Contributor: The Importance of Crisis Management/Social Networking Strategies for Behavior Change in Vaccine Adoption

In a recent interview,¹ Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, noted that if a coronavirus disease 2019 (COVID-19) vaccine with an efficacy rate of 70-75% was available, and only two-thirds of the population were to take the vaccine, it would be unlikely that herd immunity will be attained. Of note, a recent CNN poll found that one-third of Americans said they would not take a COVID-19 vaccine, even if the vaccine is widely available and at cost.² Another study of Americans’ reluctance or resistance to being vaccinated cited general disbelief in the utility of vaccines (e.g., no flu shot in the past 2 years), distrust that vaccines are safe, and discomfort with the concept of vaccines, as vaccination deterrents.³

At a recent meeting concerning the COVID-19 crisis, Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) declared, “We’re not just fighting an epidemic; we’re fighting an infodemic.” The WHO describes infodemics as a contagion of misinformation, willful disinformation, and unchecked, unsubstantiated rumors, impeding an effective public health response and sowing confusion and distrust,⁴ with disastrous effects on population health.In other words, it would be a grave mistake to treat a pandemic or epidemic only from a medical perspective, neglecting the infodemic perspective.

Since the success of a future COVID-19 vaccine will equally depend on its adoption as well as its efficacy, the infodemic must be specifically addressed to effectively mitigate viral spread, and to lay a foundation for eventual vaccine adoption.

A population health playbook of managing both an infodemic and epidemic is found in evolving crisis management strategies that employed both medical and psychosocial solutions influencing behaviors in social networks during the Ebola crises in West Africa from 2014 to 2016 and in the Democratic Republic of the Congo from 2018 to 2020.

This article will discuss these 3 crisis management-social networking strategies, Complex Engagement, Friendship Leveraging, and Positive Psychology, that almost singly contained viral spreads in the countries of Liberia and Sierra Leone and substantially partnered with a vaccine in the Democratic Republic of the Congo to contain Ebola. The successful arrests of Ebola by crisis management-social networking strategies offer a playbook for addressing the current COVID-19 pandemic and infodemic and hopefully its eventual vaccine adoption.

Isolation & Containment: The Initial, CDC, Crisis Management Response to the Outbreak of Ebola in Liberia, 2014-2015

The initial response to confirmed cases of Ebola in Liberia in March 2014 was exemplified by the United States Center for Disease Control which proposed that 20,000 to 50,000 Ebola treatment beds would be needed before 2015 to isolate patients and thereby contain the spread of the disease.⁵ This proposal reflected a traditional, crisis management reliance on establishing safe spaces for treatment that would isolate patients and contain the disease in site-specific spaces. These safe spaces would initially be either 100 bed Ebola Treatment Units (ETUs) or in the patient’s home.^6,7

In August 2014, the World Health Organization endorsed this basic approach by releasing their “Ebola Response Roadmap” that stipulated⁸ 5 key strategies to contain the Ebola virus: Building ETUs and labs; conducting surveillance and contact tracing; making burial practices safer by reducing contact with bodily fluids; and lastly. engaging community populations via social mobilization tactics.

Yet, by September 2014 a downturn of the viral spread had already been achieved, even before plans for medical operations (beds, testing, tracing, etc.) were fully implemented.9 A deadly virus first confirmed in March 2014 was beginning to be contained by late September 2014 and would be mostly stopped with occasional flare-ups by May 2015.⁹ What could explain such a dramatic turnaround?

From Containment to the Strategy of Complex Engagement

At the outset of the virus outbreak in March 2014, the government of Liberia (GOL) emphasized in their short-term, disease planning for Ebola, 2 key differences from the CDCs’ initial crisis management containment and isolation plan. The GOL strategy prioritized the importance of community outreach through (1) communication and social mobilization (2) case management, treatment, and surveillance (3) water sanitation and hygiene.⁹ This difference in prioritization would set-the-stage for later amendments to clinical strategy.

