Gillian Tett Contagion chapter

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(OR WHY CAN’'T MEDICINE STOP PANDEMICS?) “Human diversity makes tolerance more than a virtue; it makes it a requirement for survival.” —René Dubos' Paul Richards, a white-bearded anthropology professot, sat in an or- nate eighteenth-century conference room inside the Admiralty Building in Whitehall, headquarters of the British government. The walls were festooned with oil paintings of British dignitaries. Facing him, across a highly polished mahogany table was Chris Whitty, a balding doctor- turned-bureaucrat who was chief scientific advisor for the British govern- ment’s overseas aid and a respected expert on issues such as infectious diseases. It was the late summer of 2014. Whitty had reason to be wortied. Some months earlier a highly in- fectious disease called Ebola had started to sweep through Britain’s for- mer colony of Sierra Leone and neighboring Liberia and Guinea. Groups such as the World Health Organization and Médecins Sans Fronti¢res had rushed to halt the contagion. So had the UK, French, and Ameri- can governments: Barack Obama’s American administration had even sent four thousand troops to Liberia. The world’s best medical experts at

ANTHR.O_-VISION places such as Harvard were huntrng for a-vaccine, and computer scien- tists were using Big Data tools to track i it. ‘ But nothing had worked Ebola kept movrng through the vast for- ests of West Africa. The governments in, Europe and the Unrted States were braced for it to arrive 1mmrnently on their shores. Theé Centers for Disease Control in Washmgton was warmng that the world was “losing - the fight” agamst the disease and nore than 1 miillion people would die unless somethlng——anythrng—could turn the tide.? So Whitty had sum- moned Richards and other anthropologrsts with a questron. Why had - computing and medical science: apparently farled in West Afrrca> Had Western scientific experts mrssed somethrng _ » - Richards hardly knew Whether to laugh-or cry A couple of de- cades carlier a British cabmet mlnrster named Norman Tebbit had an—. nounced; ‘while workmg in-a srmrlar white stucco burldmg, that it was a waste of pubhc money to fund anthropologrsts since they just did ir- relevant research, such as “studies of the prenuptral habrts of natives of the Upper Volta valley. Rlchards eprtomrzed Tebbrts target. He hailed from the Brrtrsh Pennines and had started hrs career 4s a geographer, but then spent four decades dorng patrent partrcrpant observation among .the Mende people in the forest reglons of Srerra Leorie, living among them, spealong therr language—and marryrng a local woman, Esther -Mokuwa. She Was a seasoned researcher in her own right, and also sat - at the mahogany table facing \Whltty Richards was an expert on agricul- - ' tural practices but also fascinated by Mende ritual since he espoused a. " “Durkheimian” phrlosoph)r, named after the French intellectual Brmile _ Durlkheim, that: argued that cosmology shapes behavior (and vice versa). Richards passionately- beheved that. rrtuals matter, be they marriage cer- emonies, death rites, or anythrng else 5 Tebbrt had ‘scorned this: But in; 2014 hrstory had taken a pecu— liar twist. As-Ebola spread reports had emerged about behavior and beliefs that seemed horrrfymgly strange to Western ears: patrents were CONTAGION running away from hospitals, hiding from aid workers, attacking (and killing) healthcare professionals, holding funerals where they touched the infected—and highly infectious—corpses of Ebola victims. “I heard peo- ple kiss dead bodies,” Whitty said. Western journalists had reported this detail with baffled horror; it evoked the type of exotic—racist—images from Joseph Conrad’s novella Heart of Darkness. “They don’t just kiss bodies for no reason!” Mokuwa retorted. She had arrived at the Whitehall building stricken with grief-for her dying compatriots. But she was also furiously angry. The main reason why the anti-pandemic policy was going so wrong, she told Whitty, was that Western medical “experts” were only looking at events through their own assumptions, not locals’ eyes. Without some empathy—or an attempt to make strange seem familiar—medical and data science would be useless. The meeting drew to a close. As they trooped out, Richards spotted a historical plaque at the side of the ornate room—and burst out laughing. The meeting room had once hosted the corpse of Lord Admiral Nelson, the revered British naval hero, who had died in the Battle of Trafalgar in 1805. After death, his body was apparently pickled in a cask of brandy, brought back to Britain in a ship called the HMS Pickle (yes, really).* It was then displayed in Greenwich and Admiralty House, Whitehall. Some fifteen thousand mourners came to pay respect—by touching and kissing his brandy-soaked corpse.® “If Nelson had Ebola, everyone in London would have caught it!” Richards pointed out. Whitty laughed. However, Richards was trying to highlight a serious point: no culture has a right to dismiss other cultures as “strange” without realizing that their own behavior can also look odd. Particulatly in a pandemic. *No, I am not making this up: it really happened. If you are chuckling or wincing, ask yourself this: Why? What does it reveal about your view of ° ‘normal?” Then watch the Netflix series Zhe Crown to see how the body of King George VI was embalmed and displayed as recently as 1952. Ideas of “normal” change.

