Global health – PLOS Currents Disasters http://currents.plos.org/disasters Thu, 08 Nov 2018 15:48:50 +0000 en-US hourly 1 https://wordpress.org/?v=4.5.3 The Enduring Health Challenges of Afghan Immigrants and Refugees in Iran: A Systematic Review http://currents.plos.org/disasters/article/the-enduring-health-challenges-of-afghan-immigrants-and-refugees-in-iran-a-systematic-review/ Fri, 21 Jul 2017 09:35:19 +0000 http://currents.plos.org/disasters/?post_type=article&p=35709 Introduction

Iran is the third country in the world with the highest number of registered refugees with the majority coming from Afghanistan. They suffer major health and social risks yet their health status has never been comprehensively determined.

Methods

This systematic review of the literature highlights major disparities among documented immigrants in health access, communicable and non-communicable diseases and the increasingly desperate plight of undocumented immigrants.

Results

Comparing with Iranian population, the findings suggest the higher prevalence of most diseases among Afghan immigrants and refugees. This highlights the importance of increasing the migrants' access to health services from both public health as well as human rights perspectives.

Discussion

Although the Iranian government has taken new initiatives to overcome this challenge, certain issues have still remained unaddressed. Potential solutions to improve this process are discussed.

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INTRODUCTION

One of the effects of globalized world is the increase of human mobility across the borders resulting in rapid growth of international migration. According to the 2015 United Nations International Migration report the number of international migrants has increased significantly during the past fifteen years reaching 244 million in 2015, up from 173 million in 20001.

The huge number of displaced populations has turned migrant health into a priority global health priority. Although international migration may have some benefits, immigrants are usually among the most vulnerable groups in destination countries. Migrants are commonly subjected to multiple discriminations, violence or exploitation which may have considerable impact on their mental and physical health. According to a report of World Health Organization (WHO), in some countries migrants find themselves completely excluded from routine health services.2

Immigrants and refugees are at higher risk of developing certain diseases. Migrants originating from areas of poverty or those who are displaced by conflict or natural disaster are at greater risk of adverse health outcomes.3 In a study conducted by The Tuberculosis (TB) and Human Rights Task Force, refugees have a high risk of developing TB associated with poor nutritional status and sanitation, crowded living conditions, insufficient access to care, education and information, and other coexistent illnesses.4 Although it has always been a controversial issue for the host country, addressing the health needs of immigrants and refugees can improve health status and outcomes; facilitate integration; prevent long-term health and social costs; contribute to social and economic development; and, most importantly, protect public health and human rights.5

Iran is the third country in the world with the highest number of registered refugees (1 million).1 The majority of refugees came from Afghanistan but their health status has never been comprehensively determined. UNHCR acknowledges that “refugee” or “migrant” have distinct and different meanings and “confusing them leads to problems for both populations”. They use “refugees” when people flee war or persecution across an international border and “migrants” when people move for reasons not included in the legal definition of a refugee.6 In compliance, this study refers to Afghan refugees as nationals of Afghanistan who left their country as a result of war or persecution; and, Afghan immigrants as those who choose to move not because of a direct threat of persecution or death, but mainly to improve their lives by finding work, or in some cases for education, family reunion, or other reasons.6These terms are used interchangeably in some of the reviewed literature which ineluctably has been reflected in this manuscript. Evaluating the health needs of this population and assess their access to health services are necessary for health policymakers to develop and adopt appropriate strategies. Increasingly, this has become a major public health concern. As such, a systematic review of relevant studies including the culture profile, and health access and risks are required to better assess and respond to issues of prevention, preparedness, response and recovery.

METHODS

All national (MagIran, Science Information Database (SID) and Iranmedex) and international (PubMed, Scopus) databases were searched from November 2010 to November 2016 using keywords both in English and Persian: Afghan immigrants, Afghan refugees, Iran, infectious diseases, tuberculosis, HIV, Hepatitis B and C, non-communicable disease, food security, mental health, barriers, health insurance, access to health service. All related websites and webpages were also searched by Google with the same keywords. The author also used back-tracking to find earlier relevant sources from 2001.

