Defining political subjectivities through encounters with biomedicine during the Ebola epidemic in Sierra Leone
Over the last few decades, anthropological research has revealed the effects of biomedical technology on identity and sociality (Whyte and Gibbon 2009). Individual and community encounters with science and biomedicine have led to articulations of citizenship based on new categories and identities formed through these engagements, suggesting claims to social and political inclusion in a range of domains that transcend national boundaries (Wehling 2010). Such forms of citizenship give rise to a complexity of social identities and collective actions for knowledge, recognition, and claims to expertise (Heath, Rapp, and Taussig 2007). These include technological citizenship (Frankenfeld 1992), scientific citizenship (Irwin 2001), pharmaceutical citizenship (Ecks 2008), therapeutic citizenship (Nguyen 2008), and biological citizenship (Rose and Novas 2008; Petryna 2004).
Therapeutic and biological citizenship have become particularly influential concepts with which to explore encounters with biomedicine. Therapeutic citizenship involves claims made on a global social order on the basis of therapeutic interventions or biomedical conditions (Cataldo 2009; Nguyen 2008). Biological citizenship is the articulation of claims to participate in social and political life and the recognition of certain individual or group identities, expertise, and needs based on their biological or genetic conditions (Rose and Novas 2008). Whyte (2009, 11) writes that ‘The active biological citizen informs herself, and lives responsibly, adjusting diet and lifestyle so as to maximize health’. Petryna (2013) draws a strong link between biology and political claims in her research on the Chernobyl disaster, finding that citizens utilised technologies, knowledge of symptoms, and legal procedures to gain political recognition and access to welfare benefits.
Biological citizenship is both individualising and collectivising: on one hand, individuals are increasingly expected to be responsible for their own health and illnesses, as well as their health risks, and on the other hand they collectively organise according to shared biological conditions. Rabinow (1996) uses the notion of ‘biosociality’ to describe how biological nature, as revealed and controlled by science, increasingly becomes the basis for sociality. This can involve the formation of new groups or individual identities and practices, such as patient groups, activist organisations, and health movements, whose members share experiences and lobby for improved health care and cures. These communities themselves become central to the coproduction of biomedical technologies.
As Gibbon and Novas (2007) argue, there is a need to understand the value of these concepts of citizenship in different arenas (see also Whyte and Gibbon 2009). These concepts have become useful for describing how biomedical technologies and interventions are reshaping, and being shaped by, individual and collective identities (Whyte and Gibbon 2009). However, Wehling (2010) suggests that there are social and political consequences from such transformations of collective and individual social relations and identities. This, he argues, is because biological citizenship involves the negotiation and reconfiguration of rights, obligations, and social identities; these claims ‘have a significant political dimension insofar as they are intended to challenge dominant forms and technologies of power and exclusion’ (Wehling 2010, 240). This raises the question of how historical, social, and political circumstances contribute to the construction of biological citizenship and how this form of citizenship, itself, contributes to political and social struggles.
Biomedical encounters may not create new forms of citizenship in all contexts (Whyte and Gibbon 2009). There are concerns that the focus on identities based on categories of health may mask broader political-economic questions about health as well as other forms of social relations that may hold more importance in everyday lives (Marsland and Prince 2012; Whyte and Gibbon 2009). Whyte (2009, 13) argues that: ‘By defining research problems based on identifications like diabetic, Down syndrome, HIV+, we essentialize, fragment, and decontextualize what is really only part of a life. And it is, after all, a life and not an identity that people are usually seeking’.
Further, there are disparities in how science and medicine are present in everyday encounters, as well as complexity in how social conditions impact the making of health identities. Whyte (2009) thus suggests the need to understand the conditions in which such claims to citizenship arise, which requires detailing both history and political economy through rich ethnographic accounts, which describe social interactions, morality, and meaning.
Clinical trials provide the opportunity to explore notions of citizenship, as well as political-economic and social justice questions surrounding globally funded medical research in resource-poor contexts (Benatar and Singer 2000; Molyneux and Geissler 2008). As Petryna (2006) has argued, the outsourcing of clinical trials to the global South reveals social inequalities and inequities of health care provision in global scientific research. In exploring the experiences of women who participated in a clinical trial to test the effectiveness of a microbicidal gel in preventing HIV infection in women, Lees (2014) found the concept of biological citizenship useful for understanding how women acted both individually and collectively to ‘test’ whether the gel would work. This research revealed that women articulated their collective participation as Tanzanian citizens addressing broader histories of gender inequalities.
The 2014 to 2016 Ebola epidemic in the Mano River countries of Guinea, Liberia, and Sierra Leone was the largest in history, with over fourteen thousand cases and approximately five thousand deaths in Sierra Leone alone (WHO 2016). The epidemic saw a significant mobilisation of anthropological knowledge to analyse the social, cultural, and political determinants of the virus’ spread and a growing body of literature is dedicated to analysing the implications of the outbreak for anthropological theory and practice (Abramowitz 2014; Abramowitz et al. 2015; Anoko 2014; H. Brown and Kelly 2014; C. Chandler et al. 2015; Cohn and Kutalek 2016; Fairhead 2014, 2016; Leach 2015b; Pellecchia et al. 2015; Richards 2016; Richardson et al. 2016; Wilkinson and Leach 2015; Wilkinson et al. 2017; Wilkinson and Fairhead 2017). Using an empirical case study of an Ebola vaccine trial that commenced at the tail end of the epidemic in Sierra Leone, this article builds on the existing literature on the political subjectivities that emerge from encounters with biomedicine. We aim to show how encounters with this vaccine trial provided opportunities to articulate multiple, at times contradictory, ideas about the boundaries of political community. Trial participants appealed to abstract notions of patriotism whilst simultaneously making demands for state provision or expressing claims based on exclusive notions of ethnicity and locality. Through an analysis of these varied expressions of identity and community we show how time-bound biomedical interventions can reveal the complexities of belonging. We argue that participants used the clinical trial instrumentally to contribute to broader, often messy, discussions and contestations about their relation to the state, what it means to be a citizen, and who should benefit from interventions. Crises like Ebola expose deep-rooted mistrust and fraught relations among the state, the international community, and affected populations, as the anthropological literature on Ebola has highlighted (Wilkinson and Leach 2015; Fairhead et al. 2014). However, we aim to show that they also create spaces to redefine and contest existing political dispensations.
