Dr. Adia Benton: The West African Ebola Outbreak

August 25, 2014

This week Point Of Inquiry welcomes Dr. Adia Benton, a professor of medical anthropology at Brown University. She joins host Lindsay Beyerstein to talk about the Ebola outbreak in West Africa.

Medical anthropologists bring a unique expertise to epidemics because they study both the physiology of illness and the cultural factors that influence its transmission. That’s why the World Health Organization has deployed med anthros to combat prior Ebloa outbreaks. They ask questions like: “How do people think a disease is spread?,” “What role do traditional healers play in this culture?,” and “Do people trust Western medicine?” The answers can be used to craft more effective public health messages.

These are urgent questions for the current Ebola outbreak, where some are resisting quarantine, attacking hospitals, and blaming the outbreak on doctors and nurses. In a crisis, culturally competent care can be a matter of life and death.

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This is point of inquiry from Monday, August 25th, 2014. 

Hello and welcome to a point of inquiry. A production of the Center for Inquiry. I’m your host, Lindsay Beyerstein. And my guest today is Dr. Dieser Benton, a professor of medical anthropology at Brown University. She is here today to talk to me about the Ebola outbreak in West Africa. Medical anthropologists use expertize in biology and culture to understand and prevent disease. They look at the physiological, environmental and cultural factors that affect health and disease. And they focus on questions such as how do people believe the disease’s spread and how did those beliefs affect their behavior? What kind of relationships do they have with the medical system? How did they get information about health and what sources of information do they find credible? These kinds of questions are of heightened importance in the Ebola outbreak, which began in Guinea in 2013. There have been cases of people resisting quarantine and attacking hospitals. Some people believe it. Doctors and foreign aid workers are causing the outbreak. Medical anthropologists are trying to determine how these trust issues relate to traditional beliefs and to more modern grievances stemming from colonialism, a legacy of civil war and to the shortcomings of the international development establishment. Jim Underdown idea. Welcome to the program. 

Thank you. Can you start with a sort of 30000 foot overview of where the Ebola outbreak is now in West Africa? 

Well, right now there are about twenty to twenty three hundred reported cases, or I think they’re all confirmed in over twelve hundred deaths. It originally started in Guinea. They weren’t. I’ve been hearing that it actually the first cases were detected in December 2013, but the majority of attention started in March 2014 and to date mid August. This epidemic has spread to Liberia, Sierra Leone and to a lesser extent, to Nigeria. 

And how is transmitted? 

The Ebola virus is transmitted through bodily fluids are quite human to person to person contact with an infected person and then usually a person who is showing symptoms. 

Right. So the sicker the person is, the more they’re the more they’re experiencing the symptoms, the more infectious they are. And what usually happens is there’s up to 21 day incubation period. What that means is the time from exposure to getting sent can be up to 21 days. But most people experience symptoms somewhere between three and 10 days of within a time of exposure. And the symptoms are. Fever, joint muscle pain later. Internal hemorrhaging and external bleeding. Those kinds of things. 

And is it true that it’s not spread by airborne means? Right. You can’t get it from a person with Ebola coughing on you. It’s getting. 

So it’s it’s technically it is not airborne. And when people talk about it possibly being airborne, what they’ve heard is that it can be transmitted through droplets, which is something quite different. But it finding it hard for me to explain it to people, you know, like the fluids airborne. Right. You can. But this that infection by droplets, actually, that it’s still another kind of contact. Right. 

And, of course, in the the virus theory of Ebola is very well established here in North America. Everybody understands what a virus is. But what are some of the other ways that people think about the disease in West Africa? 

That’s an interesting question, because I’m not sure. First of all, I think one of the things is this is a fairly new disease. And in at least in West African term, people haven’t experienced it before. And so there are many people who believe in viruses, for example, and there who also believe that in addition to viruses, that there are other causes. So, I mean, it’s I guess in some ways anthropologists have like a story that they tell about beliefs and rationality and issues of causation. Which means our roots to Evans-Pritchard, who is an anthropologist who worked in Sudan during the British colonial period. And he always said he always told the story of the greenery, which is now I don’t know if you’ve ever heard the story this time, but basically that the greenery falls on someone. 

And people say, well, we know it’s because the braining with Procrit broken and termites will faded away or whatever. But we. But that’s not really the reason. It’s why we’re asking why did something happen at the time that it happened to the person it happened to. So it may be that people believe in viruses or they believe in sort of biological models of disease transmission. But there might also be other ways of thinking about why bad things happen to people at a particular moment in time. And we have to be careful about assuming that there’s only one way to think of causation. I’m thinking about how diseases are transmitted. And, of course, that educational campaigns shift and become more accessible to people. It’s not necessarily. 

