Human emotion is the variable in the Ebola crisis

Inadequate efforts coupled with traditional culture are obstacles to the prevention of the Ebola epidemic.

A French Red Cross team picks up a suspected Ebola case in Guinea
A French Red Cross team picks up a suspected Ebola victim in Guinea [Reuters]

When cases of Ebola were first reported in March 2014, signalling the start of an epidemic that would kill thousands of West Africans, WHO experts were convinced it would be only a matter of time before medical authorities would contain the disease. We were wrong.

Tried and true strategies that had worked to stop the spread of the disease in 24 previous Ebola outbreaks had failed, revealing terrible gaps in national healthcare systems and a deadly lack of trust on the part of the populations most affected.  

Just as we believed in early 2014, we now hope the epidemic is under control. Yet the conditions that allowed infections to spiral out of control last year continue to exist, and as of April 12, there are still 37 cases of Ebola infections in Sierra Leone and Guinea.

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Lack of prevention

Liberia, Guinea, and Sierra Leone have released an itemised recovery plan to revamp their healthcare systems, provide food to compensate for a disrupted harvest, and move their economies forward.

The plan has an $8bn price tag, and the World Bank and other donors have already committed more than $1bn. This plan is a thoughtful approach to recovery, but as health experts we also need to focus on preventing the next epidemic by solving the problems that made this one so deadly.

Some have blamed the cause of the epidemic on the weak health systems of the three stricken countries; others have talked about the need for improved strategies to speed international response; while others still have pointed to the need for better R&D for diseases that affect developing countries. 

There is clearly much work to be done to build trust, when we consider the human dimension of the disease and the terrible suffering it has caused.


All of those statements are true, just as it’s true that the international community has worked on all those fronts for several years. But we have missed one important factor in debating solutions to prevent future global health emergencies caused by disease outbreaks. 

Unlike a tsunami or an earthquake, the impact of an outbreak is insidious: human-to-human transmission is slow to reveal itself, and, most important, the spread and control of a disease epidemic hinges on attitudes and behaviours, many of them determined by how local populations feel about the people who are assigned to care for their health. 

Professor Cheikh Ibrahima Niang, a Senegalese socio-anthropologist who has assisted WHO in understanding the behaviour and attitudes of communities in West Africa, argues that trust and confidence are the strategic tools for ending the epidemic and rebuilding the countries.

In a recent WHO presentation he told us: “Many of these people may be illiterate, but they are not stupid. They do not want to be passive recipients; they want to be actors in their own response to the crisis. And they are in mourning – purely medical interventions are not sufficient.” 

Distrust of healthcare

There is clearly much work to be done to build trust, when we consider the human dimension of the disease and the terrible suffering it has caused.

West Africans are used to frequent touching, strong family bonds and living in close quarters, so imagine the emotional impact of the necessary isolation and quarantine measures imposed largely by foreign medical staff, many of them clothed in the otherworldly garb designed to protect them from infection.

And add to that the perception of governments that could barely deliver on simple health necessities, let alone respond to a vicious virus. Meanwhile, those of us in the role of guardians of global health failed to see the danger posed, not only by the weak health systems, but by the lack of trust of populations whose behaviours would determine the course of the epidemic.

For many years the peoples of Guinea, Liberia, and Sierra Leone have relied on themselves to look after their health problems. They go to traditional healers or, when they can afford it, they turn to the private sector, where healthcare is generally more available but paid for out of pocket.

Years of war, followed by neglect of the health sector, had already eroded people’s confidence in the system and driven them away from hospitals and health facilities. Even the medical profession itself had abandoned ship for better futures abroad. And those few who remained worked in dire conditions and were rarely remunerated.

History of distrust

So we know that addressing a history of distrust will be fundamental to inspiring new behaviours and attitudes. It will be crucial for building resilient health systems in the three West African countries. We know that to make those health systems capable of delivering quality services and absorb the shock of future crises – whether due to disease outbreaks or financial and economic downfalls – will require funding, medical training, technical assistance, infrastructure and information networks. But above all it will require the acceptance and trust of all communities. 

The process must start at the district level and work upwards. A top-down, purely technical approach has clearly failed us in responding to the Ebola crisis, and it will not work in the building of shockproof systems.

We will need to help the governments of the three countries communicate at all levels of society, down to the smallest village, and to rebuild a legitimacy we had all clearly lost.

The devastated peoples of West Africa remind us that a national health system cannot work without their full participation. They are the key to ending this epidemic and to ensuring it does not happen again.

Dr Marie-Paule Kieny was appointed WHO Assistant Director-General for Health Systems and Innovation in November 2012. She has published over 250 articles and reviews, mainly in the areas of infectious diseases, immunology and vaccinology.

The views expressed in this article are the author’s own and do not necessarily reflect Al Jazeera’s editorial policy.