Portal de Periódicos da CAPES

The Words are Maps

2017; SAGE Publishing; Volume: 34; Issue: 4 Linguagem: Inglês

10.1215/07402775-4373286

1936-0924

Adia Benton,

Global Security and Public Health

“I think an Ebola survivor’s house collapsed this morning,” said Katie, a friend who works for an international NGO in Sierra Leone. She looked tired as she approached me, phone in hand. At the edge of the hotel lobby, a colleague waited for her at a café table. It was mid-August, and I was two days into my first visit to Freetown, the country’s capital, in almost 10 years. Outside the hotel lobby’s doors, the circular driveway was flooded, as it had been for days. One expects rain during the rainy season in one of the wettest places in the world, but this much was unusual. The Western Area, where Freetown is located, had received more than four inches of rain that week, and triple the region’s seasonal average in the previous six weeks.I waited in the restaurant off the lobby in the hopes that the storm would die down before I headed off to find a rumored Ebola museum some 140 miles outside Freetown. I first learned of the museum from a vaguely worded Sierra Leonean newspaper article back in 2015. Then I forgot about it until two years later, when I had an intriguing email exchange with another anthropologist who had worked in Sierra Leone during the West African Ebola outbreak. I told her about my plan to visit Ebola exhibits in London and Atlanta, and she asked me why I hadn’t also planned to visit the museum in Sierra Leone. During one of her post-outbreak field visits, she added, the museum had been the subject of bitter debate between planners, government officials, and foreign sponsors. But that was all she seemed to know about it. Though Katie had been working with Ebola survivors for a couple of years, she hadn’t heard of the museum, and neither had many of her local co-workers. Scant information about the museum could be found online, and I had failed to reach any of its founders or planners by phone or email. All I knew was that it was somewhere on Njala University’s main campus, which is in the southeast, a few miles outside of Bo Town, Sierra Leone’s second city. I hired a car and a driver, Idrissa, and set out to find it.It wasn’t a stretch to suppose that a national museum was in the works but hadn’t yet made enough progress to warrant local attention. That seemed to be the case for a lot of ambitious projects proposed here. Sierra Leone is a beautiful and resource-rich country, but even for the elite, it is not an easy place to live. It has the dubious distinction of being near or at the bottom of most global development rankings and of having some of the highest infant and maternal mortality rates in the world. The civil war, which left a million people displaced and between 20,000 and 50,000 dead, contributed to the decline of health systems, but longtime Sierra Leone observers know that the root of the country’s woes took hold well before the Revolutionary United Front marched into Sierra Leone from Liberia in 1991. Extractive industries like diamond mining and cash-crop agriculture—and even the trans-Atlantic slave trade—have, to varying degrees, done their share of environmental, economic, political, and psychic damage to generations of Sierra Leoneans. Fiscal policies like structural adjustment, which capped wages for health workers, reduced civil-service jobs in the health sector, and led to steady declines in health financing, also took their toll.Then, in May 2014, Sierra Leone was struck by Ebola, a viral hemorrhagic fever with the potential to kill its host within a matter of days. It led to the largest recorded outbreak since the disease was identified in 1976. When it hit, there were just 136 doctors and 1,000 nurses serving 6 million people. By March 2016, when public health officials declared the country’s outbreak over, nearly 4,000 people had died and more than 14,000 had been infected with the virus. Many thousands more were affected by the byzantine rules and regulations that governed the response and restricted movements between and within cities. The disproportionate burden of Ebola on the nation’s few clinicians, along with the fear of contracting Ebola from public-health facilities led to shuttered clinics and a decline in health-care services.I had lived on-and-off in Sierra Leone as a researcher and academic for about three years prior to the outbreak, and the sobering reality of its recent history made it bittersweet to return. But I was happy to be in Freetown, if only to reunite and break bread with old friends, to see how the city had fared after Ebola, and to find this elusive museum.Idrissa and I left Freetown around noon. He wanted to avoid the traffic clogging central Freetown and the East End, so we took Mountain Road, which overlooks the city. As we drove up and around the hills, I was reminded of how I was once terrified to drive my car around the tight bends and curves that characterized Freetown’s hilly landscape. The road to Fourah Bay College, which we would pass on our way back into town, was too narrow for my comfort. I would often hold my breath