This literature review resulted in 86 articles. This process preferenced systematic reviews but due to small sample sizes of cases studied additional cases where found in humanitarian organizational reports and webpages. The final number of articles included: 8 systematic reports, 24 original articles, 7 organizational and 5 webpages.

RESULTS

Cultural Profile of Afghan Immigrants

Following the political disruptions in Afghanistan, the Islamic Republics of Iran and Pakistan experienced a massive influx of Afghan refugees during the past three decades. Currently, more than 2.5 million Afghan immigrants live in Iran accounting for 3% of total Iranian population.1 the data of this study is primarily based on the health status of documented refugees in Iran and does not contain the situation of more than 1.5 million illegal immigrants.

Over the past decade under the so-called Amayesh record system,7 the Iranian authorities have only allowed Afghans who arrived before 2001 and those who have been in Iran for a long time to register in the system and obtain legal residence. Afghans who have arrived after 2001 are now considered illegal immigrants.8 The latest registration (Amayesh XI) was completed in 2016.7

Ninety-seven percent of Afghan refugees live in urban areas while 3% reside in settlements and camps run by the assistance of the government, UNHCR and foreign NGOs.9 The Afghan immigrant population is relatively young in Iran with a median age of 31 years. In compliance with the world trend, in 2015 less than half of the international immigrants in Iran were women (47%).1 One-third of immigrants (32.7%) resided in Tehran, 13.3% in Khorasan Razavi (Mashhad), 11.7% in Isfahan, 9.3% in Sistan & Baluchistan, and the remainder in other provinces.10

A survey performed among registered Afghan employees in 2006, found that low educational attainments characterized the surveyed Afghan population. Thirty-one per cent of the population aged six and above in this sample were uneducated (women 36%, men 26%) and 50% had completed only primary or secondary school education. The average household size of Afghan population in Iran is 5.6 persons. About 80% of Afghans work in four sectors – manufacturing, construction, trade, and commerce. Less than 3% of the Afghan employees had written contracts and more than 99% of Afghan employees did not have any type of work-related insurance (accident, unemployment and retirement insurance) and only 5% were entitled to paid annual or sick leave. The majority of households (83%) live in rented houses. The main reason for their immigration was escaping from war and insecurity.11

In 2013-2014, more than 350,000 Afghan refugee children were registered in Iranian schools,9 while some 48,000 undocumented Afghan children were allowed to enroll for the first time in Iranian public schools in 2015.12

Health Problems of Afghan Immigrants

The health needs of Afghan immigrants and refugees in Iran are quite similar to other immigrants around the world. Although the lack of data is much more visible in some diseases, this study has attempted to provide a general overview to the most important health needs of Afghan immigrants and refugees in Iran. The main health problems of Afghan immigrants/refugees have been categorized into three sections: mental, communicable and non-communicable diseases.

Mental Health

In a systematic review of multiple countries on the long-term mental health of war affected refugees, the prevalence rate of depression ranged between 2.3 to 80%, posttraumatic stress disorder (4.4–86 %), and unspecified anxiety disorder (20.3–88 %). This heterogeneity in prevalence rates was mostly contributed to the methodological quality and which country the refugees came from and in which country they resettled.13

Some studies identified the prevalence of mental disorders among Afghan refugees in different parts of Iran. In a study designed to determine the prevalence of mental health problems among Afghan refugees resettled in Dalakee refugee camp of Bushehr Province, the prevalence of social dysfunction, psychosomatic problem, anxiety and depression in the studied population were 80.1%, 48.9%, 39.3% and 22.1%, respectively. In this study, the total prevalence of mental health disorders was determined as 88.5%.14 Also findings of another study conducted in Tehran showed that the prevalence of mental disorders was 55.6% (19.9% in males and 35.7% in females) among Afghan immigrants.15

Compared to the studies conducted among Iranian population,16 the prevalence of mental disorders is relatively higher among Afghan refugees especially those living in settlements and camps.

