Opinion

Cultural Barriers are an Opportunity for Healthcare Diplomacy: Why we need gloves on the ground in Liberia

I remember a time in South Sudan when I was on a surgical mission trip. The shaman of a local tribe brought us a young man who was dying. The local healers had tried everything – medicines, rituals, prayers. But the one thing this man needed was forbidden in their culture. He had a deep abscess on his inner thigh in desperate need of draining. He was clearly in septic shock from bacteria in his blood from the wound as well. But in his culture, you could not puncture the body in anyway. It was considered desecration of the body.

However, he was dying. Because I was serving with a group of established medical aid officers, our methods—though foreign—were proven. The shaman and the young man were terrified, but they were also desperate.

I took my scalpel, wrapped my hand respectfully around the shaman’s hand, and together we incised the deep abscess.

The young man immediately felt better and the infection was cured with further surgery and antibiotics. He fully recovered and the shaman eventually thanked me. He was skeptical and fearful at first, but the patient lived, and the shaman was convinced to trust me.

In dealing with the largest Ebola outbreak in history we face many challenges: the rapidly fatal course of the illness and the advanced medical supportive care required for survival. We have seen that with the case of Dr. Kent Brantley, who was recently discharged from Emory University Hospital. While he did receive an experimental drug and a blood transfusion from an ebola survivor, there is no scientific way to determine if that had any impact on his course of illness.  What we do know is he did well because he was contained quickly and had a known course of supportive care. The unfortunate fact is that we have no evidence that any amount of American medical resources or new experimental drugs will end the outbreak on its own.

The only solution is prevention, which relies on containment and isolation. The sick must be rapidly identified and contained. Their contacts must be followed for 21 days so they can be rapidly isolated, should they develop symptoms. Their care must be delivered in the a hazmat suit. If the patient dies, and 70% do, the body must be properly disposed of because a recently deceased Ebola victim is actively shedding the virus from his skin.

On August 7th we heard compelling testimony from Dr. Ken Isaacs, Vice President of International Programs and Government Relations at Samaritan’s Purse about the cultural barriers to containment. He testified before the House Committee on Foreign Affairs and related his recent experience.

Containing the Ebola outbreak requires not only the right medical tools, but a sensitive understanding of the culture in which it is flourishing.

Contributing to Ebola’s virulence are the cultural traditions around the veneration of the dead. Dr. Isaacs mentioned this in his testimony, and I later discussed this practice with the Center for Disease Control. They explained the local ritual further:

A deceased community member’s body is rinsed, wrapped in clean cloth and rolled in a mat of palm tree branches. A coffin is used if the family can afford it. The body is then buried in a community cemetery and the burial cloth may be kept as a memento of the deceased. During the process mourners will kiss and touch the body repeatedly.

These traditions are an important part of community and family mourning. But they can also be deadly to those in close contact with an infected body. Dr. Isaacs testified his staff had been threatened with violence when they attempted to collect bodies for sanitized burial.

Further testimony revealed that there has even been doubt about the virus’ existence among the local medical community. Dr. Isaacs told the story of a well-respected and educated Liberian physician who visited the facility in Monrovia and examined patients without protective gear, mocking the existence of the virus to his colleagues.  He passed away in Nigeria a week later.

Certain groups have even assaulted containment centers with looting and violence. Why? The incident in West Point Liberia was driven by both fear of having a containment center in their community as well as a complete disbelief that the virus is real – total confusion begetting total chaos.

The United States has a role to play here, but we must move forward carefully.

Starting in 2003 with PEPFAR, the President’s Emergency Program for AIDS Relief, healthcare as a mechanism of diplomacy has become a more prominent part of our foreign policy. However, foreign policy is a dance, a negotiation of shared goals and identification of conflicts between nations. Even when the goal seems clear – to stop an Ebola outbreak for example – there is always an inherent tension between cultures, a worry about ulterior motives, a distrust of the unknown and sometimes a memory of the U.S.’s past use of health initiatives as cover for military operations.

But distrust and the cultural barriers can be overcome, as I saw with the young patient in South Sudan. While that was a single incident and this is an outbreak, the underlying principles are the same: We have to be physically present. We have to prove that our strange customs and beliefs can save lives. It’s an extension of what doctors have always tried to do with scared and vulnerable patients—be at the bedside, listen, and heal.

Ebola is more rapidly fatal than HIV, and has no specific treatment. But like HIV, it is a viral illness, spread through close contact that is often exacerbated by cultural beliefs and practices. PEPFAR was successful in reducing AIDs related mortality by 33% from 2005 to 2012 and it was the result of a coordinated and targeted effort to provide treatment as well as education. It required “boots on the ground” to integrate with the culture and build trust.

Today West Africa is facing a devastating illness in a culture of distrust and mis-education. The rest of the world is working in the face of budgetary constraints and fear of personal exposure. Add in the poor press about experimental drugs with access limited to Americans, and the fog of suspicion thickens. While USAID has already committed $14.55 million in emergency funding, this money has not bought the needed trained professionals and supplies to accomplish containment. A recent Kaiser Family Foundation report noted only $13 million of the $46 million needed in Liberia and Sierra Leone has been received.

This is a time for the United States—government, NGOs and all—to seize the mantle of global health as a vital diplomatic instrument to strengthen confidence in America’s intent and motives. Everything we do on the global stage sends a message. This is an opportunity for the U.S. to be a global leader, build trust, and show that we can break down cultural and communication barriers and align for a common goal. But to do this we need to go to West Africa with sensitivity as well as knowledge, and it needs to be a priority because it is the only way to stop the outbreak.

For some, this is a terrifying proposition, but so is the devastation of the population if Ebola is not adequately contained. We have the resources to safely fight the virus. We understand transmission and containment. But putting that knowledge to work in West Africa means putting trained and funded intervention where it’s needed most: at the bedside.

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