Containing Covid-19: What lessons to be taken from ORT and Ebola campaigns?

It is clear that we have to spend a fair amount of our time, resources and imagination 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, hospitalisation. 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.

Challenges in containment, on the other hand, are different – a combination of science, governance, and society. 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 it is not all nice on the social distancing front, unfortunately.

Closing educational institutions, offices and shopping areas, long chhuti, and restricting movements on train, roads, air and waterways, etc, social distancing had been a quick time-bound, state-enforced success. Once the restrictions are over, there is 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 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? This requires 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 rate of ORT use in the world, much of which, I dare to say, is due to the uphill task done back in the 80s.

A more recent example is the Ebola outbreak in West Africa. Through 2014-2016, Ebola played havoc in some of the West African countries. 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 organisation’s responses during the epidemic, the prevention messages were strictly enforced. Much of the treatment and diagnostic activities were led by Medecins Sans Frontiere and the US Army respectively.  BRAC and other NGOs contributed in prevention through contract tracing and disinfecting. Managing stigma and mental health was one of the major challenges, recalled Salam. Ebola survivors were socially segregated and sequestered, even by their own families.

BRAC is responding to Covid-19 in Bangladesh through its various platforms including its frontline community health workers (shasthya shebika), primary schools, its grassroot organisations (polli shomaj) and microfinance groups. The organisation has suspended its normal field activities and has dedicated its volunteers and staff to create awareness, albeit critical awareness, across communities. Braving the odds, the new Samaritans are going house to house to create a new breed of conscious Bangladeshis.

Guided by the Ebola experience, BRAC has supplied necessary protective gear to its frontline workers:  40,000 shasthya 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 feedbacks speak of many hurdles in making such behavioural changes to take roots. People hardly understand what social distancing means in their own context. Despite being advised otherwise, many mosques are still holding congregational prayers. In their ORT programme, 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 stigmatised. How can we use the Ebola experience to neutralise 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 lead role in this response. It is likely that other NGOs are also contributing in their own ways. They work closely with the grassroots and thus can be more effective in raising the ‘critical consciousness’ of the citizens if they worked in a coordinated way.

It is true that no other global pandemic 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 vulnerable to further infections. The sustenance of gains of the lockdown will depend on how well are we able to sustain the behavioural changes that we hope to instill through the 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 best use of medical science, local culture, and evidence. Learning from previous experiences would help us choose the most effective and sustainable options.

Dr Mushtaque Chowdhury is professor of population and family health, Columbia University, and formerly vice chair of BRAC.