Tech + Health

08.13.14

Kissing the Corpses in Ebola Country

Ebola victims are most infectious right after death—which means that West African burial practices, where families touch the bodies, are spreading the disease like wildfire.

From 8 a.m. to midnight, wearing three pairs of gloves, the young men of Sierra Leone bury Ebola casualities. An activity that’s earned the Red Cross recruits an unwelcome designation: The Dead Body Management Team.

Some days, just one call to collect a newly deceased victim comes in from the Kailahun district. Some days, the team receives nine. The calls from medical professionals at isolation centers are met with relief. These bodies have been quarantined. The infection can—with copious amounts of disinfectant (bleach) and meticulous attention to detail—end there. Once cleaned and sealed in two body bags, the corpse will be driven to a fresh row of graves. In gowns, boots, goggles, and masks, the men will lower the body into a 6-foot grave below. In these burials, safety trumps tradition.

The harder phone calls that the Dead Body Management Team receives, and the more dangerous burials they perform, take place in the communities themselves. Here, they must walk a delicate line between allowing the family to perform goodbye rituals and safeguarding the living from infecting themselves. The washing, touching, and kissing of these bodies—typical in many West African burials—can be deadly. But prohibiting communities from properly honoring their dead ones—and thereby worsening their distrust in medical professionals—can be deadly, too.

Insufficient medical care, shortage of supplies, and lack of money are undoubtedly contributing to an epidemic the World Health Organization has a deemed a “national disaster.” But with a death toll now topping 1,000 in four countries, it’s the battle over dead bodies that is fueling it.

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In the remains of a deceased victim, Ebola lives on. Tears, saliva, urine, blood—all are inundated with a lethal viral load that threatens to steal any life it touches. Fluids outside the body (and in death, there are many) are highly contagious. According to the World Health Organization, they remain so for at least three days.

Dr. Terry O’Sullivan, director of the Center for Emergency Management and Homeland Security Policy Research, spent three years volunteering in Sierra Leone. He hasn't witnessed an Ebola outbreak directly, but has watched a hemorrhagic fever overtake the body—which he describes in vivid detail. “Those that have just died are teeming with virus, in all their fluids,” says O’Sullivan. “That is in fact the worst point because their immune systems are failed...they are leaking out of every orifice. They are extremely dangerous.” A passage in the 2004 paper Containing a Haemorrhagic Fever Epidemic published in the International Journal of Infectious Diseases paints an even bleaker picture. Citing two specific studies, the authors suggest that a “high concentration of the virus is secreted on the skin of the dead.”

With fluids seeping out of every body opening, and potentially every pore, it’s no mystery why the burial rituals of West Africa pose such a danger. In a pamphlet on safety methods for treating victims of Ebola, The World Health Organization outlines proper procedures to prevent infection from spreading outward from a deceased Ebola victim. “Be aware of the family’s cultural practices and religious beliefs,” the WHO document reads. “Help the family understand why some practices cannot be done because they place the family or others at risk for exposure...explain to the family that viewing the body is not possible.”

Villagers began running from the ambulances, trying to burn down hospitals, and attacking humanitarian workers.

Telling this to the families of deceased is one thing—making sure they understand is entirely another. In Sierra Leone, a country whose literacy rate in 2013 was just over 35 percent, it’s particularly challenging. In neighboring Guinea and Liberia, two places with similar levels of poverty and illiteracy, education alone isn’t a viable solution either.

It’s a phenomenon O’Sullivan witnessed firsthand in Sierra Leone. “People have no idea how infectious diseases work. They see people go into the hospital sick and come out dead—or never come out at all,” he says. “They think if they can avoid the hospital they can survive.” This mistrust of the medical world seems to be validated when a family is prohibited from honoring the dead, participating in the funeral, or even seeing the body.

Prior Ebola outbreaks in Africa, specifically in Uganda in 2000, have yielded similar reactions among afflicted communities. Dr. Barry Hewlett and Dr. Bonnie Hewlett, the first anthropologist to be invited by WHO to join a medical intervention team, studied the Ugandan Ebola outbreak. In a book cataloging their experience—Ebola, Culture, and Politics: The Anthropology of an Emerging Disease— they explore the dangers of African burial rituals, as well as the dangers of prohibiting them.

In the Ugandan ceremonies the Hewletts witnessed, the sister of the deceased’s father is responsible for bathing, cleaning, and dressing the body in a “favorite outfit.” This task, they write, is “too emotionally painful” for the immediate family. In the event that no aunt exists, a female elder in the community takes this role on. The next step, the mourning, is where the real ceremony takes place. “Funerals are major cultural events that can last for days, depending on the status of the deceased person,” they write. As the women “wail” and the men “dance,” the community takes time to “demonstrate care and respect for the dead.” The more important the person, the longer the mourning. When the ceremony is coming to a close, a common bowl is used for ritual hand-washing, and a final touch or kiss on the face of the corpse (which is known as a “a love touch”) is bestowed on the dead. When the ceremony has concluded, the body is buried on land that directly adjoins the deceased’s house because “the family wants the spirit to be happy and not feel forgotten.”

According to the Hewletts’ analysis, these burial rituals and funerals are a critical way for the community to safely transfer the deceased into the afterlife. Prohibiting families from performing such rites is not only viewed as an affront to the deceased, but as actually putting the family in danger. “In the event of an improper burial, the deceased person’s spirit (tibo) will cause harm and illness to the family,” the Hewletts write. In Sierra Leone, O’Sullivan experienced similar sentiments when proper burials were not performed. “It is tragic. In those countries they feel very strongly about being able to say goodbye to their ancestors. To not be able to have that ritual, or treat them with the respect they traditionally give for those who passed away is very difficult,” says O’Sullivan. “Especially in concert with the fear of the disease in general.”

Worse than stopping burial rites, found the Hewletts, is keeping the body (and the burial) hidden. Barring relatives from seeing the dead in Uganda fueled hostility and fear—leading some communities to believe that medical professionals were keeping the corpses for nefarious purposes. A mass graveyard near an airfield—an attempt to remedy the problem by allowing families to see, but not touch, the graves—didn’t help. Villagers began running from the ambulances, trying to burn down hospitals, and attacking humanitarian workers. They feared the disease—but they feared the medicine even more, as well as the people delivering it.

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In a July 28 interview with ABC News, Dr. Hilde de Clerck of Doctors Without Borders described resistance from residents in Sierra Leone, who, he says, accused him and his colleagues of bringing the disease to the country. “To control the chain of disease transmission it seems we have to earn the trust of nearly every individual in an affected family,” de Clerck said. It is, in this case, a seemingly impossible feat.

There aren’t enough health-care workers in all of West Africa to ensure that community burials are performed safely. There aren’t enough in the world to convince every family that banning such a burial isn’t the work of the devil. “It’s gotten out of control,” says O’Sullivan of this new outbreak. “So many people involved who have responded to this in the past are completely overwhelmed. They can’t get the messages out.” Until the medical community can win the trust of West Africans, the infected will miss their chance at potentially life-saving medicine.

Without it, their family members will likely face the same fate.