STRATEGIES FOR PUBLIC HEALTH
EMERGENCIES The change agenda for health Ebola in West Africa - Getting 2 zero
VOLUME 16
N2500
Combatting SARS & H1N1 International governance systems & social understandings of disease The Contagion Theory Strengthening Health systems In developing countries
His Excellency, Muhammadu Buhari, GCFR giving oral polio vaccine (OPV) to his grand-daughter to mark
One Year without Polio in Nigeria
Sustain the Wind of Change! NPHCDA
FEDERAL MINISTRY OF HEATH
Mahatma Gandhi Healthcare Management Review PAGE Volume 16 004
44 Combatting:
SARS & H1N1 Case Study: Singapore’s Public Health Control Measures
International governance systems & social understandings of epidemics
Zika Virus
Strengthening Health Systems in Developing Countries
78
The Contagion Theory
50
& THE ORIGIN OF QUARANTINE
60 62
88 90
THE SUSTAINED APPROACH
96
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E D I T O R I A L TIME AND SPACE HAVE COLLAPSED
he emergence infectious disease in human history is not new. The great plague and inuenza are well known historical examples. We are all vulnerable to epidemics of disease that can affect our economy and international relationship as well as health. We need to remember how Sever Acute Respiratory Syndrome (SARS) incubated in Guangdong province in rural China in November 2002, killed 33 people in Toronto-Canada, 12,000 miles away by June 2003 and was damaging world trade. In third quarter of 2009, the ď€ rst wave of H1N1 known as "Swine Flu" originating in Mexico, has swept around the world, bringing with it sickness and terror. The Ebola outbreak in West Africa shows that communicable diseases do not recognise National borders and that foreign outbreaks can directly affect international safety and security. The Black death in the mid 13,00's took about three years to travels across Europe Swine Flu took three days to circulate the World and set every ministry and International organization into
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whirl of activity and every government into emergency sessions, on whether to close their airport and quarantine travellers. SARS, H1N1, Ebola, and Zika are real examples, but is does not take much imagination to recognize the potential of other threats. Health security is our ability to reduce and manage these national and Man made threats and has become a matter of concern to us all. We are now beginning to understand fully that the health of one Nation affect its neighbours and we need to share our knowledge and build defences together. As time and space have collapsed, the inter connectivity of our species have increased dramatically in both speed and scale creating a highly vulnerable world susceptible to potential pandemic viruses. We are only as strong as our weakest part wherever they may be.
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The CHANGE AGENDA for Health Prof. Isaac Folorunso Adewole FAS, Honourable Minister of Health. Healthcare Management Review PAGE Volume 16 014
Extracts from the Keynote address by Honourable Minister of Health; Prof. Isaac Folorunso Adewole FAS at the 58TH National Council On Health (nch) Meeting Held At Sokoto, Sokoto State, 7th–11th March,
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William H.
Stewart
Former U.S. Surgeon General
F
ormer U.S. Surgeon General William H. Stewart has been attributed with stating in the late 1960s that the time had come to “close the book” on infectious diseases as major threats to public health. Even though this statement’s authenticity has been questioned, it is often used to convey the optimism expressed at the time by health experts and world leaders. At the time, it did appear that the age of infectious diseases that had plagued humans for millennia was coming to an end. Vaccines and antibiotics had substantially reduced the incidence and mortality of many diseases. The smallpox eradication campaign was on its way and it was thought that eradication of other diseases (for example tuberculosis and polio) would not be too
far behind. Improved food and water safety resulted in less exposure to disease-causing microbes, and the use of pesticides to control arthropod populations had reduced vector-borne diseases. It seemed the battle with the microbial world had been won, and it was time to focus efforts and funding on the looming threat of chronic diseases. This confidence, however, largely ignored the burden of infectious diseases in the developing world. Five decades later, although great strides have been made to control infectious diseases, microbial pathogens are still major threats to public health throughout the world. The last few Healthcare Management Review PAGE Volume 16 016
Former U.S. Surgeon General William H. Stewart has been attributed with stating in the late 1960s that the time had come to “close the book” on infectious diseases as major threats to public health.
...But Infectious Diseases occur so frequently despite the optimism of past generations?
decades have unveiled new challenges: “old” pathogens once thought to be controlled by antibiotics have developed multidrug resistance, new pathogens have emerged, and traditional pathogens have appeared in new locations. Furthermore, factors such as increased global commerce and travel, and the threat of the intentional release of pathogens have set the stage for infectious disease disasters with large numbers of casualties.
There is a wide body of knowledge on the emergence and reemergence of pathogens of public health importance. Humans are in a delicate balance with microbial cohabitants of the earth; circumstances can tip that balance in favor of microbes with new or renewed pathogenic vigor. There will always be emerging pathogens, and consequently there is always the chance that a virulent microbe will cause extensive human disease and death. Exactly what the causative agent of the next big infectious disease disaster will be and when it will happen is not known.
...what the causative agent of the next big infectious disease disaster will be and when it will happen is not known.
Credit: © Shantini D. Gamage, Stephen M. Kralovic, and Gary A. Roselle
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We must understand that when one country is not safe, the world is not safe. Pandemic influenza, by nature, will go around the world, so it is important for us to work as an international community to get a better handle on the issue.
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The world is now paying attention to these (neglected) diseases and making progress in unprecedented ways, with ambitious goals, excellent interventions, and growing evidence of multiple benefits for health.
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Margaret
Chan
WHO Director General.
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Seth Franklin
Berkley,
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For just a few dollars a dose, vaccine save lives and help reduce poverty. Unlike medical treatment, they provide a lifetime of protection from deadly and debilitating disease. They are safe and e ective. They cut healthcare and treatment costs, reduce the number of hospital visits, and ensure healthier children, families and communities.
�
Seth Franklin Berkley, M.D. A medical epidemiologist by training. He is the CEO of the GAVI Alliance and a global advocate on the power of vaccines. He is also the founder and former President and CEO of the International AIDS Vaccine Initiative Healthcare Management Review PAGE Volume 16 021
“The world has 6.8 billion people... that’s headed up to about 9 billion. Now if we do a really great job on new vaccines, health care, reproductive health services, we could lower that by perhaps 10 to 15 percent.”
Bill
Gates,
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CURRENT Public Health Emergency of International Concern
A
Public Health Emergency of International Concern (PHEIC) is a formal declaration by the World Health Organization (WHO). The declaration is promulgated by that body's Emergency Committee operating under International Health Regulations
(IHR).
This statement designates a public health crisis of potentially global reach.
2009 Swine u declaration
2014 polio declaration
As a legally binding international instrument on disease prevention, surveillance, control, and response adopted by 194 countries, a PHEIC was first issued in April 2009 when the H1N1 (or Swine Flu) pandemic was still Phase Three.
The second PHEIC was issued in May 2014 with the resurgence of polio afte its near-eradication, deemed “an extraordinary event”.
2016 Zika Virus declaration 2014 Ebola declaration On Friday, August 8, 2014, the World Health Organization declared its third Public Health Emergency of International Concern in response to the outbreak of Ebola in Western Africa
On Monday, February 1, 2016, the World Health Organization declared its fourth PHEIC in response to clusters of microcephaly and GuillainBarre syndrome in the Americas, which at the time were suspected to be associated with the ongoing outbreak of Zika virus. Later research and evidence bore out these concerns; in April, the WHO stated that “there is scientific consensus that Zika virus is a cause of microcephaly and GuillainBarre syndrome”.
PHEIC can also make the news when it is not invoked, as is the case to date with MERS Healthcare Management Review PAGE Volume 16 024
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The diseases/agents in the black boxes with the white dots represent select emergences that occurred since 2010
Emerging and reemarging infectious diseases/agents, 1990-2013.
Lord Nigel Crisp, The Author of ‘Turning the World Upside Down: The Search for Global Health in the 21st Century.
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“There is increasing interdependence in the face of spreading disease, the movement of populations, climate change and economic interconnectedness. The health of the world depends now more than ever on the strength of every country. New diseases will nd the most vulnerable places to incubate and multiply before they spread. We are in this together. The health of poorer populations concerns us all.”
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PLANING WITH WHAT YOU HAVE
Dr Tedros Adhanom Ghebreyesus; the Former Minister of Health was responsible for health in one of the fastest growing and poorest countries in Africa, where the annual expenditure on health is US$22 per person and the population now exceeds 80 million. His whole health plan is based on the premise that you train and employ the people you need to deal with the tasks that need doing. The foundation of the Ethiopian Service is a very large number of health extension workers who work locally and are primarily concerned with health promotion but carry out some treatment programmes. Above them sit the mid-level workers: the emergency surgeons, direct entry anaesthetists, general clinical ofďŹ cers and others who carry out the bulk of the direct patient work. Above them are the doctors and nurses and other clinical professionals and scientists. Dr. Tedros's view is straightforward: 80% of the burden of disease in Ethiopia is due to communicable diseases, and most eases can be prevented or treated by community and mid-level workers. We must use the assets at hand and provide what we can to our communities. Healthcare Management Review PAGE Volume 16 028
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Our health care plan is based on the premises that you train and employ the people you need to deal with the task that needs doing.
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We must use the assets at hand and provide what we can to our communities.
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Dr Tedros Adhanom Ghebreyesus; Former Ethiopia Minister of Health.
