Ebola and the social media

Gilles Raguin
Ebola and the social media

In October 2014, during heightened news coverage about cases of Ebola in the USA, anecdotal observations suggested that many Americans were anxious about Ebola. Given the negligible risk of infection, their anxiety was arguably driven by perceived rather than actual risk. Exaggeration or reassurance from the media can inflame or subdue people’s perceived risk of Ebola infection.1  Fear can also be acquired by observation of other people’s experiences, as expressed  on  social  media.2    Thus, social media amplified fear about the imported Ebola case.3
As discussed in The Lancet Editorial (Nov  8,  2014),4   Twitter traffic  shows an imbalance across the digital divide; there were more tweets about Ebola in the USA, where transmission was contained, than in Guinea, Liberia, and Sierra Leone, where there was and remains a continuing epidemic. Despite the risk to most Americans being negligible, many people expressed anxiety. The figure shows how worldwide traffic on Twitter and Google about Ebola increased as news spread about the first US case and how they compare with influenza (flu)-related searches and tweets. Similar peaks were observed when other news about Ebola was released. In a random sample of tweets, we observed that the frequency of Ebola-related tweets associated with negative emotions, anxiety, anger, swearing, and death, as well as discrepant  thinking  (eg,  shouldn’t),5 were higher than those associated with influenza (see figure in appendix). Twitter data can provide public health practitioners with a quantitative indicator of anxiety, anger, or negative emotions in the general public where Twitter penetration is high. This indicator could help to alleviate anxiety and correctly communicate the risk associated with Ebola.

We thank Zhaochong Liu, Chung-Hong Chan, Keisha Pressley, Benedict S B Chan, Manoj Gambhir, Martin I Meltzer, Michael L Washington, and
Jingjing Yin for their help. IC-HF, ZTHT, C-NC, and ASM contributed equally. We declare no competing interests.

*Isaac Chun-Hai Fung, Zion Tsz Ho Tse, Chi-Ngai Cheung, Adriana S Miu,
King-Wa Fu

Figure: Temporal trends on Twitter and Google about Ebola and influenza (flu) before, during, and after Ebola cases in the USA, September to November, 2014
*Numbers are relative to the highest number of searches done on Google (for Ebola on Oct 16).

Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA 30458, USA (IC-HF); College of Engineering, University of Georgia, Athens, GA, USA (ZTHT); Department of Psychology, Emory University, Atlanta, GA, USA (C-NC, ASM); and Journalism and Media Studies Centre, University of Hong Kong, Hong Kong Special Administrative Region, China (K-WF)
1    Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer, 1984.
2    Bandura A. Social learning theory. Englewood Cliffs: Prentice Hall, 1977.
3    Pidgeon N, Kasperson RE, Slovic P. The social amplification of risk. Cambridge: Cambridge University Press, 2003.
4    The Lancet. The medium and the message of Ebola. Lancet 2014; 384: 1641.
5    Pennebaker JW, Chung CK, Ireland M, Gonzales A, Booth RJ. The development of psychometric properties of LIWC. 2007. http:// (accessed Nov 18, 2014).


Ebola: national health stakeholders are the cornerstones of the response

The failure of the international response to the Ebola outbreak in Africa is sadly obvious. Without denying the commitment or the goodwill of non-governmental organisations, international agencies, and govern- ments, or the substantial funding available, the results have clearly fallen short because the methods being used are not suited to the problem posed by  this  epidemic.1     Indeed,  with  an informed population and an effective health-care system, Ebola is not very contagious, as shown by the swift control of cases in Nigeria, Europe, and the USA. But the health-care systems in the hardest-hit countries are in such poor shape that (under-equipped and severely short of health-care personnel) they are unable to respond to the emergency, no matter how much funding is placed at their disposal.
To use a war metaphor: there are not enough troops on the ground, particularly at the front-line, where new infections are occurring. There are 0·1 doctors per 10 000 people in Liberia and Côte d’Ivoire (compared with 32 in France and 25 in the USA), and 1·7 nurses per 10 000 people in Sierra Leone (compared with 93 in France).2   It is unrealistic to think that high-income countries can supply the hundreds of caregivers needed to run the treatment centres being built when Médecins Sans Frontières is having trouble finding recruits and is questioning their model (supply of treatment centres), which needs enormous amounts of money and human resources.
Furthermore, foreign caregivers— unfamiliar to local cultures, thought by some local individuals to be importing the disease, equipped with infection control suits, and the first, or even only, to receive the few experimental treatments—are perhaps not the best choice of people to curtail the spread of the disease in communities upstream of treatment centres, where the epidemic continues unabated. Other models are needed that are better adapted to local realities, and, most importantly, that arm and reassure local health-care personnel—ie, those who know the environment and can still be mobilised, despite their small number and heavy losses.
Indeed, not far from the treatment centres that have been expensively equipped by the international community, public health structures (referral centres, district hospitals, and primary health centres, which are the referral structures in the communities) remain dangerously under-equipped, with inadequately trained and ill equipped staff.
Most of the solution is to help the remaining health-care personnel to work, under the responsibility of national managers; to supply them with the personal protective equipment that is absent or in short supply; to offer them the training and the supervision they need to feel safe; and to work with them and community organisations to help in the effort of raising community awareness and ensuring early treatment via a task shifting system. National health stakeholders are the cornerstones of outbreak response.

