Most experts agree that the rate of epidemics is increasing. Having a better global response means looking at epidemics holistically and addressing the cultural challenges that they present.
The mediocre response to the Ebola crisis has a lot to teach us about how to respond to the threat the Zika virus poses. We must use these epidemics as opportunities for communal actors to empower the affected, and enable them to take ownership of their health.
Late winter 2016 has proven itself to be a pivotal time in global health; we are currently in between two epidemics. On the one hand, the 2014 Ebola epidemic that killed over 11,000 people has been declared over as of mid-January, save for the inevitable flare ups that will most likely continue to occur. On the other hand, the media is suddenly full of stories about the mysterious Zika virus, which often shows no symptoms but seems to cause babies to be born with shrunken heads.
At first glance, these two diseases seem completely unrelated: Ebola kills dramatically and gruesomely, Zika often doesn’t kill at all. They occur on opposite parts of the globe, one is transmitted primarily through contact with a diseased individual, the other is transmitted through mosquito bites. Although it captured the imagination and fear of the Western world, the latest Ebola outbreak ended up remaining rather regional in scope. Projections are currently being made that the Zika virus will stretch around the globe.
The world is increasingly mobile, increasingly populated, and increasingly interconnected. It is important that disease is removed from the vacuum that it is often analyzed in. In today’s environment, the securitization of public health is an issue that cannot be overlooked. Besides the normal quantifiable challenges (such as funding, infrastructure, education, and supplies), there are a number of cultural challenges that are much harder to assess, but that have an equally important role in determining the success of a response to an epidemic. The global response to the Ebola epidemic was heavily criticized, and generally accepted as having been mediocre at best. Identifying
these challenges, and addressing them appropriately can make an enormous difference. We would do well to apply the lessons gleaned from past experience and current study to become more responsible and reactive as a global community as a whole.
The term conjures images of the 1918 Spanish flu, which infected around 500 million and claimed the lives of somewhere between 20 and 50 million victims worldwide. If we look at more recent times, it may remind us of how we watched HIV spread across the globe, killing more quietly. For years it was an epidemic among people often seen as unimportant to Western governments: poor populations in Africa, and homosexuals across the globe. The disease became so politically charged and so marginalizing to the point where, as a culture, it took us decades and millions of deaths to understand that it affected us all.
GCSP Research Fellow - Ms Alexandra Peters
An epidemic does not need to be as destructive, deadly, or widespread as HIV or the Spanish Flu in order to warrant the world’s attention.
Over the last 15 years, the world has seen a number of epidemics around the world including SARS, cholera, measles, yellow fever, and various strains of influenza. This is due to a variety of factors: the world’s population is growing rapidly, and people are going into areas where they have not gone before, perhaps coming into contact with new pathogens.
They are more mobile than ever- an infected person can travel from one side of the world to the other in a matter of hours, and come into contact with hundreds of people during that time. In some ways, this was the case with the Ebola epidemic- the original animal vectors were introduced from nature, and then the disease used human vectors to spread.
Climate change can cause disease carrying organisms such as mosquitos to spread to geographic regions that may have been too cold for them in the past. An epidemic does not need to be as destructive, deadly, or widespread as HIV or the Spanish Flu in order to warrant the world’s attention.
From a global health standpoint, there are reasons why Ebola and Zika are seen as relatively “manageable” pathogens, even though there are no known cures for either. In the case of Ebola, the very nature of the virus itself dictates that it is difficult for it to become a full-blown epidemic in parts of the world with decent medical infrastructures. While Ebola is extremely virulent, it can only be transmitted by someone who is showing symptoms, and for all intents and purposes, transmission remains direct in the sense that one person needs to come into direct contact with the infected bodily fluids of another. If the Ebola virus had a longer incubation period in humans, then people who were infected with the Ebola virus could unknowingly pass it on to others. Many other pathogens have an extended incubation period during which they remain infectious. If this would have been the case with the Ebola virus, the epidemic would certainly have spread much farther and much faster.
Discovered in 1947 and spread by the Aedes aegypti mosquito, Zika was not even on the WHO list of the most urgent diseases to research. It was not until an epidemic of microcephaly in Brazil was potentially linked to the virus that it garnered global attention. In 2014 there were only 147 documented cases of microcephaly among babies; in 2015 there were well over 4,000. Until 2007 there were only 14 or 15 documented cases. Now the disease has spread over 24 countries and the WHO estimates that the virus will infect over 3-4 million people over the next year. The Zika virus is considered manageable in the sense that 80% of the time, an infected person doesn’t even show symptoms and generally isn’t in any danger.
Assuming that scientists will soon prove causality between the Zika virus and spiking rate of microcephaly (or even possibly with Guillain-Barré Syndrome), it remains a virus that is only life threatening to a very small percentage of the population. Still, the rate at which the epidemic is spreading is alarming, especially as there is not concrete information as to why. It is unknown but there is a possibility that the Zika virus can spread directly through human contact. If that is the case, there will be almost no way to prevent this as its symptoms are often so unremarkable.
