Health Communication in the Time of Ebola: A Culture-Centered Interrogation

Abstract

This brief essay is a commentary on how critical health communication theory can contribute to an understanding of the cultural dynamics of infectious disease pandemics. In particular, we focus on a specific trajectory of health communication theorizing—the culture-centered approach—and its heuristic and pragmatic utility in enhancing knowledge about public health crises like infectious disease outbreaks. In the backdrop of the mobilizations against the 2014 Ebola virus disease epidemic in the 3 West African nations of Guinea, Sierra Leone, and Liberia, indigenous cultural practices were construed as pathogenic and local agency of affected communities disregarded, even as the global risks of the epidemic were highlighted. In contrast to this interventionist notion of culture, the culture-centered approach offers a heuristic rubric through which to scrutinize the dialectical interrelationship between indigenous cultural practices, structural determinants of health, and the everyday agency of individuals of affected communities. We argue that such a listening-based paradigm of communication theorizing is instrumental in developing authentic, ethical, and effective health communication practice in public health crises.

In this essay, we draw on the culture-centered approach (CCA; Dutta, 2008) to offer a commentary on the potential for critical health communication theorizing and practice in the wake of infectious epidemics like the recent Ebola epidemic in West Africa. Congruent with the critical-realist ontology of CCA, we see this essay as a theoretical interrogation of the interrelated dynamics of power, culture, and allocation of material resources that accompany large-scale public health crises in the global South, and the role of critical health communication theories in uncovering these dynamics (Lupton, 1994; Sastry & Dutta, 2013).

The Ebola epidemic of 2014 was the largest on record,¹ with a total caseload of 28,601 and a total mortality of 11,300 (World Health Organization [WHO], 2015a).² Suspected to have originated in the Gueckedou region of Guinea, and subsequently spreading to Liberia and Sierra Leone, the rapid transmission rate and high caseload of this epidemic marked it out as a significantly larger global threat compared to the multiple localized Ebola epidemics in Central Africa that have been documented since the isolation of the Ebola filovirus in 1976 (WHO, 2015b). Responses (both in the popular media and among health organizations) to the threat of Ebola across the world, but especially in Europe and the United States, reflected a cultural anxiety around the globalization of contagion (Ungar, 2001; Wald, 2008) and the interconnectedness of the remote and the mainstream within our globalized world. The threat of an “Africa-style” epidemic in the West, however remote in reality, elicited responses that recast historical fault lines between the West and the “dark continent” and used tropes that reaffirmed the contentious history of the discipline of public health and its relationship to the colonial enterprise (Batty, 2014; Benton & Dionne, 2015; Sastry & Lovari, 2016).

In this essay, we focus on some crucial questions that health communication scholars ought to ask of global responses to infectious epidemics. The trajectory and cartography of the global responses to Ebola depict the inequities in the flow of disease response. Ebola emerges as a site of storytelling, punctuating stories of death amid a globally circulating network of affect. What particular stories of disease are narrated on a global map? What are the imaginaries anchored in stories for addressing epidemics such as Ebola? Drawing on the conceptual framework of CCA, we argue that interplays of culture, structure, and agency offer a roadmap for (a) understanding the global constructions of meanings and the corresponding flows of materials, labor, and capital; and (b) reimagining health communication practices in the subaltern sectors of the global South. At the outset, we present a brief overview of how the theoretical commitments of CCA are situated vis-à-vis the study of infectious disease epidemics.

CCA and Infectious Disease Epidemics

In contrast to the overwhelming majority of health communication theories focused on health promotion and individual behavior modification through persuasive message transmission, CCA is based on an ethic of listening to the unheard voices of populations that are targeted for health promotion (Dutta, 2014). In the case of the recent mobilizations against Ebola, these were subaltern³ populations from the global South that have been systematically excluded from the benefits of economic development and its concomitant relationship with health. Multiple analyses of the political economy of Ebola in Western Africa have pointed out the role of the impoverishment of the affected communities and of national health systems in Western Africa as a crucial determinant of epidemic dynamics (Benton & Dionne, 2015).

