The Angola Red Cross threw itself into a major government vaccination campaign, yet the epidemic continued. In part this was due to the scarcity of vaccines, but lack of communications played a significant role. Because vaccines were traditionally identified with women and children, men had not been specifically approached. “But the men were mobile for work and they were moving and trading, and this took the disease across the whole country and into DRC,” says the IFRC’s McClelland.
Through focus groups, surveys and feedback from the community, the Red Cross was able to counteract the situation and adjust its approach, while community workers and volunteers delivered crucial health messages that helped turn the yellow fever campaign around. The government expanded vaccination hours to accommodate men who had jobs — back in their village they might have been able to put down their tools for a few minutes and attend to their health.
Keeping up traditions
People who migrate to the city bring along their rural traditions and customs.
When someone died of cholera in Haiti, for example, friends and relatives converged upon the victim’s house, coming in close contact with each other and encouraging infection. People would then go home and spread the bacteria throughout their own neighbourhoods.
Traditional burial practices in West Africa also involved visits from many relatives, as well as extensive touching of deceased bodies. Since Ebola is transmitted through contact with bodily fluids, the more people around, the greater the risk. Given the crowded conditions of West African cities and the lack of proper sanitation, Ebola was even more likely to spread there than in the countryside, where houses are more distant from one another.
Stigma also hampered the Ebola response in urban areas. Rather than admit someone had just died, families hid the bodies at home, fearing potential rejection from neighbours. When ambulance drivers went in search of the dead, they often came away empty-handed — or worse.
At the time of the Ebola epidemic, Roselyn Nugba-Ballah was a supervisor of safe and dignified burial teams for the Liberian Red Cross Society in Monrovia. She remembers the hostility.
“Our teams were often attacked and we had to bring police officers with us. One of my teams was chased with machetes, and another was kept hostage in their car. Sometimes when we found the bodies, they had been kept so long by their families that they were decomposing.”
The traditional hand-washing of bodies was so dangerous Red Cross burial teams used plastic bags instead, rekindling difficulties eventually brought under control.
“We did community engagement before burials, and we followed the entire traditional process — apart from washing. When we explained, local people began to understand why the tradition of washing was so harmful,” says Daniel James, who served as head of National Safe and Dignified Burials for the Sierra Leone Red Cross Society during the Ebola crisis.
By working closely with communities, volunteers and health workers in all these epidemics were able to claim victories and save lives. They spoke local languages, painstakingly outlined what should and shouldn’t be done, and debunked myths, for example, that illness was brought in by aid. Ultimately, they succeeded in upending the general lack of knowledge that can develop when people live in crowded and unsanitary conditions and in poverty, with few services and not enough information.
The great unknowns
A thousand years ago, caravans travelled leisurely along the Old Silk Road that bisected Asia and Europe. Traders would inch forward, selling here, buying there, pushing towards the edge of their known world over many months.
Now, a similar trip takes only hours. In today’s globalized world, diseases that would likely die out in transit fly directly to their destination, fed through the airports that ring every large city.
All it takes is a single infected person, perhaps undiagnosed, to board a flight.
Globalization is one of the new frontiers of infectious disease, a threat few could have predicted only decades ago. The spectres of bioterrorism, anti-microbial resistance and the potential impact of climate change are equally new and even less understood. Even better-known diseases can harbour surprises: no one expected Zika to do such damage, after all.
“Since 2010 some 87 new infectious diseases have been discovered,” says McClelland. “Take Aedes aegypti, which likes the urban environment so much. That mosquito transmits Zika and dengue and chikungunya and yellow fever but potentially other diseases too, any of which could easily become the next epidemic and whose consequences we don’t know.”