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STRATEGIC RESPONSE TO EBOLA OUTBREAK IN WEST AFRICA Healthcare Management Review PAGE Volume 16 030
1. Stop transmission of the Ebola virus in a ۮected countries 2. Prevent new outbreaks of the Ebola virus in new areas and countries 3. Safely reactivate essential health services and increase resilience 4. Fast-track Ebola research and development 5. Coordinate national and international Ebola response
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T
he outbreak of the Ebola Virus Disease ( E V D ) i n We s t A f r i c a i s unprecedented in its scale, severity, and complexity. Guinea, Liberia and Sierra Leone struggled to control the epidemic against a backdrop of extreme poverty, weak health systems and social customs that make breaking human-to-human transmission difficult.
Guinea
Sierra Leone
Liberia Ebola cases over time in the most affected countries as at March 1, 2015
Getting to ZERO required a strategy to stop all chains of transmission in the affected countries, prevent the spread of the disease to neighbouring countries and to safely reactivate life saving essential health services. The Ebola response roadmap designed to stop this unprecedented outbreak included the UN system's Overview of Needs and Requirements (ONR) and STEPP Strategy that followed. These were designed to assist governments and partners in the revision and resourcing of country-specific operational plans for the Ebola response, and to aid the coordination of international support to fully implement those plans. The ONR was used as the basis for a massive scale-up in the response under UNMEER, for which WHO is the lead technical and health agency. The WHO Roadmap and subsequent STEPP Strategy outlined a phased operation in the areas of the most intense transmission, with th e in itial emp h as is o n s lo w in g th e exponential increase in cases that was documented in August – September as quickly as possible. This required a rapid scale-up of treatment facilities, burial capacity and behavioural adaptation to slow the exponential increase in new cases, followed by the rapid scale-up of rigorous case finding, contact tracing and intense community engagement to interrupt residual transmission chains.
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the STEPP STRATEGY STOP the outbreak,
TREAT the infected, ENSURE essential services,
PREVENT outbreaks in countries currently unaffected
PRESERVE stability Healthcare Management Review PAGE Volume 16 033
IMPLEMENTING
THE EBOLA Response Strategy in West Africa
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Communities, together with their governments and international responders, worked together to better understand the risks and manage expectations. They identiďŹ ed and traced people with Ebola and their contacts, treated the infected and provided safe and digniďŹ ed burials for those that have lost their lives.
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O
CASE MANAGEMENT
ver 60 specialized Ebola treatment units (ETUs) were setup, capable of providing approximately 3,000 beds for Ebola care in the three mostaffected countries. More than 40 organizations and 58 foreign medical teams (FMTs) were deployed and estimated 2,500 international personnel to operate these centres in partnership with ministries of health and thousands of national staff. This complex environment is coordinated by a WHO team in each country that works closely with advisers on infection prevention and control and clinical management to provide support to all partners deployed. In addition to the ETUs, over 63 Ebola community care centres (CCCs) were established to promote greater community engagement in the Ebola response. The increased number of beds created in August was sufficient to isolate and treat all known cases across the three countries and was a key factor in controlling the outbreak. This expanded capacity to isolate cases, along with safe and dignified burials and behavioural changes in communities has been a key factor in controlling the outbreak so far.
SAFE & DIGNIFIED BURIALS
T
hese countries had to develop sufficient capacity to bury all of the deceased in a safe and dignified manner. There were over 210 burial teams active across the three countries. This capacity has played a crucial role in helping to dramatically reduce the number of cases. WHO, with the support of UNAIDS, worked with faith-based organizations to develop safe and dignified burial protocols that were currently used. While progress has been made, there are still instances where communities perceive that there is not enough allowance for prayer and spirituality during burial services.
W
INFECTION PREVENTION & CONTROL (IPC)
HO and partners provided expertise to guide IPC policy and clinical practice through the publication of emergency guidelines and direct support for health workers in the clinical management of patients with Ebola, on personal protective equipment (PPE), laboratory procedures, contact tracing, safe burials and waste management. Such public health advice was essential to inform the health workforce and other international responders about transmission risks and safety measures. Moreover, in coordination with major partners such as UNICEF, and WFP, WHO supplied more than one million sets of PPE and provided extensive training for health workers and front-line responders on, among other Ebola interventions, infection control practices, occupational health and safety, clinical management and safe burial. There was adequate protection for health workers in all settings; health worker infection investigations, provision of dedicated treatment facilities for infected health workers. WHO played the lead role in coordinating medical evacuations where necessary. Healthcare Management Review PAGE Volume 16 036
SURVEILLANCE & CONTACT TRACING
W
HO, together with the US Centers for Disease Control, led the surveillance, case finding, contact tracing, data management and epidemiological analysis with national governments in the three most-affected countries. WHO coordinated with GOARN partners to deploy over 600 public health experts during the course of the response to assist in surveillance, field epidemiology, case finding, contact tracing, information management and epidemiological analysis. This contributed to the significant increase in the number of new cases coming from contact lists and the consistent mapping of chains of transmission. WHO coordinated the deployment of more than 230 experts to 26 mobile laboratories via laboratory partners through the Emerging and Dangerous Pathogens Laboratory Network (EDPLN), which is a central pillar of GOARN. These field laboratories tested more than 750 samples per day if needed. This capacity enabled the rapid confirmation of cases in the three most-affected countries.
W
COMMUNITY ENGAGEMENT
HO worked to strengthen community engagement in order to build and maintain trust between local communities and frontline workers. This included informing the selection, prioritization and adoption of appropriate prevention and control measures through dialogue between communities and technical teams. WHO also worked with communities to reinforce the key actions that they can take, counter misinformation that they may have received and mitigate misinterpretation of health advice by proactive listening and addressing community concerns and fears. WHO engaged anthropologists to work with community and religious leaders to address fear and stigma of the disease, to negotiate alternatives and adaptation of religious and cultural practices and to encourage seeking treatment through dialogue with communities. In collaboration with UNICEF and other partners, systems were put in place to ensure that community engagement methodologies were applied to constructively manage dialogue with communities. While progress were made, it was critical that service providers continue to build trust and make sure services were responsive to community concerns and needs. Social and traditional media were used to reach millions of people in the three most-affected countries as well as in the 14 highest- and high-risk countries in the African region. Community approaches were promoted by engaging survivors to work alongside other responders, this helped to minimize the stigmatization of communities affected by Ebola.
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BUILDING Community Trust
C
ommunities will continue to be, the most critical part of an effective response. Mainstreaming community engagement within service delivery, for example through the training of frontline staff in trust building and communication skills, and re-orientating social mobilization activities to address service uptake is a priority. Strengthening technical and operational support to the departments of health education/health promotion within ministries of health will enable sustainable capacity to be built by utilizing existing infrastructure and networks to lay the foundations for community engagement post-Ebola. A key element of building community trust is to provide the highest standard of care for all those with Ebola – and to keep family members informed of the progress of their loved ones. Establishing community liaison ofďŹ cers at treatment centres was an important good practice. Case management capacity, triage and infection control procedures need to be optimized to increase survival rates as well as to reduce the number of health workers becoming infected with the disease. It is also important to manage the capacity and geographical distribution of Ebola treatment centres and foreign medical teams as the epidemiological situation changes. This may include the decommissioning and/or repurposing of ETUs and community care centres no longer required for patient isolation, redeployment of foreign medical staff to assist with the safe reactivation of essential non-Ebola healthcare services, or using existing Ebola treatment centres to conduct clinical trials of new treatments.
In the six countries that reported an imported Ebola case or cases (Mali, Senegal, Nigeria, Spain, the United States of America, and the United Kingdom). Ebola was controlled. All of these examples conďŹ rm that a rapid and strong response to an Ebola outbreak is not only essential, but possible, and is the most important factor in controlling the disease and consequently stopping its spread. Healthcare Management Review PAGE Volume 16 038
“
IT ALWAYS SEEMS
IMPOSSIBLE UNTIL IT’S DONE.
”
= Nelson Mandela =
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BREAKING the Outbreak of Ebola in Nigeria
Nigeria’s Lesson For The West on EBOLA Healthcare Management Review PAGE Volume 16 040
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Nigeria has shown the importance of logistics and public information awareness on top of medical care in containing the Ebola virus.
“
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...they were very organized. They put resources into tracking down every contact. In the US, the wife (of the first Ebola victim in Texas) was left for five days with contaminated materials. Here they disinfected houses immediately.
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Dr. Ellish Clearly, Chief Medical Ofcer of Health New Drunswick, an expert in the epidemic who has been debrieng the Nigerian survivors. Healthcare Management Review PAGE Volume 16 043
“Fear was more of a challenge. ...it kept stimulating and challenging us to do the right thing.”
D
o you think that the fear of the consequences of handling it otherwise was part of the momentum?
Fear was a factor that helped in shaping the urge to respond but I must say that the fear did not over-ride on the technical details because if you loosely define fear, it may lead to irrational action. But in our own case I think the fear was viewed more as a challenge and not as real fear that makes you to act irrationally. I like the key words you used: “fear was more of a challenge. Yes, it kept stimulating and challenging us to do the right thing. One of the most exciting things during the programme was the Mission Control Room. We called it IMC at that time. Initially it was Incident Management Centre (IMC). It later changed to Emergency Operation Centre (EOC) because it was not just management. It was real full blown field operation with so many commanders handling different subjects. We had central EOC which every stakeholder was a part of; then we had subcommittees of the EOC. We had most importantly at that time, the Points of Entry/Exit(POE) which 1 was heading. This is a committee that determined who and who were in contact with Patrick Sawyer when he was in transit. Healthcare Management Review PAGE Volume 16 044
Certainly, fear was a factor that helped in shaping the urge to respond but, I must say that fear did not over-ride on the technical details because if you loosely define fear, it may lead to irrational action. but in our own case, I think the fear was viewed more as a challenge and not as real fear that makes you to act irrationally.
