Is Ebola a Disease of Poverty or a Function of a Dysfunctional Public Health System?

Here is a YouTube link to a video posted by WHO as it respond to the EVD in West Africa:

A lot has been said since the outbreaks of Ebola Virus Disease (EVD) in Southern Guinea, which subsequently spread in the sub-region to Sierra Leone, Liberia, and now Nigeria, Africa’s most populous country. In the past, the ebola virus was first discovered in Zaire in 1976 of what is now known as the Democratic Republic of Congo (DRC)-Kinshasa, not to be confused with the Republic of Congo (Brazzaville). A team led by a Belgian Microbiologist/Scientist worked with local health workers at Yambuku (the epicenter) of the outbreak at the time for three months and they were able to contain the virus and eventually stop the mayhem of the deadly disease, which at the time claimed the lives of 300 people.

The result of their work provided insightful hints on how to control the deadly virus from spreading and, if adequately contained, could subsequently eliminate the virus or prevent new cases. Some measures they proposed after their work in Yambuku included simple personal and public health measures. These include washing of hands, not using contaminated syringes, avoiding contact with infected individuals or if contact is unavoidable making sure you are well protected, quarantine those who are infected as well as those working with infected individuals, adequately and appropriately burying or cremating dead victims and the effective dissemination of information to the public in a timely manner encouraging people to come forward without been ‘threatened for not doing so’, which include building trust as all essential measures to contain the continuous spread of the virus are taken. These are all information that are widely used by community, public, and global health professionals as well as individuals against other forms of diseases/viruses that are usually spread through similar medium. The mentality of inducing public fear is a less effective recipe to control and contain any crisis.

These measures could also be more effective by instating a state of emergency to allow public health workers as well as other stakeholders to be able to adequately address the virus and help effectively treat those infected. Sierra Leone, Guinea, and Liberia with the exception of Nigeria (where a state of emergency was released immediately following a second dead victim) were delinquent to put in place this measure. Why were they careless? What was the psychology behind delaying a state of emergency when the outbreak was discovered and there are information on how deadly EDV is? Was their delay another public show to create a humanitarian corridor to feed into their greed and corruption at the expense of the Liberian, Sierra Leonean, and Guinean people? They could argue that well, “we did not know this was going to turn out this way.” Hello? This ebola period and that name alone, if not taken stereotypically, should evoke the inner consciousness of any public health authority, government official, and the president for that matter, to take it seriously. Their delay have caused the lives of those that are dead and infected with the virus. A state of emergency can not in itself stop the spread of EVD, but could facilitate and reinforce the process of controlling and containing the spread of the virus.

Recent statistics released by the WHO suggest that as of date, the recent outbreak of the EVD in Western Africa have killed about 1,069 people in the sub-region of which 3 dead victims were reported in Nigeria. This included a Liberian diplomat who flew there weeks ago after transiting at the Tokoin International Airport inLomé, Togo via a civilian aircraft from Sierra Leone. This new statistics more than triple dead victims reported when EVD first emerged in Zaire.

One of the weakest, ineffective, and poorly efficient public safety measure is the incitement of fear. Fear makes people to naturally build a defense system in which they fail to come forward provided that they are the supposedly target fearing that they would be stigmatized. Instead of inciting fear in people to try to contain a specific disease or virus, motivating them to come forward for their own good to seek treatment is much more effective,appropriate, and efficient.

Telling people they would be arrested because they fail to bring their infected relatives forward would do little good to contain the virus and risks the safety of the entire population. This is where an effective and well organize public health risk management system makes the control and containment of such crisis (EVD) more effective, measurable, and productive for the people who are infected to seek treatment, prevent new cases, and if all goes well, subsequently controlling and containing the virus.

Fear would not make this happened, instead it would reinforce and facilitate the spread of the virus, create a social divide amongst the population, which could potentially lead to something else. Fear makes people to naturally become resistant and would psychologically avoid seeking treatment, even if treatment were available. Given the historical past of the civilian population of Liberia, Sierra Leone, and Guinea where civil conflicts have caused significant damages, deaths, and trauma, fear would be a less effective tool to combat EVD, given that communities in these countries are still reintegrating, rehabilitating, and reconstructing from periods of senseless, baseless, and bloody civil wars or political upheavals. Fear was a recipe that was used which promoted, enhanced, and reinforced these events. So, psychologically fear would be less effective tool and if use, it could trigger unprecedented mental and personal health problems.

