What India can learn from Africa’s fight against Ebola, via a health summit in Sweden
The outbreak of 2014-16 was a reminder that what works to control an epidemic in one region may make things worse in another.
Did you know that talking about ‘goat plague’ did more to stop the spread of Ebola in West Africa than all the public service messages about not eating infected monkeys and bats?
While science and data must drive global health policies, making the messages relatable is equally vital.
India, which is facing its own communication challenges when dealing with both infectious and chronic health threats, needs lessons in cultural contextualisation.
Well-meaning public health communicators, for example, should stop using the phrase ‘kangaroo care’ when teaching women in rural India how to hold newborns to their chests to warm them and reduce risk of newborn death, because most women in remote areas have never even heard of the kangaroo and cannot possibly understand its relevance to childcare. Instead, experts say, using a monkey as a metaphor would work far better in this context.
The Ebola virus outbreak of 2014 – 16 is a perfect example of just how damaging mixed messages can be to health care and disease containment efforts.
When the virus first began to spread in Guinea, Liberia and Sierra Leone — it would eventually claim 11,000 people in the biggest such outbreak so far — global responders used lessons from past outbreaks in isolated parts of rural Central Africa, ignoring the regional and cultural context of West Africa.
They blamed the rapid spread of the disease on traditions such as eating monkeys, bats and other game meat that could be infected, and ritualistic burials that involved washing of the dead.
What they didn’t realise was that, while that had been true in remote Central Africa, what was fuelling the epidemic this time around was people-to-people transmission, most often via caregivers.
How did experts get it so wrong?
“The whole thing was driven by a great deal of panic. People made instant decisions on what should be done based on scientific literature on Ebola outbreaks in central Africa, and translated it into health messaging without actually paying attention to what has happening on the ground,” said Dr Paul Richards, a Sierra Leone-based British anthropologist, speaking at the Uppsala Health Summit on Tackling Infectious Diseases, in Sweden.
The summit saw experts across sectors recommend collaborative policies that could be adapted by countries and communities to quickly report and contain potential outbreaks.
Since Ebola is infectious but not contagious — it doesn’t spread through air like the flu epidemic — no one expected it to spread as quickly as it did. Then, as tens of thousands became infected, experts grimly predicted millions would be infected and thousands would die within months. They were wrong on both counts.
Once responders got the message right, incidences began to plummet and the infection did not spread to even 100,000.
True or false?
The garbled messaging of the initial months of Ebola 2014 was in some cases outright dangerous, said Richards, a professor at Njala University in central Sierra Leone who specialises in the Mano River region where Sierra Leone, Guinea and Liberia intersect. The Mano River region was ‘ground zero’ for the 2014-16 outbreak.
The message about bushmeat causing infection risk, for instance, backfired. “People thought, ‘I’m a Muslim, I don’t eat bushmeat or live near a forest, so I’m not at risk of Ebola. But they were at risk if they were nursing a patient with Ebola who they thought had malaria or Lassa fever,” Dr Richards said.
Messaging was part of the problem; the bigger failure was slow response.
The first case was traced back to December 2013, but the governments of Guinea, Liberia and Sierra Leone didn’t officially notify the World Health Organization until May 2014. The WHO declared it a ‘public health emergency of international concern’ on August 8, making it the third PHEIC after the H1N1 pandemic in April 2009, and the resurgence of polio after its near eradication in May 2014.
“The Ebola epidemic had been bombing along for nine months before there was an international response and then everything came at once, which made people think that things were a lot worse than they really were,” said Richards.
Control measures that were able to contain the disease in remote parts of central Africa failed to contain the infection breaking out in urban and rural areas across three countries.
“Once the infection spread to Europe and North America, there was a whole new wave of panic fed by news headlines, social media and so on, after which it was almost impossible to get any context back into the situation,” said Dr Richards.
The epidemic was finally contained by intensifying tried-and-tested methods and building on local knowledge.
“We talked to communities in rural areas about goat plague (peste des petits ruminants or PPR), which is a viral disease in goats that spreads through contact with body fluids. Many people in Sierra Leone and Liberia had lost their goats to PPR after the civil wars of the 1990s and they knew how to protect healthy goats by quarantining sick animals,” said Dr Richards, who authored the book, Ebola: How a People’s Science Helped End an Epidemic.
Once their experiences were used to illustrate the problem, people understood.
“An old granny would get up and say, ‘In the old days we had smallpox and we would always take the sick out to the farm huts and look after them there and stop their infecting others’. They already had the tools to deal with Ebola once you got the right message. And the right message was talking about PPR rather than talking about monkeys and bats and all the rest of it,” said Dr Richards.
Once they saw the risks, villagers quickly started using quarantine and adapted their burial rituals to lower infection. “It takes about six weeks to three months for a local community to understand the nature of the infection risks, to find local models,” said Dr Richards.
High community participation saw Ebola incidence fell fastest in rural south-east Sierra Leone, even though they got less aid and technical assistance. Motorbike taxis began ferrying blood samples, diagnostic results and, most crucially, data to help trained researchers do last-mile surveys and analyse information in real time from remote areas.
“This helped us develop methodologies that were highly effective in the local context and we could build the Ebola Response Anthropology Platform that put true and reliable information online within 24 hours,” said Dr Richards.