We had to reconstruct the history, document who ever came in contact with them and at that time it was a b o u t 5 8 p e o p l e . We n o w h a d t o d o a r i s k cranking(assessment) for these people. The risk cranking you might be surprised was so perfectly welldone that most of the people we predicted as high risk were eventually the people that came down with the disease but finally the list grew up to 72 for Lagos, first primary contacts of Patrick Sawyer. And all the people that got infected in Nigeria came in under this list of 72 people and even those who secondarily got infected among the secondary contact of these 72 people.
We also had a team of young and very intelligent officers who were doing data management and on daily basis prepared this report. So we had not only the Minister’s update report, we had situation reports every evening, coming out of the centre. They were coded and numbered. If you looked at them, it is sufficient history for you to reconstruct how things were flowing from the time one had the index case up to a period of
“
lull which you could have even thought Nigeria was spared because it took us about 7 to 10 days before we started seeing cases of people coming up with disease. And these are the other committees that I didn’t mention under the EOC: The Contact Tracing Committee, the Clinical Management Committee and we had a robust Logistic and Supply Committee.
Enough anxiety was created for people to comply and at the same time, this anxiety did not over-flow to cause unnecessary panic within the care givers and the general populace. How was this managed?
Exactly. That was why I was very careful when you mentioned the words fear and panic. These are not too good words when you are talking of response. But they are very good words when it comes to motivation. The panic and fear motivated people to respond and went ahead to technically channel their energy into response and that is what helped Nigerians.
...health systems determine how far an epidemic can go. Once the Ebola virus is introduced into a system, your ability to identify it quickly before it spreads, contain it and follow up all potential contacts, predict the epidemic as it grows, think ahead of it, plan and prevent it from escalating depends on the health system.
”
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Extract from HMR interview with Dr. Emmanuel Abanida Fmr. Dir. Immunization and Disease Control (NPHCDA)
E
bola entered the West African region through Guinea in February 2014 and spread to Liberia and Sierra Leone within a very short time in March/April 2014. These countries were overwhelmed by the E VI). Liberia and Sierra Leone were emerging from civil wars with civil disorientation and broken health systems. They apparently misjudged the E VI) and it got to a tipping point. The Nigerian consciousness was activated by the index case Patrick Sawyer on the 20th of July 2014. Before then the country was sensitized. Nigeria had a lot going in her favour that restricted the space of Ebola. The index case came through Lagos a highly densely populated state, this should have fuelled the spread but for the robust health system, also of importance was the doctors strike which paralyse the activities at the tertiary hospitals. Because Ebola was in West Africa there was a high index of suspicion especially for patients from the endemic areas of Liberia, Sierra Leone, and Guinea. This was critica land helped the First Consultants Hospital to escalate the risk when Patrick Sawyer arrived at the hospital.
The main strategy that worked for Nigeria was ‘PracticalOwnership.’ The level of commitment by the President of theFederal Republic of Nigeria. Dr. Goodluck Ebele Jonathan,was unprecedented in the history of virus outbreaks. Hedemanded to be briefed daily and made necessary funds available. His commitment and ownership was contagious; it strengthened the engagement pyramid and fuelled the momentum at all levels. The Lagos State Governor, was virtually on the frontline. The coordination of the multi sectorial team by the Federal Ministry of Health was exemplary. Everybody, was pulling in the same direction. Nigeria was fighting a common enemyEbola- and this provided a psychic in come for the population. No disease outbreak has ever received this level of commitment within such a short time. The Global sympathy backed up the Local commitment. The role of NPHCDA was simple. NPHCDA had a defector preparation; all staff had routine basic training on containment and barrier nursing. The State Primary Healthcare Coordinators were adequately briefed and asked to step down the Healthcare Management Review PAGE Volume 16 046
Anxiety and fear created a high level of awareness. The Nigerian population was ‘mobile’ in getting information and disseminating it. Rumours were promptly checked from the Emergency Operation Room. Societal jokes like Ebola hand shake created a sustained momentum for awareness and fear encouraged compliance and the management of mortality. One of the most dynamic aspects of the EVD in Nigeria was the sharp movement from a docile to an extra ordinary active and proactive self health care seeking behaviour. Hand sanitisers were in high demand and temperature checks were carried out inmost banks, hotels, and high tra c commercial blocks.
information as far as possible. Ad hoc planning, and technical meetings were not far in between and syndicated public enlightenments were rolled out. Anxiety and fear created a high level of awareness. The Nigerian population was ‘mobile’ in getting information and disseminating it. Rumours were promptly checked from the Emergency Operation Room. Societal jokes like Ebola hand shake created a sustained momentum for awareness and fear encouraged compliance and the management of mortality. One of the most dynamic aspects of the EVD in Nigeria was the sharp movement aspects of the EVD in Nigeria was the sharp movement from a docile to an extra ordinary active and proactive self health care seeking behaviour. Hand sanitisers were in high demand and temperature checks were carried out inmost banks, hotels, and high traffic commercial blocks. ST1GMATIZAT ION: Stigmatization always flourishes in developing countries at the ear/v stages of the advent of a disease. Managing stigmatization was a challenge. No legislation will reduce stigmatization but an adequate information about the disease and new
advancements in the cure and management of the disease. When EVD moves from the iterative state to a sequential state of care, revealing better curative and protocolization of clinical management, stigmatization will reduce. As soon as new evolving vaccines are available. stigmatization will vanish. Consider the history of stigmatization for Malaria. Yellow Fever, Syphilis, Gonorrhea, and HIV. These illness are more accommodated now due to better clinical management. However, changing the EVD communication to emphasis that early presentation guarantees 90% of survival will change the platform of compliance. The vaccine space for Ebola is being accelerated becausepatients are now available for the trials. The EVD vaccine isa matrix. The world is looking for the best fit to apply.Candidate vaccines for prophylatic prevention will not begiven as a mass immunization but to a high risk populationgroup like healthcare providers and patient’s relations(applying same logistics as in hepatitis B.)West Africa has joined Central Africa as an EVD endemicregion. The Federal Ministry of Health should raise thestatus of EVD in their surveillance and control profile. Healthcare Management Review PAGE Volume 16 047
The e ۮect of weak health systems in public health emergencies
...Ebola became epidemic in the a ۮected areas because of the weakness of the health systems. Healthcare Management Review PAGE Volume 16 048
...the scale of the crisis escalated because the health systems in the a ۮected countries lacked e ciency
E
bola became epidemic in the affected areas in large part because of the weakness of the health systems. Particular structural weaknesses included insufficient numbers and distribution of qualified health workers, and inadequate surveillance, notification and information systems. Infrastructure, logistics, governance and medicines supply systems were similarly weak. The organization and management of health services was sub-optimal. Government health expenditure was low and inadequate to ensure universal access to basic services, whereas private expenditure – mostly in the form of direct out-of-pocket payments for health services – was regressively high. External funding was skewed towards millennium development goals (MDGs) through vertical programmes with limited investments in core health systems functions. These weaknesses were further exacerbated during the epidemic, when existing public health services were almost entirely diverted to Ebola. People have
encountered significant barriers to accessing essential services, such as vaccination, maternal and child health and treatment for common illnesses. In this context, the scale of the crisis escalated because the health systems in the affected countries lacked resilience. With over 850 health workers infected and more than half dying from the Ebola virus, pre-existing health workforce shortages and poor distribution was further exacerbated. The resultant fear and distrust fuelled the mass attrition of health workers, strikes and disruptions to routine health services. Public sector labour expenditure caps resulted in 41% of government health workers working without being on the payroll in Liberia and large numbers of vacancies despite substantial needs in Sierra Leone. Rapid workforce analysis, planning, deployment, capability development and management are essential preconditions to the reactivation of essential health services and core health systems functions.
Credit: 2015 WHO Strategic Response Plan: West Africa Ebola Outbreak Healthcare Management Review PAGE Volume 16 049
Combatting:
SARS & H1N1 Case Study: Singapore’s Public Health Control Measures Healthcare Management Review PAGE Volume 16 050
This case study offers a fresh perspective on the role of the state in pandemic management. It adds to the body of knowledge on epidemic policy design specic to the region of South-East Asia. Indeed, the dominant perspective in this eld holds that the state must be able to exercise brute force and impose its will on the population. However, this dominant perspective is at least incomplete because the exercise of authority and power from the government is not a sufcient condition to contain the transmission of virulent diseases. Success in ghting epidemics is also contingent on a concerted effort of partnership between health authorities and the population at large. Beyond this key nding, this case study also contributes to the health policy eld by elucidating a conceptual model for pandemic management that is applicable to a broader context. Healthcare Management Review PAGE Volume 16 051
Combatting:
SARS & H1N1 in Singapore
Command & Control
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ombatting the outbreak of infectious diseases is a major public health imperative for the small island-state of Singapore. In this case study we review the public health measures taken by the Singaporean government to combat the outbreak of SARS in 2003 and H1N1 in 2009. Most notably, the state introduced a clear line of command and control to monitor the eectiveness and eďŹƒcacy of public health control measures as well as to oversee their implementation. Meanwhile, it has also employed moral suasion to ensure compliance with draconian health control measures by the population. At the same time, the Singapore government also established a close partnership with the population to ensure the acquiescence of the general public to these measures. Healthcare Management Review PAGE Volume 16 052
One of the most important lessons the Singapore government learned from the SARS epidemic was the significance of the role of the bureaucracy in crisis management. As it turned out, the bureaucratic structure in place prior to the outbreak in 2003 was wholly inadequate in terms of dealing with a crisis situation that was both fluid and unprecedented; consequently, fighting SARS called for more than a medical approach since resources had to be drawn from a number of government agencies that did not fall under the rubric of the MoH.
