Skip to 0 minutes and 14 secondsPETER PIOT: Up to now, every single outbreak was fairly contained in time and place and was brought under control after a few months. And usually there were like 40, 50 deaths, sometimes up to 300. But that's it. And cumulatively we've only had 1,500 deaths from Ebola, which means 40 a year in 38 years. So you can't say it was a public health problem. But now suddenly, we are confronted with not just an epidemic, but with a humanitarian crisis, and in West Africa, where never before has there been a known Ebola outbreak.
Skip to 0 minutes and 54 secondsIt is a combination of the one hand, countries that are coming out of decades of civil war or corrupt dictatorship, meaning that everybody was on one side or the other. There's no trust in government, no trust in messages. And one of the implications was that people wouldn't even believe that there is an epidemic or that there is a virus involved. Secondly, the health system, the health services, were collapsed because of civil war. And most professionals in at least Sierra Leone and Liberia had left the country. Liberia was left with 51 physicians in 2010. Some of them worked in the Ministry of Health, so they're not that useful for direct clinical care, meaning we have one physician per 100,000 population.
Skip to 1 minute and 49 secondsSo the whole system is being rebuilt but not yet to the point that it could confront an epidemic. And thirdly, there are strong beliefs in disease causation, where there is not much space for infectious agents. But it's about witchcraft, about factors that are out of control of individuals or under supposedly the control of individuals who want to do harm to someone else. And finally, I would say the fundamental reason we have this massive epidemic is the lack of response initially, the denial. It took, of course, three months to diagnose that this was Ebola. And that I can understand because you can only find what you're looking for, and nobody expected Ebola in West Africa.
Skip to 2 minutes and 44 secondsBut having put that aside, it took another five months, 1,000 deaths, and then two Americans who were repatriated before this was called a public health emergency. And there is no excuse for that. And that was a result of denial and not facing the reality by the governments, but also by the international community.
Skip to 3 minutes and 8 secondsREGINA BASH-TAQI: We had the 10-year war in which the large majority of people really suffered. But they also saw a small minority prosper, if you like. And that happens in every war, whether it's the contractors who get the opportunities to rebuild the nation or, indeed, NGOs who come in to help after the war. But what people see is that other people are prospering while they are suffering. And when that happens repeatedly, as it has now for Ebola, people just get a sense that when something goes wrong, it's something that is kind of possibly a conspiracy from the minority that benefits from it.
Skip to 3 minutes and 53 secondsSo for example, when Ebola first broke out in Sierra Leone, a number of people, including highly educated people-- because of my role in public health, I started saying to them straight away, you really must be carefully, you must do this, you must do that. And they said to me, oh, no. It's nothing. It's just the government raising a scare so that they can get donors to put resources into the country.
Skip to 4 minutes and 21 secondsYASMIN JUSU-SHERIFF: Due to the fact that for over several years during the civil war in Sierra Leone, which lasted from 1991 until 2002, the health system had collapsed. And there was a lot of damage caused to the government services during that time. We find that people don't necessarily look for their health care to be provided by the government. They tend to make their own arrangements to get health, even though in the recent past, the government has had a number of initiatives to particularly address the issue of maternal and child health and the free health policy.
Skip to 5 minutes and 21 secondsIn reality, because of problems with the system and the provisioning and perhaps corruption and inefficiency, people don't look, I think in many cases, to the national health provision for their health care. And so when Ebola came, people felt that this is something that they would deal with at home the way they usually tend to deal with their illnesses. And they looked to call on the nurses to come and treat them at home. And I think therein, perhaps, some of the problem lay.
Skip to 6 minutes and 10 secondsAnd because there's a huge shortage of doctors, a very limited number of young doctors working in the government health service, perhaps who didn't have knowledge or experience of something like Ebola, there wasn't even, for those people who did heed the call to go to the nearest health centre, they went there and found that the services were not available.
