Gitanjali Chaturvedi, Switzerland
The new coronavirus COVID-19 pandemic is savage in its rapid geographic spread and severity. As it infects an unprecedented number of people, claims more lives and throws surprises every day, it is worthwhile to take lessons from public health experiences in the past, notably those learnt during the polio campaign in South Asia and the African continent. These lessons hinge on leveraging community mobilisers – an army of women skilled at interpersonal communication – and community leaders to ensure sustained behaviours necessary to minimise transmission. Finally, the surveillance network established for polio should be used extensively for contact tracing and isolating infected persons to contain the virus.
The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.
- International Health Regulations Review Committee (2011)[i]
You need to react quickly, you need to go after the virus, you need to stop the chains of transmission, you need to engage with communities very deeply… you need to be coherent, you need to look at other sectoral impacts – schools, security, economic… but the lesson I have learnt from Ebola after so many outbreaks (…) be fast, have no regrets. You must be the first mover – the virus will always get you if you don’t move quickly. You need to be prepared. If you need to be right before you move, you will never win. Perfection is the enemy of the good when it comes to emergency management. Speed trumps perfection… Everyone is afraid of the consequence of error. The greatest error is to be paralysed by the fear of failure.
- Michael J Ryan, Executive Director, WHO Health Emergencies on lessons from Ebola[ii]
The ongoing COVID-19 pandemic comes as no surprise to public health and development professionals who have long worked to eliminate child and maternal mortality, and to improve immunisation, sanitation and nutrition. What is surprising, however, is the scale and ferocity with which the virus has spread. Its newness contributes to the surprises it throws, as it does not behave in ways that people recognise. It puts excessive strains on health infrastructure, as people get very sick and require hospitalisation but more importantly, it puts at risk, the lives of health workers who care for those affected, thus overwhelming and depleting resources at the same time.
At the time of writing, coronavirus/COVID-19 was circulating in 210 territories and infected over 2.5 million people. The current world population has never before seen a pandemic. The Flu Epidemic (commonly, but incorrectly, referred to as the Spanish Flu) occurred a century ago. There is little living memory of that event.
This challenge is not just new. It also comes at a time when humans, so accustomed to commanding and controlling nature and all her forces, consider themselves invincible. And yet, this invisible, microscopic virus that knows no colour, caste, or country has brought the world to a standstill.
Not enough is known about this virus. It reveals itself slowly and has not infected enough (yes, that is correct) to generate a body of evidence that could provide scientific conclusions. What do we know? We know that this virus moves fast. We know that certain groups – elderly[iii] and those with underlying conditions[iv] – are more vulnerable (so we know who to protect). We also know that even in the absence of a vaccine, certain behaviours are sufficient to keep circulation at very low levels. These behaviours include handwashing – generally a positive behaviour that addresses most health issues – and maintaining social distance[v]. The second has been interpreted differently by health professionals and governments, but most agree that at least two metres distance between people who do not live in the same household is required to keep the virus from spreading as viciously as it has. Then there is advice around congregations and gatherings that countries have interpreted according to their context. Switzerland limited gatherings to five people, the UK to two, India to seven.
As the world continues to grapple with the two pronged disaster – health and economic – unleashed by the virus, it is important to remind ourselves that the global community has successfully eradicated small pox, polio is very close to being eradicated, SARS, Swine Flu, and more recently, Ebola have been conquered and won. And in these battles lie lessons for this big war.
Rumours and myths
As COVID-19 spreads from high income countries to low income settings, lessons from the polio campaign are worth recalling. Polio was a disease of the poor. A child contracted polio only if s/he lived in slums where hygiene standards and sanitation were extremely poor or in remote underserved locations. Parents of such children could not afford healthcare and had little knowledge about immunisation. In fact, they viewed immunisation with suspicion and mistrust. Rumours fuelled this mistrust. A popular rumour that went around every endemic country was that the oral polio vaccine (OPV) caused infertility. Each time, a polio team went from house-to-house, children would be hidden. Aggressive parents, uncles, wizened matriarchs would appear, forbidding teams from entering homes, closing lanes, by-lanes and neighbourhoods.
After several stones and abuses had been hurled, it became clear that to make any headway, a strategic communication strategy would have to be adopted, one that engaged mothers and grandmothers. That engaged community leaders. That spoke to every single stakeholder in the community – teachers, anganwadi (nutrition) workers, faith-healers, religious leaders, traditional birth attendants. The communication strategy was aimed not just to inform but also educate. To take this to scale, every endemic country adopted a communication strategy that focused on changing attitudes and behaviours. An army of community mobilisers was deployed to work in communities and accompany immunisation teams. In Uttar Pradesh, India’s largest state, over 5,000 women worked as community mobilisers in high risk areas. They answered questions that had previously not been addressed. 'We need a road, why are you bringing us drops', would be countered with, 'if your child gets crippled, what good is a road?'