Communicable Diseases

Several studies report a relative high prevalence of Malaria,17 Hepatitis B,18 Tuberculosis,19 Cholera,20Crimean–Congo hemorrhagic fever,21 leishmaniasis,22 and HIV among Afghan immigrants in Iran.23

Tuberculosis, MDR tuberculosis and malaria are the most common infectious diseases among the Afghan immigrants in Iran. In a systematic review and meta-analysis study done on major infectious diseases affecting Afghan population in Iran, the proportion of Afghan immigrants who were infected with tuber­culosis was (29%), Multiple-Drug-Resistant (MDR) tuberculosis (56%), malaria (40%), cholera (8%), Crimean-Congo hemorrhagic fever (25%), leishmaniasis (7%), and hepatitis B (14%). The overall proportion of Afghan immigrants with the aforementioned infectious diseases is 29%.24In 2008, Jabarii and colleagues assessed the prevalence of HIV among Afghan immigrants to be 0.2% in a town to the northeast of Tehran.23

There is a huge difference between the prevalence of infectious diseases among Afghan immigrants and Iranian population. While the prevalence of some infectious disease such as tuberculosis and malaria is high among Afghan immigrants, Iran has almost eradicated both diseases among its nationals.25,26 Also, evidence suggests that the prevalence of hepatitis B is estimated to be about 1.7% among Iranians27 which is significantly lower than the Afghan immigrant population.

Non-communicable disease

Non-communicable diseases (NCDs) represent 43% of the burden of disease worldwide. The Middle East is known to have high rates of major NCDs such as heart disease, stroke, cancer, diabetes and chronic lung disease with risk factors that are the main causes of morbidity and mortality.28 The current data from Afghanistan show that the rate of NCDs is increasing with more than 35% mortality.29

According to data extracted from 23,167 registered Afghan refugees who were referred to United Nations High Commissioner for Refugees (UNHCR) offices from 2005 to 2010, the most common health referral for females and males (0–14 years) was perinatal diseases. In the females aged 15 to 59 it was ophthalmic diseases (13.65%), and for males it was nephropathies (21.4%). Overall, in both sexes the most frequent causes for referrals were for ophthalmic diseases, primarily cataracts (23.7%), neoplasm (13.3%), nephropathies (11%), ischemic heart diseases (10.4%), and perinatal disorders (9.2%).30

In 2011, a study was carried out to compare the prevalence of premature newborns’ birth among Afghan and Iranian ethnics. The rate of preterm birth prevalence was 7.1% (391 cases) and 14.5% (56 cases) among Iranian and Afghan populations respectively. Low birth weight prevalence was 6.7% (367 cases) among Iranians and 12.7% (49 cases) among Afghans. The study also found that preterm birth complications are almost two times more among Afghan immigrants than Iranians.31

A study was designed to evaluate the prevalence of food insecurity and its socio-demographic determinants among Afghan immigrants in two major cities of Iran. The results indicated that more than 60% suffered from moderate-to-severe food insecurity, 14% were mildly food-insecure while about 23% were food-secure. Food insecurity was significantly more prevalent in female-headed households, those with illegal residential status, unemployment/low job status, not owning their own home and low socioeconomic status.32 The prevalence of food insecurity among Iranians was reported in 2015 in a meta-analysis as 49% among households, 67% in children and 61% in mothers.33

Access to Health Services

Refugees have special health needs. Their fragile situation which arises from the experiences they had in their homeland and difficulties they may encounter in the host country put them at risk for developing mental and physical disorders. Improving the access to health services of this population not only is an essential human right but also has major benefits for the population as a whole.

There is scant of evidence in Iran regarding the use of health care services by Afghan immigrants and asylum seekers. According to a UNHCR report, during the past three decades, Afghan refugees have had access to basic health care, education, and employment opportunities. However, the financial constraints and lack of international support has always been a main barrier for the government to comprehensively take necessary actions. In 2014, through a joint collaboration of a private insurance company, UNHCR and Ministry of Interior, more than 220,000 vulnerable Afghan refugees including 2000 refugees with special diseases (Hemophilia, Thalassemia, Dialysis, Kidney Transplant and Multiple Sclerosis) were provided insurance services. The Government and UNHCR also provided primary health care in 15 settlements, camps and 29 urban locations.8