CCA posits the importance of attending to local articulations of disease, struggle, and the resilience of local communities as testimonials to the agency of subaltern communities in the face of broad structural determinants of vulnerability to disease (Dutta, 2008). Using culture as the third constituent element, CCA advocates complicating how marginalization influences health in positing a tripartite dialectical relationship between culture, structure, and agency (Dutta, 2008). In this model, cultural meanings around health and disease are conceptualized as being dialectically related to structures, or the institutional frameworks around which health is organized; epidemics are thereby attributed to a complex interplay between culture and political economic factors rather than simplistic accounts of “cultural beliefs” (Schoepf, 1991). CCA therefore builds on Schoepf’s (1991) social approach to understanding epidemics by introducing agency as an additional element in dialectical flux with culture and structure. We now proceed to highlight how these elements figured within the global response to the 2014 Ebola epidemic.

Culture

From HIV/AIDS to SARS and, more recently, Ebola, mediated depictions of infectious disease epidemics are replete with references to cultural beliefs and specific errant cultural practices that, owing to their unfamiliarity and/or exoticization, are used to explain the differential spread of disease vectors (Chen, 2007; Sastry & Dutta, 2011; Wald, 2008). While several commentators have emphasized the hazards of “cultural overreach” in theorizing infectious epidemics in the global South (Benton & Dionne, 2015), a CCA-focused inquiry interrogates how culture is defined in such lay etiologies. As opposed to a static, ahistorical view of culture—in this case a conception of African culture that regards the practices of Ebola-affected communities as a premodern, primitive mode of engagement with a thoroughly modern outbreak—CCA seeks to articulate culture as a dynamic entity that is continually shaping—and shaped by—broader societal structures (Dutta, 2008). This Geertzian notion of culture is central to the how culture is conceptualized in CCA.

In global media narratives, Ebola is synonymized with place. The threat of Ebola is spatialized to the sites of West Africa (ignoring that this is the first Ebola epidemic in the region). The stories of disease causality then draw on the archetypes of Africa and African culture that have been the mainstay of colonial constructions. Culture here is mapped out as a set of static beliefs, values, and practices that can then be targeted as a site of intervention. The narrative of culture as a fixed site for intervention is unfortunately also the language through which global networks of policy planners, public health agencies and experts, and nongovernmental organizations superimpose frameworks for health interventions. Cultural experts are then called on in emergency response teams to offer sets of decoded cultural scripts that would inform quick and dirty interventions. Through the example of the Center for Disease Control and Prevention’s Disease Detectives, Sastry and Lovari (2016) offered an example of how monolithic notions of culture are used as diagnostic categories onto which prepackaged solutions for Ebola can be crafted.

Yet another example of the misappropriation of culture in health interventions comes from mediated discourses (in the West and elsewhere) around bushmeat. Following the zoonotic trajectory of Ebola virus disease from fruit bats (regarded as an important reservoir for filoviruses) into human populations (Pigott et al., 2014), the role of bushmeat as a cultural practice has erroneously emerged to the forefront of popular and academic discussions of Ebola. But as McGovern (2014) and others have observed, the category of bushmeat (used among English-speaking communities in the region), as well as the locational term bush, is not a monolithic register for so-called uncivilized practices that it evokes when it is deployed as a totalizing social construction of colonial-era prejudice around African customs in the West.

For instance, in Western specialty food stores, wild-caught foods are not bushmeat but instead carry the romantic affectations embedded in the term game meat (McGovern, 2014). But even beyond such superficial semiotics of naming, the reference to bushmeat as a cultural practice in the context of Ebola carries little scientific weight. Some evidence has suggested that the recent epidemic was likely characterized by a single zoonotic source followed by exclusive human-to-human transmission (Gire et al., 2014), which in principle refutes the bushmeat etiology. And yet, as Hewlett and Hewlett (2008) have noted, the move to locate Ebola within a cultural belief matrix persists and highlights the complex chain of meaning making that is involved in such attributions. By focusing on the production of cultural meanings in conjunction with broader structural forces, as well as individual and social agencies, CCA opens the door for more communication scholarship to highlight the contingent and complicated role of culture in infectious disease epidemics.

Structure

In CCA, structures refer to the social and political arrangements that constitute how health is organized within a society (Farmer, 1996). These include, but are not limited to, social, economic, and trade policies; institutional frameworks around health care delivery; resource allocations for health services; and the availability, affordability, and accessibility of health care services. Whereas sociological and anthropological theorizing has embraced the formative role of structural determinants in shaping epidemics (Farmer, 1996; Gupta, Parkhurst, Ogden, Aggleton, & Mahal, 2008; Parker, 2002), health communication scholarship in the area of infectious diseases has not, barring a few exceptions (see, e.g., Basu & Dutta, 2009; Sastry, 2016), attended to structural determinants in any significant way.⁴ By linking the rather abstract concept of structure to cultural meanings and individual agency, CCA provides a heuristic roadmap for health communication scholars looking to engage structural arguments.

