Skip to 0 minutes and 12 secondsPAUL RICHARDS: There are a good number of similarities in the way the dead are handled in all cultures. The body has to be interred. It has to be prepared for last viewing by grieving relatives. A lot of these tasks in our own cultures are undertaken by professional undertakers. In rather poor village conditions in West Africa, you find that people do their undertaking. So that falls to the family, and often necessarily in a Sierra Leonean village, there's a tradition that says that women wash the bodies of women and prepare them for burial, and men wash the bodies of men.
Skip to 0 minutes and 54 secondsThis is really just to prepare the corpse so that it can be wrapped in a burial cloth, and sometimes it's placed in a coffin, and there can be a last viewing by the family. But that washing is a universal element. You'll find it in all cultures. The other universal element is that there will be some kind of ceremony at the interment of the body. The grieving relatives will gather around and follow the body to the grave. Part of that is as a witness to know where the body has been placed and know that that is the end of that person's life. It's very important for relatives in all cultures to know where the body is and where it's been interred.
Skip to 1 minute and 34 secondsESTHER YEI-MOKUWA: When somebody dies, my neighbour is there. It's an open place, so if you know me, my brother is dead, you come and sympathise with me. And it's tit for tat. In Creole we say it's tit for tat. You do for me, I will do it for you. So if somebody dies, you go there. You empathise, and so forth. And you even go so that the bereaved person will see you. You can go and handle hands, and touch their hand. He cries on you and so forth. We cry together. We really cry, because you know how I feel. You empathise with me. The touching of each other, holding my hand, your tears coming on my own tears.
Skip to 2 minutes and 16 secondsThen me be bereaved, I will even touch you. I say, don't cry. Let's forget. The Lord will give that person rest. So you see, the body movement, the body touching, and so forth, the sharing of tears, and so forth. And in fact, if you've done me good, and I know that you are sick, you are dead, you've not been washed, I will try to be there, if I have the means to be there, to take part in your washing. So that's to say farewell. Well, because of the Ebola now, I think people will have to change a way of bereaving now. But before, touching is very important.
Skip to 2 minutes and 56 secondsPAUL RICHARDS: So the question arises why people will continue to carry out their burial practices. And I think that follows from what Esther has been saying, that a funeral is a very important moment to express solidarity both with the dead and with the living. These are very big events because society is so very important in Sierra Leone. The people closest to the dying person have been very much involved in nursing them, so the possibility is that they are themselves already infected and developing Ebola. So then there's a great deal of touching of the living at funerals.
Skip to 3 minutes and 39 secondsIt's not so much the touching of the body, I think, which is the issue, though there are issues to do with preparing a corpse so that's its presentable and clean and so on, and that falls on the members the family to do that. But the sympathisers at the funeral are then closely in body contact with the bereaved person, and that's been explained. It's to do with encouraging them to not feel the loss too keenly so that they would do something to damage their lives or whatever. So you're often holding people, you're comforting them, and the tears are literally mingling. And it could be that's people who are already infected with Ebola, they're becoming infectious at a funeral.
Skip to 4 minutes and 25 secondsAnd I think it's an open question whether it's actually touching the body or touching the living that is the issue here. People are changing their practises because they know how dangerous the disease Ebola is, but it's a question of how quickly they can change and in what respects they change, and there are some parts of funerals that are not really negotiable. A funeral is a moment of witness. People have to go to the grave to see the body interred. OK, you can do that in different ways. You can follow closely or you can follow at a greater distance. Ebola burial teams are often very rapid in what they do because this is an emergency. They fear the disease themselves.
Skip to 5 minutes and 8 secondsAnd funerals need to be slow. People don't want to feel rushed in a funeral, so they have to observe and they have to respectfully follow the corpse to the place it's interred. And I think these are the things that are the points where, shall we say, people are digging their heels in. Not around the defence of some obscure ritual practice, but over the speed and pacing of a funeral and how well it's done according to notions of human decency. You can't go to Sierra Leone and say, OK, we have a set of rules about how you carry out a safe burial, and you must follow those rules.