S
ituated in South-East Asia, Singapore is fortunate enough to be spared from major natural disasters such as typhoons, earthquakes, and tsunamis. However, as the small city-state is one of the most densely populated countries in the world, Singapore is especially prone to transnational health threats such as pandemics. Indeed, during the last decade, Singapore has been struck by two major pandemics. In 2003, Singapore experienced the outbreak of the Severe Acute Respiratory Syndrome (SARS). Then, in 2009, the state had to take additional measures against the novel influenza A (H1N1), which put major parts of its population at risk. Even though the two major outbreaks were eventually contained through an array of public health control measures instituted by the Ministry of Health (MoH) ofSingapore, SARS and H1N1 brought about severe public health and economic consequences for the country as a whole. As it turned out, the population’s receptiveness to draconian measures was enhanced to a large extent through moral suasion and close partnership between the government and people. Indeed, the efficacy of these public health control measures was profoundly related to these two crucial elements. Meanwhile, it is important to note that these public health control measures were swiftly adjusted to
meet contingencies that arose – for example when additional epidemiological cases were uncovered and when a better understanding of the viruses was developed. This happened through the introduction of a clear line of command and control. One of the most important lessons the Singapore government learned from the SARS epidemic was the significance of the role of the bureaucracy in crisis management. As it turned out, the bureaucratic structure in place prior to the outbreak in 2003 was wholly inadequate in terms of dealing with a crisis situation that was both fluid and unprecedented; consequently, fighting SARS called for more than a medical approach since resources had to be drawn from a number of government agencies that did not fall under the rubric of the MoH. On 15 March 2003, when the epidemiological nature of SARS was still unclear, the MoH initiated a SARS taskforce to look into the mysterious strain. Only two days later, after more SARS cases were uncovered and a better epidemiological understanding of the strain was developed, the Singaporean government swiftly declared SARS a notifiable disease under the IDA (Ministry of Health, 2003). In the event of a widespread outbreak,
Healthcare Management Review PAGE Volume 16 053
Source: Adapted from Tay & Mui (2004, p. 35)
IDA made it legally permissible to enforce mandatory health examination and treatment, exchange of medical information and cooperation between healthcare providers and MoH, and quarantine and isolation of SARS patients (Infectious Disease Act, 2003, chapter 137). On 24 March 2003, the MoH was authorised by the IDA to implement compulsory home quarantine for those who had been exposed to the SARS virus. On 7 April 2003 (approximately five weeks after the first case of SARS was reported), a three-tiered national control structure was created in response to SARS. These tiers were individually represented by the Inter-Ministerial Committee (IMC), the Core Executive Group (CEG), and the Inter-Ministry SARS Operations Committee.
Following the SARS epidemic, the above command and control structure was revised to adequately reflect the need to create a multi-faceted and robust management approach – one that would be more suited to a fast changing health crisis situation that was both volatile and unheralded. The outcome was the establishment of a Home-front Crisis Management System (HCMS). Heading this new command and control structure was the Homefront Crisis Ministerial Committee (HCMC). Identical to the IMC, the HCMC served to provide strategic and political directions during health crises. Meanwhile, the functions of the CEG and IMOC were consolidated into the Home-front Crisis Executive Group (HCEG) in order to shorten the time it might take to respond to a health crisis.
Source: Adapted from Tay et al. (2010, p. 316)
The main benefit of this abridged command and control structure was that it dramatically shortened response time and facilitated the implementation of health control measures across various healthcare sectors during the 2009 H1N1pandemic. Healthcare Management Review PAGE Volume 16 054
Responsibility of Governance and Leadership Managing Public Condence & Trust Since earning the trust of the public was not given, political leaders have to be seen as doing and initiating a series of countermeasures to reassure the public.
Ex-Prime Minister Goh Chok Tong
“
I believe, however, that Singaporeans are made of sterner stu . I believe they have fighting spirit. Otherwise, Singapore would have collapsed by now…Take for instance our doctors, nurses and other personnel working to help SARS-infected patients. They have conducted themselves magnificently throughout the crises. They have displayed great resolve, and a noble sense of professional responsibility. They have chosen courage over their fear of SARS… This is the kind of steel in our character that will see Singapore through hard times. We should honour them.
”
- Goh - 2003. Healthcare Management Review PAGE Volume 16 055
A Conceptual Model of Pandemic Control
The conceptual model of pandemic control capture the essence of Singapore’s success in Combatting SARS and H1N1. Crucially, this model is composed of three critical components – adaptive governance, networked partnership, and moral suasion –. More importantly, this conceptual model o ۮers a valuable framework into the kind of approach needed to combat future pandemics.
Adaptive Governance Adaptive governance, in this context, refers to a clear but flexible command and control structure that can be swiftly adapted to changing circumstances. Among other things, the flexibility endemic to this command and control structure facilitates the building of trust between the state and its people. This in turn ensures that government measures are quickly accepted by the general public.
Networked Partnership Combatting pandemics requires multiple government agencies and private organisations to work together in close partnership – not unlike that of a network. While the health authorities of a country typically lead such efforts, the inclusion of other departments, agencies, and organisations (including non-governmental ones) is necessary and ultimately, inevitable. Indeed, major countermeasures such as public education and surveillance are often made possible with the aid of non-health agencies such as the media and schools.
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ADAPTIVE GOVERNANCE
NETWORKED
Success of Disease Control
PARTNERSHIP
MORAL SUASION
Moral Suasion Moral suasion means the use of a persuasion tactic by an authority to influence and pressure but not to force individuals or groups into complicity with a policy. Public education and risk communication are two indispensable components in health crisis management. The evidence suggests that draconian government measures, such as quarantine and travel restrictions, are less effective than voluntary measures (such as good personal hygiene and voluntarily wearing of respiratory masks), especially over the long term. Therefore promoting social responsibility is crucial in terms of slowing the pace of infection through good personal hygiene and respiratory etiquette in all settings. This, in large part, has to rely on public education and risk communication. Indeed, getting the right message across to the general public can often be a major challenge, especially when no established and respected organisation can act as the central authority for information collection and dissemination. Hence, it is absolutely necessary to disseminate essential information to the targeted population in a transparent manner.