as we drove on the edge of the steep drop into the city below.Fourah Bay College, founded in Freetown under British colonial rule, was modeled on the British system and was affiliated with Durham University in the United Kingdom until the late 1960s. It is the oldest institution in the country. Njala University, in contrast, was founded after decolonization with the assistance of the University of Illinois, on land donated by Mokonde residents. Its curriculum was modeled on those common in American institutions of higher education.The decision to locate the museum on Njala’s campus reflected many of the differences among higher education institutions in Sierra Leone. Unlike Fourah Bay College, which would have been Njala’s primary contender to house the museum, Njala University had a rural constituency, so its courses were designed to solve rural problems: agriculture, veterinary science, and so on. While Njala is a research-intensive institution focused on knowledge production, free from the constraints of NGO projects, Fourah Bay is plugged into the consultancy culture of the NGO world. Lecturers at Fourah Bay use their training and expertise to court NGOs and obtain lucrative contracts to support their meager academic incomes.The rural lecturers at Njala are less inclined—or, perhaps, not as well positioned—to tap into the funds emanating from international NGOs, and from federal government contracts in Freetown. But when Ebola hit, they were well placed to trace viral movements, locate potential Ebola hotspots, and describe the local conditions that enabled the virus’s spread. Indeed, some of the earliest and most remarkable work came from anthropologists working in the area where Njala is located. Yet as a site for a museum, the rural location made it a curious choice for attracting international tourists.Tackling the Ebola problem in West Africa was not easy. There was little reason to suspect that it would spread through the region the way it did over a two-year period. All previous recorded outbreaks had happened thousands of miles away—often in isolation from cities and large towns. When Ebola was first identified in Guinea in March 2014, officials from the World Health Organization and the Guinean government assumed that the epidemic would be like the others that preceded it. It would be contained quickly, they imagined, as long as they kept it out of the hospitals, where poor infection-control procedures often helped the disease spread further—as occurred in the southwestern city of Kikwit in the Democratic Republic of Congo in 1995. Experts also assumed that, as with previous outbreaks in Sudan, Uganda, and the DRC, it would “burn out” once standard public-health surveillance, isolation, and containment measures were put into place.Doctors without Borders (MSF), key frontline responders when Ebola first took root, opened these assumptions to public scrutiny in June 2014, when it formally announced that the epidemic was spiraling out of control. The humanitarian group had already treated nearly 500 patients—more than had been seen in any previous outbreak—and were concerned about the geographic scale of the cases (nearly 60 sites had been identified as hot spots). In Sierra Leone, there were 239 confirmed cases and 99 deaths. MSF requested more staff to work in treatment units, disseminate information, and roll out more expansive biohazard protection in facilities located in hot-spot areas. The organization urged rich countries to send resources for building more treatment centers and diagnostic laboratories. In the meantime, local health workers in places like Kenema, a city in eastern Sierra Leone with an international reputation for its research on Lassa fever, another viral hemorrhagic disease, conducted outreach. Still, in mid-June 2014, Sierra Le-one’s government, overwhelmed by the sheer numbers of sick and dead, closed its borders to Liberia and Guinea.The situation became so dire by the end of the month that MSF, widely known for its anti-military stance, called for foreign military intervention to help move equipment, build health facilities, and deliver care in areas struck by Ebola. But, they cautioned, they wanted the military assets without all the baggage of the military: no talk of security and weapons, no threat of force, nothing that could be construed in terms of violence or combat. In part, this was an effort to humanize the response by highlighting the importance of care and de-emphasizing the military’s usual role. Perhaps as a reaction to this—but more likely because two American clinicians had been evacuated to Emory University Hospital in Atlanta after becoming infected—the WHO declared the West African Ebola outbreak a public-health emergency of international concern in early August. The decision was made in consultation with the heads of state of Guinea, Liberia, and Sierra Leone, who had reached the conclusion that they could no longer manage the epidemic without substantial international assistance.Crises mobilize resources, and whoever defines a crisis gets to dictate how these resources are distributed. In Sierra Leone, the terms of the crisis were largely framed