Lessons from Ebola - Trust: the Necessary Public Health Tool

It is perhaps too soon to draw lessons from the Ebola epidemic. After all, the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recently issued projections that suggest the number of Ebola cases will rise precipitously over the next few months. If the CDC's worst-case scenario occurs, more than one million people could be infected with Ebola. While future public health responses will be informed by what happens over the next few months, to me, one of the overwhelming lessons to be learned from the Ebola epidemic is how essential trust is to effective public health action.

The current Ebola epidemic has already killed more people than all previous Ebola outbreaks combined. In a September New England Journal of Medicine perspective, CDC Director Thomas Frieden and co-authors indicate that "[t]hree core interventions have stopped every previous outbreak and can stop this one as well: exhaustive case and contact finding, effective response to patients and the community, and preventive interventions." However, each of these requires the trust of the population to be completed successfully.

There are reasons to be concerned about the success of these efforts. Public health experts have already attributed to people's unwillingness to seek medical care. As WHO Director-General Margaret Chan explains in her September New England Journal of Medicine perspective, "Fear causes people who have had contact with infected persons to escape from the surveillance system, relatives to hide symptomatic family members or take them to traditional healers, and patients to flee treatment centers." Of course, public health officials can actively seek out cases and contacts, and some of the affected countries have done just that with mixed success. In September, Sierra Leone concluded a country-wide quarantine on its entire population to identify Ebola cases and educate its public about the disease. Despite the daunting nature of its efforts, Sierra Leone completed its house-to-house search without major incidents. In contrast, a more limited quarantine in Liberia in August was met with resistance and ultimately resulted in riots. Those who are carrying out the surveillance may be subject to threats or worse, as evidence by the deaths of eight health care workers conducting Ebola education in Guinea, apparently fuelled by fear that the health care workers were spreading Ebola, a relatively common fear.

The distribution of the experimental treatment ZMapp did little to engender trust. Two American volunteers with Ebola were offered ZMapp on a compassionate use basis - that is, as a potentially life-saving therapy when no other option existed. The Americans also received supportive therapy and were transferred back to the United States for care. Both survived. However, none of the hundreds of African health care workers who have been infected since the epidemic began had been offered such an option. The difference in treatment is viewed against a backdrop of historic exploitation in the region. While ZMapp, which is in limited supply and has not been tested in humans, has since been offered to Africans, there remain concerns about who will get access to successful treatments and vaccines.

Of course, trust alone is not sufficient to address Ebola. Lack of basic prevention resources, such as gloves, masks, and other protective gear, has been an important factor in the spread of the disease. A shortage of trained health care workers and lack of health care infrastructure has also impeded efforts to contain the epidemic. The United States and others have now committed substantial resources to provide this support. For example, the United States is sending its military to West Africa to help establish additional hospitals to treat Ebola patients and to train health care workers.

Nevertheless, without trust, public health efforts will fall short. Building trust during on on-going epidemic response is challenging, especially when mistakes may be made. The news that a nurse who cared for an Ebola patient in Dallas became infected caused health care providers and the public to question the CDC's reassurances, including that American hospitals were prepared to treat Ebola. But the CDC worked to rebuild the public's trust - publicly admitting its mistakes, responding to nurses' concerns, and revising its policies. Such steps to build and maintain trust are essential. And once the epidemic is over, we must not forget the lesson. Indeed, we should redouble our efforts to build trust in the public health system so that we are better prepared for the next epidemic.