At the time of the outbreak, there was no licensed vaccine or treatment available for Ebola, placing pressure on international and local scientists, political leaders, and communities to establish clinical trials of experimental products. In early 2015, the development of a clinical trial site commenced in Kambia in northern Sierra Leone for the EBOVAC Salone trial. This trial is evaluating the safety and immunogenicity of the Ad26.ZEBOV/MVA-BN-Filo prime-boost Ebola vaccine regimen, and has enrolled a small number of healthy adults into an open-label stage of the study. A randomised, controlled study then commenced in March 2016, and recruited adults, adolescents, and children aged one year and older. Given that the trial started at the tail end of the Ebola epidemic, it provides an interesting case for studying how political subjectivities were articulated in two overlapping encounters with biomedicine (the response and the vaccine trial), with participants transitioning from one encounter to another.
As part of the trial team, Luisa Enria was based in Kambia and recruited a social science research team of local Sierra Leoneans who had recently been involved in the Ebola response. She conducted ethnographic work in Kambia during the Ebola epidemic, at the start and through the first year of the trial. Drawing on her previous work on clinical trials, Shelley Lees led the research design. This article draws on ethnographic and in-depth interview data collected by both authors to discuss articulations of citizenship in relation to an Ebola vaccine trial and the state, in the context of the Ebola epidemic and weak health infrastructure. Discussing our ethnographic material in conversation with a historical analysis of different, and at times conflicting, notions of community and belonging, we show how participation in a vaccine trial in a moment of crisis allowed people to tell stories about themselves as political subjects and to situate themselves in a conversation about the nature and boundaries of community and belonging that both pre-dates and post-dates the epidemic and the trial.
Histories of belonging
Crises, like that brought on by the seemingly incontrollable spread of Ebola in Sierra Leone, signal moments of rupture. The state of emergency that was declared on the 31 July 2014 produced new sets of relations, led to the introduction of new technologies, and resulted in unprecedented encounters with biomedicine. The crisis also generated a new language through which Sierra Leoneans could understand themselves as subjects, citizens, and members of national and international, moral, and political communities. Ruptures, however, do not occur in vacuums. In this section we situate the notions of belonging that were articulated through these new engagements within a much longer history of struggles over who sets the boundaries of political community, where, and with what consequences. These competing claims in the narratives of participants in the Kambia vaccine trials, in other words, are inscribed in a longer trajectory of political struggles and fraught state-society relations.
The historical formation of the Sierra Leonean state, like that of most modern states, is one made of contestations over the terms of belonging. Sierra Leone’s place in the history of thought about norms of personhood and practices of citizenship is in many ways unique. Through its position in the Atlantic slave trade and the subsequent abolitionist movement, its particular route in and out of colonialism, and its post-independence experiences of violence and crisis, Sierra Leone has been a testing ground for ideas of what it means to be a political subject, or even what it is to be human at all. Its history can be told through a series of struggles over the definition of boundaries of community, the markers of belonging, and the expectations and claims that stem from those competing definitions. These struggles have also concerned who has the authority to define the nature and contours of a polity, and have been characterised by tensions between external influence and localised conceptions (Enria 2018). In this section we offer a rough periodization of such struggles in Sierra Leone’s history, focusing in particular on the interconnections and frictions among three dimensions of belonging, namely: normative and universalist visions of political subjectivity, competing loci of sovereignty (international, national, local), and the expectations and claims emerging from the erection of boundaries around political communities. We show how ideas of belonging and the expectations attached to being a political subject developed over time and how West Africans’ claims and the claims made about them in Western political thought produced contrasting notions of belonging. Through this lens, we narrate how ideas of belonging were cast and recast through trade, institutional practices, and the expectations of colonial and postcolonial subjects.
There is no obvious place to start a necessarily limited historical overview. However, the ‘Mande transformations’ set in motion by the migration of Islamic teachers, traders, and warriors from the Sudanic region of West Africa to the Upper Guinea Coast offer a useful inroad into the key themes noted above. These migratory patterns produced specific norms regulating relations between ‘landlords’ and ‘strangers’, and highlight the transformative influence of foreign ‘strangers’ on social and political institutions (Brooks 1993; Wilkinson and Fairhead 2016). Brooks (1993), for example, shows the role of reciprocity in structuring hospitality norms of travelling strangers and how valued foreigners were integrated into host communities through marriage and land ownership to facilitate trade across Western Africa. Strangers, furthermore, shaped their host communities as they settled by founding the ‘power associations’, or what are now often termed ‘secret societies’, that became central in the mediation of disputes, spiritual leadership, and socioecological processes (Brooks 1993; Wilkinson and Fairhead 2016). Political power in this period was drawn from ancestry or warriors’ conquests and grew through the accumulation of dependents through marriage, birth, clientelism, and, later, capture (Brooks 1993). This pluralisation of power begins to show the fluid and shifting boundaries of political community and the role of translocal dynamics in constantly reshaping markers of belonging.