It is not necessarily that people understand that it’s transmitted through viruses, but that it is transmitted through person-to-person contact. Right. Right. 

What are some of the traditional and folk? I’ve read that there are tradition of killing traditions that exist in in West Africa that medical anthropologists are looking at closely in terms of the Ebola outbreak and what role those people might play in helping to contain it. Can you tell us a bit about that? 

So one thing that I guess I would like to preface that with the a recent story about a woman in Guinea. Apparently, she was a traditional healer who said that she could cure Ebola. And so they’re now tracing 365 deaths to her, her claims. But if you ever read close more closely, it’s not clear how many of these people actually went to her for help because they a to have actually gotten it at her funeral. But what I was going to say is there are a range of of healers, trained traditional healers, as we like to call them, who address this address, health problems that seem to be. Impervious to other kinds of treatment. If that makes sense, you know, if you are not if or are not susceptible to other kinds of treatments. So it’s not uncommon for people to say, I’m sick. I’m going to the pharmacist or the doctor. 

But they may also say, you know, this feels like a spiritual sickness or I have a feeling that this person is sending bad juju, bad spirits towards me. And so you can go to understand why it is that you’ve fallen ill at a particular moment in time and under what kinds of conditions those things might be. So, for example, of long time ago, a friend of mine came home saying that one of her Nigerian friends had had a falling out with her her boyfriend of of several years. And as they because her this friend’s mother had died, she didn’t know anything about traditional healing or medicines or anything like that. And so she’d come to my friend and she was telling me that they had never had a fight before. But all of a sudden they were boyfriend and girlfriend having a fight. 

And as they they started to do some investigating, they discovered a bunch of that that that a bunch of bones and lots had been buried under the house near the house. 

And that was basically the cause of all of this discord in the household. And as they started to trace back further and further, they found out that it was a driver and a woman who was a friend of the driver who had buried just being there. 

They’d gone through a really powerful Keiller or powerful Joujou person, probably not really in the business of healing as much as causing people. And so these are the kinds of things that you have a story that you hear more than you hear about that you hear about the discord, the illness, and then you hear about people tracing. 

You’re doing the detective work and finding out who was responsible for placing a spell or placing that juju on a video or a family. 

Do people believe that anyone is placing Ebola quite bad juju? 

You know, I haven’t. I’ve heard a little. I’ve heard indications. Right. So I’ve heard. But but I feel like those are also to be framed in a larger sort of political context as well. Sure. Right. So and I think that’s true for any of these accusations. Usually these accusations arise from other kinds of tensions that existed prior to the experiences of illness or discord. Right. So. 

In that, you know, in this case, the Liberian side I’m reading because I’m not nearly as familiar with Liberia, they are with Sierra Leone, although I have worked with Liberians in Sierra Leone. If I’m hearing a lot of stuff about God judging. 

Right, hearing a lot of I’m hearing a lot about the speech in a sort of like cannibalistic, both acting in a cannibalistic mode. So it’s hard to disentangle some of the political suspicions and fears from these hormones. 

So is when something like Ebola, which killed so many people and which have some such severe symptoms happens, people start to think about the various injustices that preceded it. So is it about the state failing to do its job? Is it about certain kinds of officials failing to appropriately care for its citizens, their communities? Is it about the failure of the health system to actually provide high level, high quality care to people? And these these sort of biological and medical and health concerns and crises emerge out of or at least they’re falling into place alongside some sort of political and sort of social tensions that already exist in. 

What are some of the tensions and critiques around the healthcare system? 

Well. They’re very inadequate. 

The system very inadequate and their country, they’re all trying to improve that right there at the medical schools and nursing schools are graduating more people than ever before. They’re recruiting more people. They have all of these schemes, these the governments do that, but they’re not building fast enough. And for them to meet the needs of the people. I remember this song. I always refer to the song by the jungle leaders. It’s a fairly Odean group. And this is where Nuvigil is much more political. Apparently, it’s becoming less so. But one of the lines in the song translated from Krio is as soon as you get sick, it’s your funeral. 

Right. 

