Julie Fraser, PhD Candidate SIM, Utrecht University, J.A.Fraser uu.nl, and Henrike Prudon, MSC, Cultural Anthropology, Utrecht University, H.H.M.Prudon uu.nl  

Culture and health are to some degree mutually constitutive. The cultural frameworks into which we are socialised often shape our views on sickness, wellbeing, the causes of illnesses, and their remedies. The UN Committee on Economic, Social, and Cultural Rights acknowledges this and, therefore, requires all health goods, facilities, and services to be “culturally appropriate”. This is an obligation on all States parties to the International Covenant on Economic, Social, and Cultural Rights to progressively realise. Culturally sensitive approaches to healthcare are important at all times, but can be especially vital during an epidemic. Our study of the recent Ebola crisis that reached a peak in West Africa in 2015 exemplified how indispensable culturally sensitive approaches to the right to health can be.

Ebola Outbreak in West Africa 2014- 2015

In March 2014, the World Health Organization (WHO) received its first report of a possible outbreak in Guinea of the Ebola virus disease (Ebola). The disease quickly spread across borders and came to predominantly affect three countries – Guinea, Liberia, and Sierra Leone – where almost 30,000 cases of Ebola were reported and over 10,000 people died by the end of the crisis in 2015.

Explanations for the severity of this outbreak included among others local beliefs and practices that interfered with containment efforts. The WHO identified burial rites for the dead as one of the contributing factors in the disease’s spread. The burial rites included family members washing and oiling the corpse, and sometimes physically modifying it for burial. These practices were problematic for containment as Ebola can be communicated through direct or indirect contact with the bodily fluids of infected people, and even after death corpses remain contagious. Because of this, burial rites and practices became a potential pathway for Ebola contamination. Additionally, the practice of moving the body to be buried in a different village impeded efforts to quarantine certain areas.

Despite calls from the government and aid agencies, many people did not discontinue their traditional practices, as the application of proper burial rites is considered greatly important for a community’s health and stability. Neglecting these rites can have consequences as real or even more salient than the threat of Ebola. For example, the improper passage of the deceased into the afterlife is perceived to cause disastrous results including crop failure or, on a more personal level, the inability of the deceased’s spirit to find peace. If the WHO and other health workers trying to contain Ebola fail to understand and appreciate the affected communities’ need to care for their dead in a particular way, it can rupture the trust necessary for communication, cooperation and effective implementation of preventative measures. In the Ebola outbreak this lack of trust was an important factor, creating chaos and putting local communities and health workers at risk.

Culturally Sensitive Approaches to the Right to Health

In the crisis, many initial emergency measures were put in place that conflicted with these traditional burial practices. For example, the Liberian Government mandated that corpses be cremated, and ‘safe burial’ teams were created to reduce contamination. These burials did not accommodate traditional burial rites. Such top-down policies that prescribe culturally inappropriate ways of handling the dead were counterproductive, leading to resistance, underreporting, and unsafe burial practices. In some cases, local populations blocked roads and even attacked and killed members of Ebola response medical teams.

Recognising the need for cultural appropriateness as part of the effective realisation of the right to health, health workers and the WHO increasingly negotiated between the wants and needs of the relevant populations and the requisite health interventions. For example, culturally sensitive practices were negotiated in Sierra Leone that relieved the family’s need to touch the corpse. The official burial teams agreed to shroud Muslims and clothe the deceased in garments provided by the family, who were allowed to perform rights or pray near the interment. To mitigate not being able to perform the rites properly, mourners adopted a new rite whereby they sought forgiveness from the deceased.

This negotiation and modification of burial practices can be seen as an element of culturally sensitive approaches to the right to health. It is not always necessary to abolish completely a traditional practice deemed harmful, but rather those aspects detrimental to health. To modify a practice, the appropriate agents to do so within a cultural community must be identified, which in West Africa include traditional leaders, traditional healers, secret society elders, and griots. Such actors are well placed to negotiate, identify, and mobilise local resources and alternatives to existing burial practices to help combat Ebola.

What should be done in the future?

Our study demonstrated that such culturally sensitive approaches can be indispensable – rather than just preferable – to human rights protection. In this case, including the user’s perspective to ensure the cultural appropriateness of health goods and services was not only an essential element, but a precondition for more effective implementation.

This study also indicated one of the main principles of culturally sensitive approaches to human rights – that modifications to cultural practices are most successful if they arise within the cultural community and are not imposed from above or abroad. It demonstrated cultures’ dynamism and rich resources from which to draw alternatives or conceive of new practices. Furthermore, it shows that cultural communities can and should play a vital role in making health policies, goods, and services culturally appropriate, as this can be a matter of life and death. Drawing on our conclusions, we distinguished three questions for further research:

1. Clearly, cultural sensitivity in implementing the right to health has to compete with other objectives in addressing an epidemic – such as containment, ensuring people’s safety, and resource management. How should these be balanced, how can human rights serve as a guide in this regard, and how can health systems be prepared for culturally sensitive responses in advance of epidemics?
2. The UN Economic Social and Cultural Rights Committee recalls that all individuals and local communities are responsible for realising the right to health. What are these responsibilities and how can they be engaged by the State?
3. Does the accommodation of cultural frameworks in the implementation of human rights dilute the power and meaning of human rights or promote their universality?