Skip to 6 minutes and 39 secondsREGINA BASH-TAQI: If you think about it, here's a health system that is quite weak. So we have like two doctors in Sierra Leone for every 100,000. The health systems have been weak for a long time. And people have learned not to trust those health systems, not necessarily for any other reason than the fact that they have poor health outcomes. So people start to think of hospitals as a place where you go to die. And if they don't trust that health system, then they don't want to go there. And now, if you have this and you know that there is talk of a deadly virus, do you then go to that hospital?
Skip to 7 minutes and 14 secondsNo, you're not sure, especially if you're unsure that it may be malaria, in which case you think, well, what if I go there and then I get infected? So these are the true fears that people have.
Skip to 7 minutes and 24 secondsPEARLYN MAMULU: Liberia recently got out of a civil war, and so there's not a lot of trust amongst the people in Liberia. When you say one thing, they don't believe you. And so when the outbreak happened, I remember I was telling my staff, and they said that they didn't believe that there was a thing called Ebola and let alone that it was in Liberia. I don't know if it was because of the war. I don't know if it's because of the government or what, but I think it's just our nature not to believe something that we hear first off. We have to see it for ourselves.
Skip to 8 minutes and 5 secondsAnd I know that it's that way because I do the same thing as well. If you tell me that it's raining fireballs outside, I'm not going to believe you. I will go outside, and I will see that it's raining fireballs, but I still won't believe you. The only way I'll believe you is if a fireball hits me on my hand, and I'll say, OK, it's really raining fireballs. And that's how Liberians are. We don't just take things right. We have to see someone catch the disease and die from it before we believe, OK, there's Ebola, and it's in our country. So I don't know where that comes from or how that came about, but that's just how it is.
Skip to 8 minutes and 42 secondsI had a staff meeting, and like, there's a disease called Ebola. And it has spread. I said, first it started in Guinea. Then it went to Sierra Leone, and now it's here in Liberia. And I was informing them on what usually happens when you catch the disease, like if you are excess vomiting. I was telling them the symptoms. And they laughed at me. They all laughed at me. The said, Boss Lady, there's no such thing. They just want us to be "queen people." And what we mean by queen is to be Western. Because they were saying stop eating bush meat and all that stuff. And so they took it as, oh, they just want us to be queen.
Skip to 9 minutes and 23 secondsThey don't want us to live the life that we're used to living. They just want us to be like them. There's no such thing. And they laughed. And as the cases grew, they were like, OK, maybe it is around. But it's not going to affect us. And then right before I left, it was within my zone. And then they were like, Boss Lady, there's Ebola. And I'm like, I was telling you guys. So it took a long time before they were convinced.
Skip to 9 minutes and 54 secondsYASMIN JUSU-SHERIFF: There is still a lot of suspicion about the conspiracy. I think some of the conspiracy has now moved to making allegations that Ebola came from a Western conspiracy, that somebody spilled something in the lab, that it was deliberately introduced by Western researchers, not anymore that it somehow came from the government of Sierra Leone.
Skip to 10 minutes and 25 secondsPEARLYN MAMULU: A lot of Liberians believe that the reason why Ebola has affected Liberia very harshly is because of the things that we've done, like we're paying for our sins by having this.
Skip to 10 minutes and 44 secondsAnd that's kind of typical of a lot of West Africans. Because I remember when I was in Nigeria when it hit Nigeria, the same thing. They were like, oh, this is because our government is corrupt. That's why we have Ebola. So that's how they usually perceive it. They perceive it as, OK, we're reaping what we're sowing. We're reaping the effects of our corruption, our bad behaviour.
Skip to 11 minutes and 13 secondsREGINA BASH-TAQI: There were lots of rumours. And it's not unlike any other situation in which there are kind of conspiracy theories. So there were lots, including, actually, a lot of religious and cultural ones, so a belief, for instance, that it's a curse and that maybe Sierra Leoneans have done something wrong. But I see that as an opportunity for religious leaders to then sort of use that. They have enormous influence. And they also have enormous access to people, to use that to say, OK, we understand that these are the beliefs that people have. Well, how can we integrate that with the messaging for prevention of the transmission of the virus?
