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Ebola and the Health Impact Pyramid

Jordynn P. Towner
Delaware Technical Community College
NUR 310: Global Health
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Abstract
Ebola is a disease process caused by a virus that can lead to gastrointestinal symptoms and
hemorrhagic fever. Transmission occurs through contact with infected bodily fluids and most
outbreaks have occurred in western and central Africa. The health determinants of this disease
process include mostly socioeconomic factors, such as poor sanitation, lack of adequate
transportation, difficulty reaching medical care and cultural practices. The health impact pyramid
looks at different levels of interventions in relation to global health issues, such as Ebola. This
pyramid is made up of 5 levels, which include socioeconomic factors, changing the context to
make individuals’ default decisions healthy, long-lasting protective interventions, clinical
interventions, and education. These five levels will be examined, as they relate to Ebola, as well
as potential future interventions for this disease process. Global health encompasses many topics,
from disease processes to improving daily living with interventions such as clean drinking water.
Careers in this ever-growing industry are plentiful and will also be discussed.
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Ebola and the Health Impact Pyramid

Ebola is a disease process caused by a virus in the genus Ebolavirus that can lead to

hemorrhagic fevers and gastrointestinal symptoms. This disease process can affect both humans

and nonhuman primates, and outbreaks occur mainly on the continent of Africa. This virus was

discovered in 1976 and the source is believed to be animal-borne through bats and primates. The

transmission of Ebola occurs through contact with bodily fluids of an infected person or infected

animal, whether those infected are alive or deceased. Bodily fluids that can lead to infection

include blood, feces, urine, saliva, vomit, sweat or breastmilk. An important note is that the

transmission of Ebola is possible even after recovery, according to the CDC “the virus can

remain in certain body fluids (including semen) of a patient who has recovered from EVD, even

if they no longer have symptoms of severe illness” (Centers for Disease Control and Prevention,

2019). Another important note from the CDC is “A person can only spread Ebola to other people

after they develop signs and symptoms of Ebola” (CDC, 2019). That means during the

incubation period of the disease, the time frame from exposure to signs and symptoms, the

infected person isn’t contagious. Those as risk for Ebola include those likely to come in contact

with bodily fluids of infected persons. That can include healthcare workers, those living with

infected persons or those dealing with the bodies of people who passed away from Ebola. Signs

and symptoms include fever, diarrhea, vomiting, abdominal pain, fatigue, muscle and joint pain,

weakness, bleeding, bruising or hemorrhaging (CDC, 2019). Diagnosis of Ebola occurs via a

polymerase chain reaction (PCR) test, which detects levels of the virus in a person’s blood, after

confirmation of a potential exposure and examination of symptoms. There is no cure for Ebola,

treatment is mainly supportive and based on the person’s specific symptoms. Most common

interventions include IV fluids to promote rehydration, oxygen therapy if needed and

medications to reduce symptoms, such as vomiting or pain. Prevention of Ebola includes taking
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necessary precautions during interactions with known positive patients, along with hand-washing

and cleaning of contaminated surfaces. A vaccine for Ebola was recently approved by the FDA

in December 2019, “rVSV-ZEBOV vaccine is a single dose vaccine regimen that has been found

to be safe and protective against only the Zaire ebolavirus species of ebolavirus” (CDC, 2019).

This should be used primarily for those at high risk of contracting the disease.

A health impact pyramid is used to illustrate different health-improving interventions

ranked in ascending order of most to least effective. “Interventions focusing on lower levels of

the pyramid tend to be more effective because they reach broader segments of society and

require less individual effort” (Frieden, 2010). The five tiers that will be examined in relation to

Ebola include socioeconomic factors, changing the context to make individuals’ default

decisions healthy, long-lasting protective interventions, clinical interventions and counseling and

education. Changes made in the lower tiers are broader and have a greater chance of affecting a

larger number of individuals, while top-tier interventions have potential but require the

cooperation of the individuals involved.