ANTHRO-VISION The word “Ebola” comes from the name of a river deep in the Aftican Congo. In 1976, doctors reported a strange—terrifying—new “hemor- thagic fever” around that Ebola River. It started with a fever, sore throat, muscular pain, headaches, vomiting, diarrhea, and rashes, but often led to liver and kidney failure and internal bleeding. The Johns Hopkins Medical Center observed that “25 percent to 90 percent of those infected” died, with “average case fatality rate . . . around 50 percent.”” That was comparable to Europe’s thirteenth-century Black Death plague.* In the subsequent three decades, the disease sporadically flared up in different African regions, but then ebbed away because its victims ex- pired so fast. That changed in December 2013 when a two-year-old child became infected in a village in Guinea, near the town called Guéckédou, located near the wiggly—artificial—borders that nineteenth-century co- lonial rulers had used to divide the vast West African forests into coun- cries called “Guinea,” “Sierra Leone,” and “Liberia.” The Jocal population were tightly entwined with one another, constantly moving across the borders, and the disease spread quickly. A dark-haired American called Susan Erikson was one of the first Westerners to hear about Ebola. Early in her life she had spent a couple of years in Sierra Leone, as an idealistic volunteer with America’s Peace Corps. She then returned to college in the 1990s to do a doctorate in anthropol- ogy but with a twist: she combined cultural analysis with medical studies. This branch of the discipline, called “medical anthropology,” champions a core idea: the human body cannot be explained by “hard” science alone, since sickness and health need to be put in a cultural and social context. Doctors typically view the human body in terms of biology. However, in *The reason for the wide range in mortality rates is that the impact of Ebola varied enormously between communities, depending on poverty levels, healthcare, and infra- structure, as Paul Farmer, the medical anthropologist, has stressed. CONTAGION most cultures the body is also treated “as an image of society” that reflects our beliefs about issues such as pollution and purity, as Mary Douglas, the anthropologist, points out.? This affects how health, sickness, and medi- cal risk are viewed. Or, as Douglas observed in a book she coauthored on nuclear, environmental, and medical risks, since “the perception of risk is a social process,” each culture “is biased towards highlighting certain risks and downplaying others.” During a pandemic, for example, people typi- cally cling to “their own” group, however they choose to define it. That means people typically overemphasize risks that arrive from outside the group and underestimate the ones that are inside the group. Throughout history pandemics have been associated with xenophobia, even if people are complacent about domestic infection risks. Erikson initially hoped to use medical anthropology to study repro- ductive health in Sierra Leone. But in the 1990s a brutal civil war erupted in the region. So she switched her focus to Germany before eventually re- turning to Sierra Leone, from her academic base at Simon Fraser Univer- sity in Canada, to explore how digital health technology was impacting public health. On February 27, 2014, she woke up in a rented room in Freetown, Sierra Leones capital, reached for her phone, and read about a “strange hemorrhagic fever presenting like Ebola” in an online news- feed. “I just went, ‘OK,’ better note that. But I wasn’t too concerned. I see a lot of ‘dread disease’ feeds like that,”'® she recalls. Then, when the health ministry called a meeting to plan its response, with government officials and representatives from groups such as Médecins Sans Fron- tieres (MSF), UNICEE and the World Health Organization, Erikson’s research team attended to do some participant observation. “An administrator begins the meeting with an overview of Ebola and the threat of its spread,” the research team’s field notes say. “Then [the administrator] moves to the task: “We have a template [to fight Ebola], but we need to bring it home, to make it Sierra Leonean.” He explains that the template is a WHO document from [an earlier Ebola episode in] 59

