The standard view of public health usually involves
the portrayal of health care workers in lab coats peering into microscopes and treating
patients combating the most severe medical issues of our time, as well as
looking ahead to circumvent outbreaks on the horizon. This vision often results
in increased research and funding for the development of a medical miracle—a
cure to save those stricken with a disease or a vaccine to keep the healthy
from getting sick.
for most populations, receiving medical therapies and supplies saves lives;
however, medications unable to reach their intended targets prove worthless.
“Vaccines that remain in the vial are 0% effective” (Orenstein, Seib,
Graham-Rowe, & Berkley, 2014). Outside obstacles stand between patients and
the administration of critical health care resources (CHCRs) including medical countermeasures (MCMs),
equipment, and supplies. These obstacles can, therefore, result in severe
consequences. From a public health perspective, resources that do not reach
those affected during an outbreak can mean the difference between a contained
disease cluster or the disease spreading
and threatening national or even global health security. This is especially relevant as “the problem of
infectious disease is no longer only one of prevention, but also—and perhaps
even more—one of preparedness” (Lakoff
preventing sick people from accessing available resources is not a hypothetical
concern any longer. Instead, it is one continually being played out both
domestically and internationally in routine and emergency response situations.
These obstacles are rooted in various causes and require more specific
identification and analysis to prevent inadequate public health responses.
Barriers to the delivery of care cost hundreds of thousands of lives simply
because they are not defined or incorporated into public health planning and
The repeated interference of these
impediments requires asking the question of whether
the current approach to public health response planning and execution
adequately incorporates all known obstacles to delivery of care and resources. Analysis
of public health operations argues that it does not
and there are critical gaps that allow
these barriers to persist. To fill this void,
previous research (Osetek
2018) introduces a new framework of non-medical obstacles (NMOs).
NMOs are material and intangible factors that slow or prevent the timely
delivery of available CHCR to populations in need during a public health
emergency or crisis. The focus on available CHCR is important because these resources essentially
provide immediate assistance in the absence of NMOs. This framework addresses explicitly obstacles to resources allocated for use to a specific
population in need. The four components of this NMO framework are Security, Logistics, Culture, and
These four categories
of obstacles play a significant role in public health responses to outbreaks.
They can be both dependent upon each
other and simultaneously demonstrate distinct differences. For example, a logistical obstacle will not
involve the same solutions or the same actors as trying to understand and
mitigate behaviors deeply entrenched in cultural practice. Additionally, in many cases, multiple obstacles are simultaneously occurring that complicate public health
efforts. For instance, there are situations when the communication aspect of response is
intimately tied to a necessary understanding of the culture and society
on the receiving end of the message. The Acquired Immune Deficiency Syndrome (AIDS) crisis in particular demonstrated the intersection of communication and culture when
a theater group tried to deliver relevant
health information via puppet shows in parts of Africa hit especially hard by
the disease. The premise and idea were
good, but it was not effective because it failed to include enough culturally
sensitive information to make the medium effective (Uwah 2013). Another example of multiple NMOs
compounding a situation existed during
the 2014 Ebola outbreak. A lack of proper, culturally appropriate communication
led to a distrust of health care workers (HCWs) deployed to help combat the
epidemic. In South-East Guinea, fearful residents
stoned a team of HCWs and journalists to
death, creating a security and safety issue (Allgaier and Svalastog 2015). To make
the response efforts successful, these obstacles need to be addressed separately and in conjunction with each other; however, not all NMOs can be taken together and considered as a
single entity to solve. Instead, they are
individual problems standing alone and complicating other obstacles. Public health practitioners need to view the
effects of NMOs in their entirety as there is no other way to approach these
interventions and have positive results. These
past examples serve to illustrate the challenges and also make it evident that this is not a new problem, nor is
it confined to a specific disease, response, or region. NMOs are a systemic problem with critical implications that continue
to demand immediate attention.
The urgency of this problem can be
currently seen in the Ebola outbreak raging in the Democratic Republic of the
Congo (DRC). On a positive note, there
have been multiple therapies developed over the last few years, including a
monoclonal antibody cocktail vaccine approved for compassionate use in the DRC
and approved by their health ministry ethics committee (Cohen 2018a). The
monoclonal antibody therapy is also advantageous from an NMO-mitigation
perspective, as it requires just single dose administration and can be shipped at temperatures more easily achieved
in developing countries (Racine 2018).
the DRC outbreak’s unique distinction as being the first Ebola outbreak with a
preventative vaccine, it is also the first outbreak to take place in a war
zone. The violent environment’s introduction of security NMOs is having a
tremendous impact on the response efforts in both direct and indirect ways.
According to Peter Salama, Australian epidemiologist and leader of the WHO Health Emergencies Programme, there are 100 insurgent groups operating in the area where response efforts are taking place, and 20 of those groups are “highly active” (Cohen 2018b). Peacekeepers have been actively targeted by these insurgent groups so public health workers operating in the area have resorted to traveling with armed military escorts (Cohen 2018b). Despite this, there are regions that have security blackouts where the WHO teams cannot spend much time on vaccinations or contact tracing.
September 2018, a rebel-led attack in the city of Beni killed at least 14
civilians. The government declared a “ville
mort” (mourning period) “out of respect for the victims,” so aid workers had to
temporarily halt their monitoring and tracing work (Bearak 2018). Amid a contagious outbreak, this lost time is
especially dangerous and potentially allows the outbreak to grow.
volatile environment within the DRC also complicates the process of contact
tracing, and consequently, curtailing the spread of the Ebola virus. Over one
million people have been displaced due to
militia activity, and there are numerous parts
of the region that are inaccessible to
healthcare workers due to fighting (Bearak 2018). The displaced
people possess less knowledge about Ebola, making them more susceptible to the
disease (Claude, Underschultz, and
concerns have also negatively impacted the Red Cross Safe and Dignified Burial
(SDB) Teams operating in the region. This
is of special concern since the safe burial of deceased Ebola patients is an
important response strategy to curtail the disease spreading. As of the middle
of October, due to an incident that injured three volunteers, Red Cross burials
in Butembo were stopped and Civil
Protection teams are responding instead. Security concerns prevented the
responses to seven SDB alerts (World Health Organization 2018).
rising death toll in the DRC emphasizes the fact that NMOs are a major problem
in public health responses and they need to be
placed at the forefront of public
health planning. Science alone cannot tackle outbreaks, but rather it requires
a concentrated balance between science and NMO mitigation. Regardless of
whether the disease being combatted is
smallpox, Ebola, polio, or a new threat that has yet to present itself, there
will always be scared patients in remote areas looking to public health workers
for help and hope. For the public health workers positions to provide that
assistance, they get the opportunity to “make a difference by reaching the
unreachable” (Boum 2018). Understanding
and planning on how to best mitigate the non-medical obstacles outlined here removes
hurdles and restores hope to scared patients and encourages the public health
workers trying so desperately to provide help.
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Jennifer Osetek received her PhD in Biodefense from George Mason University. She teaches at the Penn State University College of Medicine in the Master of Professional Studies-Public Health Preparedness program and serves as an Officer in the Coast Guard Reserve. She also works as a contractor in the Coast Guard’s Office of Specialized Capabilities.