Ebola outbreak demonstrates science’s need to ‘nudge’

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It should be a moment of cautious optimism: a second promising vaccine has become available to tackle the Ebola outbreak in the Democratic Republic of Congo. Instead, there is uncertainty and angst.

Clinicians desperately want to see the new vaccine deployed. But officials in the DRC, unnerved by public reaction to an earlier experimental vaccine, worry that introducing a second one might stoke public suspicions and destabilise containment efforts. Experts met in the capital Kinshasa last week to work out which way to jump.

The dilemma illustrates that human behaviour can be as destructive to global health as any deadly pathogen. Addressing diseases — even the organ-destroying horror that is Ebola — is no longer a matter of merely concocting a vaccine but also persuading people to roll up their sleeves for it.

Some academics are even calling for the World Health Organization to establish its own “nudge unit” to apply lessons from behavioural science. While dealing with disease outbreaks “require[s] modifying or working with human behaviour”, they wrote recently in Scientific American, “the global response to these threats lacks a coherent focus on behavioural insights.”

The Ebola outbreak in eastern DRC began almost a year ago. The area has been a conflict zone for two decades, with trust in officialdom low. Health workers have limited freedom of movement; when they do reach the afflicted, they fall under suspicion. In April, a WHO epidemiologist was killed during a rebel attack in an Ebola hotspot.

A survey of local residents, conducted by researchers from Harvard Medical School and published in The Lancet Infectious Diseases, revealed the difficult factors at play. Only 32 per cent felt local government represented their interests. A quarter did not believe there was an Ebola outbreak.

Mistrust and misinformation are the bricks from which public health disasters are built: this DRC outbreak has claimed about 1,500 lives, making it the second deadliest on record. A vaccine developed by Merck is believed to have kept the virus from running rampant. But supplies are running low. Rationing now means that only some of those eligible, such as frontline staff and known contacts of Ebola sufferers, can receive it. Selective vaccination is fuelling accusations of favouritism.

To surmount these issues, a WHO advisory group recently recommended deploying another experimental vaccine developed by Johnson & Johnson. Experts are divided, though, over how to allocate the 1.5m doses. Could the presence of this new two-stage vaccine spark scepticism about the first one — or “perturb the population”, as DRC’s health minister put it?

There are logistical questions about the new vaccine: how can clinics tempt patients, amid the chaos of conflict, to return for the booster? These issues were the focus of the Kinshasa meeting.

Professor Peter Piot, a co-discoverer of the Ebola virus and former chair of the WHO Ebola Science Committee, said that he “can’t think of a single reason not to deploy the vaccine . . . This epidemic is extraordinarily difficult to control and we need to use every tool we have.”

But Prof Piot is also convinced that improving global health demands a deeper understanding of how people think. The London School of Hygiene and Tropical Medicine, where he is director, employs economists, anthropologists and other social scientists.

“I’d love to have marketers too,” he said. “No company would dream of launching a product without understanding the user and yet this is the culture in public health.” During the 2014-16 west Africa Ebola outbreak he saw how community participation could change the course of an epidemic: “My proudest moment was people praying in the mosque to be included in a randomised trial.”

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