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Ebola, measles, polio: We have met the enemy, and he is us
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For those who are old enough to remember Pogo, we can apply this dictum to epidemiology. There are three outbreaks occurring concurrently that would be controlled if not for human behavior that is exercised in the name of religion or because of superstitions, ill-founded scientific beliefs or social folkways or more. Although Ebola virus disease, measles and poliomyelitis are all viral diseases, historically the spread of bacterial infections, such as syphilis and plague, were also affected by similar beliefs.
Ebola in West Africa
Ebola virus disease (EVD) in West Africa, currently the most flagrant example of the effect of beliefs on spread of disease, was almost controlled in late April. The outbreak was slowing with no new cases in Liberia for several weeks, and the number of weekly reported cases in Guinea was down to nine. No cases had been reported in Sierra Leone for weeks. The total number of cumulative cases in the three countries was about 260. Since then, however, there has been a dramatic increase in cases in all three countries to the point that this is now the largest outbreak ever. As of Aug. 4, there have been 1,711 cases with 932 deaths in the region.
How did this happen? The key to control EVD is to isolate ill patients to prevent person-to-person spread, track their contacts for the maximum incubation period of 21 days, use safe burial practices (no unprotected contact) and educate health care workers (HCWs) about infection control practices. Most of these practices broke down. Patients hid to avoid hospitalization because of fear and denial and were cared for by family or churches. Patients were actually removed from hospitals by families. Unsafe burial practices continued, and personal protection for HCWs was inadequate.
Donald Kaye
Much of these behaviors occurred because of superstitions and refusal to break what is considered good behavior (ie, caring for your family).
Misinformation leads to poor care
Some reported examples of break down includes suspicion of the doctors in their masks and body-length protective suits. One patient slipped out of the hospital and fled to Freetown 300 km (185 miles) away. There, he was nursed in a private home for a week before being tracked by officials.
An official said at least 57 suspected and confirmed EVD cases were “missing,” the victims having fled or gone into hiding. Also, a woman with reported symptoms of the disease initially fled the ambulance sent to take her to the hospital and hid in the bushes. Families have been keeping sick people in healing centers, prayer homes and other non-medical centers.
A second example of superstition relates to stories that were circulating that doctors were removing limbs of EBV victims before burying them. Police were deployed to prevent relatives from trying to retrieve bodies from hospitals. For example, locals wielding knives surrounded a marked Red Cross vehicle. Therefore, an official with the Red Cross in West Africa said operations have been suspended for safety reasons.
Although dedication to care of family and care of their deceased is commendable, in this case it clearly endangers the general population.
Measles and polio outbreaks
Measles in the United States is another example of human behavior affecting outbreaks, and in this instance the behavior cannot be attributed to lack of education or resources. According to the CDC, there has been a surge in cases of measles, a vaccine-preventable disease. A total of 539 measles cases and 17 outbreaks with cases in 20 states have been reported in the United States in the past 6 months. It is the largest number of cases in more than 2 decades. Many of these outbreaks can be attributed to unvaccinated children or adults. Often, these individuals were not vaccinated because of religious beliefs or philosophical anti-vaccination beliefs based on pseudoscience. Although these groups are exercising their individual rights, the cases of measles they create expose vulnerable children who are below the age of immunization, as well as exposing the immunocompromised.
A third example of superstition and fear as well as the human behavior of war or terrorism in the name of religion perpetuating outbreaks is that of poliomyelitis. A vaccine-preventable disease, and one that was close to worldwide elimination, poliomyelitis outbreaks persist in Pakistan, Afghanistan and Nigeria because of human behaviors.
According to WHO, Pakistan’s volatile northwestern city of Peshawar is the largest reservoir of endemic polio viruses in the world. Continuing violence against polio vaccination teams has impeded the eradication program in parts of Pakistan, which is also the only polio-endemic country in the world where cases rose from 2012 to 2013. In Pakistan, Taliban commanders have forbidden vaccination teams access in some areas. A handful of religious leaders have also denounced the campaign as a plot to sterilize Muslim children. As a result of the problems in Pakistan, polio was exported to Afghanistan and Syria. Suspicion of polio eradication teams and edicts from religious leaders have also interfered with polio eradication programs in Afghanistan and Nigeria.
Clearly, education helps, but it alone is not enough. Studies have shown that personal identification with political, religious and social beliefs can trump scientific knowledge in an individual. Educational level per se does not necessarily lead to scientifically founded opinions — or at least the expression of such opinions.
Climate change and evolution are two non-infectious disease examples of beliefs trumping knowledge; EBV and immunization for poliomyelitis and measles are other examples.
Disclosure: Kaye reports no relevant financial disclosures.