by international NGOs and their local sub-contractors, in collaboration with the political and business elite. In mid-September, the U.N. Security Council declared the outbreak a threat to international security. Within weeks, UNMEER, the first disease-specific U.N. mission, was established in Accra, Ghana, some 930 miles from the epicenter of the outbreak. WHO developed the “road-map” for the response, while UNMEER was slated to coordinate the wide range of international agencies and organizations involved. The U.S. pledged 3,000 troops to assist in Liberia, while the U.K. sent nearly 1,000 troops, helicopters, and a naval vessel to Sierra Leone. This move inspired critiques of the militarized responses to the spread of the disease. Alex de Waal, an anthropologist who has studied humanitarian interventions in Africa since the 1980s, asked precisely why American military intervention had become the most “logical” option for addressing a public-health emergency. “This argument has a dreadful circularity,” he wrote in November 2014. “We are in this trap because we have paid for a bloated military and a threadbare global health system.”Perhaps unsurprisingly, the post-conflict units that foreign governments provided to “professionalize” police and military in Sierra Leone, Liberia, and Guinea were not adequately equipped to carry out the tasks they were expected to perform during a humanitarian emergency. They did not know how to transport samples, facilitate the rapid movement of supplies, or staff and build Ebola Treatment Units (ETUs), centers set up to house suspected and confirmed Ebola cases. They learned many of these tasks on the job. According to official documents, it also appears that foreign militaries had no intention of providing the level of support for clinical care that MSF requested. Once on the scene, they were largely preoccupied with protecting themselves. In an interview, MSF International President Joanne Liu remarked, “Countries are approaching this with the mindset of going to war. Zero risk. Zero casualties.” She equated early military responses to Ebola to “airstrikes without boots on the ground,” and argued that these efforts needed to be balanced with building ETUs and getting supplies to clinicians.The height of the epidemic—that is, when it appeared to be growing exponentially—coincided with the peak of the rainy season and the scaling back of international flights in and out of the three most affected countries. It also coincided with the departure of personnel from development-oriented NGOs and private-sector actors. Employees of European NGOs usually take their leave during the summer months and that year were advised to not return; others were evacuated out of fear or due to agency mandates. When West African leaders announced that Ebola was a matter of national security, the U.N. Security Council passed a resolution paving the way for additional militarization of the response. By October 2014, Sierra Leonean President Ernest Bai Koroma, dissatisfied with the Ministry of Health and Sanitation’s handling of the Ebola outbreak, transferred leadership to the Ministry of Defense.On the ground, Sierra Leonean officials struggled with how to balance containment with the need to distribute goods and services and deliver life-saving care. Unfortunately, comprehensive, supportive care took a backseat to punitive measures. Paul Farmer, a physician and anthropologist known for his work in Haiti and Rwanda, often says that when he arrived in Sierra Leone in late June 2014, he found little “T” in the ETU—referring to the lack of treatment available in the Ebola Treatment Units. Three months after the outbreak began, Sierra Leone’s parliament amended a 50-year-old public-health ordinance and included Ebola as one of five “notifiable” diseases. The ordinance allowed government officials to mark houses, quarantine communities, and even evacuate populations to curb disease transmission. Perhaps more importantly, the law made “harboring” anyone suspected of having Ebola punishable by two years in jail. On social media outlets like Facebook and WhatsApp, some Freetown residents complained about being expected to obey curfews enforced by police, while elites continued to socialize in beachside hotel bars after dark.To some political commentators in Sierra Leone, Koroma’s decision to shift Ebola oversight to the Ministry of Defense signaled that the president was conferring greater legitimacy for handling national crises—public health or otherwise—to the military. It also led to speculation over whether the newly minted Ebola czar, Major Palo Conteh, was being groomed to assume the presidency upon Koroma’s departure. Not long after taking up his new responsibility, Conteh explained what he felt would be the best approach to dealing with a seemingly indifferent and recalcitrant public. People who refused to obey the official Ebola mandates laid out by the government, he said, were criminals:I am now using the “carrot and stick approach,” I have been giving out the carrot since I took over but our people still do the wrong things. When I start using the stick, I will see all kinds of headlines