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Taking the Upstream Approach to Ebola

In this editorial, NWCPHP's Tao Sheng Kwan-Gett, MD, MPH, discusses the importance of "upstream" factors of health on the ongoing Ebola outbreak and American perception.

In this editorial, NWCPHP's Tao Sheng Kwan-Gett, MD, MPH, discusses the importance of "upstream" factors of health on the ongoing Ebola outbreak and American perception.

December 5, 2014

"Go upstream" is a mantra that we in public health often chant when talking about chronic diseases such as diabetes and heart disease. It's the concept that to improve a population's health, we need to look beyond individual health behaviors and examine the social and environmental factors—the "upstream" factors—that have the greatest impact on health.

But we also need to communicate the "go upstream" message when we talk about infectious disease outbreaks like Ebola. Perhaps if Americans had understood how poverty was the kindling of Ebola's wildfire spread in West Africa, some of the paranoia that has gripped our country could have been averted.

Fear of Ebola is entirely rational—Ebola is a highly pathogenic virus with a significant case fatality rate. But our fear has been disproportionate to the actual risk. A NBC News/Wall Street Journal poll found that 71 percent of Americans support a mandatory 21 day quarantine for returning health care workers who treated patients with Ebola in West Africa, despite the fact that such quarantine periods are unnecessary and not recommended by the Centers for Disease Control and Prevention or national experts such as the Infectious Disease Society of America.

Health communications experts have long known that our perception of risk is based on more than the rational assessment of the probability that something bad will happen. There's another component deeply rooted in our emotional being: outrage.

In NWCPHP's free online course on Emergency Risk Communication, University of Washington Clinical Assistant Professor Meredith Li-Vollmer, PhD describes how "outrage" (as described by communications guru Peter Sandman) can lead to fear that is out of proportion to the actual threat. "The more outrage people feel, the more likely they are to perceive higher levels of risk," Li-Vollmer explains. "What tends to increase outrage? People are likely to feel more upset about things that trigger a higher degree of dread or uncertainty, are unfamiliar, or seem to be inflicted upon us by others."

Could an appreciation of the upstream factors complicating the Ebola outbreak in West Africa have turned Americans' outrage over the spread of an unfamiliar virus into a different kind of outrage over the all-too-familiar impacts of poverty?

Knowing that Liberia's population has an adult literacy rate of 43 percent (by United Nations estimates) might have helped Americans understand the challenges faced by health education campaigns that sought to help Liberians limit the spread of disease.

Knowing that Liberia had only one doctor for every 100,000 people before the outbreak (compared to 245 in the US according to the World Bank), and spends only $65 per capita per year on health care compared to $8,895 in the US might have helped Americans understand the context of the high case fatality rates in that country and the heroism of Liberia's under-staffed and under-resourced public health and health care workforce.

Knowing that West African countries, though rife with poverty, were poised to become an economic growth center pre-Ebola might have helped Americans see Ebola-stricken nations not as victims deserving of our charity but as places of promise that deserve our material investment and moral support at a time of crisis.

World Bank President Jim Kim hit the nail on the head when he said in a speech at Howard University, "This pandemic shows the deadly cost of unequal access to basic services and the consequences of our failure to fix this problem."

Maybe if Americans better understood poverty's role in the spread of Ebola, we would be less fearful of the virus on our shores, and more motivated to attack the social and environmental factors that may fuel future outbreaks that threaten the world's health.

Ignoring global inequity will make Americans more vulnerable to infectious diseases that know no borders. If we look far enough upstream at the factors that contributed to the Ebola outbreak, we will see that part of the problem, and the solution, lies with us.

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