These rumours, questions and doubts resonate with the COVID-19 pandemic today. So much so, that the World Health Organization (WHO) has an entire webpage dedicated to mythbusters. For example, a popular myth is that COVID-19 does not affect people living in hot and humid climates. Another myth is around possible vaccines and medication that prevent its spread. While these myths have been addressed on the website, the polio experience that used community mobilisers to spread health messages can be used to prevent its spread in urban slums and rural areas in developing countries. Behaviours such as handwashing, maintaining hygiene and keeping distance are particularly hard in these environments. The polio network can explain these behaviours and also, help track compliance around these behaviours. As COVID-19 shifts from being a rich person’s problem to becoming more universal, we should look at more community-based solutions.
Spot, track, contain…
Together with the elaborate surveillance network – which is already at work to track COVID-19 infections – these strategies can help reduce the rate of transmission in low-income settings. This surveillance network consists of medical practitioners, indigenous healthcare providers, traditional healers and other community members who report these cases and facilitate collection of samples. The surveillance in India was considered gold standard, and in Nigeria, critical in arresting the spread of Ebola.
The Nigeria story demonstrates how active surveillance stops the spread of a disease. A disease that came via air from Liberia to Lagos and spread to 19 people across two states did not descend into an epidemic. Between July and September of 2014, vigilant disinfecting, port-of-entry screening and rapid isolation but more importantly, with lots and lots of in-person follow-up visits, completing 18,500 of them to find any new cases of Ebola among a total of 989 identified contacts contributed to Nigeria freeing itself of the disease in record time[vi]. This in-person follow up or contact tracing is surveillance. Surveillance involves finding the last child to immunise so that a disease doesn’t spread. Surveillance is sensitive to every new symptom that may manifest in what can be considered a common flu, reporting and screening this to check for new diseases. And in case there is a new disease in the community, an active surveillance finds persons who have come into contact with the infected person to isolate them in turn. And to emphasise, a populous country such as India has perfected surveillance.
Community led, community owned
India and Nigeria engaged strongly with community leaders and leaders of religious communities to build ongoing support for polio. This helped in addressing rumours that sprung up frequently – when those around infertility were addressed, fresh rumours around OPV resulting in paralysis spread like wildfire. It also helped community leaders anticipate challenges such as explaining why polio rounds became more frequent. However, rather than as an afterthought, this engagement has to be done carefully and upfront. For instance, in several low income settings, explaining lockdowns that impact people economically, will have to be accompanied with a response plan involving communities and their leaders. Liberia, shut down completely during the Ebola crisis. But this was done in consultation with community leaders and detailed microplans were prepared assessing rations and other essential requirements of communities. This took a while to prepare but equipping communities (through leaders and mobilisers) with emergency plans can help shorten this time. We must anticipate a second round of measures (lockdown or otherwise) and be prepared. The time to do this is now.
The long haul
It is clear that this fight against COVID-19 will test our resilience and our patience. As the world waits for a vaccine, we find different ways to reassure ourselves. As a media-saturated, global community, we share stories of recovery, of human resilience and selfless service by medical professionals. But after weeks of isolating ourselves, working from home, handwashing, and so on, we feel the fatigue. We are desperate for it to end. And this results in many of us questioning measures, 'many more people die of hunger, why should we change our behaviours for covid-19 when hunger will kill us first?' The question does seem pertinent, especially when one considers informal workers living on daily wages in the developing world. However, if we fail to address this challenge through our behaviours, the silent, underlying conditions in the developing world will contribute to COVID-19 infections claiming many more lives.
[ii] Transcript from https://www.youtube.com/watch?v=XEUwig1GkHo
[iii] Elderly are referred to people over 65 years of age and those who live in nursing homes or long-term care facilities (CDC)
[iv] This category includes people of all ages. Underlying conditions are further specified to include: (a) people with chronic lung disease or moderate to severe asthma; (b) people who have serious heart conditions; (c) people who are immunocompromised (many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications); (d) people with severe obesity (body mass index [BMI] of 40 or higher); (e) people with diabetes; (f) people with chronic kidney disease undergoing dialysis; and (g) people with liver disease
[v] Another recommended behaviour is to call one’s doctor rather than crowding at clinics and hospitals, in case of symptoms. This has resulted in many people isolating themselves in their homes, leaving hospitals to deal with extremely sick and critical patients. Most COVID-19 cases are asymptomatic and adhering to recommended behaviours is key to stop transmission.
[vi] See FO Fasina, A Shittu, D Lazarus, O Tomori, L Simonsen, C Viboud, G Chowell Transmission dynamics and control of Ebola virus disease outbreak in Nigeria, July to September 2014; Eurosurveillance vol 19, issue 40, Oct 2014.
Gitanjali Chaturvedi worked with UNICEF on the Global Polio Eradication Initiative in India, Nigeria, and Afghanistan. She has worked extensively on gender, behaviour change, and social development with the World Bank in South Asia. She authored The Vital Drop: Polio Communication in India (Sage, 2008).