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ANTHRO-VISION Uganda that needs to be wordsmith[ed] for Sierra Leone. “We are here to make surveillance and laboratory plans.””*! “People in the audience respond as though they've done this before,” the notes continue. “The group begins discussing surveillance tools— reviewing the standards for evaluating suspected and confirmed Ebola cases. . . . People begin debating about the number of people that need to be trained for RRTs (Rapid Response Teams). People calculate that with 1200 Public Health Units (PHUs) (health posts) throughout the country plus private sector clinics, 2 RRTs per PHU means that 2500 people need to be trained.” To patticipants, the conversation seemed unremarkable, The Sierra Leonean officials were following a script to fight contagion created by in- ternational organizations such as WHO and legitimized by global health science. But as Erikson listened, she felt worried. Officials were tossing around acronyms like talismans to ward off danger, signal power, and un- lock funding from Western donors. She had seen this many times before. However the Sierra Leoneans lacked the sovereignty to make their own decisions about Ebola and nobody was asking the Sierra Leoneans what was best—or what would-be Ebola victims might want. Is #his really the best way to fight a pandemic? Erikson wondered. She feared not. Two weeks later, on March 11, a Boston-based tech ‘platform called HealthMap issued a global alert about Ebola. It seemed a victory for American innovation. Until that point, it had always been WHO that warned the world about a new disease outbreak. But HealthMap, which won funding from Google, had beaten it to the punch. “Meet the Bots That Knew Ebola Was Coming!” trumpeted a headline from' 77me maga- zine, next to some terrifying photographs of healthcare workers wearing white hazmat suits and goggles, in an African jungle.”? “How This Al- gorithm Detected the Ebola Outbreak Before Humans Could!” declared Fast Company.”® The news sparked excitement among Western medical a0 CONTAGION groups and techies. It scemed that these computing tools could not only track the disease, but also predict where it might move next in a way that would enable Ebola to be crushed swiftly. At Harvard Medical School, a British researcher called Caroline Buckee had analyzed the records of 15 million Kenyan cell phones to track the spread of malaria. She hoped to do same with Ebola and asked the telecoms company Orange for permis- sion to use cell phone data in Liberia for this purpose. “The ubiquity of cell phones is really changing how we think of diseases,” she observed.™ Half a world away in Freetown, however, Erikson was getting wor- ried. With a bird’s-eye view, the data science seemed impressive. Not so with a worm’s-eye perspective. One reason was that sites such as Health- Map tended to track news in English, not local African Janguages or even the French used in Guinea. There was no guarantee that models developed for malaria could be transposed onto Ebola.”” There were few reliable cell phone towers to dispatch the all-important “pings.” Most important, there was the problem that Intel had grappled with: it was a mistake for anybody (especially Western techies) to assume that everyone shared their attitude to life. In America or Europe, people typically have a one-on-one relationship with their phone, and these devices are re- garded as “private” property, an extension of self. Losing a phone feels to Westerners almost like losing part of themselves. Not so in Sierra Leone. “Cell phones are loaned, traded, and passed around among family and friends, like clothes, books, and bicycies. A single phone can be shared by an extended family or, in rural areas, a neighborhood or a village,” Erikson observed.' Thus while the phone records suggested that phone ownership in Sierra Leone equated to 94 percent of the population, this did 70r mean that everyone had a phone, as Western tech experts tended to assume; some people had a phone for each network, but others had none. “Pings” were not people. That made it impossible to build accurate predictive models with “pings” alone. Computer science needs social sci- ence, if you want to make sense of data.