And tell people people think of that as part of the that’s part of the critique of the state, which is it’s a shame you go into a hospital, you have to pay for even if it’s a free, free health care, you have to pay for the drugs. You have to pay for sometimes gloves or the needles. Hospitals can be crowded. They can be part of the staff to be to treat people in a certain way that makes them feel uncomfortable. And this is something that used you hear constantly when you talk to people who have to seek care. I mean, myself, I’ve had many friends and the children of friends die under the care of nurses and doctors in these militias. Right. So it’s sort of a fact of life and it’s an unfortunate fact of life that health systems are just not meeting the needs of people. 

And these are some of the world’s poorest countries, right? Absolutely. Do you feel like the health system is being mismanaged or do you feel like it’s more just how few resources there are to do anything? 

I think it’s about resources. I had this conversation actually when I was in Sweden. I was talking to a Finnish guy who’s been working in Liberia for 15, 20 years and, you know, a couple of other people who worked in Liberia and Sierra Leone and in the aid community more broadly. And it’s funny, we were talking about how. So, first of all, these governments don’t generate enough income to actually produce provide those kinds of services. So they rely heavily on development aid. And what I also have worked in the aid world. So I have some insight on this. But we spend a lot of money on we’d like to to train people or we like to buy lots of goods, but we don’t necessarily take pay for enough people and we don’t necessarily recruit the right amount of people to do the work. People are very keen on posters and books and in training sessions, short term training sessions, but not on long term investments in health, in the health. We provide. We try to provide the most basic thing instead of the best thing. Right. And that’s the cost effectiveness battle we’re fighting right now. I think what we’ve learned is for what ever progress these health systems have been making since their wars. And I’m talking specifically about Liberia and Sierra Leone because he didn’t have a war. But whatever progress that they’ve they’ve made has been. Hank. Shown to be inadequate by this kind of crisis. 

And how we simply did those wars and so fairly owned war ended in 2000 to Liberia’s, I think in 2004. It’s hard it’s hard for me to say outside of that place. But I worked with like but the reason I’m always sketchy on the details is I worked with Liberian refugees at the end of their war, and they are Sierra Leonean. We’re just resettling. But that’s 10 years ago. So. 

So whatever whatever kinds of. But I. I believe that Liberia’s medical school opened up significantly later this. Salient. But whatever they’re whoever they’re graduating isn’t sufficient. And you have to keep in mind that many Liberian doctors, many Sierra Leonean doctors left during the war. 

The older ones who came back after the war were there to train people. But, you know, there’s a very small number. There’s a very small number of health professionals in the country and very few being educated during the war. And so that to some extent accounts for why there are so few health professionals. There’s also a huge number of foreign doctors and professionals. Right. So, you know, I don’t know if you know this, but many of the people who’ve been to the clinicians who have died in Sierra Leone, Liberia and Guinea were from other countries, other African countries. So, you know, in Congo, places like that that actually have fairly good health, felt fairly good health training system, thrower of some kind of longer term commitment to producing doctors and nurses. 

Can we talk a little bit about that experimental drug that is being distributed to a select number of people? From what I’ve read, white American health care providers and aid providers who have come down with Ebola can tell us what the drug is, where it comes from and what some of the controversies are about how it’s being distributed. 

How so? There are a few drugs, but the one that has been the most controversial map that I think that was developed by a San Diego company using components from different garip different experimental drugs. That’s that’s been a tough, tough issue. So those two Americans, a Spanish priest and I think three like virion workers have received the drug so far. 

And so the two Americans were released yesterday and one, the Spanish priest passed away. So we’re talking about three people that we we have as our sort of sample size for knowing whether these drugs are effective or not. It sounds like the way be it, two of the Liberians who received it are doing better and one is still in serious condition. So it’s not clear the efficacy of Australia’s not yet known because it is an experimental drug. There have been there have been a significant amount of tension, especially racial tension related to who received the drugs and under the under what conditions they received it. And this was intensified when sheik, a doctor con doctor, said Khan, who is a was a Sierra Leonean virologist and physician working in the Kenema District Hospital. And he was also a researcher on Lassa fever, another hemorrhagic fever that exists in the region. 

But he passed away and apparently he, MSF and and other expatriate groups on the ground had the option of offering him the drug and they decided not to even tell him about it. And so this like I said, this tension, I think intensified because it made it look like. And I think I would not dispute this, but it looked like some people’s lives were valued over others. 

Why do you think they didn’t even tell him about it? 

