From Africa to America, lack of public trust makes disease outbreaks worse

By Laura H. Kahn, January 28, 2019

A nurse prepares a measles vaccine. Cases of the disease increased by 30 percent globally from 2016 to 2017. (Photo credit: Pete Lewis / Department for International Development)A nurse prepares a measles vaccine. Cases of the disease increased by 30 percent globally from 2016 to 2017. (Photo credit: Pete Lewis / Department for International Development)

 A public health crisis cannot be solved without trust. People must trust that political leaders have their best interests at heart. They must trust that government policies are based on science and the best available data. They must trust science as well as medications and vaccines. Without trust, the best laid plans for any crisis risk failure.

There are many examples of what can happen to public health when trust breaks down. The ongoing Ebola outbreak in the Northeastern part of the Democratic Republic of Congo is a case in point.

The current outbreak, centered in North Kivu province, was first identified last August. Since then, the outbreak has spiraled out of control—despite new diagnostics, experimental treatments, and a vaccine that mostly wasn’t avaible during the 2014-2016 Ebola outbreak in West Africa. The problem is, the people living in violence-plagued North Kivu don’t trust anybody or anything. Rumors and hatreds spread easily, residents have refused to cooperate with outbreak responders, and some don’t necessarily even believe that an Ebola virus exists.

Red Cross volunteers have been attacked while trying to safely bury Ebola victims. (Ebola victims’ corpses are highly contagious and must be handled using a strict infection-control protocol, contrary to the local burial customs that require bathing the bodies.) In one community, villagers protested construction of an Ebola treatment center, and helped those isolated due to their infections escape. Making the situation worse, politicians exploited people’s fears during the run up to elections in December. The government used the Ebola outbreak as justification to exclude two cities from voting, but opposition supporters accused the government of excluding them for political reasons.

The end result of the mayhem and lack of trust is that Ebola has infected nearly 700 people and killed more than 400. Disease hunters are having difficulty containing the virus, and it is at risk of spreading into nearby provinces and neighboring countries such as Uganda and Rwanda.

But a lack of trust exists in many parts of the world, not just Congo. Indeed, “vaccine hesitancy,” which is “the reluctance or refusal to vaccinate despite the availability of vaccines,” has become so widespread that the World Health Organization considers it one of the top ten threats to global health in 2019. The measles vaccine is among the most distrusted. From 2016 to 2017, reported cases of the disease increased by 30 percent globally despite the existence of an inexpensive, highly effective vaccine. The greatest increases happened in the Americas, the Eastern Mediterranean, and Europe.

Vaccine hesitancy over measles can be traced to 1998, when Andrew Wakefield and colleagues published an article in the Lancet implying a link between the measles, mumps, and rubella (MMR) vaccine, bowel disease, and autism. The paper was subsequently shown to be fraudulent, based on falsified data, and 12 years later was retracted. Unfortunately, the damage Wakefield did to trust and public opinion has been difficult to repair. In the United States, measles was a constant scourge before the vaccine became available in 1963, each year causing 48,000 hospitalizations, 400 to 500 deaths, and 1,000 cases of encephalitis. After 1963 the number of cases plummeted, and in 2000, the disease was declared eliminated from the United States. With time, though, people lost their fear of measles and focused instead on the bogus Wakefield claims. A lack of trust in the MMR vaccine has led to a resurgence in measles and other vaccine-preventable diseases in the United States.

Anti-vaccination propaganda is now more widespread on the internet than trustworthy public health information—part of a broader trend, in which the internet has provided a megaphone for conspiracy theorists, hostile foreign governments, and other fraudsters to spread false information. One result is that scientific experts are no longer widely trusted. The situation is made worse by politicians who legitimize falsehoods, spreading them in an attempt to peddle fear or hate for political gain. US President Donald Trump has tweeted about there being a link between vaccines and autism more than 20 times, the Independent reported last year. The results of spreading medical disinformation can be deadly.

The US president makes, on average, 15 false claims a day, as the Washington Post reports. As a result, aside from a shrinking base of supporters, he doesn’t have a majority of the public’s trust. Many of the crises afflicting Washington, from the recent partial government shutdown to the fiasco of family separations at the US-Mexican border, are of Trump’s own making. But imagine the chaos that could ensue if the United States were confronted with an actual crisis caused by outside forces, such as an influenza pandemic or bioterrorist attack. With so little trust in government, and erroding trust in science due to false information—sometimes peddled by those in power themselves—America is vulnerable. Distrust, unfortunately, makes it difficult to prevent, prepare for, or recover from a major public health emergency.

Vaccines are the best strategy we have against Ebola in Congo, measles in the United States, and other biothreats such as pandemic influenza and newly emerging pathogens. But if the public doesn’t trust them, or the people administering them, or the officials making policy, it will be extremely difficult to contain any outbreak no matter how effective the vaccines themselves are. Honest communication by trusted elected officials is essential, literally, to our survival.


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