In addition, since 2016, Iran has started to enroll all registered Afghan refugees (more than 950,000) under Public Health Insurance. The refugees will benefit from a health insurance package for hospitalization identical to the scheme available to Iranian nationals. The insurance covers entire treatment expenses for people with special diseases and vulnerable groups (families who have patients with incurable disease or mental/physical disabilities, children of Iranian widows who married Afghan nationals, female-headed households, families who have nine or more children, poor people, the households whose their head is not able to work due to the medical conditions or disability, Afghan nationals who married Iranian women, the head of households with 65 or more years old, unmarried men and women with more than 75 and 18 years old).8 As of October 2016, more than 250,000 foreign nationals have been covered under this insurance. The initiative took place when a tripartite memorandum of understanding was signed between Ministry of Labor, Ministry of Health and Ministry of Interior in 2015. The beneficiaries of this scheme provide a contribution to the funding; however the Government of Iran covers half of the real monthly costs of the insurance premium. This is further complemented by a UNHCR contribution of 8.3 million USD for this six month period by primarily focusing on vulnerable refugees.34

In 2008, the Executive Director of the United Nations Office on Drugs and Crime (UNODC) and the Deputy Secretary General of the Islamic Republic of Iran’s Drug Control Headquarters signed an agreement to provide HIV prevention and care services to Afghan refugees and female drug users in Iran. These services were launched through funding from the Government of the Netherlands.35

However, the situation of unregistered Afghans remains unclear. Basically, undocumented Afghans cannot register for health insurance and therefore have limited access to the public health service. According to an independent body’s report unregistered Afghans are able to obtain treatment at private health institutions, but they must pay for the treatment from private funds. They can also benefit from the free health services provided by some NGOs and charities or on an individual basis.8

Barriers to Access to Health Services

The illegal status of almost 1.5 million Afghan immigrants prevents them to access to health insurance and consequently limits their access to health services. This situation gets worse considering a large number of illegal afghan immigrants work in hard and hazardous jobs such as the construction sector36 where the risk of injuries is relatively high. Additionally, more than 99% of Afghan employees do not have any type of work-related insurance.11

In a literature-review study conducted in 2015, the authors categorized the barriers to health care for undocumented immigrants in three levels: the problems that exist in laws and policies of destination countries including limitations to access and type of health care, the barriers within health system that included bureaucratic obstacles including paperwork and registration systems and finally the hindrance that exists at the individual level focused on the immigrant’s fear of deportation, stigma, and lack of capital (both social and financial) to obtain services.37

A large number of Afghan refugees and immigrants in need of health care in Iran are among poor and economically vulnerable groups. Many refugees and immigrants struggle to find work and often take jobs with low wages. According to one survey, Iranian workers benefit from 10-23% higher wages compared to Afghans.19 This inability to pay and lack of a comprehensive health insurance have led to the late self-referral of immigrants/refugees to health care services when the disease is in advanced stages. In one study completed among Afghan refugees to detect their common kidney diseases, it was found that due to the cost of medical visits or medications, the most common health referral for Afghans was end-stage renal disease (ESRD).38 Language barriers and lack of communication are mentioned by several studies as the main obstacles to refugee health care access worldwide, is not the case for Afghan immigrants in Iran.39,40

LIMITATIONS

Although the governmental institutions are able to provide reliable data on the situation of Afghan immigrants/refugees and conduct extensive research, the data used in this study is driven from independent researches, and reports of international organizations and foreign NGOs.

DISCUSSION

Providing health care for immigrants/refugees is crucial from two different aspects: First, immigrants may increase the potential risk of spreading some communicable diseases among the national population. Several studies indicate that the Afghan immigrants have contributed to the spread of communicable diseases in Iran with an estimated 55% of new multi-drug resistant tuberculosis patients, 40% of malaria patients, 29% of tuberculosis patients and 25% of Crimean-Congo hemorrhagic fever patients in Iran are Afghan immigrants respectively.23 Illegal migration poses a serious threat to the disease elimination program of Malaria in Iran.39 It has been estimated that the government spends more than 100,000 USD annually just to treat Afghan immigrants with tuberculosis.40

The second concern is related to human rights which put the emphasis on adequate and equitable access of immigrants to health services. The right of everyone to the enjoyment of the highest attainable standard of physical and mental health has long been established in international human rights law such as the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD) and the International Covenant on Economic, Social and Cultural Rights.

