Olga Kuznetsova

How to combat mistrust of Western health workers?

When the Ebola epidemic spread through West Africa in 2014, humanitarian agencies such as the Red Cross stepped in to help combat the outbreak. However, in some regions they were greeted with mistrust and hostility. In rural Guinea for instance, many believed that the Red Cross had fabricated stories about Ebola in order to steal body parts, and did not co-operate with advice on hygiene and safe burial practices [1]. In Liberia, there were rumours that Ebola had been intentionally brought to Africa by Western countries [2]. As a result, efforts to halt the spread of the disease were slowed down.

This is just one of many examples of mistrust towards Western aid workers, which both undermines ongoing health programs, and makes any programs planned for the future difficult to successfully implement. In order to tackle this attitude, it is first necessary to understand the often complex factors that cause it. This article will present several examples of the circumstances that breed mistrust, and discuss ways to move forward from this and develop a positive rapport with aid recipient countries.

Suspicion of Western health workers does not arise without reason. Cases of medical malpractice, unethical drug trials and espionage have bred mistrust in many parts of the world. We begin the discussion with a focus on Africa. Throughout the second half of the 20th century, there have been several high-profile examples of Western health workers deliberately harming or even killing African patients under the pretence of carrying out research, with some perpetrators going unpunished [3].

More recently, in 1996, the pharmaceutical giant Pfizer went into northern Nigeria to carry out a trial for a new drug, named Trovan, against meningococcal meningitis. However, Pfizer faced allegations of ethical misconduct, including not warning African patients of potential side effects and carrying out the research without permission from an ethics committee [4]. An “illegal trial of an untested drug” damaged the reputation of Western pharma in Nigeria, and may have made the population mistrusting of future interventions, such as the polio vaccination campaign.

In 1996, the “Kick Polio Out of Africa” campaign set out to eradicate the disease by 2000, but despite intensive immunisation, surveillance and education, the campaign faced an obstacle. In 2003, religious leaders in northern Nigeria issued a boycott of the vaccination, claiming that the vaccine was contaminated with chemicals that cause infertility, cancer, and HIV [5]. The predominantly Muslim community in the north of the country was wary of Western motives after the war in the Middle East following the September 11 attacks, which they interpreted as a war against Islam. Incidentally, the boycott took place in the same region where Pfizer carried out the Trovan trial.

Another factor contributing to the mistrust is the shortage of even the most basic medicines in Nigeria, and the costs incurred in purchasing them. In such circumstances, an offer of free vaccination combined with an aggressive campaigning strategy was regarded as highly suspicious.

In a similar situation to that in Nigeria, a polio vaccination program in Pakistan was compromised in 2012-13, after Taliban leaders claimed that the program was a plot by the C.I.A. to sterilise Muslims. Some vaccination delivery teams faced violent assaults, including bomb attacks [6]. The hostility towards the vaccinators was also reflected in public opinion. Among the Pashtun ethnic group in Karachi, which displays a disproportionately high polio incidence, 28% of parents of under-fives did not participate in the polio immunisation, most of them due to the belief that the vaccine was harmful or unnecessary [7].

The suspicion arose after it was revealed that in 2011, the C.I.A. had sent a Pakistani doctor to Osama bin Laden’s compound to obtain blood samples from inhabitants under the cover of hepatitis B immunisation [8,9]. After the plot was exposed, the doctor was jailed for 33 years. However the damage was done, and the resulting setback in the polio program contributed to an increase of polio cases in Pakistan from 32 in 2007 to approximately 600 in 2012 [10]. Considering that global polio eradication was scheduled for the year 2000, the examples of Pakistan and Nigeria show how a single incident (or a compromised drug trial) can potentially reverse many years’ worth of progress.

A final example presented here is that of a political agenda gone wrong. From 2009, under the guise of various health and civic programs including an HIV prevention workshop, the U.S. Agency for International Development (USAID) sent young Latin Americans to Cuba to mobilise potential political activists to stir up rebellion, destabilising the socialist regime [11].

In parallel, USAID funded a Twitter-like social network named ZunZuneo to allow easier communication in Cuba, a country where information and communications are severely restricted. Following allegations of covert operations, USAID, more known for providing humanitarian aid and disaster relief, responded that their actions had to be discreet to protect their staff in a politically-sensitive region, but were not illegal [12].

In all the cases presented above, mistrust towards Western health workers arose due to a lack of communication with native populations about the purpose and importance of the health program, or through a ‘boy who cried wolf’ scenario: a health intervention being used as a cover-up for espionage, breaking the trust for future projects. In the latter scenario, it is important to prevent such incidents from happening in the future. Indeed, the C.I.A. has already issued a statement promising to stop using vaccination programs to gather intelligence [11].

In the case of the Ebola outbreak, hostility towards the Red Cross workers eventually subsided after the workers started encouraging families of the victims to take part in the burials. Giving the families of the deceased a sense of autonomy and participation eased the tension and helped to build trust [1]. Additionally, it has been shown that mobilising trusted community health workers to talk to local populations and refute any conspiracies helped in improving cooperation [2].

The polio elimination program has had success in a number of countries, most notably India, which was declared polio-free in March 2014. Like Pakistan, India is a vast country with a large number of remote, difficult-to-reach communities that have in some cases refused the vaccine [10]. The success of the India immunisation program was partly due to the extensive social mobilisation, and engagement of community and religious leaders. In a study carried out in the Uttar Pradesh state in the north of India, it was shown that such activities resulted in increased vaccine coverage, lower rate of refusal, and a substantial drop in polio cases. An improvement in attitudes towards the vaccine was also observed in Pakistan after social mobilisation campaigns.

