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Social Development 79 infected can create a new chain of transmission when they return home [35]. Investigators concluded that a single traditional funeral led to a rapidly growing Ebola epidemic in Moyamba, with a high rate of secondary transmission from one patient compared to the estimated basic Ebola virus reproduction number of 2.53 for Sierra Leone during the 2014–2016 outbreak in West Africa [35, 40]. The ‘super-spreader’ theory makes it clear that a prominent individual who dies of Ebola tends to transmit the virus to a large number of funeral attendees. Gender differences in risk factors for Ebola transmission During the early stage of Ebola outbreaks, differing gender roles contribute to disproportionate mortality, affecting women more than men [41, 42]. The WHO stated that elderly women traditionally care for the sick and prepare for burial the bodies of those who die of Ebola [43]. In Uganda, it is the custom for a paternal aunt or older woman to undertake this duty, and either a disease survivor or an elderly woman will care for the sick during severe disease outbreaks [44]. In the early stage of the Ebola outbreak in West Africa, a similar phenomenon occurred. In late August 2014, when the disease had already claimed the lives of at least 1,229 people in West Africa, Julia Duncan-Cassell, Liberia’s minister for gender and development, said that 75% of the Ebola deaths in Liberia occurred among female caregivers who had prepared bodies for funerals [45]. Marpue Spear, executive director of the Women’s nongovernmental organizations (NGO) Secretariat of Liberia, mentioned that it is traditional for a woman caregiver to bathe a sick man, but a man cannot bathe a sick woman in Liberia [42]. Suafiatu Tunis, leader of the Social Mobilization Committee on Ebola and a spokesperson for the Community Response Group, also commented that women who treat sick family members are at higher risk of contracting the virus [45]. West African women are also the traditional birth attendants, nurses, cleaners, and laundry workers in hospitals, and therefore they are exposed to patients’ bodily fluids [45]. However, as stated earlier, family members, relatives, or friends preparing for the funeral ritual must be the same sex as the dead in Sierra Leone. The WHO Ebola Response Team (ERT) published an article regarding these gender-specific epidemiologic patterns, citing a total of 20,035 confirmed and probable Ebola cases from December 2013 to August 2015. The data were analyzed to determine whether the different physiologies or cultural roles of the men and women actually resulted in different consequences depending on gender during the outbreak [46]. Among the 20,035 confirmed and probable Ebola cases, 51.2% were women, which is not greatly different from the proportion of men [46]. By country, the proportion of woman patients with Ebola was 52.7% in Guinea, 49.8% in Liberia, and 51.2% in Sierra Leone, which is broadly in line with the proportion of the female population in each country [46]. However, 63.4% of Ebola patients (P < 0.001) in Guéckédou Prefecture, Guinea, were women [46], which supported Duncan-Cassell, Spear, and Tunis’s comments. Additionally, even though a higher proportion of female patients were exposed to a sick person, the number of exposures reported by female and male patients was not significantly different [46]. Finally, female patients were less likely to die, and they had a lower risk of transmission than male patients because their average interval from symptom onset to hospitalization was 0.5 days shorter than that of male patients [46]. Nonetheless, designing a gender-based intervention should still be considered. Each region may have specific funeral expectations for men and women during a disease outbreak, just as in the Guéckédou Prefecture in Guinea, so it is important to address them. Risk factors associated with resistance and violence from communities During a public health emergency, such as an Ebola outbreak, laws permit the authorities to disregard survivors’ wishes regarding human remains [19]. The ERT has a clear public Journal of Health and Social Sciences 2020; 5,1:073-090 The Italian Journal for Interdisciplinary Health and Social Development 80 health policy: Those who are ill should be isolated within Ebola treatment centers (ETCs), and burials should be performed safely [32]. However, this policy is difficult to implement. The complex interaction of religious and cultural beliefs surrounding death is rooted in thousands of years of tradition [19]. Being prohibited from performing rites to ensure a deceased’s safe transfer into the afterlife is a spiritual insult to the deceased’s family and community [19]. Resistance to Ebola assistance was much more widespread and severe in Guinea than in Liberia or Sierra Leone [47]. The inhabitants of the forest region of Guinea (called ‘forestiers’) are disdained by those of other ethnicities in the country because it is believed that their practices are opposed to the laws of Islam and Christianity [32, 48]. The problem was that ERT members were not local and were appointed by political opponents of local leaders [32]. The team members were viewed as outsiders who disrespected and undermined the power of local religious beliefs and treated bodies like ‘faggots of wood’ through biomedical
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