in papers and radio programs but will not be deterred by them.This punitive strategy unevenly affected the country’s citizens. On Oct. 21, 2014, two residents were left dead and the mining town of Koidu was placed under curfew after Ebola contact tracers, individuals tasked with following up on anyone who might have come into close contact with an Ebola victim, attempted to take the blood of a 90-year-old woman against the wishes of her family. The relatives insisted that she had been convalescing at home for some time while suffering from a chronic illness and had not been exposed to Ebola. They sought assistance from neighbors to remove the officials from the area, and a clash ensued between security forces and young residents, who were described in international reports as “machete-wielding . . . hordes” resistant to public-health efforts.A month after taking office, Conteh set up District Ebola Response Centers with military officers at their helms. MSF appeared troubled by this shift and the potential security risks it posed. Concerned staff wrote in a memo:They are taking a very military approach and advising that the Sierra Leone government deploy more police and military to ENFORCE the quarantine measures at the household level . . . we have the opportunity to negotiate with them to have responsible operational model in these to help the effort without getting anyone killed. THIS MUST BE DONE in a forthcoming and diplomatic manner or we risk to clash and people will die if we don’t sort this out.In late March 2015, food and supply shortages during a countrywide lockdown set off another round of clashes between security forces and communities in Freetown. After eight months of coordinating the response to the Ebola crisis, Conteh’s perspective had barely changed. During a press conference that June, he doubled down on his earlier remarks, commenting that “lawlessness keeps the virus alive: People still wash dead bodies and bury them secretly; the sick still visit herbal healers instead of going immediately to treatment centers. And they still flee quarantine and infect others.” The government also responded with a combination of approaches that leveraged the strength and reach of community-based organizations and international NGOs. They conducted outreach and education campaigns, helped ensure that care would be provided in Ebola Treatment Units, and assisted in regulating burials to reduce the spread of the disease.In a non-official capacity, Sierra Leoneans adopted other strategies. Anthropologists like Paul Richards suggest that early on in the epidemic, in the absence of outside assistance or consistent and reliable information, some communities relied on a “people’s science,” making do with existing resources. Communities organized quarantines and checkpoints. They put together home-based care kits that would allow them to tend to the sick with some basic protection. They made alternative burial arrangements when they suspected that people were falling ill after attending funerals. In other words, they did what they often did in a time of crisis: They fell back on ephemeral, local networks of support.Ebola was not simply an epidemic in the traditional public-health sense—that is, it wasn’t only an extreme disease event in which the number of new cases exceeded an established numerical threshold of “acceptable,” or expected, cases. The West African Ebola outbreak of 2014–16 was an epidemic of signification, as communications scholar Paula Treichler would say; an epidemic in which “meanings are overwhelming in their sheer volume and often explicitly linked to extreme political agendas.” While for Sierra Leone’s government, Ebola represented an overt challenge to its legitimacy and ability to function as a sovereign state, much of the population saw it as evidence of the government’s ongoing failure to attend to the needs of its people. Many went so far as to suggest that Ebola represented the latest in international efforts to endanger, and perhaps experiment on, local people. They also saw it as an opportunity for local and national elites to profit from others’ misfortune.According to colleagues in the region and their local counterparts, the early days of the epidemic were rife with uncertainty, cynicism, distrust, and fear. The public’s inability—and even unwillingness—to comply with often confusing public-health messages were interpreted by authorities as indications of ignorance and resistance. Struggles to understand the origins, circulation, and impact of the disease—and the resources allocated to it—reflected the uneven power relations among Sierra Leone’s citizens, the national government, and international actors. Many ideas about Ebola spread in Sierra Leone and among its diaspora: that the Ebola crisis was fabricated by the government to garner funding from rich states in Europe and North America; that the crisis was initially overstated to give the government free range to limit growing challenges to its authority; that the disease had entered the community through a viral hemorrhagic fever lab sponsored by the U.S. Department of Defense and Tulane University; that clinicians