Unfortunately, there is a gap between evidence and policies in Iran. The government has not yet formulated a comprehensive policy to address the different health risks and needs of the immigrants. Considering the health and financial burden of immigrants on the host country, exclusion of immigrants from health services is not a wise approach both in terms of public health as well as human rights. Although the current initiative of the government to provide health insurance for registered Afghans was a big step forward, the plan has some major deficiencies. Firstly, the way to deal with the health needs of 1.5 million unregistered Afghan is still under question. This gains importance knowing that immigrants whose legal situations has not yet determined are significantly at higher risks of contracting disease and in developing mental health problems due to their living situations.41 Secondly, the plan entails the financial support of external donors which has always been a controversial issue.

As a part of the implemented policies, the Iranian government has put much attention on repatriation policies. From 2002 to 2014, the number of Afghan refugees who returned to their homeland voluntarily was 920,161.9 However, repatriation should not be considered as a single policy. Given the complex process of migration and its health consideration at multiple phases (pre-departure, travel, Destination, Interception and return phases),42 dealing with this problem needs a long-term, multi-sectorial approach (collaboration between government, intergovernmental organizations and civil society).

Currently by the joint initiative of Afghanistan, Iran, Pakistan and UNHCR, a Solution Strategy for Afghan Refugees (SSAR) was developed to find and implement a comprehensive solution for Afghan refugees in the region. The SSAR also seeks to improve access to health services and support from the Iranian government to this end by contribution of several partners such as governmental and international organizations, NGOs and civil society.9 Failing to address to the situation of undocumented immigrants, SSAR encompasses the same flaws as government’s insurance plan. In addition, the health solution strategies are relatively scant compared to those that addressed the education and skill training of refugees.

Given the significant threats posed by limits on illegal immigrants’ access to Iranian health system, formulation of a comprehensive and uniform strategy addressing health care needs of illegal immigrants is necessary. The current approach of the government is ignoring the problem of huge number of illegal immigrants which as stated above is not a wise approach.

The government should be persuaded to change its current legislation on illegal migration. As a part of this policy, it is recommended to extend the time needed for accepting the legal status of refugees (currently the refugees who came before 2001 are allowed to apply for legal authorization). In this context, the existence of strong civil society and NGOs to push the government to change its approach is crucial.

Conflict of Interest

The authors declare no conflict of interests.

Funding

The authors received no specific funding for this study.

Ethics Statement

Ethical approval: This article does not contain any studies with human participants or animals performed by the author.

Data Availability

All national (MagIran, Science Information Database (SID) and Iranmedex) and international (PubMed, Scopus) databases were searched from November 2010 to November 2016 using keywords both in English and Persian: Afghan immigrants, Afghan refugees, Iran, infectious diseases, tuberculosis, HIV, Hepatitis B and C, non-communicable disease, food security, mental health, barriers, health insurance, access to health service. All related websites and webpages were also searched by Google with the same keywords and used back-tracking to find earlier relevant sources from 2001.

Corresponding Author

Frederick M. Burkle, Jr. Email: burkle@hsph.harvard.edu Tel: 1-808-262-2098 (Hawaii)

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Political Leadership in the Time of Crises: Primum non Nocere http://currents.plos.org/disasters/article/political-leadership-in-the-time-of-crises-primum-non-nocere/ http://currents.plos.org/disasters/article/political-leadership-in-the-time-of-crises-primum-non-nocere/#comments Fri, 29 May 2015 10:26:58 +0000 http://currents.plos.org/disasters/?post_type=article&p=20580 Long before the 2014 Ebola outbreak in West Africa, the United States was already experiencing a failure of confidence between politicians and scientists, primarily focused on differences of opinion on climate extremes. This ongoing clash has culminated in an environment where politicians most often no longer listen to scientists. Importation of Ebola virus to the United States prompted an immediate political fervor over travel bans, sealing off borders and disputes over the reliability of both quarantine and treatment protocol. This demonstrated that evidenced- based scientific discourse risks taking a back seat to political hyperbole and fear. The role of public health and medical expertise should be to ensure that cogent response strategies, based upon good science and accumulated knowledge and experience, are put in place to help inform the development of sound public policy. But in times of crisis, such reasoned expertise and experience are too often overlooked in favor of the partisan press “sound bite”, where fear and insecurity have proved to be severely counterproductive. While scientists recognize that science cannot be entirely apolitical, the lessons from the impact of Ebola on political discourse shows that there is need for stronger engagement of the scientific community in crafting messages required for response to such events. This includes the creation of moral and ethical standards for the press, politicians and scientists, a partnership of confidence between the three that does not now exist and an “elected officials” toolbox that helps to translate scientific evidence and experience into readily acceptable policy and public communication.