Moral suasion is best illustrated in the Singaporean government’s communication strategy during the outbreak of SARS and H1N1. The lack of knowledge on the epidemiology of SARS and H1N1 at the beginning of the outbreaks inevitably led to public fear and panic. Throughout the pandemic, the Singaporean government relentlessly raised the level of public awareness on social responsibility and personal hygiene. Singapore’s approach to manage public fear and panic was through ensuring transparency and building trust. Since earning the trust of the public was not a given, political leaders had to be seen as doing and initiating a series of countermeasures to reassure the public. One good example was demonstrated by Singapore’s Senior Minister Lee Kuan Yew who told the media how he never left home without his thermometer while Prime Minister Goh Chok Tong lunched with local media editors at a hotel restaurant to show Singaporeans that it was safe to be in public places. Goh deliberately used the story of people’s sacrifices during SARS to further indicate the type of character that all Singaporeans should embrace: Healthcare Management Review PAGE Volume 16 057
All in One vs One in All Strategic Approach Combatting:
SARS & H1N1 in Singapore
Healthcare Management Review PAGE Volume 16 058
T
he manner in which SARS cases were managed clearly illustrates the significance of good governance at all levels. In particular, Singapore’s command and control structure to combat SARS was modelled after an All-in-One approach toward the management of SARS patients. Specifically, all suspected cases of SARS were confined to a single hospital designated by the MoH – Tan Tock Seng Hospital (TTSH) in this case. This All-in-One approach was unique to Singapore and was not found in other SARS-affected countries. Notably, a crucial element of this All-in-One approach to case management was that it required close partnership between three core groups of constituencies: TTSH, the general public, and healthcare providers (both in public and private practices). As opposed to the All-in-One approach in 2003, the strategy to combat H1N1 in 2009 took the form of a so-called One-in-All approach. As its name suggests, this entailed a single all-encompassing strategy to counter H1N1, which was necessary since the characteristic of H1N1 virus was different. Unlike SARS carriers, H1N1 carriers could be contagious even when they were in the asymptomatic phase of the illness (in other words, not showing any visible signs of illness). To minimise the risk of transmission, MoH imposed one standardised infection control measure on all healthcare settings (such as primary care clinics, longterm care facilities, and community renal dialysis centres). Given this imperative, the MoH again needed strong compliance from health professionals
and the general public. In practice, one triage system was implemented in all frontline settings to streamline the treatment of H1N1 patients. Once patients were laboratory-confirmed to be stricken with H1N1, mandatory isolation orders were issued and quarantine became compulsory. This was in accordance with the IDA, which, it must be pointed out, was amended in a timely manner to reflect this imperative. Furthermore, the MoH also established a specific contact tracing centre to track down all laboratory-confirmed cases. This meant that those who came into close contact with H1N1 patients were swiftly tracked down, ordered to undergo mandatory Quarantine Orders (QOs), and were given Oseltamivir as a precaution. However, mandatory isolation in a setting that was external to the traditional healthcare provider did end up raising a wide range of legal, political, and ethical issues that could potentially result in a public backlash at that policy. Indeed, even though the policy of mandatory isolation was arguably quite effective in terms of limiting transmission, such a draconian measure did challenge the public’s acceptance of it, especially those who were isolated since that presented an abrupt disruption in their lives and work. To mitigate such public displeasures, the Singapore government endeavoured to provide the affected a comprehensive livelihood support by enlisting the assistance of nongovernmental organisations. At the same time, the population was encouraged to adopt responsible social behaviours Healthcare Management Review PAGE Volume 16 059
International governance systems & social understandings of epidemics The issue of ac on or inac on is underpinned by both ins tu onal structures of risk governance and the wider socio-poli cal percep on of threat. The WHO's early reac on to Ebola, and cri cisms of that reac on, reect both conic ng social percep ons of the disease and structural disease governance mechanisms. Healthcare Management Review PAGE Volume 16 060
ACTION AND INACTION: Response to H1N1 and Ebola
T
he 2014 outbreak of Ebola has exposed the health realities faced by fragile states and fragile health systems. Just as fundamental to the current discussion is the perception of risk and action, as evidenced by public criticisms of the (slowness of the) international response. The event highlights the tensions between international governance systems and social understandings of disease. While the current outbreak first emerged in December 2013, WHO's declaration of Ebola as a Public Health Emergency of International Concern (PHEIC) occurred in August 2014. To understand this lag a contrast with the case of H1N1, which was declared a PHEIC swiftly after initial detection, is revealing. The decisions surrounding H1N1 were based upon conditions of novelty and geographic spread. For H1N1, global (over)reaction was criticised due to its perceived mildness. In contrast, Ebola is transmitted through close contact (i.e. limited geographic spread), and has been historically persistent within the region (i.e. not 'novel'); the disease therefore did not tr ig g er th e s ame P H EI C g o v er n an ce mechanisms. However, Ebola is underpinned by public fear and perceptions of global contagion. The international reaction to Ebola, and criticisms of that reaction, thereby reflect
conflicting social perceptions of disease and structural disease governance mechanisms. Officially, the declaration of the PHEIC is underpinned by two key factors. The term Public Health Emergency of International Concern is defined in the IHR (2005) as "an extraordinary event" which is determined "to constitute a public health risk to other States through the international spread of disease" and "to potentially require a coordinated international response" (WHO 2008: 9). A PHEIC decision will be based upon the following: the seriousness of the public health impact of the event; the unusual or unexpected nature of the event; the potential for the event to spread internationally, and/or; the risk that restrictions to travel or trade may result because of the event (WHO 2005). These conditions are necessarily broad in scope and provide the WHO Director-General with wide discretionary powers in declaring a PHEIC. Particularly given this definitional breadth, the Ebola outbreak may potentially have been declared a PHEIC early on in this process. However, the historical foundations of the IHR, as well as sites of particular institutional interest, determine the way in which this instrument is mobilised.
The comparison between the declaration of the PHEIC around H1N1 (almost immediately after the confirmation of the novel virus) and the 2014/5 Ebola outbreak (declaring a PHEIC in August 2014, following in initial country reporting to the WHO in March 2014) demonstrated the form and function of the PHEIC, rather than the WHO's 'neglect' of the Ebola outbreak. Healthcare Management Review PAGE Volume 16 061
S
ince the Zika virus was first identified in a monkey in Uganda in 1947, it has rarely caused illness in humans. When people have become infected with the virus, the disease it causes has generally been mild, with small outbreaks occurring in a relatively narrow geographical band around the equator. The situation today is dramatically different. Last year the virus was detected in the Americas, where it is now spreading explosively. Possible links with neurological complications and birth malformations have rapidly changed the risk profile of Zika from a mild threat to one of very serious proportions. The Zika situation is particularly serious because of the potential for further international spread, given the wide geographical distribution of the mosquito vector, the lack of population immunity in newly affected areas, and the absence of vaccines, specific treatments and rapid diagnostic tests. WHO has activated its Emergency Operations incident management system to coordinate the international response to this outbreak. This Strategic Response and Joint Operations Plan aims to provide support to affected countries, build capacity to prevent further outbreaks and control them when they do occur, and to facilitate research that will help us better understand this virus and its effects. Healthcare Management Review PAGE Volume 16 062
“
Possible links with neurological complications and
birth malformations have rapidly changed the risk profile of Zika from a mild threat to one of very serious proportions.
”
Margaret Chan
Director - General World Health Organization
June, 2016
Healthcare Management Review PAGE Volume 16 063
STATUS OF RESPONSE
T
he current Zika virus outbreaks and their possible association with an increase in microcephaly, other congenital malformations, and GBS have caused increasing alarm in countries across the world, particularly in the Americas. Brazil announced a national public health emergency in November 2015. An International Health Regulations (IHR 2005) Emergency Committee met on 01 February 2016, and WHO declared the recent clusters of microcephaly and other neurological disorders in Brazil a Public Health Emergency of International Concern (PHEIC). Colombia, Dominican Republic, Ecuador, El Salvador and Jamaica have all advised women to postpone getting pregnant until more is known about the virus and its rare but potentially serious complications. The US CDC has also issued a level 2 travel warning, which includes recommendations that pregnant women consider postponing travel to any area with ongoing Zika virus transmission. Healthcare Management Review PAGE Volume 16 064
NEED FOR RESPONSE
M
ajor, epidemics of Zika virus disease may occur globally since environments where mosquitoes can live and breed are increasing due to recent trends including climate change, rapid urbanization and globalization. For the Americas, it is anticipated that Zika virus will continue to spread and will likely reach all countries and territories where Aedes aegypti mosquitoes are found. Other Aedes species are believed to be competent vectors for Zika virus and have a much farther geographical reach. For example, Aedes albopictus is found in temperate climates.
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STRATEGIC
RESPONSE RESPONSE Ÿ Engage communities to communicate the risks associated with Zika virus disease and promote protective behaviors, reduce anxiety, address stigma, dispel rumors and cultural misperceptions.
SURVEILLANCE Provide up to date and accurate epidemiological information on Zika virus disease, neurological syndromes and congenital malformations.
Ÿ
Increase efforts to Control the spread of the Aedes and potentially other mosquito species as well as provide access to personal protection measures equipment and supplies. Ÿ
Provide guidance and mitigate the potential impact on women of childbearing age and those who are pregnant, as well as families with children affected by Zika virus.
RESEARCH Investigate the reported increase in incidence of microcephaly and neurological syndromes including their possible association with Zika virus infection.
Ÿ
Ÿ
Fast-track the research and development (R&D) of new products (e.g. diagnostics, vaccines, therapeutics).
The over-arching goal of this strategy is to investigate and respond to the cluster of microcephaly and other neurological complications that could be linked to Zika virus infection, while increasing preventive measures, communicating risks and providing care to those affected.
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STRATEGIC
CONTEXT The current cluster of microcephaly and other neurological complications that could be linked to Zika virus infection affect countries differently – the response strategy will be tailored to meet specific needs.
I
n countries where there is spread of Zika virus and increased congenital malformations / neurological syndromes, a full range of response activities will be applied. These include enhanced surveillance and outbreak response, community engagement, vector control and personal protective measures, care for people and families with potential complications, field investigations and public health research towards better understanding risk and mitigation measures. For countries that are already experiencing the spread of Zika virus or have a documented presence of the Aedes mosquito, the first priority will be to enhance surveillance (for both Zika virus infection and potential complications to establish a baseline) as well as increasing community awareness and engagement in vector control and personal protective measures and understanding the risks associated with the Zika virus. Risk assessment will be conducted to identify areas and populations at high risk of infection and assess the systems and service capacity to respond. For all other countries, risk communications for the public regarding trade and travel will be the main line of engagement, as well as reducing fear and misconceptions of the virus for those that are imported.
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Coordination
Research
Care for those affected
Vector control & personal protection
Community engagement & risk communication
Surveillance
STRATEGIC
IMPLEMENTATION & COORDINATION
Healthcare Management Review PAGE Volume 16 068
Zika
WHO Country Incident Management Team
Members States
Interna onal Incident Management
Int’l NGOs
Global Coordina on Mechanisms
Regional Networks
Regional Coordina on Mechanisms
Local/Int’l NGOs
Na onal Incident Management Teams1
Research Partners
WHO Regional Incident Management Team
UN Agencies
WHO Global Incident Management Team
GOARN
IHR Emergency Commi ee
R&D Partners
A coordinated response of partners across sectors and services at the global, regional and national levels is required.
Country Coordina on Mechanisms
Coordina on Mechanisms
Credit: Healthcare Management Review PAGE Volume 16 069
“
There's a fundamental
distinction between strategy
and operational e ۮectiveness.
If a strategy meets a goal: It's working. If a strategy meets a target: It's a success.
” “
“
”
Good leaders need a positive agenda, not just an agenda of dealing with crisis.
“
“ ”
Billions are wasted on ine ۮective philanthropy. Philanthropy is decades behind business in
Sound strategy starts
applying rigorous thinking to the
with having the right
use of money.
goal
”
”
Healthcare Management Review PAGE Volume 16 070
“
Health care historically has been a very siloed field that's organized around medical specialties - urology, cardiac surgery, and so forth - and around the supply of these specialty services. The patient is the ping-pong ball that moves from service to service.