Why this outbreak is different: the social and political context of the 2014 Ebola outbreak
The largest previous Ebola outbreak involved 425 reported cases. By the end of 2014 there were approximately 20,000 reported cases in the West African outbreak. The spread of Ebola has been facilitated by weak health systems, slow reaction of governments in affected countries and the international community, distrust of foreigners and governments by the public, and traditional beliefs about the source of diseases. Such factors combine to drive behaviour which may be viewed as illogical to those who come from a different worldview. It is necessary to understand the contextual factors contributing to the spread of the virus in order to contain it.
Speaking to the BBC in December 2014, Margaret Chan,1 Director General of WHO, while acknowledging that WHO had failed to act quickly enough, emphasised:
‘There was no trust in the community. When they see people in space suits coming in to their village to take away their loved ones they were very scared… and they hide their sick relatives at home. They hide dead bodies at home. And these are extremely, extremely dangerous in terms of spreading the disease…. We must bring the community on our side to fight the Ebola outbreak.’
In the video, Professor Peter Piot describes the factors that have combined to make this outbreak different from all previous Ebola outbreaks: recent wars in the region; distrust of government; weak health systems; traditional beliefs in disease causation; and a slow response. Three residents of the region, Regina Bash-Taqi and Yasmin Jusu-Sheriff from Sierra Leone and Pearlyn Mamulu from Liberia, discuss the issues from their perspectives, highlighting distrust as a basis for denial, the changing conspiracy theories, and the problems with healthcare.
Historical and Cultural Factors
Sierra Leone and Liberia have both been through years of civil war and Guinea has suffered coups and political violence. The wars decimated health sectors, rendering them overly reliant on outside aid.2 During the wars and post-conflict period, large proportions of state budgets have been dedicated to shoring up security forces to the detriment of health sectors3. Liberia, Sierra Leone and Guinea ranked extremely low in the 2012 human development index, at number 174, 177 and 178 respectively, out of 185 countries. Estimated life expectancy in Sierra Leone was 48.1 years, the lowest in the world.4
The consistent lack of investment and leadership in health infrastructure has led the citizens in West Africa to believe that their governments do not care about their welfare.5 Liberian journalist Mae Azango6 described the Liberian government’s handling of the crisis early in the epidemic: ‘[T]he government didn’t care. Only normal people were dying, poor people were dying’. She reported that it was only the death of a member of staff of the Finance Ministry that triggered an official response, a response which many viewed as too late. She goes on: ‘The people feel the government downplayed them and they say the government isn’t doing anything. Money that comes, they don’t know where that money goes. So they are angry.’ These sentiments were also expressed by Liberian health workers on strike from an Ebola Treatment Unit (ETU), who were promised but then denied increased pay for risking their lives. One health worker argues:6
‘This government has been a failure to the Liberian people. They sit in their offices and just make decisions against us. The government feel they’re in a secure position where they can’t get easily infected with the virus and the common people are getting infected, so they don’t care.’
Mistrust of government is also common in Sierra Leone. Sierra Leonean lawyer and women’s rights activist, Yasmin Jusu-Sheriff, states,7
‘Because the districts in the East, especially Kenema and Kailahun are opposition strongholds, the people felt that, they didn’t expect much from the government. And there were a lot of complaints that the government was not providing the PPEs [personal protective equipment] to the nurses who worked in the districts, they were not providing funds for sensitisation [awareness-raising], in those districts. So those people felt very much that they were on their own.’
The mistrust also leads to denial. Jusu-Sheriff states,7
I know from speaking to family members in Kailahun District, that there was a widespread feeling amongst people that, there was a lot of denial. They felt, in Kailahun, young people and old people, that this was a ruse by the government, to try and prevent them from being counted in the national census. In other parts of the country later on, some people felt that it was being exaggerated, so that, I’m not quite sure how, that somebody could make money out of it. […] People didn’t understand and see that it was something very serious. They felt that somewhere along the lines someone was not telling them the truth.