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Introduction

“…the scary thing is that I want a leader who consults experts and thinks about all of the different sides to an issue before making statements and policies that are unfounded in science.”

Kaci Hickox, RN a quarantined nurse, February 2015

A failure in the timing and content of the expression of risk, both immediate and long term, has always proved a critical misstep in communicating to the public. As the medical crisis appears to be coming to a tenuous closure in West Africa it is time to reflect on the response to Ebola in the United States which unfortunately resulted in a manufactured social and political crisis. It shouldn’t be this way, yet an exploration of numerous critical events over the past quarter century demonstrate that time and time again, politics trumps science. Unfortunately, the promotion of evidenced based decision making has too often taken a back seat to policies based upon fear and insecurity. And the great facilitator, the 24 hour news cycle, has been there to fuel the fire of fear as the American public contemplates the risks and threats of a disease that at the time of this writing has only resulted in the import of a handful of cases. Humanitarian healthcare workers and a journalist have been repatriated for evaluation and management in the United States, one imported case from the epicenter in Liberia made its way to Dallas, Texas, unrecognized in its initial presentation, and two nosocomial infections transmitted to a poorly prepared healthcare workforce occurred as a result. In fact, more people will be injured or killed on the nation’s highways in the time it takes to read these opening comments than have been affected by the Ebola virus disease (EVD) in the U.S.

The Ebola epidemic was not the first time that US federal and state issues have clashed over ownership to respond with authority to an infectious disease emergency. In fact, during the 2003 SARS pandemic it was argued by states that possession of the legal responsibilities, including quarantine, under the US Constitution belonged to them rather than the federal government.1 Yet today, laws within states vary widely in defining what criteria establishes a quarantine. This includes five states in which CDC has unique authority to issue a mandatory quarantine at ports of entry—but only if the infectious agent is on the list of diseases specified under Executive Order of the President.2,3 In most cases in which the clinical expression of infectious disease is concerned, uncertainty often precedes definitive diagnosis. Reliance upon basic clinical laboratory efforts that take time to achieve definitive diagnostic analysis is the norm. Yet, there is often a rush to make crucial public decisions despite incomplete evidence, placing responsibility for defining these risks to the public health on political actors within state and local governments.

The political climate that enveloped the U.S. polity, where mistrust in government runs high, and partisan accusations rule the airwaves, made the complexity of the Ebola response all the more difficult to explain to the American public. As the epidemic mushroomed in West Africa, the front line responders from Medicin sans Frontieres raised and waved their arms and called upon the global community to pay attention to the fact that Ebola had gone urban where the greater density of the population would contribute to its rapid spread. It became increasingly clear the outbreak was very much out of control. WHO was slow to react and political attention in the U.S. was focused upon other competing national security priorities. Over the summer of 2014, the shooting war in Ukraine, Syria and the Gaza crisis, reminiscent of the ‘spy versus spy’ political instability of the cold war era, easily bested a medical crisis developing in a part of the world that has only know war, famine, and political upheaval. How could Ebola be of concern here? In the absence of a firm grasp of what constitutes the global health security agenda, political leaders were unable to fathom the consequences of an emerging infectious disease spreading out of control. And they were not ‘managed up’ by those medical leaders in positions of authority to do so. When the first two US humanitarian healthcare workers who contracted EVD were repatriated to the U.S., the framing of a cogent dialogue related to the management of Ebola were instead replaced by abject fear and concern magnified out of proportion to the risk. In the absence of a process that can be used to help political leaders navigate the complexities involved in the evaluation of medical, public health and scientific concerns, discussion revolved around the emotions of response, not the science. Because most political leaders have no grounding in scientific inquiry and are unable to recite even basic tenets related to public health and medical response, Ebola was addressed as if it were the latest terrorist faction to emerge seeking to disrupt civil society.