Capacity-building at all levels of health care is key. Although such groundwork must occur in addition to emergency interventions, it is essential to change the situation where the virus is being spread—ie, in the primary health-care facilities and  the  community.3   Treatment  of confirmed cases in treatment centres with specialised staff is necessary at the height of the epidemic; but upstream actions in community and national health-care facilities, with local workers who have been given the methods they need, is indispensable, before, during, and after the peak of the outbreak.
Health-care workers  from high-income countries could help their colleagues in Africa in a capacity development strategy. Many are accustomed to participating in such capacity-building programmes (eg, the ESTHER European initiative), through existing hospital partnership cooperation networks, international programmes like the WHO’s African Partnership for Patient Safety, partnerships and professional networks. Mobilisation of these workers and their professional networks would have unquestionable value, provided the mechanisms and policy initiatives existed to promote and support them. Such approaches have real potential if response to this epidemic looks towards the medium term and sustainably strengthening depleted health-care systems.

We declare no competing interests.

*Gilles Raguin, Serge Eholié

Department of Infectious and Tropical Diseases, Hôpital Saint Antoine, Assistance publique– Hôpitaux de Paris, Paris, France (GR); groupement d’intérêt public ESTHER, Paris, France (GP); and Department of Infectious and Tropical Diseases, CHU de Treichville, Abidjan, Côte d’Ivoire (SE)
1    Piot P, Muyembe JJ, Edmunds WJ. Ebola in west Africa: from disease outbreak to humanitarian crisis. Lancet Infect Dis 2014; 14: 1034–35.
2    World Bank. World Bank statistics. http://data. (accessed Nov 11, 2014).
3    Breman JG, Johnson KM. Ebola then and now.
N Engl J Med 2014; 371: 1663–66.


Ebola and the UN’s responsibility to protect

The Lancet Editorial (Oct 25, p 1477)1 on the Ebola epidemic concluded that “the military seem set to play a greater part in global civilian health in the future”. This is challenging and deserves comments.
Liberia has 0·1 physicians, and 1·7 nurses and midwives for every 10 000   people,2       compared   with 5·4 soldiers for every 10 000 people. Does Liberia need more soldiers or more health-care workers?
Since 1999, the UN has intervened in many countries to protect civilians from the effects of armed conflict—the responsibility to protect (resolution 1265). Should the Security Council now also be in charge of deployment of military personnel to fight health-care crises? Considering the likely incompetence of WHO, this move might be wise.3
On May 21, the Ministry of Health for Guinea reported 258 cases of Ebola, including 174 deaths (17 of health-care workers).4 Without showing much concern, WHO held its annual meeting on May 19–24, at the Palais des Nations, Geneva, with more than 3500 participants.
It seems wiser to rely on the military—they cannot do worse than WHO.

I declare no competing interests.

Alain Braillon

Public Health, University Hospital, Amiens 80000, France
1    The Lancet. National armies for global health? Lancet 2014; 384: 1477.
2    Tomori O. Ebola in an unprepared Africa. BMJ
2014; 349: g5597.
3    Kmietowicz Z. WHO will review its response to Ebola once outbreak is under control. BMJ 2014; 349: g6390.
4    CDC. Ebola: 2014 west Africa outbreak updates. May 23 report. vhf/ebola/outbreaks/2014-west-africa/ previous-updates.html (accessed
Dec 2, 2014). Vol 384 December 20/27, 2014

3 décembre 2020