The wars that characterised this period, however, also contributed to a profoundly transformative development in the history of political subjectivity in the region: the Atlantic slave trade. The trade in humans, often captured through war, was a central component of European forays into West Africa and thus of increasing external influence in the region. First under the Portuguese and later the British, by the eighteenth century, thousands of West Africans every year were being enslaved and shipped across the Atlantic before being bought by American plantation owners. The slave trade fundamentally reconfigured the nature of social relations and marked the beginning of violent encounters with Europe and the West. Even more profoundly, slavery’s commodification of bodies reflected chilling assumptions about what it meant to be human in West Africa at the time. The bodies of slaves leaving the estuaries of the Sierra Leone River represented the very negation of subjectivity. These histories of dehumanisation profoundly shaped Sierra Leonean ideas about subjectivity, power, and moral economy (Shaw 2002).
The formal end of slavery, through an abolitionist movement born out of Christianity and humanist ideas about the rights of man, marked yet another iteration of how West Africans featured in larger, international debates about belonging and personhood. Yet, as freed slaves and the ‘black poor’ arriving on the shores of Sierra Leone at the end of the eighteenth century to establish a ‘Province of Freedom’ were soon to find out, reality did not live up to these normative ideals. Sidbury (2015, 127) recounts how 1,200 settlers from Nova Scotia, arriving in 1792, gathered on the shores and sang a hymn to celebrate their new-found freedom on the Old Continent: ‘The year of Jubilee has come/ returned ye ransomed sinners home’. However, the arrival of these settlers and the establishment of what would come to be known as Freetown gave rise to a new set of tensions and contestations over definitions of political community and sources of sovereignty. These tensions were visible in two ways. Firstly, the settlers were bitterly disappointed by their discovery that the promise of a new start based on freedom and political rights for freed slaves was not to be fulfilled. They quickly found themselves dependent on the British and were almost immediately made into subjects of the British Empire when the colony was annexed in 1808. This tension between settlers’ attempts to found their own nation and imperial assumptions of sovereignty were compounded by internal tensions between indigenous populations and settlers. The latter’s ideas of what it meant to be ‘African’ as a freed slave and their ‘project of transformation’ in Sierra Leone, influenced by their Anglo-American experience and Christian beliefs, often came into conflict with indigenous practices (Sidbury 2015).
The creation of the Crown colony and its later expansion beyond the Western Peninsula to form a Protectorate in the hinterlands in 1896 had profound consequences for the institutional development of modern Sierra Leone and the externalisation of sovereignty. At the normative level, the significance of colonisation and later reinterpretations of economic motives into humanitarian ones, in the ‘mission civilisatrice’, also reflected contemporary European thinking about the ‘immaturity’ of African political subjects and the impossibility of their self-rule (Mamdani 1996). The British colonial practice of indirect rule was similarly important in terms of defining political communities as it placed power in the hands of the more or less ‘invented tradition’ of the chieftaincy in the provinces (Wilkinson and Fairhead 2016). The establishment of indirect rule and the imposition of central power from Freetown into the provinces were met with a variety of responses. On the one hand there were instances of resistance to foreign rule, such as the Hut Tax War of 1898, led by Chief Bai Bureh. On the other hand, chiefs exploited their new position as intermediaries between centre and periphery, and acted as gatekeepers of trade, most notably controlling the influx of labouring ‘strangers’ into mining communities (Reno 1995). The increasing political salience of being able to fix the boundaries of communities and subordinate strangers from outside, as we shall see, set in motion some of the conflictual dynamics that came to a head during the civil war. Experiences of colonialism, then, were characterised not only by Britain’s formal denial of the indigenous population’s political rights and sovereignty but also by the local elite’s instrumentalisation of the boundaries of belonging.
Across Africa, the process of decolonisation was by definition a move to reclaim political sovereignty. In Sierra Leone, the nationalist movement driving electoral decolonisation was primarily led by elites. The rural masses, though finally citizens, were mobilised through chiefly houses (Harris 2013). In the decades following independence, under Siaka Stevens’s All People’s Congress (APC) one-party rule, there was a significant shrinking of state expenditure, with power increasingly centralised in Freetown and access to resources more and more dependent on inclusion in the personal networks of the president (Reno 1995). At the same time, given the regime’s enormous economic challenges, much of the country’s economic policy was determined, as elsewhere in the continent, by international financial institutions’ demands for structural adjustment, a new incarnation of externalised sovereignty (Reno 1996). The erosion of services to citizens in the midst of an economic downturn culminated in the APC regime being brought to an end by an eleven-year civil war (1991–2002). The roots of the conflict have been extensively debated, with some focusing on external facilitating factors such as the war in neighbouring Liberia and others debating whether economic imperatives, criminality, or political ideology could explain the actions of the rebels, the Revolutionary United Front (RUF) (Keen 2005; Gberie 2005; Richards 1996; Abdullah 1998).
For our study of belonging and political community, we found it useful to focus on two key aspects. The first is that, despite the intricacies of the conflict and the motivations of the plethora of actors involved, it is clear that its origins can be traced to a failed social contract, as the expectations of development and prosperity on the postcolonial state failed to materialise. Across the spectrum of analyses, high rates of unemployment, lack of education, and lack of access to opportunities have been cited as relevant, whether as drivers of criminal behaviour or grievances that underpinned RUF’s political plan (Abdullah 1998; Richards 1996). Debates amongst donors, civil society, government, and scholars about postconflict governance also took up the role of chieftaincies in the marginalisation of rural youth before the war. Alongside the failed expectations of independence placed on the central state, rural recruits’ confessions and post-war reconciliation processes revealed a great deal of resentment regarding rural chiefs’ abuses and specifically their exploitation of young people. Such intergenerational conflicts revealed both young people’s dissatisfaction with their political and social exclusion in the provinces and the ‘unresolved tensions between land-holding elites and dislocated peasants or “strangers”’ (Peters 2011, 13), and can help to explain rural recruitment into the RUF. Both of these points featured in the Truth and Reconciliation Commission’s Report (TRC 2004). The terms and expectations of belonging were thus important in how Sierra Leoneans came to understand the roots of the civil war that wrought chaos in the country for eleven years.
