By Melissa Hersh:
We already knew before the latest Ebola epidemic in West Africa that emergency planners should plan for how communities and individuals will act as opposed to how we want them to act. The international community steadfastly clung to our ideals instead of managing expectations. The collective response to the Zika virus (see Box 1) already reflects lessons learned from Ebola’s miscalculated response. Often paternalistic tendencies overshadow the critical role played by framing issues in a context consistent with cultural beliefs and norms. And even though cultural sensitivity has been an important consideration for some time, formally integrating behavioral science insights into public health interventions is increasingly essential. Developing strategies and tactics that include behavioral change objectives into strategic communications and implementation can play an effective role mitigating public health fears — and reducing fears can pave the way for effective interventions.
There are many variables that impact the success of evidence-based public health interventions, these include:
- A willing population or a willing leader to take the helm;
- A demonstrable correlation or credible causal relationship;
- Transparency and frequency of strategic communications (this isn’t just about the message, but who is delivering the message);
- The responsible authority and population/community perceptions about the criticality of the issue;
- Funding; and
- The value proposition for deciding to intervene. For example, how is this risk weighed in the affected population compared to other risk or security vulnerabilities and threats?
And, seemingly basic, but often overlooked, what works in one community may not in another. The use of behavior science in designing public health interventions is not just about disease prevention, but also about health promotion. Consequently, the baseline resilience of a community to withstand particular shocks to their health – either from nutritional deficiencies, availability of health systems, conflict, contamination, disease prevalence and community-based heard immunity – is particular to each community. For example, prior to the civil war — on the whole — Syrians immunized their children against vaccine-preventable diseases, including measles, mumps, rubella (MMR) and polio. Since 2011 vaccine and immunization uptake has been severely disrupted.
Elsewhere in the Middle East and parts of the world where insurgents and extremists have sustained ‘success,’ e.g. Pakistan, Nigeria, and Somalia, for some, there is reluctance to immunize children based on the creation of cultural taboos. The taboos are in response to perceived deliberate actions to eradicate ideological supporters and their strongholds. And, like with many vector-borne diseases, mosquitos aren’t the only thing that rapidly breeds. Mistrust is a powerful prophylaxis against effective disease prevention and health promotion strategies. Building trust and confidence is at the core of behavioral science. Case in point — we witnessed how shifting burial practices reduced the accidental spread of disease from corpses. However, even after the knowledge of the risk was widely shared across severely impacted communities in Sierra Leone and Guinea, communities still refused to change their traditional practices.
For the good of the local population, decision makers must tackle an ethical question in deciding between science and culture when confronting acute public health crises: the duty to treat or contain, individual versus population health, the use of force and noncompliance, amongst other challenging and seemingly no-win scenarios. Whether there is any way to approach these matters with equanimity is case specific. However, psycho-social interventions based on behavioral insights are gaining traction —their utility is not just relevant for populations receiving guidance but also for those administering it.
Melissa S. Hersh is a Nonresident Fellow with the Stimson Center.
ZIKA Information – What we know, what we don’t
The current landscape with respect to the Zika virus, a mosquito-borne disease, that manifests similarly to other vector-borne diseases, like dengue, chikungunya, and malaria, is that there is no vaccine or specific prophylactic treatment available. In most cases, Zika presents itself with mild symptoms including fever, skin rashes, conjunctivitis (eye inflammation), muscle and joint pain, malaise, and headache. An infected person may experience none, all, or some of these symptoms. While the incubation period (or time from exposure to mosquito bite or in some cases, contact with semen) ranges from a few days to a week and should someone become symptomatic, general symptoms can last for between a few days and two weeks. Long-term effects of Zika and recurring problems are less well understood at this time. As we saw with Ebola, the virus stayed in semen for up to 9 months after patients were reportedly cleared of all other infection. Yet, being asymptomatic is not necessarily the all clear patients were hoping for. And now, many months after the height of the 2014 outbreak we’re seeing some complications, predominantly in health care providers who were infected. These complications may appear as a relapse or recurrence of the underlying disease but are generally associated with other sequelae or complications of the disease, e.g., meningitis.
Despite Zika’s discovery in the late 1940s, there really haven’t been any significant outbreaks to warrant further attention since 2007 (Asia Pacific) and 2015 (Americas). In the recent outbreak with Brazil at the epicenter, there has been increased awareness over a possible correlation or causal relationship between Zika virus being associated with congenital, e.g., microcephaly, and peripheral nervous system effects, e.g., Guillian-Barré Syndrome. To date, there is no definitive causal relationship established. That being said, health care workers and epidemiologists are closely looking at reported perinatal, semen, and blood transfusion as possible transmission routes.
To add insult to injury, women experiencing Zika virus symptoms are being advised not to take aspirin-based medicines or steroidal-based anti-inflammatory agents due to the increased risk of possible hemorrhaging. Furthermore, pregnant women who may be affected with Zika who take these medicines can cause developmental delays, e.g., Reye’s syndrome, in their fetuses. The same applies if children or teenagers use the medicine – they too are vulnerable to negative consequences – when using certain types of medicine for symptomatic relief.
So, as it stands, the world is being vigilant, increasing surveillance, and responsible authorities are communicating what can be done to limit mosquito reservoirs in communities, and to communicate the need for regular personal protection, e.g., insect repellents and light clothing covering most of one’s body, etc. Three issues stand out, however. First, increasing surveillance is only beneficial if effective interventions to prevent or mitigate the spread of the disease or its severity are available and accessible. Second, not all people develop symptoms, and thus literally transmission can occur under the radar. Third, communicating what can effectively be implemented to prevent unnecessary risk exposure does not translate into adherence or compliance. And, as behavior science indicates, adherence to disease prevention is not a one-size-fits-all set of guidelines.