....wrong health seeking behaviours of Africans

It is no news to state that West Africa is confronted with the largest and most severe Ebola outbreak since the virus was first identified in 1976. The current outbreak is the most severe Ebola virus outbreak recorded in terms of human cases and fatalities. The outbreak began in Guinea in March 2014 and has since spread to Liberia, Sierra Leone, and in the last few weeks, in Nigeria. On 8th August 2014, the World Health Organization (WHO) declared the outbreak a Public health emergency of international concern. A total of 1779 suspected cases with 961 deaths have been reported by WHO as of 6th August 2014, of which 1134 cases and 622 deaths have been laboratory confirmed to be Ebola.

This week, the Nigerian Minister of Health, Prof. Onyebuchi Chukwu announced to a very scared country that Ebola Virus Disease (EVD) is now considered a national health emergency and proposed the deployment of an action plan to contain it. By this singular step, Nigeria have learned a quick lesson from the experiences of the Sierra Leonean and Liberian authorities and decided not to wait for the cases to escalate into full epidemic proportions. The Nigerian public health authorities deserve commendation. Given its broad social, economic, psychological and security implications, no one African country has the capacity to curtail a full EVD epidemic. It is therefore critical for the West African sub-regional body (ECOWAS) to come out with a cogent action plan that cuts across international, national, interagency, states, and community levels.

The deadly EVD has arrived in a sub-region that is already struggling with weak health systems. Answering questions from a BBC reporter, the MSF coordinator in Liberia did not mince words; “official figures were under-representing the reality; the health system is falling apart". No doubt, West Africa's rudimentary healthcare systems are swamped by Ebola. The already over-stretched health workforce is running away with top speed from the very patients they committed their lives to serve. Liberia and Sierra Leone have already deployed troops in the worst-hit areas in their remote border region to try to stem the spread of the virus that has no known cure.

But EVD also arrived in West Africa with its own ‘usual suspects’; rumors and conspiracy theories, largely driven by fear. Not so different from the sub-region’s response to the HIV epidemic a few years ago. In the early days of HIV, people accused the Americans of spreading the virus via second hand clothes, aiming to kill Africans. In Ghana, the local healers who came up with local therapies were many. The worst belief was to sleep with a virgin. Last Sunday in church, I was confronted with similar reasoning. One colleague church member insisted that Ebola was ‘created by the Americans’ and another added that the “Americans already have a secret cure” and are planning to make money out of the outbreak. In the past week, social media has been busy with messages encouraging people to bathe with warm water laced with some quantity of salt. Others are encouraging us to chew bitter cola as a prophylaxis against Ebola, a theory that is credited to Professor Maurice Iwu of Nigeria. Understandably, we learned that the price of bitter cola has already quadrupled in and around Lagos.

Experts in public health have every reason to worry because, just like previous rumours on HIV, these remedies do not meet concrete scientific requirements. Some authorities have argued that the use of bitter cola should not be condemned out right, no matter how minimal its antiviral, antibacterial or antimicrobial effect recorded through in-vitro laboratory experiments. Arguing that such precautions are better than nothing, especially in our parts of the world where hygiene is not very primary among over 80% of the population. Encouraging people to bath with salty water or even washing hands with it has some disinfecting effect too. Indeed, unlike disinfectants and hand sanitizers, salt and bitter cola are common items found in virtually every home and people can easily lays hands on them. And salt indeed has some sterilizing or disinfecting properties; rubbing salt on your hands is almost as effective as using a sterilizer.

However, the worries rest on the unproven claim that bitter kola or saline water can 'cure' EVD. "Cure" is grossly misleading and must be debunked rapidly before we encourage the wrong health seeking ideograms as we push to curb this deadly disease. A significant number of laboratory tests never measure up to final clinical phases. Secondly, the salt-bath has a trado-religious origin to it. It is not the same as using salt or saline as a disinfectant. For anyone to wake up in the wee hours of the morning to bathe with salt water and drink salt due to misinformation has already caused untold havoc in some parts of the Ebola afflicted countries. We need to give the right health information.

The International Public Health Forum (IPHF), in response to these rumours and misinformation sent out a public health advisory that Ebola threat is real and people should aspire to stay healthy with the ‘right information’ from credible sources. It has emphasized that EVD is a class IV containment disease, and as such, where patients are being treated, or specimen from them are managed, are considered high risk environment, and the disease portends a grave threat to the world if not dealt with effectively. Good personal hygiene like regular hand washing and basic sanitation like household and facility cleaning with disinfectant, eating well cooked meat (especially wild animal), as well as non-body contact with a very sick Ebola victim or a corpse remain the key prevention mechanisms . The main reservoir remains the fruit bat.

For those of us in public health practice, the medical odyssey of the two Americans Dr. Kent Brantly and Nancy Writebol who were infected in Liberia with EVD and being treated at Atlanta’s Emory Hospital by US Centers for Disease Prevention and Control (CDC), offer glimmers of hope for a disease that currently has no cure. In the past week, we saw massive movements in the biotech sector on early-stage Ebola drugs, galvanized by the good response of the two Americans to an experimental drug by Mapp Biopharmaceutical (zmapp). Another firm Tekmira has a drug that has gone further down the line of testing which the US Food and Drug Agency had initially put on full clinical hold, but last Thursday switched it to a partial hold, clearing the path to its possible use for EVD. Even with admission by US health authorities that Ebola's spread beyond region of West Africa was ultimately inevitable, the CDC has deployed 31 disease control experts to the countries affected by the disease in West Africa, and an additional 50 to be deployed in a month. Last Saturday 9th August, we read that the National Health and Family Planning Commission (NHFPC) of China is sending three expert teams and medical supplies to Guinea, Liberia and Sierra Leone to assist the prevention and control of the Ebola virus. These experts would also use a tool to enhance the tracing of the contacts of those infected by EVD.

Our public health lenses should focus on these developments. But we must not neglect public education with the “right massages”. There is enormous lack of health literacy of people in West Africa, if not the whole continent. Many people simply do not understand and agree with the Western concept of medicine, which attributes infections to viruses, beliefs in isolation to stop transmission, etc. People cannot believe that there are diseases without cure, because in the views of many, death is caused by some external cause, often witchcraft here in Ghana. Dying is because not getting access to strong enough curatives. That is why people are eager to believe in any cure, in a desperate situation – a situation that is already under heavy exploitation by religious leaders to amass wealth. We in public health have a responsibility to improve health literacy among the people, so that they better understand the real nature of diseases, preventive measures, curative measures, etc.

Ebola is a relatively easy disease to contain with proper public health measures. However, if the population does not accept our approach, we are lost. We have to learn an important lesson from this epidemic and put much more energy in improving health literacy in West Africa. Otherwise, fear will kill us before the Ebola virus gets to us!

By John Kingsley Krugu

The writer is the Executive Director of the Youth Harvest Foundation and a PRO of the Ghana Public Health Association. He is also an external PhD research fellow of Maastricht University in the Netherlands. Email: jk@harvestmail.org