As Ebola struck in 2014, Sierra Leone had been grappling for over a decade with these questions about how a new viable polity could be built to avoid relapse into conflict (T. Brown et al. 2005; Benton and Dionne 2015). A pertinent example of the much larger debate about postconflict reconstruction is the heated dispute about the role of chieftaincies and the shape that decentralisation efforts should take. Older controversies were rekindled as the issue of what to do with the chiefs raised questions about who sets the boundaries of community and where, how these are to be governed, and how to determine who ‘really’ belongs (Geschiere 2009; Fanthorpe 2005; Jackson 2005). Decentralisation, as Geschiere (2009) notes, is significant for notions of belonging on two levels: it increases the salience of setting boundaries for resource distribution and it weakens the salience of national citizenship as resources are increasingly accessed through district-level circuits. The involvement of the international community, this time as state-builders, added another level of complexity in the restructuring of political sovereignty in the aftermath of war (Chandler 2006; Enria 2012). Identities, communities, and layers of political power were once again in flux as Ebola arrived. Indeed, the outbreak of Ebola can be viewed as a tragically premature test for postconflict institutions (Benton and Dionne 2015; Enria 2015b). Several analyses of the epidemic point to a lack of trust in the response to the epidemic, yet this was manifest in different – sometimes overlapping, sometimes contrasting – ways. As Bolten and Shepler (2017) note, the crisis made visible once more the ‘fractal’ nature of political power, through the varied roles of local, national, and international actors.
Rumours surrounding the spread of the epidemic show its ‘political’ nature in ways that touch on the historical developments outlined above. To begin with, these social commentaries offered important insights into Sierra Leoneans ideas about the post-war state. The fact that the outbreak began in a southeastern district and coincided with a population census, for example, sparked widespread speculation that the ruling APC, with its traditional support base in northern districts, was attempting to decimate the population in opposition strongholds in view of the 2018 elections (ICG 2015). Scepticism of the government’s involvement in the outbreak was also evident in the accusations of officials ‘eating Ebola money’ (Shepler 2017; Enria 2015b). Aside from social commentary, there were very tangible ways in which the outbreak’s evolution can be linked to mistrust of government health care services and more specifically their efforts to contain the disease. Such mistrust was manifest in widespread avoidance of health care centres and failure to report illness and death, and in widely reported cases of people escaping quarantined homes. These reactions were understandable responses to a frightening and unknown disease, but they also signalled significant misgivings about the motives of government in dealing with the disease and its capacity to do so effectively. On the other hand, commentators also highlighted how, in certain parts of the country, community cohesion and ingenuity, often in opposition to state-led or international initiatives, developed solutions to end the disease (Richards 2016). Similarly, health workers and unpaid volunteers came out in the thousands to support the national effort to end the disease (CAFOD 2016).
As Shepler (2017) has incisively argued, theories of mistrust in a weak state have not only obscured how Sierra Leoneans continued to look to the state for answers in times of crisis, as we elaborate further below. They also overshadow the similarly contested nature of international involvement, this time in the guise of a humanitarian assemblage. Rumours about international blood stealing, resistance against foreign workers, and important questions about the accountability of the international response complemented ambivalent feelings towards the national response (Leach 2015). Similarly, challenges to epidemic control strategies revealed fundamental clashes between international perceptions of local ignorance and communities that demand their dignity be recognised in sickness and death (IFRC 2015; Bolten and Shepler 2017).
The way the epidemic unfolded therefore mirrored many of the tensions inherent in the competing ideas of belonging that have played a role throughout Sierra Leone’s history. Popular challenges were raised against the dehumanising practices associated with disease containment, such as burials in mass graves with black body bags. People debated the interplay of national responses and international involvement. Tensions were apparent between the central powers in Freetown and sceptical populations in the peripheries. And such scepticism was countered by ideas of patriotism and sacrifice, invoked by volunteers and health workers in the Ebola response. Normative ideas of personhood and citizenship overlapped and contrasted with multiple layers of sovereignty and questions about resource distribution. Our analysis begins here, at this moment of great uncertainty and fear that opened up old questions in new terrains. As we show, new encounters with biomedicine offered avenues for Sierra Leoneans to talk about their visions and expectations in times of crisis. Viewing these in historical perspective is not to suggest determinism or to make facile historical parallels, but rather to show how these avenues were forged from older paths.
Belonging and biomedicine during Ebola: The EBOVAC Salone trial
As the EBOVAC Salone trial arrived in Kambia, the small border town was at the centre of attention in the fight to end Ebola. The epidemic had dragged on for much longer than any previous outbreak, reaching unprecedented levels of transmission. Fear and mistrust, alongside dilapidated health care systems and a sluggish international response, were seen as some of the key factors hindering an end to the outbreak (Leach 2015a). By June 2015, as EBOVAC Salone’s clinical protocol was being finalised and an old NGO building was being renovated as clinic space, national case counts seemed to be finally dropping. Kambia, however, was singled out, together with neighbouring Port Loko District, as holding up the national fight towards a ‘durable zero’. This triggered Operation Northern Push, led by the National Ebola Response Committee and the military, involving curfews, strengthened checkpoints, and a tightening of disease-containment regulations (NERC 2015). It was under these conditions that the EBOVAC Salone trial’s community engagement team began planning their volunteer enrolment strategy (see Enria et al. 2016). Community leaders were visited individually and then encouraged to hold community meetings with the assistance of the trial’s community engagement team. Volunteers were enrolled initially through a lottery system, in which members of the community were asked to draw household addresses from a bag in a public ceremony; winning addresses would be invited to participate in the trial. Households were visited by the community engagement team and given an overview of the trial; individuals who were interested in joining were invited to the clinic where they underwent an individual consent session with a member of the clinical staff. Participants who consented underwent a medical check-up and, if they met the conditions set by the trial protocol, they were given the first vaccine and a boost after two months. Participants who enrolled in the trial were guaranteed health care by the trial’s clinic for the duration of their participation.