ANTHRO-VISION By the early summer of 2014, Ebola was spreading fast. On the advice of global health groups, the governments of Sierra Leone, Guinea, and Liberia rolled out the standard protocols that Erikson had heard dis- cussed in March: they imposed quarantines and lockdowns, ordered sick people to go to isolation centers, known as Ebola Treatment Units, and banned victims from seeing (let alone touching) families and friends. They also insisted that the corpses of anyone who died be buried in a “safe” manner, without human contact, since they were extremely infec- tious. Messages about all this were placed on posters, in, radio bulletins, and on pamphlets. It made perfect policy sense to Western eyes. But something was going tragically wrong. Another anthropologist, named Catherine Bol- ten, had a grisly—ghastly—view of the problem. She had done her field- work in a bush town called Makeni, the northern regional capital, a few years before Ebola hit. After she returned to America, she stayed in close touch with friends there, such as a local lawyer who worked at the Uni- versity of Makeni, named Adam Goguen. When Ebola arrived in his district in the carly summer of 2014, Goguen sent Belton daily emails on real-time events. Goguen’s own village was one of the few that obeyed the govern- ment’s orders, since his local village chief spoke English, regularly tuned in to the BBC, had good relations with a local NGO, and thus under- stood the WHO pandemic-fighting rules. He sealed off the village to the outside world and imposed a quarantine. Everybody lived. The chief who ran the neighboring village, however, took another tack. He decreed that the source of Ebola was a witchcraft curse and refused to send any- body infected with Ebola to “exclusion” hospitals or to impose a lock- down. “Bvery resident targeted for quarantine had another household to shelter them, and this was exactly how they reacted to the prospect of the authorities isolating them from the only people they believed would CONTAGION care for them properly,” Goguen and Bolten subsequently explained in a joint article. “Even residents who suspected that Ebola was a contagious disease, and not [a witchcraft curse], nursed family in secret.”"’ The vil- . lagers also rejected the “no touching” rule for the living—and the dead. When Ebola victims died, the so-called secret societies that ran village rituals organized traditional burial ceremonies—with infectious corpses. A local nurse tried to stop people touching the living and dead bodies of Ebola victims, explaining the medical risks. “The nurse had conducted contact tracing from the first funerals and accurately predicted who would fall ill [after touching the corpse],” Goguen told Bolten. However, the villagers attacked the nurse, accusing her “of slaughtering them with witchcraft.” When soldiers stepped in and buried infected corpses, locals later dug up the bodies and reburied them—touching them. With great bravery, the local nurse kept trying to spread the WHO message. How- ever, when she visited a family whose members had just died from Ebola, she was “prevented from quarantining the house by the village youth, who were armed with machetes, and the residents of the homes targeted for quarantine . . . dispersed among related households, whose members concealed them.” That lead to forty-three more infections. Similar scenes were unfolding across Guinea, Sierra Leone, and Li- beria. The WHO officials, MSE and local governments tried to fight back by intensifying the lectures about medical risks and using soldiers to impose its orders. “It was assumed that if communities had correct infor- mation on Ebola risks then appropriate actions would follow, Richards explained.® But that backfired. Villagers continued to blame the virus on witchcraft or a government plot. An angry mob attacked a MSF isolation unit in Guinea.’? In southern Guinea, villagers killed eight members of 2 so-called national Ebola awareness team and dumped their bodies in a latrine. By the autumn, an average of ten attacks per month were taking - place in the region against medical burial and infection control teams. In September 2014, the Centers for Disease Control in Washington

ANTHRO-VISION warned that the contagion was so bad the disease would soon spread to the West and could kill up to 1.2 million people. There was no prospect of a cure or vaccine in sight. “Medical education seemed helpless against »» 1« < ) . . pavement radio,” Bolten recalls.” “In the United States there was near panic about the prospect of it coming here.” In October 2014, some of the American anthropologists who had worked in Sierra Leone, Guinea, and Liberia held an emergency meeting at George Washington University. Emotions were running high. “We . were sitting there in this room feeling just overwhelmed with grief for the . . . people we knew [in West Africa],” Bolten recalls. She had just learned that two of her friends had died and could hardly concentrate “since I kept checking my phone for news” to see if a truckload of rice she had dispensed as aid had arrived. She also felt frustrated and guilty. The anthropologists in the room had spent years patiently trying to un- derstand the cultures of West Africa, hoping to spread a little empathy in a globalized wotld. Now prejudice and racism was exploding. “I had an American journalist call me up and ask why the Africans kept behaving in this barbaric and stupid way,” Mary Moran, one of the anthropologists in that Washington room, observed. She argued that these labels were unfair. Until the early decades of the twentieth century, Americans had routinely kept the bodies of deceased family or friends in their