Several excellent commentaries have highlighted the political-economic landscape of the three Western African countries on which the 2014 Ebola virus disease crises unfolded (Benton & Dionne, 2015; Schroven, 2014) and how epidemics in the region ought to be viewed with what Paul Farmer calls a “geographically broad and historically deep” analysis (as cited in Benton & Dionne, 2015, p. 225). Although it is common knowledge that the extremely rudimentary and/or severely deficient public health infrastructure in the three West African nations exacerbated the Ebola virus disease epidemic, the causes of such privations are generally missing from mainstream accounts. Attending to the role of structures partly explains why health systems in the region became disease vectors in themselves (Abramowitz, 2014). The impact of Ebola on the three Western African countries must be seen within historical relief offered by a political economy perspective—from the historical debilitations of colonial expatriations to the decades-long erosions in public sector investment under the auspices of the Structural Adjustment Programs and the more recent preference for specific disease preparedness and response infrastructure (most prominently HIV/AIDS prevention) rather than overall health sector development. It is important to point out that much of the public investment in health infrastructure for the three affected countries is funded not by national governments but rather by a consortium of international entities, including aid agencies, intergovernmental institutions, and the like (Harman, 2014). The economic, cultural, and social impact of the 2014 Ebola epidemic is testimony to the devastating impact of neoliberal ideologies in public health, including emphasizes on privatization, cost efficiencies, and individual entrepreneurialism (Pfeiffer & Chapman, 2010; Sastry & Dutta, 2013).

Moreover, because a narrow set of powerful actors get to be the storytellers on the global map, the stories of diseases like Ebola unfortunately are also hegemonic stories serving global power structures and reinforcing the inequities in the flow of resources. Solutions such as deploying the military to fight Ebola fit within this macronarrative, situated amid global structures. Although Ebola has not been the first infectious epidemic to be militarized, the deployment of military forces (e.g., the United States Africa Command [AFRICOM]) demonstrates the symbolic and material resources afforded to powerful actors like the United States in conflating humanitarian impulses with discourses of surveillance and security (King, 2002; Sastry & Dutta, 2012). Such militarized narratives eclipse the role of native actors and local communities in addressing the social, cultural, and structural challenges presented by communicable diseases while reducing relief efforts to the coordinated efforts of militarized interventions (see, e.g., the pioneering work done by Dr. Mosoka Fallah as an excellent example of localized efforts to counter the epidemic; Onishi, 2014). The systematic deinvestments in basic public health systems in turn lead to states of disease exceptionalism wherein militaristic solutions become everyday practice within global health governance. Here, the African landscape is cast as a negative space, defined by a lack of infrastructure or indeed the agentic resources to address widespread infection (Airhihenbuwa, Makoni, Iwelunmor, & Munodawafa, 2014). The CCA perspective offers a theoretical tool for scholars to question the ideological and pragmatic implications of neoliberalism and militarism in infectious disease governance.

Agency

In the second half of 2014, as the scripted fear of a full-blown domestic Ebola epidemic was raging in mainstream U.S. media, accompanied by calls to close borders and quarantine health workers, precious little time and attention was spent on the lives and experiences of the individuals, communities, and societies bearing the local brunt of the epidemic in Western Africa. Although the Ebola crises engendered an unprecedented volunteer effort from individuals across the globe, the overwhelming emphasis on health workers’ safety, sacrifice, and heroism at the cost of narratives of local populations suffering from the disease was a strong index of how abject African bodies are rendered within global media discourses. The voices of marginalized, subaltern communities that enacted their everyday agency in responding to diseases and outbreaks at the local level were almost entirely missing from mediated narratives of Ebola. From a CCA perspective, such elision of the everyday agency of subaltern communities is ideologically congruent with the colonial heritages of public health practice, wherein local community strengths, cultural practices, and prevention behaviors were collectively rendered as primitive and construed in opposition to the modern, scientific practices of the West (Greene, Basilico, Kim, & Farmer, 2013).