By October 2015, as the vaccine trial opened its doors to potential participants, Kambia was nearing yet another countdown to zero after a new death from the disease in August. As we have discussed elsewhere, despite the dominance of frightening narratives about the epidemic and the very real concerns expressed by Kambians as the trial was being set up, the numbers of volunteers in the first stage of the trial were high and motives for participating ranged from altruism and access to health care to hopes in the vaccine’s healing powers (Enria et al. 2016; Tengbeh et al. 2018).[note 1]Out of 200 households visited following the household lottery, 202 individuals signed up for Stage 1, of which 43 were enrolled.
Whilst the reasons for joining the trial were many and varied, here we focus on how those who decided to join the trial spoke in the language of citizenship and belonging in their reflections on their participation. We do not suggest that these were participants’ principal reasons for joining the trial. Rather, we show how participation in the trial was used instrumentally to express a variety of political subjectivities. Drawing on our historical analysis, we show how these narratives rested on three, at times contradictory, notions of belonging: normative ideas of citizenship and patriotism, notions of dependency, and visions of community.
‘As a Sierra Leonean, I should give up myself’: Citizenship and patriotism
The trial’s arrival during the epidemic meant that Kambians’ encounters with this new technology could not be disentangled from their views and experiences of the outbreak. Some dubbed it ‘Ebola Phase 2’, a second attempt to kill those that had been spared in the first attempt (see Enria et al. 2016). Other rumours circulated around issues to do with blood stealing and the possible impact of the experimental vaccine on participants’ fertility. And yet, people volunteered. Participants in the trial, as we discuss elsewhere, expressed their participation as a form of sacrifice in the face of great perceived risks (Tengbeh et al. 2018). What was especially interesting was how participants linked sacrifice to broader notions of citizenship and patriotism. Such narratives were in stark contrast with the more popular analyses of the epidemic that emphasises mistrust and avoidance of the state.
Thomas[note 2]Participants’ names have been changed.
was one of the first participants in the EBOVAC Salone trial. He was a popular man in Kambia; he owned a small shop and was very active in one of the local Pentecostal churches. He had been born in the eastern part of the country but his educational ambitions led him to join his father in the northern town of Lunsar. He ultimately settled in Kambia just before the war to set up a new shop to expand his father’s business. After the RUF’s attacks on Kambia in 1995, Thomas briefly escaped to neighbouring Guinea, like the majority of Kambians, before returning to open the shop in 2003. He had stayed in Kambia since then and experienced the outbreak up close as one of his closest friends from church contracted Ebola and survived. In describing his involvement in the trial, as one of the first round of participants, Thomas recalled being taunted by his friends who were sceptical about the new clinical study. Initially, he explained, they had thought he must be doing it for the money, but he was keen to express a different motive:
I told them that they are not giving us money, but they didn’t believe me. They said I was going to die for nothing, but I told them that if I die, then I am going to die for this country. I have an example about what the white man does. I said: ‘the white man can stand for his country if it is for the good, just to leave a name’. I said: ‘so that is what I am going to do’. So they said: ‘Ok, you are the Jesus, you go and die for us’.
Despite being unsuccessful in his attempt to convince his friends, who continued to joke about his sacrificing his life, Thomas’s words show important, and perhaps unexpected, allusions to sacrifice and patriotism. He later added: ‘We are the heroes in this country, because we are ready to die for this country’. Others echoed Thomas’s idea of participation as a commitment to a broader community, defined by national borders, and also saw participation as a duty to the nation. Hassan, a participant in the second stage of the trial noted: ‘I see that as a Sierra Leonean, when they say they are studying a particular medicine, I should give myself up to be part of the study so that tomorrow, if this particular marklate [vaccine] that they are trying to find out [about] becomes [effective], history must talk, and people must say that there were people who participated’.
Others talked about their wish to encourage others to join ‘as a citizen’ and ‘for the love of our country’. These notions of patriotic sacrifice as Sierra Leoneans complicate common notions of ‘failed states’ and institutions that fail to penetrate society, instead evoking shared sense of unity away from the centres of power. Of course, as we shall see below, patriotism did not make Kambians uncritical about the failures of the post-war state to fulfil its end of the social contract. However, the Sierra Leonean nation and normative ideals of a common good were evident in participants’ understanding of themselves and their participation in the trial. In their discussions of the new biomedical interventions accompanying the outbreak, the importance of the state was especially vivid as many characterised the state as gatekeeper of medical research. With this perception of the government as being in charge of determining whether an intervention was allowed in the country, participation ‘as Sierra Leoneans’ was linked directly to an idea of sacrifice under the scrutiny of the state.
Fatmata, a middle-aged woman from Guinea who had married a Sierra Leonean and naturalised in Kambia, strongly dismissed the rumours that the vaccine had come to kill Sierra Leoneans:
The government cannot sit and look at the country and bring a bad thing [trial] for their people to join it, for them to die just like how Ebola has killed so many people? Do you think you would agree for someone to come with a bad thing in your country, to give people an injection for them to start dying again? I looked at all of those things and said it was a lie. The government is not so foolish as to give white men bad things to come and kill us.
Fatmata’s words encapsulate a logic that several other participants expressed, as they explained away popular fears around the potentially sinister intentions of Western medical research: the government would not allow them to come in. This counternarrative to the rumours and conspiracies is significant in that it allows us to see how, for those who decided to actively engage with it, biomedical research offered a language through which to express ideas about what it meant to be a citizen in Sierra Leone or rather, normative ideas about political subjectivity in times of crisis.