In late July of 2014, health workers and properties were being attacked, prompting the GOL with CDC support to establish a crisis management infrastructure, Incident Management System (IMS),⁹ separate from the treatment reliance on ETUs. Its assessment function would become further operationalized in October 2014 with the formation of quick response teams, tasked to rapidly deploy into “areas with new cases to investigate, quarantine, and begin treatment.”⁹

In their analyses of these interventions, Johns Hopkins’ Thomas Kirsch and colleagues assessed that behavior changes, expedited by psychosocial mobilization, were the core drivers of the Ebola epidemic’s decline.9 Paralleling U.S. perceptions that concerns regarding COVID-19 may be overblown or a “hoax,”^{10, 11} public disbelief, distrust, and discomfort were initially widespread in Liberia. The authors cited a July, 2014 survey documenting that 84% of Liberians did not believe that Ebola even existed in the country; however, by the end of September after mobilization efforts, the authors cited another survey of 5 Liberian counties finding that 98% of people believed that Ebola was real and 89% were now concerned that they were at risk.The authors noted that social mobilization activities supported by both the public and private sector, appeared to be changing public perceptions of and attitudes toward Ebola, and concluded, “This is a remarkable turn-around in attitudes and may represent the most important aspect of the response.”¹²

The plurality of tactics of the psychosocial mobilization strategy, as described by Dr. Kirsch and colleagues, included the following¹²:

• Active community engagement, supported by an Incident Management System, to create a clear chain of command and “whole of country response”
• Engagement of local leaders, trusted faith-based leaders and community members in mobilization efforts
• Use of narratives, with community members performing skits to inform fellow citizens about Ebola
• Coordinated public/private sector multi-media campaigns, leveraging radio, journalist training, community meetings, a telephone hotline (established with private cell phone companies), and dissemination of educational information by radio stations
• A ‘train the trainer’ model to train volunteers in all counties and a registry of social mobilization activities conducted
• Complementary use of community engagement strategies to help communities “own” their interventions, thereby reversing the cycle of mistrust, stigma, and non-cooperation, and boosting participation with hygiene (e.g., hand washing), safe burial, and case finding, thus decreasing high-risk behaviors.

The authors summarized the critical factors that arrested the spread of Ebola before clinical operations became fully operational¹²:

• Behavior changes by individuals and communities were critical to bending the curve. This was likely facilitated by social mobilization initiatives (community engagement and communication), as well as organic change within communities and households
• Local leadership provided vital organizing efforts, responses to changing conditions, and positive direction, with necessary international, monetary, technical and logistical support
• Removal of infected bodies from the community and safe burial likely helped reduce the epidemic, and attested to communities’ and households’ eventual willingness to modify traditional behaviors for survivors’ safety
• Whereas Ebola Treatment Unit beds were important for providing treatment for Ebola, the majority of the beds were constructed too late and became available after the epidemic curve had declined
• Future efforts to strengthen health systems should focus on enhancing community capabilities and leadership, rather than focusing on building more physical infrastructure

The behavior change in Liberia reflected a crisis management-social networking Complex Engagement approach, wherein a cloud of continuous and simultaneous contacts from different sources reinforces behavior change faster than serial transmissions of information that migrate like an infectious disease from person to person. In other words, infodemic transmissions differ from pandemic person-to-person infections because humans are more likely to accept and pass along information that seems confirmed from multiple sources.¹³ If the faster spread of information helps to change behaviors that sustain the slower, physical spread of infection, then the informational spread can almost by itself stop the more slowly developing physical, viral spread as the Liberian example demonstrates.

Liberia employed multiple sources (international, national, and local) of uncoordinated, overlapping population contacts that would expedite behavior change but would also leave irregularities of reporting and tracing. These potential gaps of care could produce unexpected eruptions of disease. Sierra Leone would present an example of how these gaps of reporting could be closed.

