One of the key reasons the Ebola outbreak got out of control in West Africa in the early days of the crisis was a lack of trust among community members, frontline health workers and the broader health system, suggests new Johns Hopkins Bloomberg School of Public Health research.
Had the citizens and their health care community developed a trusting relationship prior to the outbreak, important messages about the disease and how to stop its spread would likely have gotten through to people much sooner and slowed the march of Ebola, says Timothy Roberton, MPH, MA, a DrPH candidate in the school’s Department of International Health.
Roberton visited Guinea in July, spending two weeks with the Guinea Red Cross as part of a study initiated and funded by the International Federation of Red Cross and Red Crescent Societies. He was based in Gueckedou, the town on the nation’s southern border with Sierra Leone where the current Ebola outbreak began last winter. In an effort to understand the drivers of the outbreak, Roberton and his colleagues interviewed 41 Red Cross staff and volunteers who had been mobilized to raise Ebola awareness and teach families how to protect themselves. By then, Ebola had already spread from Guinea into Sierra Leone and Liberia. Now a handful of cases have also been diagnosed in Europe and the United States.
Roberton presented his findings at the American Public Health Association’s Annual Meeting in New Orleans, La.
In many villages, the messages about Ebola – how to identify its symptoms, to go to health facilities if symptoms appear, not to touch anyone who is sick, to isolate the sick, not to handle the bodies of the dead – got through and families adopted safe practices. But in some villages, he says, people refused to listen. They didn’t believe Ebola existed or thought it was scaremongering to secure humanitarian aid for their poor nation or a foreign plot to steal body parts. In those cases, the public health messages of the Red Cross volunteers were ignored.
Often, the Red Cross advice went against the way the Guineans had lived for generations. It is customary to clean the bodies of the dead, for example. But touching those who have died of Ebola promotes the spread of the disease. Villagers instead were being told not to touch the bodies or to place them into body bags before burial – concepts that were abhorrent to them and were often disregarded.
“This is a nation where many people are hesitant to seek health care at the best of times. Suddenly people are being told not to touch their sick children and to come to health facilities as soon as they have a fever,” Roberton says. “We assume as health professionals that everyone is just going to follow our advice, that we can fight these things with our intelligence and resources. But it’s not irrational that they chose to ignore the advice. Unless we appreciate how difficult it is for families to follow the guidance we give them, our Ebola control plans look wonderful on paper, but they’re going to fail.”
The importance of trust and strong relationships may seem obvious now, but it wasn’t well understood in the early days of the outbreak, Roberton says. While in Guinea, he learned of one village that had deaths from Ebola but essentially barricaded themselves in, refusing any help. It took a group of politicians and religious leaders to get together and drive to the village to meet with elders there in the hopes that the Red Cross could have the time and space to educate the village about the dangers.
The success of future public health campaigns in places like West Africa, Roberton says, requires stronger and more trusting relationships between health workers and community members, so families will believe and accept future campaigns’ important health messages.
“In order to control the current outbreak and prevent similar ones in the coming decades, health professionals in Guinea and other countries must take urgent steps to cultivate the confidence of community members in the health system and in emergency responders,” he says.