This needs to be qualified by considering the political context in which these statements were made. In the first two post-war elections (2007 and 2012) Kambia was an APC stronghold. It is therefore likely that the district’s strong support for the government shaped participants’ views on its ability to act as a benevolent gatekeeper. One participant, a local dignitary who had agreed to join the study as a ‘role model’ for his community, made explicit this connection to Kambia’s support of the ruling party: ‘I have seen that Ernest Koroma – who is the president, and it happens that we voted for him – he would not encourage anybody who would come into our country to come and destroy lives. He would not have that mind [he would not dare] because it will not create any impact for him if he does that to his people, so what is he going to do that for?’
It would however be simplistic to reduce these evocations of patriotism and citizenship to political loyalty. Mistrust, rumours, and widespread criticism of the government were rife in Kambia during our ethnographic research (Enria et al. 2016; Tengbeh et al. 2018). Still, on a normative level, these evocations encourage us to take sentiments such as nationalism seriously, in a way that they often are not in developing country contexts. These participants were making powerful statements about civic duty, which they performed by engaging in clinical research into a disease that had recently devastated their communities. By portraying themselves as patriots, participants not only were identifying themselves as citizens but also setting the stage for making claims based on their sacrifices. It is to these claims that we now turn.
Dependents: Claims and the political imagination
Alongside their sense of patriotism, participants in the EBOVAC Salone trial conveyed their expectations of the state to which they proclaimed membership. Articulating their participation as a sacrifice they were making as citizens opened up the possibility to make specific claims about the obligations that they perceived the state to have and, often, that they saw the state as failing to fulfil. Recent developments in theorising moral economy are useful to analyse this, as they highlight how notions of dependence and interdependence are key in such claims. In her study of wartime relations in northern Sierra Leone, Bolten (2012) highlights the crucial role that norms of reciprocity play in regulating Sierra Leonean social relations. Redistribution, especially amongst unequals, is characterised as a form of ‘love’ as opposed to the ‘betrayal’ of individualistic accumulation. Ferguson (2013, 237) usefully extends the analysis of such moral norms to state dependency in times of economic (but also social and political) insecurity, noting how the ‘positive content of citizenship itself may increasingly come to rest precisely on being a rightful and deserving dependent of the state’.
Such ‘declarations of dependence’ were manifest in two main ways amongst trial participants. The first was through the use of the vaccine trial as a mirror to reflect the performance of the Sierra Leonean state and to articulate the rights that participants expected as citizens. It is important to note here that these expectations were separate from those that were directly targeted at the trial team. Indeed, despite the fact that the trial was funded and led almost entirely by a foreign team, in interviews participants clearly articulated a relationship with their government. Whilst in the next section we discuss how specific expectations were leveraged against the trial, here we discuss how people involved in the trial described expectations of government provision and conceptions of the state as carer for its citizens.
The trial’s facilities and offerings – including the state-of-the-art equipment in the clinics, health check-ups for establishing inclusion criteria, and the provision of health care for participants in the study – were clearly set apart from people’s previous experiences with health care providers. As one participant stated, ‘The whole process [of the trial] was so unique, it is like the advanced world’. By contrasting the trial and government-provided health care, participants explicitly expressed their expectations of the state. Mr Suma, a teacher and farmer who joined the second stage of the vaccine trial, did so especially vividly:
You see, as far as the [vaccine] clinic is concerned, compared to the government hospital it is just like [the difference between] death and sleep. The government is death, [the clinic] is sleep. So these [people at the clinic] are the types of people we want in the community… . But at the government hospitals if you don’t give money they won’t even touch you. Why should a hospital be like that?
These comparisons were springboards for much bigger discussions about their perceptions that the government’s provision of health care was falling short in terms of professionalism, capacity to deliver efficient services, and in its failure to provide free health care for children under five and pregnant and lactating mothers, as promised. Despite this long list of disappointments, government services were very much present in participants’ imaginations of how things ought to be. The trial’s facilities, recognised as only temporary, were used as yardstick, the standard to which the government’s provision should rise.
In the context of unfulfilled promises, the trial served a second purpose in participants’ articulations of claims on the state. By emphasising their sacrifice, participants appealed to a notion of community that established exclusive reciprocal obligations between themselves, as participants in a new biomedical project, and the state. Being a participant in an Ebola vaccine trial created avenues to qualify the more universal claims of patriotic citizenship outlined above. Sacrifice, the argument went, should be rewarded through preferential treatment when it came to the government’s distributive choices. Ahmed, a young participant from the rural outskirts of Kambia, imagined that given that the government had allowed the trial to come to Kambia, he would ultimately be recognised as a participant and be prioritised when future work opportunities became available after the trial had ended. He described his calculations as follows:
Even if I did not get good health [by participating], it is a benefit, because I know that if the government starts to recommend somebody, [it will say] that this person is going to work here. Anything that they bring here has been recommended by the government, and anybody who takes the marklate has been recommended by the government.
In a labour market where recognition by those in positions of power is seen as key to gaining employment (see Enria 2015b), taking part in a government-sanctioned initiative could be a way to stake a claim for future preferential treatment. In other work we have shown how employment generation has been the basis for visions of citizenship and discussions of rights in post-war Sierra Leone (Enria 2018). Rather than being materialistic claims, jobs have underpinned Sierra Leoneans’ ideas of a post-war state that is able to take care of its citizens. These imaginations of the state as an abstract provider, as Enria (2018) shows, are separate from the everyday ‘navigations’ of citizens who try to build personal relationships with individual representatives of the state in the hope of making it in a system seen to be ruled by nepotism and connections.
Thomas, the business owner introduced above, echoed such hopes. He was certain that should another Ebola outbreak happen, participants, by now immune to the disease, would be the first to benefit from the job opportunities that have come to be associated with humanitarian interventions (for which the government was imagined as gatekeeper): ‘When there was the Ebola outbreak, if we had taken the marklate, they would not have bypassed us to hire someone else who is not secure [for jobs like] the burial team or for taking swabs’.