houses after death, for a few days, posing them in “lifelike” tab- leaus with living people for photos. What happened to Admiral Nel- son’s body—or that of King George VI—was not an outlier. Yet Western journalists, doctors, and aid workers were now decrying the West Afri- cans’ “primitive” rituals and claiming (wrongly) that Ebola was caused by strange “natives” eating “bushmeat.” The anthropologists considered this not just unfair but also cruel. The West Africans were facing terrible trauma in a place with little— or no—infrastructure. They wanted to grieve their losses in a way they CONTAGION considered proper. Their- local bellef systern asserted that- When some— body died, their lrvrng frrends and famlly needed to pay respects by pat- ‘ticipating in a funeral, with the body present; Wrthout that, the deceased would be consrgned to permanent hell and everyone else around them would suffer. That rrte had often been 1nterrupted durrng the c1v1l war, creating the risk of a curse. Nobody‘ wanted that cycle to continue. “An Ebola death is not nearly as bad. as an Ebola burial,” Goguen explarned to Bolten. Only the body dies from Ebola, but an Ebola burial kills the spirit.”* There was another crucial pomt that scornful Western critics failed to understand: there were also real-world pract1cal 1mped1rnents to following the WHO advice, since there was so little preexrstrng health infrastructure. While the academic anthropologrsts were meeting in Washington, another medical anthropologist, named Paul Farmer, was. arriving in West Africa. Twenty-five yeats earlrer he had cofounded a nonprofit called Partriers in Health to-offer. medicine to emerglng market regions such as Latin Arnerrca, Ham, and (latterly) Central and West Afiica. Although Farmer was a tramed physician Who believed i in the power of medical science—and: the need for. tangible “stuff, staff, space and systems” to fight dlsease—he belleved that healthcare needed to be offered with respect for local cultures. and an awareness of social context. He was appalled by what he saw in Srerra Leone, Gurnea, and Liberia.”? Ebola victims were coIlapsrng in pools of vom1t, sweat; and drarrhea on the road in taxrs, at hospltals, and at home, Large numbers of doctors. were dying. The already weak. rnedrcal 1nfrastrueture was falling apart. And while medical groups such as. MSF and WHO were trying to con- ) tain the disease, they were not really trying to offer therapeutrc care. The Ebola Treatment Unrts had “too l1ttle “T” in the ETU,” he fumed Given that, it was not surpnsrng that Ebola victims kept running away or ignor- | ing orders, and it was wrong for outsiders to scorn people for domg that. After a long civil war and with a history of colonial oppression, there was

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ANTHRO-VISION little reason for ordinary people to trust their government or hectoring Western “experts.” A lack of empathy was quite hterally killing people and fueling the spread of the disease. * Could anthropologists do anything to counter this? Opinions in the room in Washington were divided. Some academic anthropolo- gists were leery of working for a government of any hue. Others felt that only West Africans should speak for the region, not Europeans or Americans. Many academics had little practice at engaging with policy makers; they preferred to observe, not agitate.”* “Economists don’t have any problems with standing up and saying clearly: “This is what is going to happen next!” They have the networks to reach people in power and the confidence to forecast the future—and if this turns out to be wrong it doesn’t matter, they just carry on!” says Erikson. “Anthropologists are not like that.” But the anthropologists knew they had a moral obligation to do something. Or as Bolten observed: “We sat there [in the room] and asked: Is there any point to what we have been doing all these years if we don’t speak out?” In subsequent weeks Farmer and his colleagues at PIH angrily cam- paigned for a policy change, to focus on patient care, with empathy, not just disease containment. The academic anthropologists also did something they had almost never done before: tentatively organize themselves to offer advice on culture. In America, the AAA society pro- duced memos for the Washington administration about local culture. French anthropologists did the same in Paris. A United Nations Ebola- fighting team hired a medical anthropologist named Juliet Bedford. “It was a watershed moment,” she recalls. “There was a real sense in the UN that they had to change the standard operating procedures [for medi- cal help] but didnt know how.”” In London, a group of anthropolo- gists, including Richards, Melissa Leach, and James Fairhead, created a dedicated website called the Ebola Response Anthropology Platform. CONTAGION “The objective [of Ebola-fighting measures] is to combat a virus, not local customs,” one memo sternly declared.2® Whitty, the British doctor- . turned-bureaucrat in Whitehall, convened meetings with them in the ornate Whitehall buildings to hear their advice. Then Mokuwa volun- teered to go to the forested region in eastern Sierra Leone where the epi- demic was raging. For weeks she walked the arduous off—road tracks to, . visit communities she knew well from earlier fieldwork and sent reports to Whitty and others, hoping to offer a local, worm’s-eye perspective to balance the top-down view of scientists. “I walked and walked and tried to listen,” she recalls ‘ - The drspatches were a revelation to the British bureaucrats. Untll that point, Western ‘medical experts——and Whltty——had assumed the o best strategy to contain Ebola was to'put sick people in