Maximizing Trust Maximizes Reporting: Networks Perceived as Friendship Relationships Leveraging Behavior Change in Sierra Leone

A further refinement in the crisis management-social networking playbook would culminate in the formation of Community Care Centers (CCCs) in Sierra Leone. Unlike the Ebola Treatment Units of 100 beds that employed mostly medical personnel, the CCCs were 8 bed clinics and community liaison hubs that were staffed mainly by community members. These health care peers were given 3 days of onsite instruction in infection prevention and management and were mentored 24-7 for an additional 2 weeks.⁷

The small number of beds (8) in CCCs relative to the ETUs indicate that the CCCs were tasked with a primary mission different from the emphasis on containment and isolation, adding another tool to the crisis management toolkit. CCCs did not possess the equipment nor the medical professionals of larger ETUs. They represented a new model of crisis management-social networking intervention emphasizing community engagement, tasked with overcoming fears and building trust by relying principally on local staff and community liaisons.⁷

How did community stabilization in Sierra Leone differ from socially mobilizing communities in Liberia? In Liberia irregularities in reporting cases of contact tracing were perceived primarily as difficulties in coordinating data collection among international, national, and county health organizations.⁶ But there is another more dangerous cause for data irregularities and that danger is underreporting by people who distrust and fear the intrusions of foreign influences.

In Sierra Leone people hid or fled to avoid engaging with the multinational Ebola treatment services or attempted to treat themselves in their homes. CCCs in Sierra Leone successfully addressed this problem of underreporting. Rather than viewing communities as social networks connected by cultural traditions of information exchanges and themselves as foreigners on the periphery of these social networks, the substantial reliance on community health care peers redefined a community as a social network of friends, integrating medical outreach into the intimacy of trusting, friendship relationships. In other words, if I’m a friend of a friend or a friend of a friend of a friend…, then as a health care worker and friend, I already live at the heart of a personalized, intimate social network, which are its overlapping circles of friendships. Friendship encourages trust and trust boosts the feelings of security in self-reporting an infection and in trusting the purposes of viral seclusion.⁷

Chaos, Paranoia and Seizing the Moment: Crisis Management, Coaching and Positive Psychology in the Democratic Republic of the Congo

The severest test to the efficacy of crisis managing-socially engaging populations would come with the spread of Ebola into the Democratic Republic of the Congo (DRC) in August 2018. By then, the nation had been ravaged by 2 major wars lasting over 2 decades (since 1994) with more than 5.4 million dead. The country had experienced political destabilization and people had suffered from displacement from homes and villages, robberies, enslavement, sexual violence, hunger and disease.¹⁴

This mayhem occurred in the eastern part of the country where the Ebola outbreak erupted. Add to this political nightmare, a legacy of more than a century of colonial conflict, economic exploitation and political corruption, producing a deep-seated skepticism of outsiders within “an environment rife with paranoia, conspiracy theories, and disinformation, aided and abetted by social media and local political opportunists.”¹⁵ It becomes understandable that even innocent, humanitarian gestures like vaccinating populations against Ebola would be met with the paranoiac skepticism of deep suspicions, distrust, hostility, and violence.¹⁶

This situational paranoia, a historical outcome of war and the legacy of exploitation, is so pervasive that it can neutralize the strategic advantage of using peers to leverage friendship relationships into trust and participation with medical interventions like vaccination. For example, in the DRC, health care professionals and peers were viewed as injecting Ebola into their patients as a nefarious way of spreading the disease. Their patients were viewed as traitors working with them, and these medical “villains” and their loyalists were then attacked and even killed.^{17, 18}

Yet, despite this chaos, the DRC declared the Ebola crisis over in the eastern part of the country after about 2 years¹⁹ with more than 70 patients and medical personnel injured by attacks, while at least 11 were killed.²⁰ In this part of the country beset by civil paranoia, leveraging friendship into cooperating with care, even given the availability of an effective vaccine, was not guaranteed because situational paranoia was understandably too ingrained in many eastern DRC communities to lend trust easily.

