Author: Heidi J Larson, PhD, London School of Hygiene & Tropical Medicine and Dept. Global Health, University of Washington, September 5 2014 - The myriad of challenges contributing to the persisting spread of Ebola in West Africa - the biggest Ebola outbreak since the viral haemorrhagic fever was discovered in 1976 - echo some of the biggest obstacles which continue to challenge the global efforts to eradicate polio.
Misinformation, strong traditional beliefs, and distrust of health workers - sometimes resulting in aggressive attacks on those trying to help - have all challenged the polio eradication initiative. The difference is that, while polio can be disabling for life, Ebola is far more fatal. As of August 28th, there have been 3069 cases, with 1552 deaths, across the four affected countries: Guinea, Liberia, Nigeria and Sierra Leone.
Both Ebola and polio have been declared International Public Health Emergencies by the World Health Organization (WHO) this year. On the 5th May 2014, WHO Director-General Dr. Margaret Chan announced that “the international spread of polio in 2014 constitutes an ‘extraordinary event’ and a public health risk to other States … If unchecked, this situation could result in failure to eradicate globally one of the world’s most serious vaccine preventable diseases.”
On the 5th August 2014, Dr. Chan made a new announcement. This time, the Emergency Committee advised that “the Ebola outbreak in West Africa constitutes an ‘extraordinary event’ and a public health risk to other States.”
Two “extraordinary events” are posing international health risks - both exacerbated by distrust, strong cultural traditions, politics and violence. None of these are the expertise of the health systems and medical professionals. What polio learned, not unlike the early AIDS response, is the importance of working collaboratively with a range of expertise as well as partners who are involved in the daily lives of those affected - local religious institutions, youth or women’s groups, schools, businesses, and local media, to name a few.
One decade ago, Nigeria resolved an eleven-month boycotting of polio vaccination in the northern part of the country after extensive efforts to overcome the rumours and distrust that drove the boycott. Rumours abounded that the oral polio vaccine caused sterilization, and there was widespread distrust of the motives of the vaccination campaign and those who delivered it - especially in the face of other health issues that were perceived to be neglected. The Kano state governor who called the boycott was himself driven by a mix of political motives and distrust of outsiders. Although the boycott finally ended, underlying concerns lingered, and new distrust led to the killing of nine polio workers in northern Nigeria last year. Pakistan - another of the three remaining polio-endemic countries - has had over 80 polio-related killings and is now facing the third year of a boycott against polio vaccination in a Taliban-controlled area. The Nigeria boycott not only allowed the resurgence of polio locally, but led to over 1200 Nigeria-strain polio cases spreading globally, as far as Indonesia. Similarly, the northern Pakistan boycott has allowed the persisting spread of polio, including to Syria where the travelling polio found fertile ground amidst the conflict, a destroyed health system, and fleeing migrants further contributing the disease spread.
In West Africa, reports on denial and disbelief that Ebola even exists, as well as perceptions of witchcraft and sorcery at work, may seem incredulous to well-intentioned and experienced public health experts and medical professionals, but these beliefs are powerful drivers of behaviours that can amplify rather than attenuate the spread of disease.
One of the most important things that the global polio eradication initiative has learned is the importance of engaging local communities, trusted community members, and local traditional and religious leaders. Building on previously-existing trust networks has been key to overcoming challenges such as the Nigeria boycott. The challenge is finding locally trusted community leaders who also understand the public health issue and can somehow translate needed public health practice into locally accepted solutions.
In Sierra Leone, one local newspaper reported that a Paramount Chief in the north had asked communities to help raise awareness about the Ebola and he temporarily banned secret society activities, hunting and selling bush meat, and conducting traditional burial ceremonies, appealing to the community for cooperation. In polio’s experience, the voice of local leaders is more accepted than from central government or from international bodies. Trust is local.
The winning combination for both diseases will bring together both global and local expertise and what anthropologist Clifford Geertz called “local knowledge.” All sides need to not just build trust, but earn it. The mistrust and fears holding back progress in containing the Ebola outbreaks and in achieving polio eradication will never be overcome without a strong principle of trust underlying all the important interventions needed.
Let’s not wait for another crisis for public health to build relationships outside of health systems in time of peace.
 The Salone Monitor, August 18 2014.
Image credit: The Salone Monitor