Ebola in Africa: Overcoming the role of traditional doctors and fraudulent spiritual leaders.

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Liduina Ngundam is a Cameroon born Registered Nurse working on a medical oncology unit in the D.C. metro area.  She earned her undergraduate degree at the University of Virginia. She is currently completing a dual Masters’ degree in Nursing-Family Nurse Practitioner and Public Health at Johns Hopkins University. Her interests include healthcare policy, disease prevention, and occupational health.  She can be reached at @LiduinaMPH.

According to the World Health Organization, there are 745 confirmed cases and 422 confirmed deaths from the Ebola virus in Guinea, Sierra Leone, and Liberia as of July 17th. Yet even as the virus continues to spread across West Africa and ravish small village communities, citizens remain unconvinced the Ebola virus exists. Not too long ago many Africans had the same reaction to the HIV virus until death hit closer to home and the death toll became palpable. Similar rumors that surrounded HIV surround the Ebola epidemic, based on uninformed methods of transmission coupled with layman and traditional quick fixes. Progress containing the disease has been marred by traditional superstitious beliefs. There have been reports of quarantined patients escaping treatment facilities to seek treatment from local herbalists or traditional doctors. Just as worrisome is that some believe they can pray it away with cleansing from their local pastor. So why has informed public reaction to public health crises remained stagnant in a continent with burgeoning economies and telecommunication systems? We shall use Cameroon, a country with strong cultural and economic ties to West Africa, as a reference.

Cameroon is a small central African country with a population of almost 22 million bordering Nigeria to the east. It maintains a 71 per cent literacy rate, among the highest on the continent, and has modest economic development according to UNICEF’s 2012 estimates. Cell phones are ubiquitous and internet access has rapidly become affordable to the masses. Long gone are the days when relatives called their families in the West to send them the latest fashion trends. Western goods, including automobiles and electronics, are no longer a novelty one had to travel out of the country to acquire because local markets for these goods are expanding. Unfortunately, the contrast between the country’s economic advancement and overall health remains rather stark. In the midst of health education levels as low as in Cameroon, is “literacy” really relegated to books, as bodies like UNESCO define it?

When it comes to health maintenance, even the most educated and affluent citizens in Cameroon sometimes turn to traditional beliefs or seek medical advice from their pastors. Last year the president, Paul Biya, ordered the shutdown of dozens of churches over several deaths that had occurred there. Relatives of those who attended these churches reported that sick relatives had refused to seek medical help at the behest of their pastors. Moreover, in a country where many believe that the 81year old president with a 32 year tenure is part of a witchcraft cult that keeps him in power and stellar health, it comes as no surprise that they also believe that witchcraft may have an effect on their health in the same way that sin could. Traditional doctors may point fingers to “malicious” relatives to blame for their sickness, while church leaders blame “sin”. In other words, why consult with a doctor when the cause of one’s illness is known and your traditional doctor or pastor has the solution?  As the saying goes, “old habits die hard,” but tradition has its purpose. After all, there are so many facets to African tradition, some of which influence its fashion, hospitality, respect for elders, resilience, and joie de vivre. By no means should these be taken for granted, but the divergence of medicine and public health from traditional thinking is long overdue.

As Pope John Paul II once famously said, “science can purify religion from error and superstition… .” Superstition is overwhelming when there is no scientific explanation for a phenomenon. Whatever is tangible to the human eye hardly gives in to superstition. Whatever one is able to understand, there is little room for superstition or rumor.  African governments would therefore need to lean on science to purify its citizens from popular disease misconceptions. They could take advantage of the proliferation of cell phones and other media devices and services in Africa to make public service announcements. They could establish public health agencies charged with dispatching information via mass text message about transmission of disease, measures to prevent or limit transmission, available treatments, and near by health facilities. When insufficient information is available as was the case during the early days of the Ebola outbreak this year, reassurance and standard precautions should be provided using the same measure. So far, Nigeria, Guinea, Sierra Leone, and Kenya have already experimented with sending out mass text messages to guide and survey civilians during general elections. Therefore, the effort could be replicated for public health interventions.  Of course, underlying mistrust in government-sponsored messaging must not be underestimated, but if everyone in a country receives the same information regardless of social status, occupation, or tribal affiliation, it limits the opportunity for superstition and rumors to sweep a region. 

Use of mass text messages monitored by government agencies could be expected to limit the spread of disease to the city centers from remote areas where historical trends reveal most outbreaks originate. In the remote areas where people are less likely to have access to telecommunications, public health agencies could allocate more resources to setting up health care centers and containing disease in case of outbreak. However, text messages and resource investments in the hinterlands alone are not sufficient. African governments would need to forge community alliances with local church leaders and even local chiefs to boost their chance for success. Furthermore, more than pouring logistic and financial assistance, perhaps developed nations could ensure effective public health intervention in Africa by tying visa quotas for government officials and their relatives to government performance in the public health sector.

With the Ebola infection and death rates on the rise, we can only hope the governments of Guinea, Sierra Leone, and Liberia will recognize the necessary lessons, make desperately needed improvements, and develop an effective public health response model for other African countries to emulate.

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