These two articulations of citizenship mediated by participants’ involvement in the EBOVAC Salone trial show how encounters with biomedicine during the outbreak are part of broader conversations about citizenship and the social contract. The state’s role in participants’ political imagination points to the continued relevance of citizenship, even when the state is essentially absent. The state remained the target of claims and expectations; even if it was objectively falling short of its obligations, it does not disappear from people’s understanding of what it means to be a political subject. This, as Shepler (2017) has argued, is significant in a context like Sierra Leone where the state is invariably defined as weak or ‘failed’. It is also significant in showing the continued relevance of the state in people’s imagination alongside appeals made directly to global medical communities that have been chronicled elsewhere across the continent (for example Nguyen 2008).
People also used their identity as participants to delineate the boundaries of distributive obligations. Petryna’s (2002) work on biological citizenship indicates how biology, whether through illness or by becoming a subject of medical research, is used to make oneself a recipient of state support in moments of great uncertainty. In Kambia, biomedical research offered a new avenue to express postcolonial expectations of development. At the same time, the trial as a yardstick for absent government health care services also shows the deep tensions arising from citizens’ expectations being defined through external interventions. Visions of the state as gatekeeper of potentially dangerous Western forays into Sierra Leone were contrasted by holding the state accountable through comparisons with an internationally funded clinical trial.
Sons of the soil: Ethnic demarcations
That the boundaries of community were malleable was most visible in participants’ use of another notion of belonging, an autochthonous one: the ‘sons of the soil’. Geschiere (2009, 27) shows how the image of being ‘from the soil’ affords a ‘promise [of] some sort of primal belonging’, making such claims appear self-evident. As our previous reading of Sierra Leone’s history makes clear, notions of belonging defined by direct descent and connection to the soil are at once entirely ahistorical and incredibly powerful in rationales for exclusion. Geschiere (2009, 27) puts it succinctly: ‘The preoccupation with purifying the community of alien elements leads people to redefine autochthony at ever closer range, especially when certain “spoils” – resources, political posts – have to be divided’. This inevitably gives rise, he continues, to ‘fierce debates about who “really” belongs’ (Geschiere 2009, 27).
Throughout Sierra Leone’s history, the juxtaposition of ‘strangers’ to ‘sons of the soil’ has been salient in different, more or less conflictual ways, at different times. During the outbreak these distinctions gained renewed meaning; for example, chiefs were asked by the emergency response team to keep strangers out of their chiefdoms to control chains of transmissions. During the setting up of the trial, the notion of ‘sons of the soil’ was used to draw the boundaries of a specific moral economy. This was expressed primarily through debates across town about EBOVAC Salone employees. Concerns were often expressed in ethnic terms, as community members complained about only seeing ‘Mende’ faces from the southeast and that many staff members were unable to speak the local Themne language. Participants and other Kambians contemplating whether to participate in the study often emphasised that seeing their ‘brothers and sisters’ or ‘children’, that is, fellow Kambians, in the study, made them feel more at ease. In more than one instance, for example, participants told Kambian members of the social science team associated with the trial that they had joined because of them. They expressed both trust that their ‘children’ would not lead them into something dangerous and their expectation that, should something go wrong, their ‘children’ would not leave them – unlike the ‘strangers’. This was made clear one evening at a popular palm wine bar, as we sat talking to the customers. As the conversation turned to the vaccine, Kallon, a regular at the bar, turned to one of the social science team members and said: ‘You would not bring something to kill us; if it was strangers telling us, we would not take it’.
Members of the clinical staff, who were for the large part not from Kambia, remarked on several occasions on what they saw to be stronger trust in the Kambia-born team members. One particular research assistant was very popular in town and many participants said that seeing him there soothed their anxieties. In the first week of screening participants for inclusion in the trial, for example, an elderly woman with very high blood pressure was offered a ride home by the clinic staff. As she sat waiting for the car, she saw the Kambian research assistant leaving and asked, anxiously, ‘You are not leaving me alone, are you?’
The flipside of this argument became evident in various confrontations between the trial and key Kambian stakeholders over what the latter saw as the excessive recruitment of ‘imported faces’. Several participants reported being put off by the fact that arriving at the clinic they heard people speaking Mende, the language of the southeast, and various community leaders challenged the trial on their recruitment policies, urging them to employ more local people. Apparent imbalances in the ethnic make-up of EBOVAC Salone staff can be explained through a number of different factors, including historically higher access to higher education in the southeast. Still, Kambians were likely to draw sharp lines about who should benefit from a large new intervention in the district. Indeed, conversations about jobs brought out most starkly the two sides of the ‘sons of the soil’ argument: trust in ‘children’ of the district and grievances over the influx of ‘strangers’. Mr Santigie, a local stakeholder, called the research assistant mentioned above every time he had a complaint about the trial in which he had taken part. He had initially complained when he found out that as a participant he would not be eligible for a job due to trial regulations. The research assistant had calmed him down at the time, and in doing so, emphasised his respect for him as a local stakeholder and ‘begged’ (asked for his understanding), presenting himself as his social inferior. At that point Mr Santigie had relented, arguing that he, as a respected leader in Kambia, would not be the one to ‘sabotage a good thing for the community’ but suggesting that the trial ought to hire Kambians because ‘when they come to give the marklate they don’t give it to outsiders’. It was Kambians, in other words, who were taking this vaccine, so they ought to be the ones benefiting from the developments brought by the trial.
Whilst patriotism defined through the idiom of the nation was cited as a reason for sacrifice and the state was made recipient of citizens’ expectations, the notion of ‘sons of the soil’ was mobilised in attempts to exclude ‘strangers’ from benefiting from what was seen as rightfully a development for the district.