What else then could credibly explain how the containment of the virus was achieved in a war zone within 2 years? This author thinks the answer may lie in the implicit use of positive psychology concepts. Positive psychology scholarship is now published in over 46 countries in Africa, the Americas, Asia, Europe, and Oceania, influencing such disciplines as coaching, psychotherapy and public health and addressing circumstances including healthy lifestyle, trauma and resilience.²¹ The story below exemplifies the use of positive psychology, and involves Julienne Anoko, a medical anthropologist, noted for changing burial customs in handling dead bodies infected with the Ebola virus. It is an example of her special expertise in using implicitly or explicitly positive psychology tactics:¹⁶

“On Anoko’s most recent trip, she had ridden motorcycles through the jungle with a handful of other Ebola responders. At 1 town known to have housed several people with Ebola, a community refused to allow the group to enter. “I tried to talk with the mothers, but they just stared at me,” Anoko says. As people gathered to watch, she asked a boy for his name. He sassily said he was Lionel Messi, the Argentinian football star. So, she told him to call her Cristiano Ronaldo, (another soccer star) and then challenged him to arm-wrestle her for the World Cup. “So, we wrestled,” she says, “and everyone was watching and laughing.” Anoko returned the next day with a football as a gift. And then the community agreed to let in health workers with vaccines.”

Unlike, for example, how conventional health care professionals might manage this confrontation with village mothers, Anoko did not try to argue with them that she and her company of WHO professionals were altruistic and so their paranoia was misdirected. She did not blame them for using their paranoia or extreme distrust as a precaution against a surprise attack. Instead, she seized the moment with a child to express a tenet that merges the practice of crisis management with positive psychology: Don’t be solely patient focused when attending to a crisis. Spread your clinical concerns to the patient’s supportive network who aspire to share a better life with the patient!

The village mothers might expect to be tricked as adults because of their social power in the village. But what would be the point of attempting to fool a child with little social power, who compared to them could be easily fooled anyway? So, in engaging a child who seemingly possesses little social power, what does Anoko gain? She shares a moment of emotional support for a child whose dreams of a better life won’t be stifled.

For the child unlike the mothers still has the emotional and moral strength to openly aspire for a time when dreams of being a soccer star are permissible and safe. Anoko joins with the child in his dream by giving herself the name of another soccer star. She then reinforces the realism of his dream by arm wrestling him for the World Cup championship. She brings a soccer ball as a gift the next day, as if to say, “Someday your dreams of playing league soccer will be realized.” Seeing that Anoko respects the child’s dream for a better village life that 1 day will allow soccer to be openly played, the village mothers decide to cooperate and have their village vaccinated.

Anoko’s brilliant coaching, consciously or unconsciously, exemplifies in a war zone key concepts of positive psychology, cited in a 2020 article²² authored by Drs. Tal and Kerret. In population management, Tal and Kerret note that a key contribution of positive psychology is shifting the focus from dwelling on dysfunctions of personality (as Anoko demonstrated) to the promotion of desired social outcomes, emphasizing those aspects in an individual and family’s life that make them happy and well. Those aspirational aspects lend themselves to the following empirical determinations:²²

• Understand the contexts that drive the decisions of individuals, families, and businesses in order to
  • Impact their behavior
  • Overcome biases
  • Customize messaging tailored to their priorities and desired goals
• Be guided by policies and practices stressing
  • Action and solutions
  • Flexibility and incremental steps
  • A positive, future-oriented focus offering individual and collective promise

Anoko’s example presents an evidence-based, social mobilization option using positive psychology, when even the basic trust among friends is doubted.

