What the Ebola outbreak -- and other experiences -- teach us about containment
Covid-19 is still raging. Save Wuhan, which is returning to normal, much of the remaining world is struggling. The epicentre is shifting -- Wuhan to Europe to New York. Which is next?
It is clear that we have to spend a fair amount of our time, resources, and imagination in the next few months in tackling the disease and its fallouts. The immediate challenge is two-fold: Mitigation and containment. Mitigation has a number of strands which include identifying cases through valid tests, isolation, and, if needed, hospitalization.
Like many other countries, Bangladesh is experiencing huge challenges in doing this in a credible and acceptable way. Most of such challenges are technical, with their solutions lying in the appropriate use of medical science, concomitant support services, and transparent governance.
On the other hand, challenges in containment are different -- a combination of science, governance, and society. The science tells us that we have to religiously practice two things -- strict regimes of hand-washing and social distancing.
Thanks to the decades of promotion, hand-washing is on the easier side. Reports show that people are indeed practicing it to a large extent. But, unfortunately, it is not all nice on the social distancing front.
Closing educational institutions, offices, and shopping areas, a long holiday, and restricting movements on train, roads, air and waterways, etc, social distancing has been a quick time-bound state-enforced success.
Once the restrictions are over, there is a danger that we may return to square one. In my opinion, the practice of social distancing is a behavioural phenomenon and has to be addressed from that perspective. The state interventions have helped raise the initial awareness but to sustain it we have to start addressing it as a behavioural challenge.
Like the disease itself, the concept of self-isolation is also a novel one. To most Bangladeshis, this is “foreign.” We love being together socially in addas or gatherings, we are used to big political meetings and demonstrations, we congregate for prayers, and so on. But how can we shun all these and restrict ourselves to a strict code of social distancing when needed?
These require what the great Brazilian philosopher and educator Paolo Freire called “critical awareness” or “critical consciousness.” It is not enough to just “know” but how much of the “knows” are being put into practice. “Know-do gap” is a popular concept that describes this phenomenon well.
A good example is oral rehydration therapy (ORT) for the treatment of diarrhoea. In the early 1980s, Brac started teaching mothers on how to prepare ORT at home.
Health workers taught ORT to mothers in every family who learned it brilliantly. But the disappointment came when surveys found that only a small fraction of the mothers were using the solution when their children had diarrhoea. As Brac wanted to sustainably change the behaviour towards ORT through a cultural transformation, a series of research studies were fielded to understand the constraints that impeded the use of the solution.
This led to a better understanding of the cultural domain regarding health practices. Brac used these findings through modifications in policies and implementation. Now, Bangladesh has the highest use rate of ORT in the world, much of which, I dare to say, is due to the uphill task done in the 1980s.
Another recent example is the Ebola outbreak in West Africa. During 2014-2016, Ebola played havoc in some of the West African countries.
It started in Guinea, it then spread to Sierra Leone and Liberia, smashing their entire health systems. Ebola is much more fatal than Covid-19. In Liberia, for example, 10,675 people got infected out of whom 4,809 died (death rate: 45%).
Unlike Covid-19, Ebola is spread through direct contact with infected blood, secretions, sweat, and other bodily fluids from dead or living infected persons. The prevention slogan in Liberia was: No touch, no handshake, no hug.
According to Abdus Salam, the country representative of Brac in Liberia who led the organization’s responses during the epidemic, the prevention messages were strictly enforced. Much of the treatment and diagnostic activities were led by Medecins Sans Frontiere (MSF) and the US Army respectively. Brac and other NGOs contributed in prevention through contract tracing and disinfecting.
Guided by the Ebola experience, Brac has supplied necessary protective gear to its frontline workers: 40,000 shebika, 20,000 teachers, 5,500 Polli Shomaj members, and 50,000 microfinance staff. But how well this is being done and what has been its impact so far are perhaps too early to gauge.
However, early feedback speaks of many hurdles in making such behavioural changes take root.
People hardly understand what social distancing means in their own context. Despite advice to the contrary, many mosques are still holding congregational prayers. In their ORT program, Brac successfully used the mosques for ORT messaging.
Can Brac convince the mosques to suspend the congregations for a few days? The returnee expatriates are being stigmatized. How can we use the Ebola experience to neutralize it and convince them to strictly observe the quarantine?
We need a third eye to look at our interventions, said Morseda Chowdhury, who is playing a leading role in this effort. Indeed, Brac was much known for its dependence on this third eye -- research.
It is true that no other global pandemic has affected so many people as the coronavirus. About a third of the world’s population is under lockdown now. But lockdown is harsh and only a temporary measure.
What will happen once the lockdown is withdrawn? People will probably return to old habits, making the world still unsafe to further infections.
Sustaining the gains of the lockdown will depend on how well we are able to sustain the behavioural changes that we hope to instill through current efforts. For this to happen, we must make sure that the current efforts in creating those changes are done in the best possible ways, making the best use of medical science, local culture, and evidence.
Learning from previous experiences would help us choose the most effective and sustainable options.
Mushtaque Chowdhury is Adviser and Founding Dean, James P Grant School of Public Health, and formerly Vice Chair, Brac.