Photo by Morgana Wingard/USAID
Africa / Ebola

Diagnosing Culture Before Treating Disease: Challenges in Fighting Ebola in West Africa

As the Ebola epidemic becomes more widespread and deadly in West Africa, some of the flaws in the current containment strategies are more evident.  While Western governments are directing billions of dollars in aid, those efforts often fail to take into account local attitudes and health behaviors.  Increased sensitivity and understanding of West African cultures would improve the effectiveness of the efforts underway.

The outbreak originated right outside a village near Guéckédou, Guinea and quickly thereafter spread to Liberia, Nigeria, Senegal, and Sierra Leone. Since March, over 10,000 people in West Africa have suffered from the disease and over 4,900 people have died. Even more alarming is that there is little indication that the epidemic will be stopped in the near future. The New York Times estimates that the outbreak will likely last for up to a year and a half and could infect hundreds of thousands more people.

The Center for Disease Control and Prevention and President Obama have been criticized in recent weeks for poorly handling the few cases of Ebola that occurred in the United States. However, it is illogical to focus the attention, as the media has done, on the American cases when the African cases are much more numerous, severe, and unable to be fully treated because of a lack of resources.

The efforts of the United States to help contain the outbreak in West Africa have included sending military personnel, bags to contain infected dead bodies, and money.  While the support is generous and has been helpful in treating patients in hospital systems, the strategy has flaws that will prevent public health officials from effectively containing the outbreak. The current efforts do not take into account the cultures and societal structures of the West African countries where the outbreak is centered, a flaw that is present in the United States health care system as well.

Firstly, the current interventions fail to consider the distrust that many West Africans have of the health care system. Intervention efforts of Western countries, including the US, have mainly consisted of sending personnel and supplies to hospitals. This is not a completely effective strategy since many West Africans are suspicious of physicians and thus are unlikely to seek care from the hospitals. In fact, many individuals in Liberia, Nigeria, Senegal, and Sierra Leone, where the disease is most prevalent, are blaming physicians for the spread of the virus. Therefore, focusing resources in hospitals and in supporting physicians is an incomplete solution.

Furthermore, interventions have not taken into consideration the trend of infected individuals going to witch doctors instead of health care professionals. Many West Africans believe that Ebola is a bad spirit, a manifestation of the devil, or poisoning. The distrust of and nonbelief in the health care system prevents health care workers from effectively dealing with the outbreak through the health care system, which is the standard and most straightforward method of intervention. In order to achieve the containment outcomes that they seek, international public health officials will have to create more tailored and effective containment strategies.

Insensitivity to cultural factors in considering health interventions is an issue within American society as well. Drastic health disparities between people of different races, ethnicities, socioeconomic statuses, sexual orientations, and education levels are present in the United States. These disparities stem, in part, from the inability of the health care system to account for individual personal backgrounds. Physicians struggle to give medical advice that takes into account various medical beliefs that differ from traditional Western medicine. Many doctors also are not well equipped to tailor medical advice to the living and working conditions, educational level, or English language abilities of their patients. These challenges are similarly evident in the American effort to contain the Ebola epidemic as these interventions as well are not being tailored to the West African culture and society.

Western intervention efforts also could be improved by taking into account the breakdown of the West African health care systems. The international public health community has not fully addressed the issue of “significant declines in most public health measures” that the World Health Organization has identified. These declines are occurring because hospitals are closing, health care workers are wary of admitting patients who may or may not be infected with Ebola, and individuals do not want to go to the hospital for other health concerns for fear of contracting Ebola. As a result of not having access to health care, people are dying of malaria, diarrhea, pneumonia and strokes. The extent of this problem is vast and deleterious, and thus needs to be incorporated in the efforts to manage the Ebola outbreak. Recently a lack of vaccinations led to a small measles outbreak in Liberia. Moreover, pregnancies have been very affected. In Liberia, the percentage of infants delivered by a skilled birth attendant has dropped fourteen percent in the last year and the percentage of women who received prenatal care within six weeks of confirming their pregnancies dropped sixteen percent. One woman, named Comfort Fayiah went into labor in Liberia and could not get into a medical facility so she was forced to give birth in the dirt outside her church. Many officials have begun to take notice of this issue. As Shledon Yett, the Liberian representative for UNICEF stated in an interview by the Washington Post, “If you stub your toe now in Monrovia, you’ll have a hard time getting care, let alone having a heart attack or malaria…It’s a tremendous threat to children and a tremendous threat to families.” In an interview with the Washington Post, Joanne Liu, the president of Doctors Without Borders gives the grim report that “Mounting numbers are dying of other diseases, like malaria, because health systems have collapsed…Today, Ebola is winning.” However the words have not been turned into actions. Western efforts must work to take into account the incredibly acute impact that the decline of the health care systems has had on West Africans.

The need for a containment strategy that is much more aligned with local culture is clear. Support from Western governments arrived too late and have focused on supporting the African health systems.  While the support is having an impact on the quality of care for many Ebola patients, it is not effective in reaching the many West Africans who are distrustful of the health care system and believe in alternative methods of medicine such as witch doctors. Furthermore, many hospitals are shutting down because of Ebola, causing other health issues to go untreated. The lessons we are learning about tailoring health care delivery in the context of culture is a lesson that the United States is also learning at home. The United States must recognize and respond to these critical difference in beliefs and behaviors in order best contain the crisis of the Ebola epidemic as well as correcting endemic problems in its own healthcare system.