Crisis Management-Social Networking:Payers, Health Systems, Pharmaceutical Manufacturers and Government

So far, containing the transmission of the Ebola virus in West Africa and the DRC required a coalition of multinational organizations with national, state/province, and county/village governing entities. These interdependent relationships permitted flexibility in adopting crisis management-social networking strategies that could address each of the unique, regional, infodemic and epidemic challenges presented in the countries above. These strategies presupposed perceiving the spread of Ebola as complex, reinforcing networks of biological and informational contagions that either must be swamped by a plurality of healthy contacts, or using peers extensively to maximize the self-reporting of friends to close gaps in care, or using evidence-based tools like coaching and positive psychology to disarm high levels of distrust, fear, hostility, and violence to promote the acceptance of treatment and vaccines.

The example of Ebola presents a framework for the future of managed care in this era of the pandemic. There are 2 reasons for this prediction, the first being that Ebola and COVID-19 are both viruses leading to deadly epidemics. The complexity of collaborations in Africa offer strategically possible collaborations that are already being anticipated in the US.

For example, in a recent PRECISIONvalue survey²³ of health systems and plans to investigate their population health priorities and collaboration opportunities since the onset of the pandemic, 87% of respondents indicated they will need at least “some support” from pharmaceutical manufacturers, when a COVID-19 vaccine becomes available.In addition, 80% of respondents expressed an openness to collaboration with manufacturers on crisis management for COVID-19 or future crises.

The crisis management-social networking blueprint for care, exhibited in the containment of Ebola, will become the paradigm of care in our pandemic environment. The uncertainties of vaccine effectiveness and containment of an infodemic in a capitalistic democracy place the burden of care on sustainable for-profit options, specializing in technologies and flexible tactics of prevention and detection. Thus, opportunities will exist for collaborative private/public sector development and deployment of crisis management-social networking strategies that address the current infodemic and expedite the adoption of vaccines and other pandemic mitigation activities.

Current examples of global collaborations that beckon the future dominance of a crisis management-social networking playbook are offered by the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA). Recognizing that COVID-19 is a “major public health threat for all, with profound health, social and economic impacts around the world,” the organization’s members are pledging international cooperation and multi-stakeholder action, including the private sector as a critical partner to address COVID-19 on 7 fronts.

One of those fronts is supporting global health care systems, offering services such as health registries and initiatives to address health inequities, social risk factors, and provide patient support during the COVID-19 crisis.²⁴ Further, citing antimicrobial resistance (AMR) as a “looming global crisis that has the potential to dwarf COVID-19 in terms of deaths and economic costs,”²⁵ IFPMA announced that 20 pharmaceutical company members are banding together to bring 2 to 4 new antibiotics to market by 2030 and foster long-term solutions to antimicrobial resistance (AMR), including forging global private-public partnerships.

The urgency of research in the pandemic era and its rapid application into viable market solutions will force current CMS restrictions that were relevant in the managed care era to become irrelevant and fade away in the era of the pandemic. In the hot, crisis management-social networking ecology of current and potential pandemics, direct patient engagement and service accelerates immediate access to the larger pool of diverse populations and genomes needed to expedite effective antibiotic and vaccine development and dissemination.

The global public good is served when the playbook of crisis management-social networking allows flexible for-profit networks to accelerate research through a variety of models, including performing direct patient care that gathers diverse, genomic data to expedite market solutions addressing the current pandemic and others to come. To that end, for example, entities such as coalitions of manufacturers offering social determinants of health services might in the future serve a similar function to the CCCs in Sierra Leone, providing supportive services and direct care, including testing, crisis stabilization beds, in-home care kits, remote/monitoring, collection of genomic data, and prevention through administration of vaccines as they become available.

As the Ebola experience shows, the wheel doesn’t have to be reinvented to adapt it to addressing future national and international pandemics, epidemics, or infodemics. A playbook for these crises already exists, but an additional spoke is needed: powerful leagues of manufacturers gathering data and clinical experience to address the biological transmissions of disease and messaging acumen to address the accelerants of infodemics. For, as former U.S. Surgeon General C. Everett Koop famously observed,²⁶ “Drugs don't work in patients who don't take them.”

References

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