In December of 2013, an 18-month-old boy fell ill in a small village in Guinea. Although it was not initially apparent, he had been infected—most likely from a bat reservoir—with Zaire ebolavirus. Within months, the outbreak had spread to the major cities of neighboring countries and in August of 2014, the WHO declared the West African Ebola outbreak a Public Health Emergency of International Concern.
In total, the outbreak would span two and a half years, involve 28,600 cases and 11,325 deaths, a number that would have been significantly higher without the heroic interventions of communities and health workers. This outbreak was complicated by an unprecedented spread in urban areas, conflict between infection control practices and local customs and beliefs—particularly those surrounding death and burial—and distrust of medical authorities.
These barriers necessitated creative solutions, and in Sierra Leone, one of the groups that stepped up was Commit and Act. A group that was founded in 2010 to support healthcare professionals treating individuals suffering from the after-effects of trauma, as well as other mental health issues including domestic and gender-based violence. The group specializes in administering and training others in Acceptance and Commitment Therapy (ACT), a psychotherapeutic modality that emphasizes psychological flexibility and living according to one’s values. When the Ebola epidemic began in force, local director of Commit and Act, Hannah Bockarie, realized that that the organization’s skill set was uniquely suited to assist healthcare workers in interfacing with local communities.
Through their work, they were able to provide therapy to hundreds of people whether individually, in groups, or in workshops. Their mission was twofold: first, to provide basic information about Ebola and its prevention, and second, to work with their clients to encourage acceptance of their feelings and encourage behavior change that was adaptive.
For example, in Sierra Leone, burial rights involve prolonged contact with the bodies of dead loved ones, including often hugging and kissing the departed. This was an extremely problematic practice in the context of the Ebola outbreak and as a result, medical authorities were quick to discourage such activities. However, in populations with low medical literacy, this was anathema and quickly engendered hostility and distrust. Noting this tension, workers with Commit and Act provided education in a non-judgmental fashion and worked with communities to brainstorm ways in which they could employ psychological flexibility to continue honoring the dead while modifying their behavior to be safer. The solution that one group came up with was to substitute the corpse of a loved one with a banana trunk that could be blessed, touched, and kissed before being lowered into the grave.
Asking a family to imperil their loved one’s journey to the afterlife is a hard thing to ask in any culture, but in these communities, individuals were able to alter the symbolism of actions like washing or laying upon a loved one with similar enough mechanisms that they were able to act both according to their values and in accordance with medical advice. With this new cognitive frame, families were able to honor their dead in traditional ways while halting the spread of Ebola.
Kissing the banana trunk was a truly beautiful solution, and notably, one that ACT (as opposed to CBT or Psychodynamic Psychotherapy) was particularly adept at reaching. This solution provides a model for addressing the culture wars surrounding COVID-19 restrictions in the US. Using the principles of ACT, healthcare providers could help to decrease vaccine hesitancy or anti-mask sentiment by starting with empathy, seeking to understand the patient’s concerns, and figuring out how the issue might be reframed to allow the patient’s actions to be more consonant with medical facts. For example, both masking and vaccinating could easily be reframed as patriotic, by protecting others in the community and emphasizing the feelings that accompany different actions and whether those are consistent with the patient’s values (i.e. wearing a mask to show you are a caring person rather than not wearing a mask because no one can force them to).
Obviously, engaging in full-blown therapy in a 10-minute clinic appointment is impractical from the standpoint of training and time, but invoking the principles involved in ACT could go a long way towards achieving a safer community and may prove to be a useful tool in the fight against COVD-19. We all should reflect and decide if we would be willing to kiss the banana trunk.