“
”
Strategy is choice. Strategy
means saying no to certain kinds of things.
“
“
”
poorly a strategy will perform
if the 'wrong' scenario occurs.
The essence of strategy is that you must set limits on what you're trying to accomplish.
Risk is a function of how
”
”
M
ichael Porter is the founder of the modern strategy field and one of the world's most influential thinkers on management and competitiveness. Throughout his career at Harvard Business School, he has brought economic theory and strategy concepts to bear on many of the most challenging problems facing corporations, economies and societies, including health care. Healthcare Management Review PAGE Volume 16 071
OPEN AND TRANSPARENT COMMUNICATION DURING PUBLIC HEALTH EMERGENCIES
E ۮective management of public health emergencies d e ma n d s o p e n a n d tr a n s p a r e n t p u b lic communication. The rationale for transparency has public health, strategic and ethical dimensions. Healthcare Management Review PAGE Volume 16 072
“Information should be communicated in a transparent, accurate and timely manner. SARS had demonstrated the need for better risk communication as a component of outbreak control and a strategy for reducing the health, economic and psychosocial impact of major infectious disease events.”
O
ngoing work to address the challenge of p u b l i c h e a l t h e m e rg e n c i e s h a s increasingly recognized the role that public communication plays in their effective management. Pro-active communication, as one example, allows the public to adopt protective behaviours, facilitates heightened disease surveillance, reduces confusion and allows for a better use of resources, all of which are necessary for an effective response. The severe acute respiratory syndrome (SARS) crisis of 2003 stands as a recent example of the risks and benefits arising from open information associated with a public health threat. Reluctance by authorities to acknowledge and communicate a potential problem in the first stages of the outbreak aided in the quick global spread of the disease.1 In contrast, the eventual break in transmission and international control was rooted in public awareness, community surveillance and behaviour modification – all of which was directly supported by a massive international public health information effort.
risk-related information has been echoed time and again when senior public health representatives meet to discuss public health emergency management. But beyond a rhetorical commitment to transparency, does this translate into substantive action by public health authorities and governments? Unlike many other public health indicators, transparency by public health authorities can be difficult to track. Definitions of transparency may vary, measurement norms are ill-defined and, ultimately, assessments may be subjective. The strong sense among those closely involved, h o w e v e r, i s t h a t t r a n s p a r e n t p u b l i c communication during crisis situations remains an elusive goal. Indeed, interviews conducted with WHO communication staff who were involved in various high profile public health emergencies between 2004 and 2008 reflect several persistent challenges that tend to undermine transparency: v
reluctance to announce a potential health threat and inform an at-risk population of appropriate precautionary measures until all information is scientifically confirmed and formally endorsed;
v
a tendency to withhold information that is potentially damaging to an economic sector – often against the recommendations of public health experts;
v
an emphasis on strict information control within organizations, making constructive engagement of potential partners in coordinated public communication difficult.
The final report of the WHO Global Conference on Severe Acute Respiratory Syndrome held in 2003 in Kuala Lumpur was clear in its conclusions: “Information should be communicated in a transparent, accurate and timely manner. SARS had demonstrated the need for better risk communication as a component of outbreak control and a strategy for reducing the health, economic and psychosocial impact of major infectious disease events.” This emphasis on proactive dissemination of
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The Bunker
Mentality The “bunker mentality” during a crisis results in a less inclusive decision-making process because fewer stakeholders are involved. This in turn results in less transparency and accountability.
B
eyond the immediate public health and broader Strategic advantages of transparency there exists an additional, longer-term rationale, central not only to the management of a particular incident, but also to the capacity of the public health authority to fulfil its ongoing responsibilities – that of preserving and building trust. Recent scholarship in the field of public health ethics and pandemic influenza planning has emphasized the importance of transparency in managing infectious disease outbreaks. In this context, transparency not only provides individuals and communities with information needed to survive an emergency, it is also an element of procedural fairness in decision making and priority setting. It is also a necessary, if not sufficient, condition for accountable decision-making and for the promotion of public trust. The reality is that most measures for managing public health emergencies rely on public compliance for effectiveness. Measures ranging from hand washing to quarantine require public acceptance of their efficacy, as well as acceptance of the ethical rational for cooperating with instructions that may limit individual liberty so as to protect the broader public from harm. This requires that the public
trust not only the information they are receiving, but also the authorities who are the source of this information, and their decision making processes. WHO’s Outbreak communication planning guide 2008 highlights the crucial importance of information transparency in maintaining trust during an emergency but also in building risk communication capacity to support all phases of emergency management. As previously acknowledged, convincing public health authorities and governments to be transparent in their communication in the face of scientific uncertainty can be difficult. Transparency, however, about what is not known is just as important to the promotion of public trust as transparency about what is known. Trust requires honest, open and twoway communication. For countries where public trust in government and public health is low, efforts to build and maintain trust are best made in collaboration with stakeholders before a public health emergency occurs. The “bunker mentality” during a crisis results in a less inclusive decision-making process because fewer stakeholders are involved. This in turn results in less transparency and accountability. Healthcare Management Review PAGE Volume 16 074
support those countries that may suffer economic or health consequences as a result of transparent communication.
As research on SARS in Toronto has shown, in times of uncertainty and crisis, the notion of accountability is more important, not less so. Without it, public trust is diminished and it is difficult to restore. When this happens, the effectiveness of risk communication diminishes and public health emergency management efforts may be significantly less effective. At times, transparency during public health emergencies can result in collateral damage, such as economic loss, to other sectors. While it is beyond the scope of this paper to explore this in detail, this does raise an important ethical issue.
This is especially true for those countries that benefit directly from information about public health emergencies to which they may be vulnerable. Exactly to whom in the global community these reciprocal duties apply, however, and how to discharge such duties remains a question for the international community to debate; reciprocity can take many forms such as financial compensation, human resource support, etc.
Global public health measures and international trade and travel bans can have significant economic impacts on countries that declare public health emergencies. If countries have a moral duty to be transparent, then the global community has reciprocal moral obligations to compensate and
There is little dissent, however, about whether or not reciprocal moral obligations for compensation or assistance exist in situations where collateral damage results from a country’s compliance with the moral and regulatory imperatives for transparency.
WHO’s outbreak
communication planning
guide
2008 highlights the crucial importance of information transparency in maintaining trust during an emergency but also in building risk communication capacity to support all phases of emergency management.
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The Strategic communication of information is a fundamental public health emergency management tool and needs to be recognized as such.
THE LIMITS TO TRANSPARENCY
W
hile the goal of transparency suggests that all relevant information ought to be communicated or made accessible, it has to be recognized there may be legitimate reasons for withholding certain types of information in any public health emergency. For example, the following types of information might justifiably affect how information about risk is communicated: v
Information that jeopardizes national security or an ongoing police investigation;
v
Information that unnecessarily violates the privacy and confidentiality rights of individuals;
v
Information that might lead to undue stigmatization of individuals or groups within society;
v
Information that, if released, might lead to behaviours that would result in increased spread of disease.
When determining who needs what information to achieve public health goals, and the limits to transparency, it is important that the views of relevant stakeholders are solicited and included. This includes people who are most affected by the decisions being taken as well as their proxies, including leaders of representative organizations and news media. Under conditions of scientific uncertainty, it may be difficult to determine what information is needed and by whom, and when to favour other considerations, such as those listed previously, over protecting the public from harm. Given the relationship between transparency and trust, a precautionary approach would support disclosure, rather than withholding information. Healthcare Management Review PAGE Volume 16 076
When determining who needs what information to achieve public health goals, and the limits to transparency, it is important that the views of relevant stakeholders are solicited and included.
If NO, there may be no compelling public health rationale for communicating this information.
Identifying the appropriate level of transparency in a public health emergency information policy In deciding whether or not to release a given piece of information, public health officials can ask three questions:
3. Is there a compelling reason to withhold or modify the information, such as:
1. Is the information needed by at-risk parties to avoid illness, reduce the spread of a disease and/ or help cope with the impact of an event?
i) Could the release of the information compromise national security or an ongoing police investigation?
If YES, the information should be communicated to at-risk and implicated audiences in a timely, accessible and proactive manner.
ii) Will release of the information violate privacy laws and/or existing confidentiality policies or unnecessarily violate personal privacy?
If NO, there may be no compelling public health rationale for communicating this information. 2. Is the information relevant to decisions made by public health authorities or about the emergency management decision-making process itself? If YES, this type of risk management information should be made available to stakeholders and the public.
iii) Could the release of the information result in stigmatization of specific ethnic groups or people in specific geographical regions? If the answer is YES to either (i), (ii) or (iii), modifications to the information may be appropriate. If modifications are not possible, then the information may be justifiably withheld. The core public health imperative of informing those at-risk, however, must always take priority.
Acknowledgement Alison Thompson’s research is supported by the Canadian Program of Research on Ethics in a Pandemic funded by the Canadian Institutes of Health Research. Credit: P O’Malley,a J Rainfordb & A Thompsonc
Healthcare Management Review PAGE Volume 16 077
Ape Bike Mozambique Community Worker USAID Development Healthcare Management Review PAGE Volume 16 078
Strengthening Health Systems in Developing Countries The World Health Organization (WHO) and other inuential bodies have recognised that we can't apply the knowledge we have without a functioning health system in place within a country and international eorts to increase health funding are concentrating on strengthening systems and on re-emphasising the important role of national leadership.