and researchers in hospitals were stealing blood and organs from people who entered with mysterious symptoms; that mining, agriculture, and biofuels interests were using the disease to secure more land for extractive industries; that pharmaceutical companies were infecting people to test their vaccines and medicines; that international humanitarian organizations had brought the disease with them to Ebola-endemic areas; and, finally, that Ebola was an enemy of the people—a virus possibly released to decimate the population.These are clear political and economic critiques. They concern the maldistribution of Ebola risk and the financial resources derived from the country’s extractive industries, health-care efforts, and scientific labor. They are also rooted in other questions: Why had Ebola struck in this particular country, where there had been no previous outbreak? Why had it done so at this time? Had the growth of palm plantation agriculture, deforestation, and mining operations introduced the virus? Had the medical humanitarians who moved from outbreak to outbreak carried the virus with them? What had all the hemorrhagic fever research in this local laboratory been for, if not to produce effective diagnostics and therapeutics for people living in the virus’ “hot zone”? Grappling with the answers to these questions was, in part, an attempt to explain yet another round of misfortune befalling the residents of this region. Yet if these concerns, which were widely shared among Sierra Leoneans, were discussed in media depictions of the Ebola outbreak at all, they were often dismissed as wild conspiracy theories. Rather than being understood as “rational” critiques of existing and observable power dynamics in the region, they were instead labeled as beliefs to be overcome through effective messaging—not through addressing underlying causes. The crisis of Ebola, in other words, became a crisis of meaning. In years to come, debates over what Ebola meant to everyday Sierra Leoneans, how it is collectively remembered, and by extension, how these memories will be preserved and mined, will shape the national conversation about health and development. The outcomes of such debates will also affect how Sierra Leoneans see themselves involved going forward and the roles they will play in responding to future crises.Once we were on the far east side of Freetown, the roads widened. We came across another thing I had never seen in Sierra Leone before: a toll road. The three stops on the way to Bo were not yet operational, but the fees were posted on the side of the road. Toll booth staff stood in their kiosks, explaining to anyone who bothered to stop that they would start collecting tolls the following week. We reached Bo within three hours. Idrissa drove me over the bumpy, rutted road to Njala’s campus, where I inquired at the school’s main office about my one contact, a veterinary scientist who had reached out to me via LinkedIn.Staff in the main office directed me to Roland’s office. School was still on break, and Roland was away from his desk, so I asked his colleagues for his phone number. The next day we drove to meet him in a government office parking lot. When I explained why I had traveled to Sierra Leone—to find the National Ebola Museum—he looked up toward the sky, as if consumed by his exasperation, and asked us if we were available to give him a lift back into the center of town.As we drove around Bo and then back to campus, he explained his frustrations. The museum had been in the works for some two years, and had received funding from various donors, he told us, including the BBC World Service, Plan International, and the Sierra Le-one Union of Photographers—but it did not yet have anything in it. It was not clear how much money was allotted for the project, but as Roland spoke, it seemed that the potential for garnering financial backing was what had initially attracted outsider attention, rather than support for the idea. The museum’s organizers continue to seek funds. Only days before my meeting with Roland, he had been notified that more money was coming in to pay for the project’s clinical database component.The museum, he continued, was the brainchild of Paul Richards, a British anthropologist who has spent decades studying culture and agriculture in southern Sierra Leone, and is a member of Njala’s faculty. When the outbreak happened, Richards was on the ground conducting a longitudinal study on how burial customs shape disease transmission routes. His idea was to start a museum and build an Ebola archive in order to re-center Sierra Leone’s role in knowledge production about the epidemic—that is, to showcase the meanings that emerged outside of the international and governmental narratives around the crisis.Richards’ motivation echoed that of Bo’s mayor, Harold Logie Tucker. At a ceremony in early February 2015, the mayor openly criticized white experts for showing up and assuming the role of Ebola experts, when so many local scholars and community workers had studied Ebola full-time during the crisis. For him, the fact that so many people experienced the outbreak as