This post was co-authored by Richard E. Nisbett, PhD, and Sten H. Vermund, MD, PhD.
Online and print media news sources have attributed a portion of blame for the 2014 West African Ebola Epidemic to witchcraft, ignorance, and illiterate people not understanding “germ theory.” Yet, global ethnographic studies have shown that the cosmology and disease etiology of indigenous people can very easily accommodate biological transmission of pathogens as we understand it in Western biomedicine. While Western scientists were still attributing malaria to “miasma” in the late 19th Century, many Africans understood well that malaria and mosquitoes were linked causally. As in our own society, native cultures accept dual causality. In other words, there is both a “how” one becomes ill and a “why” one becomes ill. The “how” takes into account what we call germ theory (now subsumed under “multi-factorial causality”) but the “why” accounts for personal or behavioral issues, timing, and broken taboos or societal norms.
One must be prescient in asking the correct questions. Borrowing the title of William Easterly’s The Tyranny of Experts, we would like to express concern about the failures of local and foreign experts to use participatory approaches, humbly asking local communities for help, knowledge and support in the prevention and control of Ebola virus. Often, “grassroots” programming as used by “top down” organizations assumes that if one goes to a community, they are taking a grassroots approach. But, properly used, “grassroots” in community development implies initiative taken by, and strategies emanating from, the local community. Communities can play a vital participatory role in assessing, designing, and implementing their own interventions in concert with outside partners. In Liberia, a prime example is the ad hoc women’s group, WIPNET, which may have done more to end the Liberian Civil War (1989-2003) than the aggregate efforts of political leaders, global organizations, and peacemakers.
Several traditional Liberian proverbs are enlightening:
“Hands dipped into the same rice bowl may not be raised against one another.”
“It is the small sticks that cause a fire to burn.”
“One person alone cannot reach the truth.”
“Baby deer show their mothers the trap.”
For millennia, communities have had complex and sophisticated leadership structures for addressing internal and external threats and for adjudicating conflict. Global health is the integration of biomedicine (prophylaxis and treatment) and social medicine (prevention and control). It builds multi-stakeholder and multi-sectoral partnerships to deal with health threats which are transborder in nature and require collaboration. The World Health Organization has pioneered collaborative partnerships with the community in the driver’s seat to achieve international targets for gold standards of care, improved health coverage, and reduced incidence/prevalence. This approach garnered the Bill & Melinda Gates Foundation Global Health Award in 2011.
Yet, in the Ebola epidemic, households, communities, civil and faith-based organizations have been bypassed. Much blame goes to the local experts who were unaware of the gold standards of community-directed interventions, but much blame goes equally to the external experts who knew, or should have known, that top-down strategies do not work in low-resource settings characterized by poor healthcare infrastructure and mistrust for authorities and outsiders.
When the post-mortem on this tragic epidemic is written, there will be many lessons learned. One lesson we hope is underscored is that in multi-lateral, cross-sectoral global health, hubris is lethal. Communities know their strengths, weaknesses, priorities and resilience. Health system strengthening must be grounded in respect for the dignity, native intelligence, and resilience of local people and communities.