In mid-March dozens of foreigners began arriving in Angola's remote northern province of Uige. The strangers, who were mostly white, declined polite handshakes and interfered with hallowed burial customs, explaining their actions with a strange foreign word: Marburg.
The people of Uige, bordering the Democratic Republic of Congo, were already terrified by a spate of sudden deaths, mostly of children, from an incurable haemorrhage fever. Some greeted the foreigners angrily, pelting their vehicles with rocks and driving them out of their villages.
They were upset by the outsiders, clad in full body-suits of white a colour associated with witchcraft who forbade them from washing and kissing dead relatives goodbye, as per local custom. They rebelled when Médecins Sans Frontières (MSF), a medical charity, moved to close down temporarily the city's hospital, which served about half a million people.
Now the United Nations, MSF and other organisations fighting the outbreak of Marburg in Angola are shifting their focus. They are stepping up communications and community relations effort to fight the disease, whose deadliest-ever outbreak has already killed at least 215 people. The atmosphere in Uige is edgy.
The 50,000-strong population has been supplemented by a small but growing number of aid workers and, in the last two days, international camera crews have arrived. The UN World Health Organisation has deployed two anthropologists on its “social mobilisation” team, which is combing the vast province to tell Angolans how to deal with suspected illnesses and deaths from Marburg. At stake is the epidemic's further course, as medical experts must rely on Angolans to come forward with information on suspected deaths, illnesses and infections from Marburg.
“We see we are not getting admissions, and we fear there are people from the bairros [neighbourhoods] who are not coming forward,” says Raquel Ayota, emergency co-ordinator for MSF Spain in Uige. “These kinds of epidemics are always very hard to control because you're facing local fears and traditional beliefs.”
The tensions in Uige highlight a paradox of the increasingly sophisticated global response to epidemics. The UN, the US Centres for Disease Control and MSF organisations from three European countries had expert personnel and equipment on the ground within days, in some cases hours, of the epidemic's confirmation on March 21.
But in rushing to contain one of the world's most virulent diseases, they now admit they neglected the human factor. “There is a lot of fear about this outbreak,” says Nestor Ndayimirije, team leader for outbreak response with the WHO, who has encountered similar cultural frictions in previous outbreaks of the similar Ebola virus in Uganda and Congo-Brazzaville.
When international medical officials arrived in Uige three weeks ago, cultural factors took a back seat to a contagious-disease emergency in a city with intermittent power and water supplies. About 20 corpses were piled up at Uige's hospital, whose personnel had fled after at least eight nurses died of Marburg.
MSF identified Uige's hospital as a main source of transmission of the disease, which is spread through contact with blood, sweat and other bodily fluids. But local health authorities decided to keep the hospital open, and MSF is now focusing on disinfecting it and training staff to avoid contamination. Last week the WHO had to abandon its mobile contacts units going out to find people who have had contact with victims of Marburg for two days after people threw stones at its vehicles. The UN has since stepped up its efforts to communicate with local communities, including through pamphlets, in the Portuguese, Kikongo and Lingala languages.
On Friday the Marburg Trio, a local musical group, released its first-ever single with WHO support. Formerly a quartet, the ensemble's lead singer Neru and several members of his family died of Marburg this month. The song, broadcast on local radio and civic loudspeaker trucks around Uige, warns people about the disease and advises how to deal with ill or dead people.
The WHO is also seeking to refashion local burial customs for the conditions of a viral epidemic. All the UN technical mobile teams, including the “astronauts” in biohazard suits, must automatically address condolences to the family and community of victims.
Families must be present before bodies of Marburg victims are transported to cemeteries. When the bodies are buried, ritual ablutions are simulated by allowing family members to splash them with disinfectant.
While past outbreaks of Marburg and the similar Ebola virus were typically contained within three months, health officials will not say whether Angola's epidemic has peaked. “The big problem is we still do not know where in the epidemic we are,” says the MSF.
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