Socioeconomic factors have a large impact on many aspects of the Ebola disease process

and how it affects an individual. These factors can affect who contracts the disease, who is able

to receive medical treatment, the probability of their outcome and the overall effects on the

community in which they reside. All ages and genders are able to contract Ebola, though the

immunocompromised are more at risk. Since transmission occurs through bodily fluids, factors

such as sanitation come into play with decreasing the risk. The World Health Organization

defines sanitation as “the provision of facilities and services for the safe management of human

excreta from the toilet to containment and storage and treatment onsite or conveyance, treatment

and eventual safe end use or disposal” (Water sanitation hygiene, n.d.). When thinking of
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sanitation, it is important to remember it is not only focused on somewhere to put human excreta,

it is the containment so excreta does not enter the drinking water system, it is the ability to wash

one’s hands, and it is the ability clean and sanitize items needed for everyday life. This is

especially important when dealing with a disease process that is spread by bodily fluids, proper

cleaning is essential to stop the transmission. Some of the communities at the center of Ebola

outbreaks were rural populations with limited access to healthcare services. The majority of

outbreaks occurred in western and central Africa, with a concentration in the Democratic

Republic of Congo, Liberia and Guinea. With this decreased access not only did the patients

have a decreased chance of survival, but those that assumed roles of caretakers were at

increased risk of infection due to lack of medical knowledge and protective equipment. For

example, if the patient was experiencing vomiting and diarrhea they weren’t able to get the

rehydration therapy they needed or medications to relieve the symptoms. Also, the caretaker

was then exposed to contaminated bodily fluids without proper personal protective equipment.

Another factor that plays into the limited access to healthcare is weakness of the

transportation system. “These weaknesses greatly delayed the transportation of patients to

treatment centres and of samples to laboratories, the communication of alerts, reports, and

calls for help, and public information campaigns” (WHO, 2015). So even if a patient was

suspected of having Ebola, getting them treatment and a confirmed diagnosis was difficult.

The employment and working conditions of countries affected by Ebola are dwindling and

lead citizens to cross borders in search of work. This can lead to increased spread of disease,

and can be devastating to areas in which the outbreaks were thought to be controlled. It can

also have an effect on the economy, if individuals are searching for work elsewhere and

spending their money elsewhere, the economy has the potential to crash.
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Cultural practices are another variable factor that can impact transmission and

treatment of Ebola. “According to WHO [13], about 70-80% of the population in some West

African countries depend on traditional medicine” (Manguvo, 2015). This cultural belief may

prevent individuals from seeking modernized medical help in favor of spiritual or traditional

cures, this not only puts the patient at risk of worsening but also the healer at risk of becoming

infected. For example, “A previous study by Hewlett and Hewlett [15] reported similar claims by

traditional healers in Uganda who were making incisions into people's bodies and rubbing herbal

medicine in” (Manguvo, 2015). This is incredibly dangerous to attempt with a disease process

that spreads via body fluids. When a patient passes away cultural practices include bathing

with the body and everyone touching the body during the burial. “Data available in August, as

reported by Guinea’s Ministry of Health, indicated that 60% of cases in that country could be

linked to traditional burial and funeral practices” (WHO, 2015). This makes sense because

bodily fluids can be present in the bathwater or on the body when mourners are touching it.

Another popular practice is “that of relatives of the deceased washing their hands in a common

bowl after which they touch the face of the deceased in what is perceived as a ‘love touch’ that

cements unity between the living and ancestral spirit (Manguvo, 2015). Once again this can

perpetuate the spread of Ebola because of contamination of the bowl by the deceased person’s

bodily fluids carried by a family member’s hands.