Examination of previous events that have been characterized by epidemics of fear share a number of key attributes. First, these claims that fuel fear have no weight. They are always driven by the media. They occur because the voice of science is overtaken by the voice of fear. In the case of the Ebola crisis, neither the voice of politics nor the media have provided any alternative science that adequately counters observable evidence or the risks facing the nation. Unfortunately, this most often occurs because rapid evolution of policy based on available and changing evidence makes it difficult for the “message” to keep up with the facts. In the gap between what is known and what is needed to know lies the opportunity for fear to dictate the messaging and, therefore, policy.

Since the second half of the 20th century, “the world has seen the relationship between society, politics and science become increasingly complex and controversial.”4 A decade of climate change debate has exemplified this building frustration. There is no lack of studies in health sciences or medicine that have shown that making information useful demands engagement with those who will use it.5 Shamefully, the political climate, both in Europe and the U.S., has not allowed this to happen; allowing “politicians, influential intellectuals and lobbyists who oppose research and innovation for various reasons”, which include political prejudices and religious arguments, to adopt “a strategy of manipulating and censoring facts.”4 In fact, the more politicians ignore science the more it represents a failure of governance .6

President George W. Bush upset the previously guarded political independence of science and politics by establishing controversial key appointments and science and health policies that went against expert advice4. Today, politicians listen to economists not to scientists. 6 Scientists must be impartial arbiters of evidence based data, they cannot join politics, be political agents or compete as lobbyists.6,7 Unfortunately, many politicians, when challenged with views of the science, too often lead with harsh and glib retorts that prove beneficial when facing uninformed electorates. Indeed, it has been recognized that the poorly debated Ebola controversies influenced the 2014 U.S. mid-term elections.

The unsettling irony is that while “public prestige of science is higher than ever it remains disturbingly removed from the centers of power.”8 Nine out of ten scientists believe that political parties have adopted an “anti-science stance on issues ranging from evolution to climate change”.9 While this unproductive competition has smoldered unnoticed by the public over the past decade, the Ebola crisis and the outright dismissal of science by political decision makers has revealed today the absolute depths of the conflict. Worse, while politicians readily engage on a ‘one sound bite’ level on Sunday morning television they quickly refuse to debate the science…or flippantly state they’ll “leave that to the scientists to explain” while leaving the strong impression that the scientists and practitioners of that science need to do a better job.

The Political and Scientific Challenges of Public Health Emergencies

Reflex charges of incompetence of public health experts and unfounded disagreements over proven health management protocols have resulted in delayed interventions. Scientific input and their evidence base has been marginalized or discounted in favor of partisan interest. This is nothing new. The reliance on and incorporation of scientific framing of the public health issues related to the Deepwater Horizon oil spill 10 and the Fukushima Daichi nuclear disaster 11 were similarly cast in the context of fear, not evidence. Hysteria generated over the return of asymptomatic healthcare workers from Ebola endemic regions to stigma and isolation forced on them by a poorly informed political class are just the latest examples. In the case of the debate over quarantine, the inability to develop consensus on this issue across the U.S. Federal interagency, with Department of Defense personnel being subject to forced 21 day quarantine, exacerbated the tremendous uncertainty mirrored by public confusion.

In an increasingly globalized world, scientists recognize that health alone will not solve what demands multidisciplinary and interdisciplinary solutions. The emerging global health discipline requires “composite research” of many disciplines for which health is but one.12 Current political discourse, however, tends to favor single discipline concrete answers that are contrary to more insightful, reflective and abstract thinking that decision making skills of diplomacy typically relies on. Macilwain cautions that while “everyone knows that the most valuable work is now multidisciplinary”, the U.S. Congress, during a critical time when the social sciences would benefit them most in improving their “public engagement” and image, have “expelled” social sciences research from their agenda.8

Kassen contends that poor scientific decisions in politics is primarily a “failure of scientists to communicate their message effectively in what is ultimately a political, not a scientific, arena.” 13 Recognizing that it is the role of journalists to “ask the tough question”, the authors acknowledge that politicians become vulnerable and susceptible when such questions are no more than a convenient trapdoor designed more to measure the mettle of the politician through a challenging and often unanswerable query than as a test of their immediate knowledge of the politician’s grasp of the science. It is during the palpable silence between the question and the answer that scientists experience the most anxiety. Scientists do not know what information the politicians have, from what source the information originates (e.g., CDC, NIH, military) or how solid the information is before they speak with the authority of their office. In defense of the politician, we remind the readers that “the practice of science cannot be, nor should it be, entirely apolitical.” 14 The rush of anxiety among scientists occurs when there is violation of the principle of separation of science and politics that “first we need the science, then the politics.” 14

What Needs to Occur?

