Disconnect Between Workers Fighting Ebola and Those at Risk

Caroline Helwick

November 26, 2014

NEW ORLEANS — The Ebola virus will probably not be contained until the public health community better appreciates the culture of the people at risk, according to specialists who have spent time in the areas of West Africa dealing with the epidemic.

During a session here at the American Public Health Association 142nd Annual Meeting, speakers who have worked in Guinea, Liberia, Nigeria, and Sierra Leone said there is a pervasive cultural disconnect among the citizenry and the healthcare community trying to help.

"The 2014 Ebola outbreak is unprecedented in the number of cases, deaths, and geographic score. It is the largest, the worst, and the first to affect multiple countries in history," said Olajide Idris, commissioner of the Lagos State Ministry of Health in Nigeria.

According to the Centers for Disease Control's case scenario, the outbreak may continue until late 2015.

The containment of the virus in Lagos has been a success; the city has seen only 20 cases. Other communities, however, have been far less fortunate. Efforts to better understand these communities are clearly needed, according to the speakers.

A multifaceted approach must be taken, said Kim Kargbo, president and chief executive officer of Women of Hope International, who has lived half her life in Sierra Leone.

The Ebola virus is much more than a disease or a public health crisis, she said during her presentation. Ebola "is only revealing the problems in West Africa," she explained. "It is bringing to light the underlying perfect storm."

Ebola Revealing Underlying Problems

The issues and challenges include an inadequate healthcare system and government corruption; billions of dollars in aid are unaccounted for, according to Kargbo. The containment of Ebola has also been hampered by an insufficient infrastructure that impedes infection control and an inconsistent and ineffective educational process.

"For instance, the educational materials we received from the CDC were all written for Westerners. We developed new materials that used storytelling methods," she said.

"We have been teaching the what but not the why of such things as avoiding body contact. The communities want to know why," she explained.

Lessons learned from the experience of Red Cross volunteers in Guinea were shared by Timothy Roberton, MPH, from the Johns Hopkins School of Public Health in Baltimore. He said that for "rational and logical reasons," residents of rural Guinea have often not cooperated with volunteers and healthcare workers to stop the spread of the virus, and some have been "outright hostile."

Resistant villagers, disbelief in the existence of Ebola, and fear of the hospital have been major obstacles to overcome, and the "behavioral change message" has been slow to catch on.

"But," he maintained, "families who chose to reject information about Ebola made their decisions for good reasons. It probably wasn't in their best interest, but it wasn't irrational. For instance, after centuries of burying their dead in a certain way, the citizens were reluctant to change for a disease they did not believe existed."

Mistrust and Resistance

The Red Cross volunteers ultimately overcame obstacles by recruiting village political and religious leaders as advocates, and by allowing families to suit up in protective gear to participate in safe burial practices.

"Building trust and relationships are critical," he said.

"A big part of fighting Ebola and getting support is communicating the right message," agreed Emmanuel D'Harcourt, MD, senior director of the International Rescue Committee in New York City.

This starts by dispelling some myths about relief work in developing countries, which include "the idea of the savage, the White Knight to the rescue, and the concept that the healthcare system, through more resources, can stop Ebola," he explained.

"These myths don't lead us toward the right solution," he said.

One obstacle, he added, is "the vast disconnect between the government and the people" in Liberia, where he has worked. There, he reported, the citizenry is already suspicious of the government. The quarantine of villages did not foster trust. "Not surprisingly, people didn't take to this," he said.

"You have to have a handle on this disconnect and address it, not just give more money to the government," Dr. D'Harcourt added.

To stop the spread of Ebola, public health officials must "understand the setting," he said. This means knowing the acceptable practices in terms of culture and religion. "You need to address the belief system," he emphasized.

Understanding the local culture is the key to success.

The best way to win trust and effect change is to work from within, he said. Making use of trusted and respected community leaders who are trained with the right message is the one approach that can work. "Using those with influence in the community — that's what effective Ebola control looks like," he said.

In communities where this strategy is being used, infection rates have declined, demonstrating its effect.

Although medical treatment is clearly important, the public health component is critical, said Barry Levy, MD, from Tufts University in Boston, who moderated the panel discussion.

These speakers, who have worked in West Africa, all emphasized that "understanding the local culture is the key to success in preventing and controlling the outbreak."

Ms Karbo, Mr Roberton, Dr. D'Harcourt, and Dr. Levy have disclosed no relevant financial relationships.

American Public Health Association (APHA) 142nd Annual Meeting. Presented November 17, 2014.


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