Followers of this blog will have noted its interest in the current Ebola outbreak in West Africa. Parallel Twitter exchanges have criticized its advocacy of the importance of a social science contribution to the international response. The blog’s analysis has, however, received an extraordinarily blunt endorsement from the panel created by WHO itself to review the outbreak’s management. In five paragraphs of their report (#55-59), the panel set out the case for the social science contribution – and underline the extent to which its neglect really did cost lives.
Predictably, this finding has been largely ignored by WHO and other commentators. It is, though, so important, and has so many other resonances for the public role of social science, that it must become part of the working knowledge of any national or international agency dealing with pandemic or emerging infectious diseases.
The panel declare themselves ‘surprised and dismayed’ by the poor community engagement in the early months of the Ebola outbreak, which is continuing. The result was a lack of culturally sensitive messaging where ‘medical anthropologists and other social scientists should have been better utilized.’ Words like ‘surprised and dismayed’ are almost unheard of in documents of this kind, where more diplomatic language usually prevails. Translate them as ‘astonished and appalled’, and you will get closer to the strength of feeling expressed here. The same tone continues:
‘Given WHO’s extensive experience with outbreaks, health promotion and social mobilization, it is surprising that it took until August or September 2014 to recognize that Ebola transmission would be brought under control only when surveillance, community mobilization and the delivery of appropriate health care to affected communities were all put in place simultaneously.’
For at least five months people died throughout the affected countries because the right expertise was not brought to bear.
The need for such expertise was entirely predictable:
‘The difficulty of effectively engaging communities was a problem that could have been foreseen had a social and political analysis been conducted to complement the epidemiological assessments.’
Epidemiology alone can only get so far in outbreak control. Community engagement is critical, an ‘absolute necessity’ in the panel’s words. They conclude:
‘Social science expertise is critical to understanding local beliefs, behaviours and customs. These experts can inform those who are at the front line, enabling them to better understand the context and work more effectively with communities to change behaviour. This must become part of standing protocols and standards for health emergencies.’
Social science is a core resource for WHO, and other organizations involved in public health emergency response. It is not an add-on, an afterthought or a secondary player to the real work of biomedicine. It is a necessary condition for successful management of infectious disease outbreaks anywhere.
In fact, the report also points to a much wider set of issues that would benefit from social science input. It is highly critical of WHO’s established organizational culture, which is clearly unfit for purpose in public health emergencies. Some of this is due to resource limitations and the constraints created by member states – but not all. Silo thinking means key lessons were not transferred from the experience of the 2009 influenza pandemic, and, I would add, from the management of HIV/AIDS since the 1980s. Institutional responses to infectious disease cannot be reinvented every time a new viral threat emerges: we only had to develop the wheel once. WHO clearly needs to involve social scientists who understand knowledge management, knowledge brokering and organizational memory.
WHO’s own communication skills are also criticized:
The Panel is clear that WHO failed to engage proactively with high-level media and was unable to gain command over the narrative of the outbreak. This weakness had repercussions for many areas of the response; a better approach to communications could have improved confidence in WHO and reduced levels of fear and panic…Communication of risk and promotion of appropriate safe behaviours need to be much more thoroughly researched and documented, so that WHO and other entities engaged in this activity have a better impact in their risk communication efforts to the public.
This will require engagement with the social sciences of risk and communication to enhance skills at both strategic and operational levels.
There is a gap in the panel’s discussion of the need for a ‘platform for the development of diagnostics, therapeutics, and vaccines’. This platform must also have social scientific input to ensure that the resulting products are designed in ways that make them acceptable to end-users. The ruthless focus on user experience that marks ICT industries has yet to make much headway in biomedical research but is just as critical. There is no point in doing great science if the results cannot be taken into practice.
The Ebola Interim Assessment Panel may have performed even more of a service than it recognized in identifying the importance of the social sciences for effective responses to pandemics and emerging infectious diseases. If its lessons are going to be adopted, however, the report cannot just lie on the table, alongside the report on the 2009 influenza pandemic. WHO must ensure that it has a strong in-house team of social scientists who are actively networked with the wider international community of academics in the field. This team should be led by a senior figure with membership of the agency’s core management group.
No-one should take pleasure in being proved right when so many people have died and so many health professionals, West African and international, have shown exceptional courage and commitment in the face of acute personal risks. We can, however, try to ensure that the spirit of professionalism, and the lives taken by the Ebola virus, have not been given in vain. The best memorial to those who have struggled in West Africa for the last two years is a reconstructed WHO that is capable of learning from experience and working more effectively in the future. The social sciences, collectively, have a big part to play in this.