large, specialized isolation centers. But Mokuwa explained that approach did not work, since the ETUs were far from the villagers and victims could not travel . " more than a few miles. It was also a terrible mistake to build exclusion centers with opaque walls; if nobody knew what was happening inside ‘the buildings, sick people were more likely to run away. Sending young outsiders into villages to dispense medical advice was equally disastrous ‘since the villagers usually only accepted advice from village elders. So the - other anthropologists offered some policy ideas: Why not change the style of the exclusion centers to make them transparent? Put lots of small : treatment centers in Jocal communities? Use v1llage elders to transmit messages about Ebola safety? Devise funeral rituals that would be safe in medical and social terms? Recognize that many people Would insist on . *Molkuwa, like other anthropologrsts, stresses that she would have preferred to have had more local voices speaking to Western governments; or have the message coming . from a group of West Afican anthropologists. But one failing of twenty-first-century . " Western anthropology is that there are relatively few non-Western adherents. Mokuwa - and Richards have been trying for many years to build the discipline in local West Af- rican universities, but it is uphill work, since these departments are very underfunded . (like so much of the wider infrastructure in the region),

ANTHRO-VISION caring for their sick relatives at home and advise them on how to make their homegrown solutions safer? It echoed, in a sense, what Bell had told the Intel engineers when she saw that drivers kept using their own devices in cars, in defiance of the engineers’ ideas. Why not work with the local culture, not against it? . The messages slowly had an impact. Inside MSFE, some doctors started to call for more emphasis on therapeutic care, not just con- tainment.* The international agencies changed the design of exclusion centers to make the walls transparent.?” In Whitehall, Whitty switched policy on the ETUs and declared that the British government would fund the construction of dozens of smaller triage and treatment points close to communities. Medical teams began to talk with local communi- ties about how to modify their funeral rituals to make them safe while also respecting the dead. One template for how to do this was set down when an ugly incident erupted in a village in the forest of Guinea. When a pregnant mother died, the local WHO officials initially tried to bury the body rapidly away from the village. But local villagers were deter- mined to do funeral rites and remove the fetus to avoid a curse. A dan- gerous battle exploded. However, Julienne Anoko, a local anthropologist, stepped in and worked with the community to adapt existing rituals to remove potential curses—and persuaded the WHO to pay for that ritual. It worked: the body was buried safely, mourning rites were held “in the presence of administrative officials, the WHO team” that left villagers so reassured that “the community thanked everyone involved with tradi- tional songs of peace,” she later observed.? Local communities also started to devise their own solutions to care for patients outside the hated ETUs, at home—and Western doctors *The internal fight about MSF and WHO policy in West Africa was (and is) a matter of great controversy that I cannot give justice to here. However, for details see the ac- count in Farmer’s magnificent book Fevers, Feuds, and Diamonds: Fbola and the Rav- ages of History (New York: Farrar, Straus and Giroux, 2020).. CONTAGION reluctantly began to accept these. In Liberia, villagers donned raincoats, worn back to front, over garbage bags as a rudimentary form of per- sonal protective equipment. Villagers created homegrown protocols to use survivors to perform contact tracing and treat sick patients. Then the old men and women who ran the Poro and Sunde secret societies, which controlled funerals for members, got involved too. “We held a seminar at Njala University [in 2015] where a paramount chief came with some elders who asked us for some white hazmat suits,” Richards later recalled. “When we asked why, they said they wanted to create a dancing ‘devil’ that would teach the girls of the chiefdom about the Ebola hazard.” It was radically different from the messaging tactics used by WHO and the governments. But it was far more effective. By the spring of 2015, Ebola patients weré no longer running away from exclusion centers, nor were communities digging up bodies to re- bury them or attacking the medical staff. The contagion slowed. By the summer WHO had declared that the Ebola epidemic was over. The final death toll was estimated to have been between eleven and twenty-four thousand.* Tragicélly high, it was also a mere 2 percent of the worst sce- nario projected by the CDC in the summer of 2014. “It was a good news story—in the end,” Rajiv Shah, the man whom President Barack Obama put in charge of the White House Ebola response, later told me. “What we learned was that you can make policy much more effective when you work with the communities and bring them into solutions.” To which the anthropologists might have replied: “Of course.” Five years later, Richards and Mokuwa—along with other veterans of the Ebola fight—found themselves beset with unexpected déja vu. This time *There is obvious uncertainty about the numbers given the weak health care infra- structure. The WHO put the final toll in the summer of 2016 at 11,000; observers such as Farmer consider this a gross underestimate: https://www.ids.ac.uk/opinions/a -real-time-and-anthropological-response-to-the-ebola-crisis/.