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Strengthening Health Systems in Developing Countries
F
or some years the organisations running the Global Health Initiatives, such as the Global Fund, President's Emergency Fund for AIDS (PEPFAR) and Global Action on Vaccination and Immunization (GAVI), were able to operate by setting up their own project management and delivery systems and ignoring wider health issues in a country. It was the fastest and most efficient way to deliver their services, but this had some downsides including the fact that national leadership and national health systems were often sidelined or even weakened. Thinking has moved on, lessons have been learned and there is now a great deal of activity internationally designed to bring together efforts at strengthening systems with the Global Health Initiatives and creating new ways of working that
strengthen national systems and leadership whilst delivering on the specific goals. The WHO has described system strengthening as being about six elements service delivery, financing, governance, health workforce, information systems and supply management systems. These elements should be coupled with increased and sustainable funding and better use of funding. It should be supported by an implementation process that employs a systematic approach to improvement and quality and create local solutions, designed by local people for the local cultural, social, physical and economic environment.
Health Systems IMPLEMENTING IMPROVEMENT
Don Berwick, President of the Institute for Healthcare Improvement Healthcare Management Review PAGE Volume 16 080
“
The robust health system in Lagos was of great advantage as it made easier to accelerate and speed up actions. However, if Ebola had come in through state with weaker health systems, those with stronger health systems would have to rally round them as a backup system as was experienced in Rivers State.
”
Prof. Abdulsalami Nasidi Fmr. Director, Nigeria Centre for Disease Control
Effective health system strengthening starts with a good understanding of how systems function in health and elsewhere. At its simplest a health system can be viewed as made up of a number of parts such as patients and health workers, facilities and equipment, governance arrangements, processes and subsystems which work together to perform a function. Changing one part by, say, introducing new equipment or providing new information to patients will affect every other part in some way. Successful implementation takes account of these simple insights. Successful implementers need the practical knowledge of how to do so. Don Berwick, the charismatic president of the Institute for Healthcare Improvement (IHI), puts it very simply:
“
Our approach to quality improvement views healthcare as a large, complex system of interdependent actors (patients, care providers, payers, policymakers) and organisations (hospitals, primary care, public health entities, communities). This approach views performance as an inherent property of the system, linked inevitably to its design. Just as the top speed of a car is a property of that car, the waiting times in a healthcare organisation or the maternal death rates in a community are properties of that organisation and that comm unity as they are currently designed. From this viewpoint, all improvement requires change to existing processes. Simply stressing or exhorting current systems to 'do better' will not yield fundamentally di erent results. Changing those systems may.
”
Healthcare Management Review PAGE Volume 16 081
Societal & Cultural Influence Culture, beliefs, traditions and ways of looking at the world all affect what we believe we know and how we act.
v How do people think about their illness? v Do they see it simply as a physical phenomenon
or do they perhaps think that someone or something caused it? v Was it retribution or punishment? v What about the treatment that was on offer? v Do people believe in the medicines available? Healthcare Management Review PAGE Volume 16 082
l
Health need to be seen as part of the wider picture and wider goals. It doesn't stand alone. She saw it as contributing to indigenous success or, in the words of Professor Mason Dune, a public health expert from New Zealand,
l
This could only happen if everything done to improve health was fully aligned with all other aspects of their society such as family relationships and cultural and religious beliefs. Working to tackle a particular disease, for example, wouldn't work well and might even be counter-productive unless all the actions fitted in with other things that were happening.
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Specifically, health professionals need to consider all the different sorts of evidence they were presented with, the social as well as the scientific, and to find ways to evaluate how they can be used to improve health.
These three messages may seem to be very much common sense and as if they should apply to every health system in rich or poor countries. In reality they are not how most health systems operate. Individual clinicians may well try to take account of all of these factors; however, the health systems within which they work in rich countries will, typic ally, focus on the disease or condition and pay little or no attention to the rest of a patient's life.
Cultural and behavioural approaches are needed alongside medical treatment and drugs Healthcare Management Review PAGE Volume 16 083
Socio - Cultural Challenges Associated with
Public Health EMERGENCIES Case study:
EBOLAVIRUS OUTBREAK
IN WEST AFRICA
Dr. Paul C. Abolo President Ecologistics
T
he socio-cultural change process associated with this virus involves critical psychological, emotional and value adjustments - adjustments for prioritizing survival over cultural beliefs and social pressures; adjustments in cultural beliefs regarding rituals for burying the dead; adjustments for social pressures for family support within the care giving environment. This approach demands for stakeholder collaboration in addressing this change and facilitating the change process. The transition for the change must be executed with speed and smoothness to a avoid compliance-hitch with the stipulations of the preventive mechanism for Ebola prevention and containment. Family and friends need to be freed from the psychological and emotional ties to values, and cultures that are at variance with those stipulations; and their full cooperation must be gained. Healthcare Management Review PAGE Volume 16 084
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This situation presents two critical socio -cultural issues: challenges arising from administration of the informal patient-care support provided by family members and relatives, simultaneously with the structure patient-care process; and the administration of respect and honour accorded to the dead by relatives of dead patients.
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With a fatality rate of about 90%, the Ebola virus disease (EVD) is causing a scare in the countries where it has been identified. There is no licensed specific treatment or vaccine available for its cure or containment. That it is transmitted to people from wild animals is not as much issue of concern as the fact that it spreads in human population through human-to-human transmission; and its transmission continues through dead bodies. The Ebola virus is not airborne like the flu but the human-to-human transmission is primarily through direct and indirect contact with bodily fluids such as saliva, urine, faeces and semen. It also includes contacts with contaminated items such as soiled bedding or clothing or needles. Family members and relatives of patients play enormous roles in the care of their patients, which impact on the patient well being. Though there are varying developments of interventions targeted at alleviating the burden of informal care giving in the patient care environment, close family
members still feel obligated to be physically present at the bedside of their sick relative. Cultural expectations increase the complexity of the construct of family support in care giving; making it difficult to agree on a simple definition. What is clear is that the burden of family support in care giving involves psychological state, physical work, emotional and social pressures. In most recovery environments in Nigeria, relatives, family and friends of the sick share the patient-care environment with their sick relatives in hospitals while they are receiving treatment. Some close family members informally check into the hospitals, sleeping on floors or under the beds of their sick relatives, providing physical and emotional support to their ward. Church members visit to pray, lay hands, anoint and provide faithbased support to their sick members and others willing to receive such support in the hospital environment. Healthcare Management Review PAGE Volume 16 085
These activities arc part of the Nigerian cultural support system and entrenched as behavioral expectation from family and friends of the sick. Reverence for the dead and burial rites vary within the Nigerian culture but generally, cultural protocols for handling the dead include purification of the body, laying-in-state and other rituals that encourage contact with the dead-body before it is finally buried. Four major classifications of cultural approach to death include rites before death; preparation of body for burial; disposal of body; and post-burial rites. Rites before death include confessions, recitals and last sacrament (for some religious groups). Bathing and dressing the corpse, laying in state and vigil keeping are also part of the burial rites. Fear of failure to perform culturally approved funeral rites is based on the belief that there arc psychological and unpleasant consequences to the dead and the survivors. Primarily, protection against contamination is to avoid contact with bodily fluids of someone suffering from Ebola or already deceased from it. It is recommended to wash hands with soap and water or with alcohol-based sanitizer when at risk
of such contact. The use of gloves, mask and long protective gowns are recommended when coming within 1 metre of an infected patient; and anyone suspected of contacting the virus should be isolated. Given the parameters of protection against contamination of the Ebola virus; and government overarching intervention to ensure that the virus is contained, socio-cultural challenges are eminent. This heralds the beginning of new concepts, beliefs, values and general attitudes towards dealing with the sick, the dying and the dead. An inclusive participatory approach to the sociocultural challenges associated with the virus is recommended. Family members, relatives, friends and religious support groups arc to be thought to rethink their approach to informal support in care giving. The exigency of this inclusive participatory approach is strengthened by the experience from Sierra Leone, where surveillance officers were attacked and there were rumours that the disease does not exist; and that medical officers were either not properly diagnosing the disease or working for organ donors. Healthcare Management Review PAGE Volume 16 086
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This was not the work of health ministry alone. This matter involved; health, cultural & social issue and many more. The ministries of Information, Culture & Tourism, Environment, Aviation & Interior Ministry were the key stakeholders in the collaborative framework to successfully manage this change.
” In Sierra Leone’s Kenema Government Hospital a crowd was demanding the release of family members admitted to Ebola treatment Centre. About 57 patients were reported missing in the country fleeing or avoiding treatment. The socio-cultural change process associated with this virus involves critical psychological, emotional and value adjustments - adjustments for prioritizing survival over cultural beliefs and social pressures; adjustments in cultural beliefs regarding rituals for burying the dead; adjustments for social pressures for family support within the care giving environment. This approach demands for stakeholder collaboration in addressing this change and facilitating the change process. The transition for the change must be executed with speed and smoothness to avoid compliance-hitch with the stipulations of the preventive mechanism for Ebola prevention and containment. Family and friends need to be freed from the psychological and emotional ties to values, and cultures that arc at variance with those stipulations; and their full cooperation must be gained.