Skip to 5 minutes and 47 secondsI think what you can do is you can explain what the transmission pathways are. You can explain that there's a very high virus load on the sick person. Body washing is going to be a dangerous moment. You can explain that touching the corpse may also be highly infectious, and then you say, now what can we do to help you to reduce that risk? I don't think anyone would object to wearing some safety equipment to do corpse washing. What they would object to is not washing the corpse. That would be deeply disrespectful.
Skip to 6 minutes and 21 secondsAnd as Esther has already said, that in some way if you're loyal to that person because they've helped you in your life, you will actually struggle to take part in the washing if you possibly can because it's one of those chores that shows the respect that you have and the gratitude that you have to that dead person. So you have to get local ideas about how protection can be improved in those difficult moments Cremation is going to be looked at very negatively. It's a complicated question to say why people would be so negative about cremation, but it's to do with their ideas of the spirit and the transition of the body into a spiritual existence.
Skip to 7 minutes and 14 secondsThe body needs to be placed. It needs to be in a place where future ceremonies can be carried out, where libations can be poured, because the living need to communicate with the dead. The living need to know that the dead are living in peace. And so the grave is a very important place where you articulate that relationship over a long period. What cremation was proposing, at least in Liberia, was that this will become the norm for all Ebola victims. So if we're talking about 10,000 bodies in West Africa that are being cremated and put perhaps even in mass graves, this really challenges people's notions of what is good and fitting.
Traditional funeral practices in West Africa can exacerbate transmission of the Ebola virus. This video discusses traditional practices and changes that might be made to prevent transmission during funerals. The training of burial teams and development of funeral guidelines are discussed below.
The key role that burial practices can play in the spread of Ebola has been apparent since the first outbreak. In 2014, “in Guinea […] 60% of cases have been linked to traditional burials.”1
In the video, anthropologist, Professor Paul Richards and social scientist, Esther Yei-Mokuwa, discuss the cultural basis of funeral and burial practices and emphasise how important it is in West African communities to attend funerals and offer emotional support to the bereaved. To show respect for the deceased, mourners may offer to help with the cleansing of the body. Physical touching and ‘mingling of tears’2 with the bereaved are important elements of showing support.
They discuss how changes must be made in consultation with communities, keeping key elements such as washing the body, allowing the burial to be witnessed, and conducting proceedings at a respectful pace, all while maintaining safety. Cremation (which was made compulsory for Ebola victims in Liberia in August 2014) is particularly problematic in this cultural context because knowing the resting place of an individual is fundamental.
Safe burials have been introduced in many areas. Médicines Sans Frontières has provided safe burial training in affected countries, and the International Federation of Red Cross and Red Crescent Societies have been actively implementing safe and dignified burials; procedures are explained to the families, and those that handle the body use Personal Protective Equipment. Social attitudes are changing and more people are accepting the new procedures. A Red Cross volunteer recently reported that3 ‘the communities trust us to take care of their loved ones. Now we have no problems recruiting other volunteers. People feel safe and believe in what we are doing.’
Drawing on advice from anthropologists and religious leaders, the World Health Organization (WHO) produced a new protocol in November 20144 for safe and dignified burials that sets out the steps in detail. The training of burial teams and the number of safe and dignified burials carried out were included among the key indicators of the Ebola response in the earlier WHO situation reports.5 Nevertheless there continue to be reports of unsafe burials and hiding corpses from the authorities. The number of cases detected only after death and the number of unsafe burials are now reported weekly on the WHO website.
Once the body is inside the bags used for safe burial the risk of contamination should be very low. Nevertheless there is interest in how long the virus remains viable. Recent data from animal studies suggest that this is up to 7 days.
© London School of Hygiene & Tropical Medicine