2014-2015, it was a compass for health workers struggling to get their message across to local communities.

Professor Mats Utas.

Anthropology professor Mats Utas.

When hospitals began treating the first Ebola patients in Liberia in 2013, health authorities were met with suspicion. Soon the high fatality rate made treatment centres seem like places of contagion and death. There were rumours that foreign powers had implanted the virus and were using Liberia as a lab.

For international health organisations operating in Liberia, it was crucial to understand communities’ fears and misconceptions, according to anthropologist Mats Utas who trained and helped Swedish health experts in the country in 2014.

Utas says that many organisations arrived with little understanding of local culture, and were often incapable of adjusting to and navigating the strange environment.

“For doctors wearing protective clothes that looked like spacesuits, it was hard to gain the confidence of patients and people in the communities”, says Utas, a professor of anthropology at Uppsala University and former NAI researcher.

As an anthropologist with long experience from Liberia and Sierra Leone, Utas he prepared health workers for the new cultural setting where they were about to operate.

Compared with political scientists, for example, who typically spend a few weeks of fieldwork investigating a single phenomenon in detail, anthropologists may spend years in a country observing culture more broadly.

While Utas was studying the reintegration of young former combatants in informal settlements in Liberia and Sierra Leone, he developed tacit knowledge about local cultural phenomena, such as funeral and health practices, which were identified as a common transmission path during the Ebola outbreak.

Gas station in Gbarnga Liberia.

Gas station in Gbarnga Liberia. Photo: Mats Utas

Much cultural understanding has to do with local information systems, according to Utas.

Rather than using radio messages during the Ebola epidemic, the standard format for public health information in many African countries, it proved to be more effective to let local leaders with high standing in communities tell people about the virus, Utas explains.

“If you can identify the leaders people trust, then individuals are more likely to change their behaviour. They can be religious leaders, village elders or local youth leaders”.

However, they cannot be members of national elites or representatives from other countries, he adds.

“People generally don’t trust them”.

Anthropology also proved crucial in dealing with the many rumours and conspiracy theories circulating about what the virus was and where it came from.

“Instead of just saying, ‘Well, that’s a lie’, you need to understand how the rumour works. In order to dismantle it you need to identify the right individuals in the community who can come in and tell people the facts”.

Utas argues that some anthropological lessons from the Ebola epidemic in West Africa are also valid as health systems across the world try to contain the spread of Covid-19. If health authorities or organisations are insensitive to cultural characteristics of the communities they try to target, then they are likely to repeat the mistakes of early operations in the Ebola crisis, he warns.

The importance of communication and cultural sensitivity also became clear during the chikungunya epidemic in the French overseas department of Réunion in 2005-2007.

Karine Aasgaard Jansen, a medical anthropologist at Umeå University and former guest researcher at NAI, studied interactions between authorities and the public.

She describes how French soldiers entered private gardens to smoke out mosquitoes, the vectors of the virus, often without asking for permission.

When people felt their fundamental rights had been violated, they were less inclined to listen to information from the authorities, she explains.

Medical anthropologist Karine Aasgaard Jansen.

Medical anthropologist Karine Aasgaard Jansen.

“People on the island had lived with mosquitoes for years. Since malaria had been eradicated in the 1970s, there had been no vector-borne epidemics. When the French government suddenly told people that mosquitoes were transmitting a potentially deadly disease, they didn't always believe it”.

The chikungunya virus infected a third of the population – around 266,000 people – and caused 254 deaths.

Engaging in dialogue, visiting schools and working to change children’s behaviours that they would pass on to their parents would probably have been more effective than strict, top-down communication, according to Jansen.

“In principle, my research is about improving communication between the public and the health system, taking into account the respective cultural characteristics”, she says.

TEXT: Mattias Sköld