Culture proves a critical factor in epidemics

Following the devastating impact of the tsunami, public health officials are worried about epidemics. The World Health Organisation warns that millions of people are threatened by outbreaks of dengue fever, malaria, typhoid, cholera and other water-borne diseases that have the potential to cause as many casualties as the unforgiving waves of the Indian Ocean.

Epidemics have killed far greater numbers than natural disasters. The flu pandemic of 1918 alone caused the deaths of an estimated 20 million.

So can history help us to understand and control outbreaks of disease?

People and disease have always co-existed. The world's most isolated communities, from Africa to Papua New Guinea, developed ways to contain the most virulent of epidemics. The native inhabitants of early 20th-century Belgian Congo lived amid malaria, leprosy and many other infections. Sleeping sickness, unleashed by the ecological disruption of colonisers, was kept under check by indigenous mechanisms.

When epidemics occur, the fear and stigma associated with the disease can alter the behaviour of a whole population. In the town of Mbarara, during the 2000 Ugandan outbreak of ebola - an acute viral disease in which 90 per cent of the victims die - inhabitants refused to shake hands or handle notes and coins and wore latex gloves.

The intensity of the stigma can be so great that epidemiologists have referred to the phenomenon as a "second epidemic". Reducing social stigma through a clear explanation of the disease to local communities should be a priority in the effort to control the impact of epidemics.

Fear is a common characteristic. Flight from the hospital, by both patients and hospital staff, often happens when a virulent disease breaks out.

In the 1995 ebola epidemic in Congo, most patients and health workers deserted the hospitals and only dying patients and voluntary workers remained. When Tom Ksiazek of the Centres for Disease Control visited an abandoned hospital, he found 30 dying patients, left to care for themselves, sometimes in the same beds as rotting corpses.

Maryinez Lyons, a medical historian, has described how colonisers neglected African customs during the sleeping sickness epidemic that ravaged the Belgian Congo, and the hazardous effects of this disdain.

For the afflicted Africans, the invasive colonisers prevented their movement, touched their bodies in unfamiliar ways, forced them to take drugs whose efficacy they doubted, and sent their loved ones to contagious-disease hospitals from which they were unlikely to return. So many villagers hid during the much-feared doctors' visits and revolts occurred. In many ebola outbreaks, bodies were buried before family members could identify the corpses. As a consequence, families hid their sick and refused to send them to hospital. Rumours of Europeans selling body parts for profit proliferated. In South Asia today, many bodies are buried en masse, amid ill-placed fears that corpses trigger epidemics. The World Health Organisation emphasises that survivors pose a much greater risk of infection, because most infectious agents cannot live long in a corpse. Few consider the psychological effects that burying the dead in mass graves will have on still-hopeful or grieving relatives.

Whereas in colonial times the medical staff were often based on site and - as a result of longer stays, became more aware of indigenous practices - much of the help today comes from overseas. Scientists from disease control centres are often sent on assignment at short notice and with little knowledge of the cultural context.

The closure of former training bases has affected the number of trained scientists. Dan Bausch, an epidemiologist with the Centres for Disease Control, says there is a big shortage of young researchers fully familiar with tropical diseases.

Most severe epidemics of infectious disease share a set of common features. Fear, flight and stigmatisation appear time and time again. A knowledge of the anatomy of past epidemics, of the success stories and disasters, can reveal insights to help us deal with epidemics in the most efficient and culturally sensitive way.
* Daniel Sokol is a medical ethicist at Imperial College, London

- INDEPENDENT