This is not the work of health ministry alone. This matter involves health, cultural and social issues and many more. The ministries of Information, Culture & Tourism, Environment, Aviation and Interior Ministry arc key stakeholders in the collaborative framework to manage this change. Government is important both as a stakeholder and as an institution with power to institutionalize and legitimize collaborations. A success story is the experience in Central Africa where anthropologists were part of the stakeholdcrs included in the response team to facilitate engagement of local knowledge in strengthening control measures and minimizing fear. Moreover, government has the resources such as expertise, infrastructure, networks and technical to promote exchange of knowledge and experience to sustain collaborative environment. Social workers, communication and information professionals, schools and religious institutions are essential for this stakeholder collaboration in order to facilitate the social negotiations, emergent shared understanding; and development of trust and mutual understanding to propel the change. Healthcare Management Review PAGE Volume 16 087
A
s this photograph from about 1930 shows, anyone arriving at the Immigration Station on New York's Ellis Island who appeared to have a communicable disease was immediately segregated. If diagnosis conďŹ rmed the suspicion, that person was
quarantined in a hospital until he or she was no longer contagious. Credit: Courtesy of National Library of Medicine.
Healthcare Management Review PAGE Volume 16 088
The Contagion Theory
& THE ORIGIN OF QUARANTINE The practice of quarantine, as we know it, began during the 14th century in an effort to protect coastal cities from plague epidemics. Ships arriving in Venice from infected ports were required to sit at anchor for 40 days before landing. This practice, called quarantine, was derived from the Italian words quaranta giorni which mean 40 days.
T
he practice of quarantine—the separation of the diseased from the healthy—has been around a long time. As early as the writing of the Old Testament, for instance, rules existed for isolating lepers. It wasn't until the Black Death of the 14th century, however, that Venice established the first formal system of quarantine, requiring ships to lay at anchor for 40 days before landing. ("Quarantine" comes from the Latin for forty.)
The Venetian model held sway until the discovery in the late 1800s that germs cause disease, after which health officials began tailoring quarantines with individual microbes in mind. In the mid-20th century, the advent of antibiotics and routine vaccinations made large-scale quarantines a thing of the past, but today bioterrorism and newly emergent diseases like SARS threaten to resurrect the age-old custom, potentially on the scale of entire cities. Healthcare Management Review PAGE Volume 16 089
" he kind of 'assisted emigrant' we can not afford to admit."So reads the caption to this 1883 Puck drawing, T which shows members of the New York Board of Health wielding a bottle of carbolic acid, a disinfectant, in their attempts to keep cholera at bay.� credit: Š Corbis Images
Healthcare Management Review PAGE Volume 16 090
For quarantine to work, you should make people comfortable, so it’s in their best interest to participate. Past outbreaks have shown that the more content people are in quarantine, the less likely they are to attempt to escape it.
Healthcare Management Review PAGE Volume 16 091
n modern times, the yellow flag depicted in this cartoon was used to announce that a quarantine against yellow fever was in effect. Although the use of flags to signal a quarantine is a recent phenomenon, societies have, since ancient times, used strategies to isolate persons with disease from unaffected persons. Some of the earliest references to these strategies are found in the books of the Old Testament. In Leviticus, chapter 13, it is stated that anyone with leprosy remains unclean as long as they have the disease and that they must live outside the camp away from others [Lev. 13.46]. Numbers, chapter 5, prescribes a duty to expel from camp everyone with a dreaded skin disease or bodily
discharge [Num. 5.2]. However, nowhere in these early accounts does the term “quarantine” appear. How, then, did the term become part of the modern lexicon? The answer to this question can be found in the history of the black death in Europe. Beginning in middle of the 14th century, repeated waves of plague swept across Europe. After arriving in southern Europe in 1347, plague spread rapidly, reaching England, Germany, and Russia by 1350. During this time, it is estimated that one-third of Europe's population died. The profound impact of the epidemic led to the institution of extreme infection-control measures. For example, in 1374, Viscount Bernabo of Reggio, Italy, declared that every person with plague be taken out of the city Healthcare Management Review PAGE Volume 16 092
From
Trentino to Quarantino, ...a term derived from the Italian word quaranta, which means “forty” into the fields, there to die or to recover. A similar strategy was used in the busy Mediterranean seaport of Ragusa (modern Dubrovnik, Croatia). After a visitation of the black death, the city's chief physician, Jacob of Padua, advised establishing a place outside the city walls for treatment of ill townspeople and outsiders who came to town seeking a cure. The impetus for these recommendations was an early contagion theory, which promoted separation of healthy persons from those who were sick. Unfortunately, these measures proved to be only modestly effective and prompted the Great Council of the City to pursue more radical steps to prevent spread of the epidemic. In 1377, the Great Council passed a law establishing a trentino, or thirty-day isolation period. The 4 tenets of this law were as follows: (1) that citizens or visitors from plague-endemic areas would not be admitted into Ragusa until they had first remained in isolation for 1 month; (2) that no person from Ragusa was permitted go to the isolation area, under penalty of remaining there for 30 days; (3) that persons not assigned by the Great Council to care for those being quarantined were not permitted to bring food to isolated persons, under penalty of remaining with them for 1 month; and (4) that whoever did not observe these regulations would be
fined and subjected to isolation for 1 month. During the next 80 years, similar laws were introduced in Marseilles, Venice, Pisa, and Genoa. Moreover, during this time the isolation period was extended from 30 days to 40 days, thus changing the name trentino to quarantino, a term derived from the Italian word quaranta, which means “forty”. The precise rationale for changing the isolation period from 30 days to 40 days is not known. Some authors suggest that it was changed because the shorter period was insufficient to prevent disease spread. Others believe that the change was related to the Christian observance of Lent, a 40-day period of spiritual purification. Still others believe that the 40day period was adopted to reflect the duration of other biblical events, such as the great flood, Moses' stay on Mt. Sinai. Perhaps the imposition of 40 days of isolation was derived from the ancient Greek doctrine of “critical days,” which held that contagious disease will develop within 40 days after exposure. Although the underlying rationale for changing the duration of isolation may never be known, the fundamental concept embodied in the quarantino has survived and is the basis for the modern practice of quarantine. Credit: Dr. Paul S. Sehdev Healthcare Management Review PAGE Volume 16 093
Healthcare Management Review PAGE Volume 16 094
THE CIRCLES OF RING
Healthcare Management Review PAGE Volume 16 095
A fire-brigade approach is clearly not appropriate. ...a sustained, coherent policy is vital to preventing pandemics. Nathan Wolfe, Founder/CEO Metabiota
Ebola is not the rst virus to threaten the world, and it won’t be the last. Stopping the epidemic was vital, but the world cannot afford to go to sleep after it was stopped. Unless we prepare for the nest epidemic, we will nd ourselves forever nailing down outbreaks just in time to see the nest ones pop up. Healthcare Management Review PAGE Volume 16 096
cases. In regions that are susceptible to pandemics. It will be crucial in the future to coordinate the efforts of different branches of government. A model for this is Cameroon, where the government has a national emergency committee for pandemics and epidemics and a national program for zoonosis prevention and control, both aimed at infectious agents including Ebola and others that move from animals to humans. These organizations-the product of efforts begun six years ago-help to integrate the monitoring of animal and human diseases, and have advocated in 2014 for dedicated training and early shipment of critical equipment in anticipation of the potential regional spread of Ebola. The Cameroon emergency committee has also helped coordinate efforts in 2014 equipment in anticipation of the potential regional spread of Ebola. The Cameroon emergency committee has also helped coordinate efforts in 2014 to fight against cholera and polio. Even when national and regional systems are in place, there will be times when the developed world cavalry will need to rush to the rescue as it is in 2014, but ultimately there are more important ways that wealthy nations can assist. For examples, the disease surveillance and diagnostic systems in Cameroon and Congo have been facilitated for more than a decade by financial and technical support from US governmental agencies, groups within the defence department and United States agency for international development. (USAID) implemented in part by Metabiota. More work of this kind is needed, and it is vital that other countries get more involved in this kind of effort. Today, the length of me needed for foreign aid to reach its des na on as well as the ability of countries to rapidly and effec vely use assistance pose real problems in need of solu ons. Innova ve financial tools such as parametric catastrophe bonds, an insurance – like instrument – could at least improve the speed of funding. Payment of these bonds is triggered based on the measurement of an actual hazard, such as wind speed in the case of a hurricane, and so they are paid immediately rather than wai ng for a claim based on damages. In the case of outbreaks, the bonds would require more standardized and widely distributed measures of early detec on, but since such measures are needed anyway, the development of such financial instruments and the push for improved surveillance systems could work hand in hand. Credit: Nathan Wolfe Founder/CEO Metabiota, which develops systems for monitoring and managing disease spread.
Healthcare Management Review PAGE Volume 16 097
Benjamin David (Ben) Paul, A Professor of Anthropology and leading medical anthropologist
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If you wish to help a community improve its health, you must learn to think like the people of the community. Before asking a group of people to assume new health habits, it is wise to ascertain the existing habits, how these habits are linked to one another, what functions they perform, and what they mean to those who practice them.
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All the aspects of habits that Paul draws attention to are important. Our beliefs and habits don't exist in isolation from everything else about us. Improving health is not as simple as just changing one belief or one habit. Healthcare Management Review PAGE Volume 16 098
Vaccination is Free, Safe & Saves Life! NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY (NPHCDA) Plot 681/682, Port Harcourt Crescent, Off Gimbiya Street, Area 11, P.M.B. 387, Garki, Abuja. FCT Website: www.nphcda.gov.ng Email: info@nphcda.gov.ng
NPHCDA
FEDERAL MINISTRY OF HEATH