In an article in The New England Journal of Medicine entitled ‘An Epidemic of Suspicion — Ebola and Violence in the DRC’ Vinh-Kim Nguyen writes about violent attacks on Ebola treatment units and other health facilities. Nguyen argues that: “Epidemics thrive on fear — when they are frightened, patients flee hospitals, sick people stay away to begin with, and affected communities distrust groups trying to respond to the epidemic.”
But there’s an important sense in which the opposite may be true. When people fear something that has proven dangerous in the past, avoiding that something may be the only rational response, the only way to avoid the danger. After all, several well-documented epidemics have been shown to thrive on unsafe healthcare. Examples are Ebola Virus Disease (EVD), hepatitis C (HCV), extensively drug resistant tuberculosis (XDR TB) and MRSA (Methicillin-resistant Staphylococcus aureus).
The second ever outbreak of EBV, which occurred in Yambuku (in Zaire) in 1976, was a result of unsafe healthcare: “Peter Piot…concluded that it was inadvertently caused by the Sisters of Yambuku Mission Hospital, who had given unnecessary vitamin injections to pregnant women in their prenatal clinic without sterilizing the needles and syringes.”
WHO has recently announced that “The outbreak [of EBD] in Katwa and Butembo health zones [in DRC] is partly being driven by nosocomial [=originating in a hospital] transmission events in private and public health centres. Since 1 December 2018, 86% (125/145) of cases in these areas had visited or worked in a health care facility before or after their onset of illness. Of those, 21% (30/145) reported contact with a health care facility before their onset of illness, suggesting possible nosocomial transmission.”
Globally, hepatitis C virus (HCV) has infected an estimated 130 million people…. [T]he wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs. A significant healthcare associated outbreak occurred in Egypt in the 1970s.
Associated with poor infection control in health facilities, one of the first outbreaks of XDR-TB was discovered in Tugela Ferry Hospital, KZN, South Africa, in 2005. And a significant proportion of healthcare associated infections are resistant to methicillin (ie, MRSA).
Nguyen goes on: “In areas where the epidemic response has not involved security forces…people ask to be vaccinated.”
But rolling out vaccinations in environments where infection control is inadequate (for example, healthcare facilities) might increase the risk of viral strains developing resistance (for example, among healthcare practitioners). Going to a healthcare facility during an outbreak of Ebola may be the worst thing a person can do. When people didn’t go to health facilities during earlier outbreaks, case numbers were limited, and the outbreak didn’t last long.
Nguyen has also highlighted the importance of trust, and the consequences of mistrust of authority, experts and science. But if people are right to question the safety of healthcare facilities, as it would appear from above considerations, how can the trust of people at risk of exposure to ebola and other pathogens be regained?
As long as continued Ebola transmission is blamed on what is depicted as an irrational fear of healthcare and vaccinations, people will stay away from healthcare. Because their fear is far from irrational, it is supported by scholarly research, expert opinion and even communications from the WHO. XDR TB, MRSA, HCV and other outbreaks have been shown to be healthcare associated outbreaks. Healthcare facilities also contribute the lion’s share to anti-microbial resistance (AMR).
Modern healthcare facilities are potentially dangerous places. If patients were informed about the dangers, they would know better how to avoid them, and healthcare facilities would be compelled to address those dangers. Some of the earliest EBV outbreaks occurred when people came together around healthcare facilities, and died out when healthcare facilities closed, often because healthcare staff had been wiped out by Ebola.
Trust in healthcare in developing countries may be regained, slowly, if people are adequately informed about the greatest risks they face, such as poor infection control, lack of hygiene, AMR, etc. Trust will not be regained by dreaming up new misinformation, nor by reinforcing old misinformation.