The World Health Organization Executive Board has just met to prepare for the May 2015 World Health Assembly. The board had a special session on the Ebola outbreak, which demonstrated how little its leadership have learned about the challenge of managing future pandemics and emerging infectious diseases. The physicians who run WHO are clearly struggling to accept their own organization’s evidence about the best strategy for dealing with the next attack from a mutated human virus or an animal disease that has crossed the species barrier. Their failure has already cost many lives in West Africa. How many more will be lost next time because the right lessons have not been learned?
The director-general, Margaret Chan, presented a report to the special board session. She accepted that WHO’s response had been slow but claimed that many of the factors involved in the spread of the disease were unpredictable: mobile populations, porous borders, air travel, and compassionate care of the dying. This is simply incorrect. All of these have been implicated in HIV transmission in Africa and are well-documented in the social scientific literature. Several of them, air travel in particular, were also associated with the transmission of SARS and have been incorporated into pandemic influenza planning. Only a silo mentality could miss their relevance to other emerging infectious diseases.
Dr Chan acknowledged the international effort to provide personnel and treatment facilities, and develop vaccines, therapies and diagnostic kits. Many individual health professionals have, indeed, accepted great personal risk and some have paid the ultimate price for their altruism. However, Dr Chan credits these efforts with turning the tide or ‘bending the curve,’ a questionable conclusion that leads into recommendations for strengthening the medical bureaucracy at WHO, training more local health professionals and encouraging the development of new biomedical products. Although she nods to the importance of society and culture, she clearly does not appreciate the priority that this should receive.
There is, though, abundant evidence for that priority in WHO’s own background paper for the meeting. This determines that the persistence of the outbreak had two causes: one was the virus but the other was “the fear and misunderstanding that fuelled high-risk behaviours.” It estimates that 60-80 percent of Ebola transmission in Guinea and Sierra Leone was linked to traditional burial customs. Burial teams using local community members met less resistance than those composed of outsiders. The lists of contacts to be traced were interpreted as ‘death lists,’ especially when carried by outsiders. Incoming health professionals failed to collaborate with traditional healers, who were often more accessible and more trusted than government health systems. Public health communications were poorly designed and may well have promoted rather than reduced risk behavior. Indeed, the paper comments “when technical interventions cross purposes with entrenched cultural practices, culture always wins.” It concludes that “community engagement is the one factor that underlies the success of all other control measures.”
Nevertheless, the background paper still fails to draw out the implied need for better use of the social sciences. Anthropologists are not mentioned until May 2014, when the outbreak was already well-established, and the paper gives far more weight to the engagement of the international pharmaceutical industry from September 2014. Again, this is in the face of evidence such as the interview with Cheikh Niang, a Senegalese medical anthropologist, published in the WHO Bulletin’s February issue. He notes, for example:
Medical experts don’t have the tools or the expertise to deal with (community resistance). They only see things on the surface and failed to see the underlying cultural realities. I found buckets of chlorine for hand sanitization in the places, doorways etc., that were controlled by men, not women. Women had not been consulted on their position but given their caring role for the sick, they were particularly vulnerable to infection. I also found that people were fed up with being told about hand sanitization, they knew how Ebola is transmitted but wanted to express themselves, be heard and take charge of their health matters and not be told how to do this in a paternalistic way.
As such observations were incorporated, interventions became more effective. Nevertheless, it was only in December 2014, nearly a year after the initial case, that the first properly designed community campaign was launched, in western Sierra Leone, with the involvement of religious and traditional leaders, and popular entertainers: “This time the government made sure that calls to the Ebola hotline would be answered, with callers referred to local people, local services, local help and local success stories.”
As the importance of community engagement has become better understood, infection rates have fallen. It is questionable whether there will be enough cases left to conduct trials of the vaccines and other therapies that are only now becoming available. If the outbreak had been better managed initially, the huge biomedical research effort may have been unnecessary rather than pointless. At best, it may eliminate the last cases in this one, much as vaccines always have done.
The Ebola outbreak’s real lesson is that biomedical interventions will always come late. Social interventions can break the transmission of infection and leave very little for biomedical research to add. New vaccines may help to prevent future outbreaks of a disease – but they will not help with a new disease or a mutated version of a known one. There is an irreducible lag between the first case appearing and a vaccine or therapy being produced. The first duty of the WHO is to promote the effective use of the social sciences in understanding, and then interrupting, disease transmission. Everything else is an afterthought.
Making friends with social scientists is less glamorous than rubbing shoulders with global political leaders, snuggling up to multinational pharmaceutical companies or helping billionaire philanthropists tell nice stories about themselves at Davos. Unless WHO start doing it, however, I, for one, will need to be convinced that they are seriously interested in saving the lives of the ordinary people who are the victims of novel infections. Only when the WHO leadership includes a credible advocate for social science, can we really conclude that the world is a safer place.