When attending to the richness of the local, to the everyday capacities of subaltern communities to make sense of the symptoms they experience, the responses they create, and the narratives they produce, we are drawn to the role of health communication as a narrative resource. In the case of Ebola, we witnessed the tremendous strength in local efforts of disease response even amid a health care infrastructure that had largely been gutted by World Bank–imposed reforms to public health in a number of these countries. In Sierra Leone, for instance, local communities organized taskforces to brainstorm on solutions, address logistical issues, and coordinate response. In Nigeria, the Halt Ebola campaign, a locally developed intervention, used mobile services to reach out with messages to community members in rural areas. A CCA-driven interrogation is premised on the assumption that communities offer narrative, cultural, and agentic resources in coming up with solutions. Our role as health communication scholars is to address the larger global communicative inequalities so that communities have opportunities to voice their solutions, not as strategies to be co-opted into a random one-time top-down campaign, but much more systematically into spaces for sharing their voices, understandings, and interpretations. Fostering opportunities for subaltern voices in decision-making structures is a challenge that lies ahead for health communicators.

Hewlett and Hewlett (2008) have demonstrated that among communities having a sustained experience with Ebola, the disease is not just an inchoate, emergent threat but a familiar exigency against which local cultural practices are shaped and reshaped. That some communities have been facing the threat of Ebola for a sustained period of time and have fashioned indigenous cultural responses to the disease has been foreclosed in the discussion of Ebola as a global risk. For instance, Hewlett and Hewlett documented the Ebola care protocols instituted among the Acholi community of northern Uganda, which physically quarantining patients in the community, enlisting epidemic survivors as caretakers, and creating signs to identify affected villages and homes. Perhaps the first step for health communicators engaging with infectious disease epidemics is to allow for indigenous knowledge practices to disrupt the unquestioning universality of Western knowledge systems.

The social construction of Ebola as primarily a global threat over the very real local impacts of the disease further hinders learning from the wisdom and experiences of indigenous communities as they experience the disease firsthand. Culture-centered interrogations must take into account both (a) the existence of subaltern agency in the face of structural forces like epidemic outbreaks and (b) the discursive and ideological moves within global health governance that obscure the agency of local communities (Leach, Scoones, & Stirling, 2010).

Conclusion

In this essay, we have outlined the potential scope of health communication scholarship within the complex terrain of infectious disease epidemic governance. Infectious disease outbreaks are earmarked by semiotic uncertainties. Significations around a disease—meanings, associations, risk, stigmas—are central in how the disease is understood, who is assigned responsibility (and blame), what resources are allocated, and what solutions are considered. Consequently, how the story of the epidemic is told is of crucial importance to how the disease will progress and its human impact. It is in this spirit that Priscilla Wald (2008) speaks of the outbreak narrative, the globalized paranoia around emergent disease formations with the potential to unsettle the interconnected systems of modernity. Although the domain of meanings and social constructions of diseases is well within the provenance of communication scholarship, there is a curious lack of health communication theorizing on the socially constructed and ideological nature of categories like “outbreaks” or “emerging diseases” and the communicative premises of such articulations. CCA provides a broad heuristic framework to conceptualize how communication perspectives can contribute to infectious disease outbreaks.

Through the dialectical tripartite of culture, structure, and agency, CCA advocates a macro- (or meso-) conceptualization of communication that departs from the message-based emphasis of much health communication theorizing. The exceptional scale, impact, and mortality of the 2014 Ebola epidemic, together with the recognition that interactions of global climate change, mass migrations, and the globalization of transport systems will likely cause escalations in the frequency and scale of such epidemics, speaks to the urgency of the task at hand.

Notes

¹ The epidemic was still ongoing as of December 2015 but at that time was limited to three new cases in Liberia and none in Guinea and Sierra Leone over the previous 21 days (WHO, 2015a).

² WHO figures including confirmed, probable, and suspected cases.

³ The term subaltern was used extensively in the writings of Antonio Gramsci (Hoare & Nowell-Smith, 1972) and was subsequently taken up by the subaltern studies historians, including Guha (1982), to refer to an underclass, a section of society subject to foreclosure or erasure from political (and historical) representation.

⁴ This is not entirely surprising in itself, given that the individual loci of most traditional health communication theories emerge from the interpersonal communication tradition, itself a product of social psychological theories.