ANTHRO-VISION the disease was COVID-19, not Ebola. However once again the problem _had started in a place that seemed so exotic to Westerners that it was easy - to demonize: Wuhan, China, “Blaming the neighbors {in a pandemic] is " an eternally popular sport and so is mocking their food,” Farmer tartly wrote in April 2020, as COVID-19 spread across Europe and America. “The Ebola-era obsession with bushmeat is neatly enough reflected in commentary about Wuhan’s wet markets, where (one imagines) caged civets pace, eels and strange fish squirm and flop and pangolins shed scales‘like golden tears.”® However, COVID-19 did not stay in exotic " lands. “Ebold happened in the dark heart [deep corners] of Africa. Much of the general population in the global north thought it was ‘out there,’ a 1ong way from them,” 'Bedford observed. “But then they discovered that COVID was happening in parts of the world where they [the general population] never expected to be facing this threat.” ' Could Western governments learn from the past to devise a better re- sponse? The anthropologists initially hoped so. By 2020 the British burcau- crat Whitty had been promoted from the development agency in the UK into an even more influential role as chief medical officer for the entire Brit- ish government. He was thus advising on the COVID-19 campaign. He scemed perfectly placed to draw the right lessons from the Ebola saga about the need ‘to blerid medical and social science since he had written joint pieces with social scientists in 2014 championing precisely that.*® Groups such as WHO had also used the Ebola experience to improve their tactics to fight other infectious diseases, such as a 2016 outbreak of Zika. Com- puter scientists were becoming wiser too, blending social and data science. At HealthMap, the disease tracking platform that John Brownstein had cre- - | . ated in Boston, the doctors and scientists had increasingly realized the need to put data into social context. “Big data is not the holy grail. We know it s " only useful if you understand the social context,” Brownstein told me. “For COVID-19, we need a hybrid: machine learning and human curatic_)n.”31 Or as Melinda Gates, cochair of the Bill & Melinda Gates Foundation, CONTAGION which focuses on global healthcare, also told me: “We have been forced to rethink some of the way we use data. At the beginning there was a lot of excitement about Big Data, and we still firmly believe that getting better statistics is very important and technology can do amazing things. But we cannot be naive—understanding the social context matters.” So, with a sense of optimism, the anthropologists presented ideas about how to harness cultural awareness to fight COVID-19.% They suggested that policy makers recognize that kinship patterns affect trans- mission rates (intergenerational households in Northern Italy, say, posed risks). They warned that cultural attitudes toward “pollution” can distort people’s perception of risks, leaving them fearful of outsiders but ignor- ing insider threats. The US president, Donald Trump, demonstrated that: he referred to COVID-19 as a “Chinese invasion,” and shut the US border, but downplayed risks from “insiders” to such a degree that an outbreak of COVID-19 erupted in the White House.> The anthropologists also warned that the messaging around COVID- 19 needed to be clear, sympathetic, and in tune with the needs of com- munities. Top-down orders alone did not suffice. “The name for Ebola in Mende, one of the main languages of Sierra Leone . . . was bonda wore, literally ‘family turn round.” In other words, it was clearly recognized that this was a disease requiring families to change behavior in major ways, especially in how they cared for the sick,” Richards wrote in a memo posted on the Oxfam website in the spring of 2020.” “Covid-19 will require similar changes at the family level, especially in terms of how the elderly are protected. The buzz words for epidemic responders include self-isolation and social distancing, but the details of how to implement these vague concepts have been left to local social imagination. Should grandpa be packed off to a shed?” The anthropologists also stressed that the need to blend social and medical science was demonstrated not just in evidence from West Africa but from Asia too. The tale of face masks was particularly striking. After

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* ANTHRO-VISION the SARS epidemic swept through Asia in the éaﬂy years of the twenty- first century, several anthropologists and sociologists—such as Peter Bachr, Gideon Lasco, and Christos Lynteris—studied the emergence of a “mask culture” in the region. They concluded that masks had helped combat contagion, but not jusf because of hard science (whether masks stopped the inhalation or exhalation of virus particles), but also because the ritual of putting on a mask is a powerful pé,ycholo‘gical prompt that reminds people of the need. to modify their behavior. Masks are also a symbol that demonstrates adherence to civic norms and community sup- port.