Well, so they say and I understand what they say, but they say that it’s because they didn’t like it. Give him the drug and then be blamed if something bad happened. You, because that also looks bad. There’s also this suspicion and sort of history of a lot of experimentation and European experimentation on Africans and people of African descent. And so to some extent, they were, I think, hemmed in by fears about being mis misjudged by their motives. But as most people have argued, who, who who see this as a problematic sort of decision, Dr Khan, of all people, was very he was more than capable of giving consent. It would have understood that it was an experimental drug and certainly his family would have understood that he was doing this can improve his chances of living. So, yeah, that’s it’s it’s a very it’s been a tough, tough few. It was a tough few weeks when the math became became available for some people and not others. 

And what’s there is experimental evidence from rhesus macaques that it works pretty well. 

Right, right there. There. There have been animal experiments that showed, I think, in, I guess, fairly good efficacy in the first 48 hours after exposure. The two Americans who received it got it much later than that. And so they they were the people who were looking at the effects of this drug, where it were concerned that whatever effect they saw may have nothing to do with the drug itself. 

Right. And who ultimately gave the Americans the drugs? Was it MSF or was it somebody else? 

So I I’ve been following this and I know what how I read it because it wasn’t it wasn’t explicit with Samaritan’s Purse and the other organization that was working with Samaritan’s Purse, his name of forgetting right now those photos that the organizations that employed the two Americans secured the drugs and they were the ones who who paid for the transportation and they’re the ones who paid for the care. And we’re talking millions of dollars ultimately. 

When you secure the stroke, do right to the drug company, how do you how do you go about getting it? 

That’s also a great question. I believe they actually did talk to the company. 

That’s how I believe that’s how they got it, because there is a request. The Liberian government made a similar request. It. It could be that they all. I remember the petition happened. I’m just not sure who they petition did, too, but I thought it was for the drug companies with medical anthropology. 

You guys use your joint knowledge of medicine and culture to try and make containment more effective. Can you give some examples of how anthropologists are working on the front lines to do that with Ebola right now? 

So I’ve only heard of a few anthropologists who have been called in and there has been some criticism from anthropologists who have worked on Ebola outbreaks in the past that anthropologists were used earlier. So anthropologists have been used to understand. Trust issues. Right. How do you how how do you make sure that people how how you carry out your interventions in a way that’s sort of open and transparent and that people understand that they’re more likely to comply? One of the things that people are currently criticizing is this cordon sanitaire or this this big, basically quarantine zone around the most affected region. And because it’s been highly militarized. Right. So they are guarding these places. And this is true in West Point in Liberia. I’m sure you heard about the violence by Radio out West Point. So this is one of the places where anthropologists might have been very useful, like they would have said, you know, they had these existing tensions. You’re going to have to explain this to people in a way that can engender trust. So not only knowing that, but also help you all the various routes of transmission and how those might be impacted by sort of daily social practices in places like Sierra Leone, where you must shake a hand or you left hug a person or when you have to look for or we’re keep certain there certain kinds of burial practices or rituals that those are the areas in which an anthropologist may be able to to intervene. One of the things that I’m trying to understand right now is the effect of gender. So they’re not collecting or at least they’re not making public bailable that by they I mean, the WTO and the Ministry of Health, they send out numbers almost every day, but they don’t tell us what the sex gender breakdown is, which may explain different ways, different different ways of transmission. So, for example, the Liberian in Liberia. Not in Liberia, actually, yet in Liberia, London mining company. But this off miners. Mining companies also closed down in Sierra Leone. And you have to wonder whether miners who are largely male, we’re also experiencing this epidemic in a particular way. Earlier on. And that’s how I got into the community. It’s not clear. And so those kinds of questions make a difference, not only for epidemiologists, for anthropologists. They want to know what the social and cultural dynamics are that may assist in not only in transmitting the disease, but also in stopping that transmission. 

So there have been media reports that say that the cases are disproportionately skewed towards women. And people are speculating that maybe that’s because women have a disproportionate role in caring for the sick. Where are people getting that information that more women are dying? If it’s not coming out of the official health statistics? 

Great question. And it’s a question that I have been asking. 

But I do know some journalists on the ground who say, well, absolutely. The people who are doing who are burying the bodies are saying the ones that are big about now volunteering, they’re paid volunteers. But people who are now volunteering to bury the bodies are saying they’re seeing a limit. But people in the hospitals are saying, I’ve seen more women. But those are snapshots in time. I think what I the reason I sort of criticized this, the ideas of the official counts, is that how something is being counted always counts more this of. 

And it’s so it’s not. It’s not. I think it’s fine to say that there are more women. But if we aren’t able to see the extent and if we are able to show the pattern, I think it actually minimizes what we can do and say about gender differences in this epidemic. 

Why do you think they’re not releasing gender information? I mean, it seems like the most basic thing that they would have on everybody. 