Politicians should be prepared to define health and public health entities and be able to explain them to a broad public audience who look to them as both leaders and educators. Predictably, politicians are expected to explain complex situations in a manner understood by the public at-large, reinforce that information during press conferences and bring in experts at the proper time. Particularly given the complexity involved in those situations in which the science unfolds over time, such events ought to be slowed down and can be better managed. The public deserves it and the politicians should demand it. Once misinformation is blurted out the scientific community is often pressed to correct, recover and reason the confusion in facts… not a position that most scientists relish or are readily prepared to do especially when the science is still not known or well understood. Accountability and transparency is expected; the public is more trusting and less suspicious of information that is admitted to be either unknown or still being studied.

Recognizing the impact of rapid advances in communications and social media, the most desirable outcome of the Ebola tragedy, or any crises that has the potential to be or has already been declared a public health emergency, is that politicians, journalists and scientists must address, debate and develop a working framework, including the adoption of moral and ethical standards, that are mutually defined and agreed upon as partners in bringing the proper information to the public in a timely and effective manner. The bottom line is that all “scientists need to be able to negotiate with governments, irrespective of their political hue, and to advise politicians in a useful and timely way.” 6 Politicians do not read scientific journals 5 nor are likely to do so even during a health crisis, when the knowledge-base is imperfect.15 Britain, in particular, “loves its scientific advisors”, boasts that “almost every government department has one” and the central government “in turn, looks to their Chief Scientific Advisor to enhance the credibility of their policies. ” 8 Favaro sees that “scientific-liaison offices” would give scientists an apolitical route to policy formation. This would make research results accessible and enable politicians and policy makers to reach informed decisions 6 and further allow politicians to benefit politically from emphasizing the importance of communicating the value of that science to the public.

Scientists and practitioners must recognize that politicians will always possess a bully pulpit access to the public that they themselves will never have.16 For example, work by a multidisciplinary panel of scientists, health practitioners and legal scholars on crisis standards of care 17,18,19 and the promotion of health care emergency operations 20 were able to highlight the importance of promoting involvement of the highest levels of elected office, in part by promoting the development of targeted risk communications strategies. It is increasingly evident that such efforts must include the direct engagement of elected officials in the crafting and delivery of crisis communications, particularly when complicated health and medical issues may be part of the core message. This can take the form of an “elected official’s toolkit” developed to promote understanding of basic health and medical concepts, and should serve to translate science into policy in a manner in which the political agenda can be supported, not subverted, by fact and evidence.

Indeed, in February 2015 the (US) Presidential Commission for the Study of Bioethical Issues, in making recommendations for the next epidemic, concluded that the nation must improve its health infrastructure, emergency response and be ready to respond quickly. The Commission urged that ethics expertise be part of the planning. Among the controversial issues that were politically charged, the Commission stated that a single US health official be placed in charge and that health officials communicate often and clearly explaining the “rationale behind health policies to a frightened public.” “Travel curbs and quarantine must be based on science and use the least restrictive means necessary”, emphasizing that “needlessly restricting the freedom of expert and caring health workers is both morally wrong and counterproductive.21 Craig Spencer, a physician who developed Ebola after returning to the US, wrote that “politicians should have educated the public about the science of Ebola and acted accordingly.”22

The Ebola crisis has become a teachable moment in the nexus between politics and science. Experts and advisors in scientific knowledge, methods and substance can provide lessons emanating from this current crisis that will be of tremendous benefit in future events. We must first teach our political leaders what has been a fundamental medical precept of Hippocrates, that of primum non nocere, first do no harm.

Competing Interests

The authors have declared that no competing interests exist.

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