To conclude, a number of incidents caused by Western governmental organisations and large pharmaceutical companies have harmed the reputation of Western aid workers in the developing world. Governments and intelligence agencies must be fully aware of the ramifications of using health programs as cover-ups for gathering information. Likewise, tighter control of pharmaceutical trials would reduce incidents of malpractice that could damage the perception of Western aid.

In every case, extensive dialogue with aid recipient populations is essential to ensure understanding and cooperation, and this is best achieved through the engagement of community and religious leaders, who are in a position of trust and authority.

Science Daily: Returning West Africa researcher says distrust of health workers made ebola worse

Oxfam: Mistrust and confusion are allowing Ebola to thrive in West Africa

New York Times: why Africa fears western medicine

British Medical Journal: Pfizer accused of testing new drug without medical approval

PLOS Medicine: what led to the Nigerian boycott of the polio vaccination campaign?

The Independent: Taliban renews assault on Pakistani polio vaccination teams, killing two

Parental perceptions surrounding polio and self-reported non-participation in polio supplementary immunization activities in Karachi, Pakistan: a mixed methods study. Bulletin of the World Health Organization 2012;90:822-830

New York Times: C.I.A. Vaccine Ruse May Have Harmed the War on Polio

New York Times: Fallout of Bin Laden Raid: Aid Groups in Pakistan Are Suspect

Achieving polio eradication: a review of health communication evidence and lessons learned in India and Pakistan. Bulletin of the World Health Organization 2009;87:624-630

The Guardian: USAID programme used young Latin Americans to incite Cuba rebellion

Integration of neglected tropical disease control - how to eliminate schistosomiasis on a tight budget

Although there is increasing awareness of the need to combat neglected tropical diseases, 

NTD control programs are often still underfunded

. Consequently, donors are encouraging new solutions that would make the most efficient use of resources.

Luckily, such solutions are possible, and they rely on the fact that 

the distribution and treatment of different NTDs are often quite similar

. NTDs such as schistosomiasis, soil-transmitted helminthiasis (STH) and lymphatic filariasis are often found in the same geographical area, and their treatment involves mass administration of safe drugs. Combining, or integrating, the treatment of several NTDs would therefore reduce costs and allow wider coverage. This article is based on the talk given at the 2014 Schistosomiasis Control Initiative Open Day by Dr Anna Phillips, and describes how the SCI is participating in NTD control integration.

“Integration” can mean different things, depending on the context. One type of integration is when drugs against several diseases are administered to the same community at once, usually under an “umbrella” program that oversees the work of individual NTD programs. Alternatively, preventative chemotherapy can be integrated with other sectors, such as water, sanitation and hygiene (WASH). Finally, drugs can be distributed in “community-based integrated delivery”: not as a stand-alone program but through existing health and education structures. Each of these will be discussed in turn.

In 2007, a grant from the U.S. Agency for International Development (USAID) allowed the SCI to 

integrate national schistosomiasis and STH control programs with lymphatic filariasis and trachoma

, in areas where these diseases overlap. SCI’s role is to work with Ministries of Health (MoHs) of its target countries to provide support and funding. As a member of country specific NTD Task Forces SCI, the MoH NTD Committee, the World Health Organisation, NGOs, funders and programme managers from each of the individual NTD programmes, work together to provide technical support for integrated staff training, drug storage and delivery, sensitization and education, and MDA across several NTD programmes. This results in considerable cost savings and multiple drug administration for the treatment of several NTDs becomes possible.

A specific example is the triple drug administration that the SCI is carrying out in parts of Mozambique, where the population is simultaneously treated against lymphatic filariasis, STH and schistosomiasis Integrated MDA is still in its infancy and not as yet fully endorsed by the WHO.

Integrating the delivery of several drugs comes with its challenges. Increased workloads for already overburdened staff, possible power struggles between the different NTD programs, and delays to the supply of one drug can set back the treatment of other diseases.Making the treatment more efficient could also result in less funding for NTDs in the long run.

multiple drug administration has the benefit of saving costs and time compared to running separate NTD programs

. For instance, the community advertisement and sensitisation is reduced to just one campaign, freeing up resources to be used to expand coverage.

In its 2010 Report on Neglected Tropical Diseases, the WHO outlined the strategies necessary for NTD elimination. Because multi-drug administration (MDA) alone is not enough to break the disease cycle, the WHO highlighted a need for “complementary interventions”: in addition to chemotherapy, it is recommended to implement vector control and improve WASH and veterinary health [1]. This makes sense because several diseases, such as schistosomiasis, trachoma and STH are transmitted as a result of poor water, sanitation and hygiene. Likewise, eliminating parasite vectors such as mosquitoes and molluscs can be integrated into existing disease control programs.

Although such interventions are expensive to implement, they carry significant cost-benefits in the long run. However, their success depends on sufficient funding, integrating the different skills across sectors, successfully coordinating different interventions, as well as reducing damage to the environment when insecticides or molluscicides are used.

The idea behind community-based integration is 

using existing structures within the community

 to deliver NTD treatment services. This can include drug administration within school feeding programs or during mother-to-child health days. As the drugs used to treat NTDs do not require refrigeration and can be administered after receiving a short training, delivering NTD programmes through the community is viable, increases coverage and reduces costs significantly.

In 2003, the WHO suggested a paradigm shift in the response to global health needs. This new approach would 

integrate NTD control to make sure the money and resources are used in the most efficient way possible in the battle against poverty and disease

. Since then, organisations such as the SCI have been putting this into practice by integrating different NTD programs to deliver combined treatment, or more comprehensive control of individual diseases. Despite a number of challenges, integration is one of the most efficient ways to bring us closer to NTD elimination.

Olga Kuznetsova

Articles

How to combat mistrust of Western health workers?

Integration of neglected tropical disease control - how to eliminate schistosomiasis on a tight budget