Well, it’s like I was saying, and I myself have studied the politics of numbers. It’s it’s what it’s not what counts. Right. They really want the body counts and in the case counts. And they’re not thinking about the implications of gender. So while there are people giving that sort of, I guess, qualitative that qualitative rhythm, it gives you the qualitative information to get to that they’re not. So I would say that it’s it’s right now that the reporting requirements came in, what is possible to be what can be said about the epidemic? 

Are they publishing any other information about this, these cases besides that they’re confirmed and the people died? Or are they saying who is a health care provider or how old people were? 

So Liberia definitely publishes the number of health workers who are dying. 

And if we assume that most of the health workers are nurses and many nurse, most nurses are women, that we could probably say something about that to some extent. Right. We say something, but it’s I I have another reason that I’m concerned is it seems that the volunteers for various. Bodies are now all men, and so if they didn’t, the dead body is also highly infectious and some might if we see an uptick in men, might that mean that there’s something going wrong in burial proceedings? And so these are the other kinds. This is a lie. I think it’s actually really important to collect that data. I’m sure they’re collecting it. It’s just that it’s not publicly available. There are a lot of armchair epidemiologists out there who who kind of want to know. And I think it’s probably really useful for management as well as they’re tailoring their messages. So if you’re discovering that it’s mostly caregivers and how you talk to women who are giving care and how like how how are you? 

How are you communicating to or so say if you you learn that it’s actually very young girls doing this. How do you reach out to them? So this is what I mean by, you know, it’s they shouldn’t be simply concerned with reporting concerns, but also with the potential for targeting messages and changing their interventions on the ground. 

Is there any move afoot to pressure them to release or gather different information? 

I don’t think so. I read that on Twitter maybe every other day, but I don’t I haven’t seen many people. 

I just keep getting links to the reports from journalists who have written about it. So and I’ve I’ve like I said, I’ve been in conversation with those journalists and most of them say when I asked for the numbers, they say they have, they don’t, but they aren’t able to provide them before a deadline, which says to me that they might be collecting it, but they’re not doing anything with those numbers unless someone calls in like the president or the minister of social welfare or whatever and says, hey, I need to know how many women are dying, stat. One of the reasons I became interested, besides my own interested in gender is I heard like at one of the Liberian ministers had said that 75 percent of those deaths were women. 

And to me, you can make that kind of claim a very you know, obviously it means that there must be numbers somewhere. 

So it seems like it’s on every hospital intake form anywhere you go in the world. The first box you check is gender. It’s like they can’t help. I mean, maybe their medical system is totally different than anything I’ve experienced before. It’s modeled on our system. You would think that data would be right there. 

You would think that might. Again, I do have experience built collecting data. 

And if you’re talking about, you know, people on the ground with notebooks, just writing down names, ages, addresses and maybe sex, they they may not have maybe that data systems just aren’t geared towards that kind of correlation. 

Not one that the WHL reporting system is primarily about. OK. How many people died and how many people are confirmed dead? How many? You know what I mean. 

Yeah. But I see. 

So basically, the need to report drives how the information is managed to begin with. It’s possible that there are hundreds of sheets of paper with names that haven’t been translated into two data points or whatever. 

I read the other day that there are only 14000 Internet users in the entire country of Sierra Leone, which I mean suggests a lot of stuff is being collected. 

That’s pretty crazy on your cat thinks that ends up being like. 

That’s a very small percentage of the five to six million people living in that country. Yeah. 

And other effort. I mean, who’s in charge of all this paperwork? Ultimately, is it the ministries of health of the different countries? 

So it seems that it’s the Ministry of Health. So I I’m assuming that the chain is like this because they’re CDC, WHL workers right now is they send people out to do contact tracing. They have people who register folks that pass at the health centers. And then every day, someone probable, someone who’s probably solely responsible for numbers since is up the pipeline to the next level of person. He’s a minister of health. That that would be my task or need a person in the Ministry of Health. That would be my guess based on my own experience. I’ve asked people, journalists who maybe don’t have the same number crunching experience, but they say that something like that. Right. So. Yeah, that’s that’s my assumption. I would love. I have a friend on the ground in Guinea. I’m hoping will send me a little bit more information. But the way it’s sounding is that. That’s how the numbers move up a trickle up. 

And they better situation report every day. 

On August 22nd, just today, the World Health Organization came out with us an analysis that said that Ebola cases are being underestimated, the size of the outbreak is being underestimated. Why do you think that is? 