Current testing of antibodies in a patient’s blood cannot distinguish between Zika virus and Dengue fever, although better tests are in development.
Illness is one thing, human behavior is another. There are two types of issues: “hard” quantifiable ones, and “soft” cultural ones. Quantifiable variables include the presence of natural vectors for the disease, lack of resources, a bare-bones medical system, infrastructural weaknesses, budgets and funding for combating the epidemic, importance given to it internationally, agility of governments and the international community.
The cultural set of issues occurred on the ground, at the interface between what was happening in West Africa and the International effort to stymie the epidemic. These were harder to quantify, and often took place on the ground. They included issues of trust, race, communication, education, heritage and social mores.
When the outbreak first started there was often an extreme mistrust of aid workers, with “panicked villagers spread(ing) conspiracy theories that the virus was nothing more than a neocolonial ploy to weaken already marginalized ethnic groups.” Considering West Africa’s history, these fears are understandable.
One of the biggest challenges for aid workers was teaching and convincing a population to act responsibly vis-à-vis the virus. Some of this had its roots in societal mores and in education. One main challenge was convincing people who believe in witchcraft and traditionally rely on healers or community leaders to trust a stranger’s medicine. It also meant finding ways to adapt traditional burial rites in a manner both sensitive to the family’s cultural values and in line with biorisk safety protocol.
But sometimes keeping the populations safer was not always the safest choice for the individual, which gave people very little incentive to comply. Because of the similarities of Ebola symptoms with other illnesses endemic to the area such malaria, typhoid fever, and meningitis, it is impossible to tell what earlyonset symptoms are from a purely clinical standpoint. If a person experiencing flu-like symptoms went to the hospital, that person would usually be put in a waiting room full of other people with similar symptoms, and possibly contract Ebola in the process. Community engagement is crucial, and participation by communal leaders gives legitimacy to international assistance. The Ebola epidemic proved that if the community can’t correctly understand the issue and take ownership of addressing it, then any level of intervention and aid from outside will inevitably fail.
While the characteristics of the Ebola virus made it less dangerous to countries with good medical infrastructures, Zika seems to be garnering more attention in the early phases of the epidemic, probably because it does not discriminate to whom it spreads. Access to healthcare in Brazil and the Americas remains miles ahead of access in West Africa, especially in regards to available supplies and the number of doctors per capita. One might even assume that unlike Ebola, Zika does not discriminate and could have the same effect in a community with virtually no medical infrastructure as it will in the most modernized countries.
However, this argument overlooks two key issues. Firstly, an epidemic of babies born with birth defects could conceivably put a damaging strain on a state’s already fragile health system. Developed nations with more robust systems would probably have a far easier time absorbing those costs. Secondly, the biggest consequences of this disease affect women who are of reproductive age. And numerous states are officially instructing women not to get pregnant for at least the next two years.
The level of reproductive health care available to women varies greatly from one country to another, and is not only linked to affluence. Religion also plays a major role. Numerous South American countries are staunchly Catholic, and the Churches’ view on contraception and abortion is quite strict. Although the UN recently affirmed abortion as a human right, there are only three countries in South America where abortion is broadly legal. In other countries, abortion is completely illegal in all circumstances, including if there is physical danger to the mother or in cases of rape. Options for reproductive health are often limited, and contraception can be very difficult to acquire, inciting many women to adopt extreme solutions or subject themselves to having little control over their family planning. Because of the draconian stance on reproductive rights, 40% of El Salvadorian women opt for sterilization as birth control.
The future will be determined by how societies decide to protect their women. As with Ebola, community engagement remains key, except that instead of needing to engage healers, one must engage the Catholic Church.
If women’s reproductive rights do not improve, there is a risk that there will be an immense number of disabled children being born, many of whom may not have the level of care that they may need. With Pope Francis being a quite progressive and immensely popular figure, there is an opportunity for the Church to support women’s reproductive rights. Without their support, the consequences could be hellish, and a large number of babies will be disabled, suffering, and dying.
Epidemics always have a random component, and luckily for us, neither Zika nor Ebola have the potential to be the next Spanish flu. But the next pathogen might be. It is crucial to be reactive to all epidemics not just for the people affected, but for the health of the global response. It goes without saying that standards for responding to a potential health crisis must be in place, so that it is met with a maximum of foresight and coherence. But one must also give increased attention to the cultural component of epidemics. According to most experts, the rate of emerging diseases is both unpredictable and increasing. If we cannot address them holistically when the pathogens are traditionally seen as “manageable”, then how can we expect the world to respond appropriately to more difficult ones.
Ms Alexandra Peters is a GCSP Research Officer in the Geopolitics and Global Futures Programme