clinicians, patients, caregivers, educators, and members of burial teams meant that they were uniquely positioned as experts on the disease. During this same event, another official accused white foreigners of stealing his idea for containing and reintegrating people who had fallen ill with Ebola. The ceremony became a venue for authorities to voice their frustrations with a particular version of expertise that they saw as displacing their own locally developed forms.Sierra Leone’s Ebola museum was intended to afford people who had experienced Ebola the opportunity to harness the knowledge and legitimacy associated with recognized institutions. The museum also planned to use its archive to advance and distribute information about the disease. This would counter the combination of extractive and top-down approaches that had characterized Western responses: The vice chancellor of Njala, Abu Sesay, made clear that “anyone who wants to know about this time, what happened, and how we went through” could visit the museum located on Njala’s Bo campus. After the government agreed to support the museum, it seemed that filling it, building the archives, and creating a system for managing researcher inquiries about clinical data would soon follow. But, as one economist involved told me, things take longer than planned, and red tape still hampers the project—even with an endorsement letter signed by the president himself.After meeting with Roland, we drove to the university’s main administration building, which loomed large near the center of the small but sprawling Njala campus. Dirt roads led from that multi-story building to dormitories, a visitor’s guesthouse, and small cinder-block buildings housing a number of science departments. At that time, a university-wide strike was pending. Staff had gone months without their salaries, and lecturers faced a backlog of unpaid benefits and allowances that were a crucial part of their compensation packages. Meanwhile, in newly outfitted $2-million laboratories donated by the Dutch government, Njala researchers ran experiments on influenza, Lassa fever, and rabies. We drove a few minutes to the museum site. It consisted of two empty buildings once occupied by the university’s department for natural resource management. The logos of a wide range of international donors were advertised prominently on an already deteriorating sign in front of the buildings. Through the translucent windows, I could see nothing. It was dark inside, and, we were told, empty. No one there seemed to know when the buildings would begin to look like a typical museum.The museum, as it currently stands, does not provide many answers to how the story of Ebola will be told in Sierra Leone. Plans for exhibits are fuzzy. Organizers are considering collecting oral histories from Njala and the surrounding communities. They have made progress on setting up a repository for clinical records stripped of identifying information. Researchers have already requested access to those data, and the protocol for procuring it has been developed. A Ph.D. student from the U.K. recently began working with two anthropologists to help build exhibits and write a thesis about health communications during the outbreak. Yet there are still many more stories that need to be told. There are the stories of the community members who organized house-to-house education campaigns before the government did so; the individuals who secured donations from Sierra Leoneans living among the diaspora in North America and the United Kingdom; and the community stringers who communicated with the outside world via WhatsApp, Facebook, and Twitter to tell us about life under a nationwide lockdown.As Sierra Leone and the global health community continue to deal with Ebola’s impact, we are still learning from the outbreak. Many survivors bear the burdens of ophthalmological and neurological problems, as well as the profound economic and social losses that come with illness and isolation from loved ones. The survivors that my friend Katie had been working with at her NGO were among the “lucky” ones: Through her organization, they received financial support, jobs, and clinical care. Some of the systems that had been put in place to respond to Ebola had saved lives. When I returned to Freetown, I discovered that the collapsed house she had mentioned earlier was only one of many that were crushed by a mudslide that killed 1,000 people and displaced several thousand more. The emergency response sys tems that had helped bring Ebola under control had been mobilized to address this crisis. They enabled officials to efficiently recover bodies, transport them to the morgue, and organize speedy mass burials. There were, however, still few resources for predicting or preventing such emergencies, or for dealing with matters of health, rather than death. Two years after Ebola, the questions remain: Will the lessons of the outbreak lead to the development of robust and resilient health systems? Can better infrastructure be developed to limit the reach of such disasters? And until any of this happens, will the mechanisms in place be able to fully absorb the shocks of recurrent crises?