Why do they so I’ve been I’ve been intrigued by the fact that Alito has been talking about this for the past couple of weeks. They’re the political scientists. That’s Kim Deon’s, who actually wrote something about this a couple of months ago, I think. No, maybe not a couple of months ago, but certainly before the WTO did. And it’s it’s just a fact. It’s how it’s how all data collection goes. We know that we don’t know everyone who has the disease. Otherwise it would have stopped spreading. 

Right. And so. And so good point. 

So basically, that’s that’s the reason that they’ve underestimated the numbers. They could only count. They see. And we own that. And we know that people have been resistant to coming in. We know that people are turned away because there aren’t enough beds for people. So those so many cases and it’s the rainy season. If you’ve traveled the payload district in the rainy season, you know, it is hard to get to a health facility quickly and so or in rural Kenema. Even so, those things all impact how well people are able to count or be counted. 

If it were up to you to, you know, if you could name any measures to help contain the outbreak, they’re not being done now. What would you do differently? 

I would I mean, I would sound the alarm for more health care. I mean, health workers are the backbone of this whole thing. 

So many of them got sick and so many of them ran away when they discovered that they weren’t protected, when they discovered there weren’t enough gloves, when they knew that there weren’t there wasn’t enough protective gear for them when they weren’t properly trained in how to handle a disease this infectious and this deadly. 

So that I mean, I think that’s the first piece, which is is that which is working on that human resources piece. There also has to be you know, they have to be a lot more people on the ground who are doing outreach and in a way that actually meets people where they are, which is that actually understands how people are experiencing their fear and their mission and meeting them, meeting them there. 

And I know there are lots of people who know how to do that and can do that. But it’s a concerted effort. And I hear more and more people, Sierra Leonean, Liberians and Guineans who are involved in this fight throughout the world. Right. So diaspora are stepping up, sending gloves and people and stuff like that. So the next pieces, the equipment, making sure that there are enough beds, facilities, equipment for help to protect health workers to do this work. So that’s to me, those are the critical elements. It’s just this this the response was a little too late. They had it to stop the big explosion of cases. So, Ed, I mean, this is so now that that. That it’s it’s kind of out of control, so to speak. There just needs to be more people on the ground. 

What are some of the cultural attitudes or assumptions either in the aid community or in American public opinion that are affecting the way that we’re responding to this crisis? 

Well, there’s certainly a lot of alarmism and there is more. There is more of it. 

When those Americans were coming right, it became more of an issue of how do we contain this? How do we keep this in West Africa? And I think that’s been what’s that’s what’s been driving essentially the economic. Boycott. That reads him right? No Arab. Very few airlines are going in there now. Mining company elders, resource extraction companies have stepped out. International development agencies are telling their people to go on leave, to stay on leave. They don’t want it technically or formally evacuate them, but that causes a whole lot of other sort of feared suspicion and to some extent, the fears of contagion by the sort of very brutal sort of. Mysterious disease is causing all kinds of fear. So, yeah, this it’s I mean, I think that’s sort of the fundamental the fundamental cultural belief that that’s really damaging to to this part of West Africa right now is the fear of contagion. By the mysterious disease, the desire to contain this thing in that place. 

Our West Africans feeling abandoned or stigmatized because of this by the West? 

I think so. And I have been so when I I hesitated all this talk about when I was when I was in Sweden. 

And I was talking to this Finnish aid worker who worked who’s been working in Liberia for those many years. He said talking to him about things. I wanted to raise it in a lecture that I was giving. And he said, you cannot say that these aid agencies have evacuated their staff. And I said, why can’t I say that? Because that’s essentially what’s happening, even if it’s not formal. And even, you know, it’s what’s happening. People are leaving and being told that they all. That sounds like an evacuation. And he said because that that creates fear on the ground. That scares people because that’s what happened during the war. You know, they started pulling people out and they were left to their own devices. People who and I think it hurts more when it’s the aid community that says with aid they care. They want to help. Yeah. Right. So to some extent, it’s like, OK, they’re out. They’re out for there for themselves. And they’re. And no one can really blame them for that. But it also, I think, furthers the sort of division that I think also precedes this crisis, which is that there that people are claiming to help. But it’s in some ways are in collaboration with local elites and making money off of their misery. And in some ways, I think it perpetuates that that sort of abandon, that kind of perpetuates that existing kind of unspoken tension starts to do. 

Thank you so much for coming on the program. Thank you for having me. This has been a point of inquiry. You can follow us on Twitter at point of inquiry. Tune in next week.