The Ebola epidemic of 2014–2016 was what Das (1995, 6) would call a ‘critical event’, as ‘new modes of action came into being which redefined traditional categories’. Focusing on the perspectives of the participants in an Ebola vaccine trial, we have shown how the epidemic, and the biomedical interventions that it produced, created the tools for telling new stories about what it is to be a political subject as well as expressing expectations and hopes attached to citizenship and belonging to specific political communities. Placing these ethnographic encounters in conversation with Sierra Leone’s history reveals how the new language developed through biomedical encounters allowed participants to situate themselves in a longer history of struggles for political inclusion. Participation in the trial, and experiences of the Ebola crisis more generally, served as tools for redetermining and negotiating the terms of state-society relations in new terrains.
Participants’ narratives about citizenship and belonging in the context of their engagement with the vaccine trial suggest three key insights. Firstly, participants’ expressions of patriotism and feelings of sacrifice highlight the importance of taking the emotive and symbolic dimensions of citizenship seriously. Building on a history of struggles over definitions of personhood and for the achievement of human dignity, the views of Kambians who took part in the vaccine trial and emphasised their sacrifice for the nation also make clear that there is not a single story about the Ebola outbreak. Mistrust, fear, and avoidance undoubtedly played a large part as a number of anthropologists have rightly highlighted (Yamanis, Nolan, and Shepler 2016; Wilkinson and Leach 2015; Pellecchia et al. 2015; Fairhead 2014), but the perception that this was a national threat that could be overcome through collective sacrifice was equally important.
This brings us to the second important point, which is that despite the depiction of Sierra Leone as a ‘fragile state’ and the absence of state services as made evident by the epidemic, the state remained present in participants’ political imagination. As Shepler (2017) has crucially argued, allegiance to their ‘so-called weak state’ remains meaningful for many Sierra Leoneans. In the case of the vaccine trial, this meant both that participants used the trial’s facilities to articulate their expectations of government services and that they hoped that becoming participants would strengthen their claims for redistribution, by making them visible to state actors. In practice this raises some challenges for the future of governance in Sierra Leone, in terms of the inequities it exposes and the implications for a state that may not be in the position to fulfil these expectations. Furthermore, recognising the long-term tensions between layers of sovereignty, what are the consequences of having expectations of government performance defined by international interventions? And how are international actors to be held accountable?
Finally, the appeal to old notions of ‘sons of the soil’, in opposition to strangers, to express trust and questions about who benefits from development, highlights the complex nature of belonging. This case study has shown that patriotism and autochthony can coexist in Sierra Leone, and that encounters with biomedicine can reveal, rather than create, multiple expressions of belonging and expectations of political community.
These insights have important implications for how we think about biomedical encounters as social scientists and for the future of citizenship politics in Sierra Leone. The EBOVAC Salone trial shows how the arrival of new biomedical technologies can create a space for conversations that transcend the encounter. The trial was integrated into a discourse about inclusion and rights that pre-dated the crisis, which was one way that participants sought to renegotiate the terms of the conversation. In response to Whyte’s (2009) call for the need to understand the conditions in which claims to citizenship arise, we have shown how theories built on the political subjectivities articulated through encounters with biomedicine can be useful if they are able to look beyond the specific biological conditions or interventions around which the claims are being made and situate them in larger political discussions. Biomedical encounters may be instrumental rather than producing citizenship in their own terms. Similarly, participants’ stories show that the state remains important in the Sierra Leonean political imagination and suggest that the expectations of citizenship should be taken seriously, by governments and scholars alike. EBOVAC Salone participants’ experiences show the complex nature of citizenship in Sierra Leone, as local, national, and international dimensions come into play, at times in contradictory ways, to shape the contours of belonging.
In contributing to the broader literature on biomedicine and political subjectivities, we suggest that whilst this case study is in many ways an uncommon event in Sierra Leone and elsewhere, it provides insights into how encounters with biomedicine are inextricably linked to everyday experiences of belonging. Biomedical interventions such as vaccine trials during emergencies are time-bound and short-lived. In this article we have aimed to show how such encounters with biomedicine can be discursively instrumental, contributing to long-standing contestations about what it means to be a citizen, and where the boundaries of political community are and claims for inclusion and redistribution lie. These articulations are messy and complex and yet they are central to citizens’ everyday struggles for recognition.
The authors would like to acknowledge invaluable research assistance by Angus F. Tengbeh, Mahmood H. Bangura, Kadiatu Bangura, Rosetta I. Kabia, Alhaji Nyakoi, and Mohamed Lamin Kamara. This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 11585 and the Economic and Social Research Council project States of Emergency: Citizenship in Crisis in Sierra Leone,Grant Number: ES/N01717X/1.
About the authors
Luisa Enria is Lecturer in International Development at the University of Bath. Her ethnographic work has been primarily in Sierra Leone, focusing on the political dimensions of development, humanitarianism, and global health. She currently holds an ESRC Future Research Leaders Fellowship (ES/N01717X/1) to explore how moments of crisis shape young people’s experiences of citizenship, using the case study of Ebola in Sierra Leone. In 2015–2016 she was a Research Fellow at the London School of Hygiene and Tropical Medicine, where, as part of the EBOVAC team, she carried out research on community experiences of the Ebola outbreak and the clinical trial.
Shelley Leesis Associate Professor in the Anthropology of Gender, Violence, and HIV at the London School of Hygiene and Tropical Medicine. The focus of her research has been on gender and health in Tanzania. She has conducted anthropological research on HIV and gender-based violence prevention trials in Tanzania. She is the lead anthropologist on the EBOVAC-Salone vaccine trial in Sierra Leone and manages a study on the anthropology of vaccine deployment during epidemics. For the UK Public Health Rapid Support Team, she has conducted research to explore the role of anthropologists in disease outbreaks.
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