“The second tier of the pyramid represents interventions that change the environmental

context to make healthy options the default choice, regardless of education, income, service

provision, or other societal factors (Frieden, 2010). The focus in this tier, changing the context to

make individuals’ default decisions healthy, is to reduce incidences of Ebola by means of

prevention through healthy choices. Some of the simplest interventions that can be put in place to
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decease the spread of Ebola include proper hand hygiene and proper cleaning of household

surfaces. As stated by Frieden (2010), “The defining characteristic of this tier of interventions is

that individuals would have to expend significant effort not to benefit from them”. This

statement is definitely true for handwashing and cleaning, individuals would have to go out of

their way for those interventions to not be beneficial. Some larger-scale interventions include

improved sanitation conditions and improved transportation. As discussed previously the

transportation in some of these rural communities is lacking and is not adequate to get patients to

the medical care they need. Improvements in this area could lead to seeking professional medical

help becoming a default decision for sick individuals. Improved sanitation conditions could lead

to a decreased spread of Ebola due to containment of contaminated body fluids. There are many

different levels of sanitation that are available, they can be related to location and the technology

available in that area. Some of the simpler forms include bucket latrines and simple pit latrines,

which are basically just a place for the excreta to collect and do not require running water. Those

systems are the cheapest to install and maintain, but they have the potential to perpetuate the

spread of disease if strict hygienic measures aren’t taken. Systems can then advance to include

sewer systems or septic tanks, the potential complications to those systems include the need for

running water and the cost.

A potential long-lasting protective intervention would be for individuals to seek

professional medical care at the first signs of Ebola. If the individuals default decision was to

seek care when they first get sick, their chance of survival will increase due to early

interventions. This could also help decrease the spread of the disease because the healthcare

providers caring for these patients will be able to don PPE, unlike the traditional healers who are

vulnerable to exposure. This tier of the pyramid depends more on personal choice, and the
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effectiveness of this tier depends on how many individuals are compliant. A huge topic to be

addressed in this fight against Ebola includes cultural burial practices, considering they have the

potential to perpetuate transmission. If modifications could be made, then these long-lasting

interventions could help immensely. There has been attempts to address this topic, but they were

done in poor fashion and did not lead to making any progress. Some of the tried interventions

included cremating bodies despite this being frowned upon culturally and disposing of bodies

before informing family of the person’s passing. “Moreover, in an effort to quickly dispose dead

bodies and reduce spread of the disease, some ‘Dead Body Management Teams’, often carried

out burials prior to notifying relatives of the deceased” (Frieden, 2010). This led to families not

disclosing when individuals had passed away so they were able to perform their traditional

practices. It also led to the creation of black market death certificates and distrust in the

government. Interventions need to be put in place that respect cultural practices, but also protect

individuals from infection. Some suggestions could include education about the risks of

traditional practices and modifying the current practices. Instead of having individuals touch the

deceased skin to skin, a covering of some sort could be placed on the body so they are touching

that and not coming into contact with body fluids. Instead of bathing with the deceased,

individuals could just bathe the body and use gloves.

When an individual falls subject to being infected with Ebola the clinical interventions

performed are based on the symptoms displayed by the patient. As stated by the CDC (2019),

“symptoms of Ebola virus disease (EVD) are treated as they appear”. This can include

intravenous fluids to help rehydrate patients suffering from vomiting and diarrhea or to help

decrease and manage a fever. Medications can be given for vomiting, diarrhea, pain, etc.

depending on what the patient is experiencing. If there is any kind of secondary infection, then
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antibiotics can be given. The healthcare providers caring for these patients should use PPE

during any interaction. The patient should be repositioned at least every 2 hours and should be

sitting up to prevent aspiration during vomiting. These patients should be in a private room and

kept on isolation during their stay.

Education is a crucial aspect to implementing any of the interventions mentioned above,

without it things will just continue the way they have always been. When nurses are caring for

patients suffering from Ebola they can educate them about transmission risk factors and how to

decrease the chances of transmission. They can also take this opportunity to educate family

members about the same, if they are present. When Ebola outbreaks occur, like the 2017

outbreak in Democratic Republic of Congo or the 2014 outbreak in Liberia, those communities

can be targeted for individualized education. The communities can be analyzed to determine

their biggest risk factors, whether that be burial practices or use of traditional healers, and given

education about how that contributed to the outbreak and how to prevent it from happening

again. An important part about education is first understanding why a person engages in certain