Fear also promotes the possibility of infected victims been stigmatized against. Fear reinforces stigmatization and reduces personal motivation, which leads to social isolation and discrimination of the victim. If President Ellen J. Sirleaf of Liberia wants to the operations to contain and control the EVD, the fear she has provoked into public consciousness should be undo. Telling people that they would be arrested and persecuted for not bringing love ones, relatives or friends infected with the virus to be quarantine and treated makes people to naturally resist.

While it is true that her point is about public safety and the objective is to control the continuous spread of the virus, fear would do little to achieve those objectives. The outbreak of the EVD and the increasing deaths have already provided much fear to induce victims to consciously seek treatment. One of the reasons victims are not coming forward is their lack of confidence in the government and its health programs. The public has all reason to fear the continuous lies, mistreatments, deceptions, and corruption that are so commonplace in the Liberian government and the health system is not exception. What they lack is the motivation to trust the government’s ability in the presence of a fail and poorly managed health system to provide the necessary treatment to keep them alive. This trust is what the current government of Liberia should be trying to rebuild instead of inciting fear in the people.

With the continuous reports of new cases within the affected countries and evidence of cross border spread of the disease through the movements of people, all air travels, border crossings, and costal travels should have halted or if not, strict health and safety measures put in place to control and contain the disease. These were not happening! The inability for the respective government agencies in these countries to have instituted proactive and robust public health safety measures at all entry points reinforces and continues to facilitate the spread of the disease. The absence of these, which should have been to enforce public health policy prior to the outbreak of the disease serve as a clue that EVD is not just a poverty-oriented ideas, but a product or function of a dysfunctional public health system, which needs significant reforms at the local, community, regional, and national levels.

Ebola may be seen as a poverty based virus, however, I would argue that there are equally poor countries where ebola hasn’t occur even though these countries could have their own social, political, and health problems. Associating poverty as a recipe for the outbreak of ebola is distracting us from the true reason why ebola outbreaks do occur. If you notice carefully, most of the countries where ebola has emerged or re-emerged over the last several decades including the 2014 outbreaks are countries that are either politically unstable, emerged/emerging from long political and civil unrests/conflicts, which left social, political, economic, and health infrastructures severely damaged. EVD emergence in Nigeria, though is an exceptional case because it will be controlled and contained earlier, given the Nigerian government’s earlier response.

However, this doesn’t erase the fact that people have to take their own health with caution. Poverty could be a contributing factor to the outbreak of ebola, but not exclusively the main recipe. Poor governance, which focuses its development operations and apparatus within a centralized system without decentralizing services (including health and other social services) throughout the country is the driving force for the spread of ebola. Health authorities in Guinea, Sierra Leone, and Liberia should have known enough from information already available out of the enormous public and global consciousness from the devastating emergence of ebola in Zaire to which we all derive clue on how to control and contain the spread of the virus, treat infected victims, appropriately bury dead victims, and how to adequately disseminate health and safety information without fear and discrimination.

Ebola may be a poverty-based disease, but it is mainly caused by poor public and personal health practices and systems, which could spread quickly most especially in regions prone to civil unrest, which left social and health systems severely damaged or technically dysfunctional making the population more vulnerable to respond. The spread of EVD could also be potentially unprecedented in countries with a vulnerable centralized health system as evident from the cases of Sierra Leone, Guinea, and Liberia. EVD outbreak in Nigeria would short-live given Nigeria’s robust, effective, and decentralized health system. The earlier instatement of a state of emergency in Nigeria and other measures taken give insights to the rigorousness and robustness of the health sector and the overall government’s response to ensure public safety.

Sources:

Figure 1: http://www.popularmechanics.com/science/health/med-tech/seeing-the-impossibly-small-10-wild-scientific-visualizations-7#slide-7. Accessed: 07/30/2014.

Figure 2: Deaths caused by the EVD by countries in Western Africa, 2014 cited in http://www.bbc.com/news/world-africa-28769678. Accessed: 08/14/2014.

Figure 3: http://www.bbc.com/news/magazine-28262541. Accessed: 07/30/2014.

Figure 4: http://www.bbc.com/news/magazine-28262541. 07/30/2014.

Figures 5: Confirmed cases of EVD in West Africa as of August 7, 2014. http://www.who.int/csr/disease/ebola/maps/en/. Accessed: 08/14/2014.

Figure 6: Geographic distribution of EVD outbreaks in animals and humans. http://www.who.int/csr/disease/ebola/maps/en/. Accessed: 08/14/2014.

Figure 7: Emerging and Dangerous Pathogens Laboratory Network (EDPLN). http://www.who.int/csr/disease/ebola/maps/en/. Accessed: 08/14/2014.