In March 2014, Liberians were given contradictory information on whether there were any cases in Liberia, leading many to distrust Government announcements on Ebola, and the Government’s interest in the outbreak.8 Many Liberians viewed the Ebola epidemic as something made up by their government in order to receive donor aid, to be divided among those who have political power.9
There are many conspiracy theories. Some, while accepting the virus as a ‘real’ phenomenon, question its origin. For example, some believe that the disease was introduced to Africa by white foreigners, and that doctors are intentionally infecting West African citizens with Ebola in order to carry out drug tests.13 Others argue that a new strain of Ebola was deliberately created by a pharmaceutical company in order to benefit financially from selling the cure, which had also been created. Such theories can be contextualized within the mistrust that some West Africans feel toward white foreigners, due to historical wrongs including colonialism and the slave trade.14
Barriers to seeking health care
Within weak health care systems, hospitals are often in disrepair, overcrowded and chaotic.5 Care can be prohibitively expensive and patients rely on family members for provision of food, medication, and supplies such as dressing, antiseptics, and other materials.10 Some Liberians were initially unwilling to bring sick relatives to Ebola care centres as they feared they would not be provided with food in the centres.8 Citizens of Guinea, Sierra Leone, and Liberia recognise that hospitals in their countries are ill-equipped with poor sanitation and a low quality of care. In those circumstances, the decision to avoid existing health facilities can be viewed as a rational choice.
The distance people have to travel to such facilities presents another access barrier.10 Many rural villages are not connected by roads suitable for motorised vehicles.
Rather than making an arduous journey to a dispensary or health care centre on foot, rural Sierra Leoneans commonly seek help from healers who are mobile, visiting the ill in their own homes. Ferme10 notes:
‘[F]or most rural Sierra Leoneans, getting to hospital involves long, uncomfortable, and expensive journeys, navigating Kafka-esque bureaucracies. Repeated payments are required and long waits are interspersed with inconclusive interactions with medical personnel. After all this, one often returns home as one had left or dies from the journey’s hardships and lack of care.’
For those willing and able to transfer family members to hospitals, some report being turned away upon arrival because the Ebola Treatment Units are already full. For example, Robert, whose brother died of Ebola in their family home in Liberia, reported that he had brought his brother to hospital, but the hospital would not receive him.6 As a result, Robert cared for and fed his sick brother, and carried his body outside the family home after he died. He explains why he did what he did, despite warnings not to come into contact with those who have Ebola symptoms:
‘That’s my brother so I have to be by his side. No one could be allowed to go near him, helping him to eat, feeding him. Taking care of him, that is brother love. There was no one else to console him, so I had to be by his side.’
The fear of Ebola has caused hospitals to turn sick people away, even if those who present at hospitals do not have Ebola symptoms. The daughter of a member of parliament in Liberia, died of an asthma attack after the hospital refused to admit her due to fears over Ebola. He states,6 ‘They killed my daughter. The institution killed my daughter. The government killed my daughter. The Ebola crisis has exposed how bankrupt our health system is’. (The impact of Ebola on treatment of other diseases is discussed further in a later step.)
Traditional explanations of disease form another barrier to seeking health care, and give rise to rumours and myths about Ebola. One myth is that Ebola is due to witchcraft. Attributing sickness to witchcraft is prevalent in parts of West Africa, particularly isolated rural areas.11 Jusu-Sheriff notes that the belief in witchcraft is particularly strong in the Port Loko and Tonkolili Districts. According to Bolten,12 there is a belief in northern Sierra Leone that people become infected via invisible witches with guns who ‘shoot’ their victims with Ebola.
Conspiracy theories about the treatment of victims’ bodies by the health staff at treatment centres create another barrier to seeking care. For example, stories have circulated that organs are being harvested from the dying in order to sell them in the international market, and that the reason the public cannot view the bodies of victims is because body parts have been removed for witchcraft.
Further issues around using Ebola care centres, including stigma and infection risk, are discussed in week 2.
It is important to recognize that not all citizens of the countries most affected by Ebola give credence to myths and conspiracy theories on the origins and treatment of Ebola. Speaking in December 2014, Jusu-Sheriff states,7 ‘People do understand that there really is an illness which is different to cholera and malaria, and these other things, in many parts of the country’.
© London School of Hygiene & Tropical Medicine