behaviors, this will give insight into how likely they are to change the behaviors. I believe the

health behavior model that best fits into the situation of Ebola is the ecological perspective. This

model states that there are multiple levels of influence that affect individual’s health behaviors

and choices. According to Skolnik (2015), “health related behaviors are affected by, and affect,

multiple levels of influence: intrapersonal or individual factors, interpersonal factors,

institutional factors, community factors and public policy factors”. Taking into account a specific

health behavior, such as visiting a traditional healer, one can examine how many levels of

influences play a role. Individual factors include the attitude and belief that this is the correct

choice, interpersonal factors include family and friend’s perspectives on the subject and
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community factors include the tradition that its always been done that way. Being able to identify

the logic behind the decisions allows insight into necessary topics that need to be addressed for

change.

The most powerful tool in the fight against Ebola outbreaks is education. I think future

interventions should be based on what we have learned from prior Ebola outbreaks and should

focus on improving those areas where the weaknesses and lack of education were noted. All of

the interventions mentioned here have been discovered because of weaknesses noted in the

current practice. Those the changes that need to be made have been recognized, it is not an easy

one-step process to accomplish those changes. Education needs to be implemented that highlight

the trouble with the current practices and offer possible alternatives. For example, when trying to

convince individuals to seek professional medical care over that of traditional healers, the risks

of transmission with traditional healers and their practices need to be relayed. The benefits of

early intervention with non-traditional medicine needs to be highlighted as well. It can be

difficult to change a person’s mindset about their cultural practices so alternatives, such as

visiting the traditional healer first but not engaging in any procedures involve bodily fluids could

be recommended. Interventions need to recognize the importance of culture and traditions while

incorporating scientific facts and education.

There are many different aspects in the topic of global health, whether the focus be

disease processes that span across countries or improvements to daily living, such as clean

drinking water, that are needed across the globe. With some many different avenues available,

there are many ways to get started in a career focused on global health. With a background in

nursing one can join organizations, such as the Alliance of Nurses for Healthy Environments,

that are fighting for things such as clean drinking water and improved sanitation. Looking at the
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disease processes side of things becoming an epidemiologist is an option, they focus on studying

disease processes and their spread. If one has an interest in teaching a career as a global health

educator is a possibility, they educate about how to maintain health based on the needs of

individuals and communities. Public health advisors provide input on public health programs and

interpret rules and regulations to meet health objectives. Any of these careers and more have the

ability to be employed by organizations such as the CDC or the World Health Organization.

Global health concerns, such as Ebola, have the potential to affect large amounts of the

population across a multitude of countries. It is important to not only examine what is making

certain communities vulnerable to outbreaks, but also what can be done to stop and prevent

future outbreaks. The health impact pyramid helps to lay out the effectiveness of different levels

of interventions, which is crucial to the improvement of health for those affected.

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References

Centers for Disease Control and Prevention. (2019, Sept.). Ebola (ebola virus disease). Retrieved
from https://www.cdc.gov/vhf/ebola/index.html

Centers for Disease Control and Prevention. (2017, Sept. 6). Employment opportunities around
the world. Retrieved from
https://www.cdc.gov/globalhealth/employment/employment.htm

Frieden, T.R. (2010, April). A framework for public health action: the health impact pyramid.
Am J Public Health 100(4), 590-595. doi: 10.2105/AJPH.2009.185652

IHME. (2018, November 8). Global burden of disease. Retrieved

from http://www.healthdata.org/gbd

Manguvo, A., & Mafuvadze, B. (2015, October 10). The impact of traditional and religious
practices on the spread of ebola in west Africa: time of a strategic shift. Pan Afr Med
22(1), 9. doi: 10.11694/pamj.supp.2015.22.1.6190

Skolnik, R. (2016). Global health 101  3rd ed. Jones & Bartlett Learning

 
World Health Organization. (2015, Jan.). Factors that contributed to undetected spread of
the ebola virus and impeded rapid containment.  Retrieved
from https://www.who.int/csr/disease/ebola/one-year-report/factors/en/