®® The ritual of “masking up” changes other behavior. ' Some government officials listened. In New York, for example, local * officials swiftly unleashed a campaign to persuade residents to embrace masks. It initially seemed unlikely to wotk since masks were associated with stigma in New York and wearing one appeared to offend New York- ers individualistic culture. But billboards around Manhattan were fes- tooned with messages that tried to change the ¢ ‘webs of meaning” around masks, as Geertz might say, redefining them as a sign of strength, not ')) stigma. “No mask? Fuggedaboutit!” read one. “We are New York tough,” declared another, and (at Thanksgiving), one read, “Don’t be a Turkey, Wear A Mask!” It was the Big Apple’s equlvalent of the Sande secret so- ciety dances that Richards and Mokuwa had noted in Sierra Leone. It worked: New Yorkers quickly adopted misks with near religious zeal. If nothing else, it demonstrated the point that Richérds often stressed: while cultural belief systems mattered deeply, they were not fixed in stone. In Boston, Chatlie Baker, the Republican governor of Massachusetts, was also creative. He hired Farmer and his PIH team to import the les- sons they had learned from West Aftica and elsewhere for the COVID- 19 fight. “This is reverse innovation,” Farmer explained. He told Baker that the best way to curb COVID-19 was to offer care and empathy, working w1th ‘communities rather than just relying on top-down orders or digital : apps. “No [contact tracing] app can provide [a COVID victim] CONTAGION with emotional support or address their complex and unique needs,” explained Elizabeth Wroe, a Harvard-trained doctor at PIH.¥ “You have to walk with the person and address whatever they need.” Yet in many other places, officials ignored the lessons from Fbola-—— and social science. In Washington, Daniel Goroff, a scientist at the Na- tional Science Foundation, created a dedicated network to help “decision makers at all levels of government” build effective pandemic policy with social and medical science.® But Trump’s White House displayed no de- sire to embrace behavioral science or reverse innovation. In Britain, the Scientific Advisory Group for Emergencies (SAGE) invited a behavioral scientist into their group, David Halpern, who circulated memos suggest- ing (sensibly) that the British government should import lessons about masks from countries such as Germany and South Korea.”” But SAGE was dominated by politicians and scientists from fields such as medicine and unveiled policies that were often the precise opposite of what an- thropologists (or behavioral scientists) suggested. First, Prime Minister Boris Johnson declared that people should 7ot wear face masks. Then, he backed masks but shunned them himself. Policies were imposed in a top-down manner (even though Britain had excellent local community health centers), and the government poured money into expensive digital contact tracing technologies (which barely worked). “The government’s incorporation of expertise from behavioral and other human sciences has been woeful,” lamented Gus O’Donnell, the former head of Britain’s civil service, in November. “When the government says it follows the science,’ this really means that it follows the medical sciences, which has given it a one-sided perspective and led to some questionable policy decisions.”® Why? Politics was often one explanation.* In America, Trump had *1 realize I am ignoring other Western countries, such as those in continental Europe, which had varied responses, but for reasons of space I am focusing on the Anglo-Saxon world.

ANTHRO-VISION risen to power with an anti-immigration, America-first message that derided poor countries in places such as West Africa as “shitholes.” In London, Johnson relied heavily on advice from Dominic Cummings, who often seemed dazzled by empirical science.*! There was also hubris; the British and American government presumed their medical systems were so world-beating that there was no need to embrace reverse in- novation.”? Howevet, the anthropologist Richards suspected there was another problem too: that deceptive label “exotic.” When Whitty had summoned anthropologists for meetings in Whitehall in 2014, he had done so because British government officials thought they were deal- ing with strange others. In 2020, they thought they were in a “familiar” landscape. They thus felt little need to learn from others or hold a mirror to themselves, even though a mere two years earlier a Halpern-led behav- foral insights team created by the British government had stressed the importance of thinking about “how elected and unelected government officials are themselves influenced by the same heuristics and biases that they try to address in others.”# This produced tragic mistakes. If only Western governments had looked at themselves in the mirror at the start of the COVID-19 crisis, they might have seen the weaknesses of their own pandemic-fighting systems. If they had looked at the experience of West Africa or Asia, they would have also (re)learned another essential lesson: when doctors work with communities, with empathy, it is far easier to beat a pandemic, Or as Richards said: “The government knows you need anthropologists to help if it is culturally difficult like in Afghanistan. They don’t think they need anthropologists in inner Manchester or South Yorkshire. “They do.” PART TWO The gist: It is human nature to assume that the way we live is “normal” and everything else is weird. But that's wrong. An- thropologists know that there are multiple ways to live, and everyone seems weird to someone else. We can use thisin a practical sense: when we look at the world through someone else’s eyes, we can look back and see ourselves more objec- tively too, seeing risks and opportunities. | have done this as a journalist. A host of consumer goods companies have used variants of this. tool to understand Western markets. But it can also be used to understand what is happening inside in- stitutions and companies, particularly when you borrow ideas and tools from anthropology, such as the power of symbols, the use of space (habitus), foot-dragging, and the definition of social boundaries.