Let's think prevention and mitigation
AS I followed the public debate on the current chikungunya outbreak in Jamaica, I was disappointed, though not surprised, that the majority of discussions on radio as well as articles and letters to newspapers focused on the emergency response, and to a lesser extent on preparedness, rather than on the possibilities for prevention and mitigation.
Prevention refers to avoiding the impact of hazards. For example, locating houses outside the flood plain of a river will prevent the houses from being flooded when that river is in spate.
Mitigation refers to reducing the impact of a hazard. So, to use the example of houses and flooding, the impact of flooding can be reduced by raising the floor level of the living space of houses so that water does not enter the house although ground level may be flooded.
Why are prevention and mitigation important? Apart from saving lives and property, it is a well-established fact in disaster risk management that the cost of prevention and mitigation is less than the cost of repairs and reconstruction. Much of the data on cost-effectiveness of prevention and mitigation comes from the study of natural hazards. Geoscience Australia, for example, conservatively estimates that, in general, including mitigation in design of structures will result in 15 per cent savings in damage costs. An analysis of 67 projects in Australia concluded that for every dollar spent on flood mitigation there was a saving of $2.10 in damage and reconstruction costs. An Organisation of American States (OAS) case study done in the Caribbean following hurricane damage to two facilities concluded that the cost of including mitigation measures in the original design would have been two to four times less than the cost of reconstruction. The authors note that this calculation includes only figures for direct costs -- the savings would be greater if indirect costs, such as loss of use, for example, were included .
But it is not only in the area of infrastructure and buildings that prevention and mitigation make sense. The chairman and CEO of Johnson and Johnson is quoted by the Centers for Disease Control of the USA as saying that every dollar spent by his company on preventive health care results in US$4.00 of savings in health care costs. A study on dengue in Venezuela concluded that, for every US$0.46 spent on control, US$1.00 was saved in economic costs. The figures from analyses of natural and medical-related hazards clearly illustrate the benefits of ex ante or proactive approaches to hazard management.
So to return to Jamaica and its battle with CHIKV, I maintain that much illness and suffering could have been avoided, and much money saved, if the country, led by the Government -- and here I mean all arms of government -- had adopted an ex ante approach by emphasising prevention and mitigation. The fact that CHIKV is spread by mosquitoes means that eliminating the breeding sites of mosquitoes, and by extension the mosquitoes, will eliminate the means of transmission of the disease. It is unlikely that 100 per cent elimination will be achieved, but certainly a preventive approach would have reduced the mosquito population and the spread and impact of CHIKV.
So, what could have been done differently for an ex ante approach? In addition to any internal preparations which I assume would have been done by the Ministry of Health, I suggest that the public campaign should have started before the onset of the rainy season with:
1. Identification and mapping of high, medium and low-risk communities. In the context of restricted resources, high-risk areas would be targeted for initial action.
2. Mobilising the country. A ready-made source of already employed (and therefore already paid) personnel exists in the Jamaica Emergency Employment Programme (JEEP). JEEP personnel could have been used as the core of community teams, supplemented by volunteers from community disaster management groups and other community-based organisations. These teams would go through communities to identify breeding sites, destroy those which they could, and report remaining sites to the public health departments for treatment. They would also have distributed information, flyers and posters, for example.
3. Organise community clean-ups. Labour Day would have been a good focus for this; all members of parliament and councillors would be expected to support and participate in these clean-up activities.
4. Initiate a multi-media awareness and education campaign involving printed material, audio-visual material such as cartoons and videos, and verbal communication via radio and television interviews.
5. Saturate the country with information. The importance of information cannot be overemphasised. A highly informed population is the best defence for any hazard. Appropriate information provided at the right time empowers the population to act correctly and fosters a sense of confidence in the authorities. Information given on clothing, medication, insect repellent, and so forth was very useful and, based on anecdotal evidence, was followed. However, had other types of information been given before onset of the outbreak, much of the acrimonious public debate could have been avoided. Valuable media time and column inches could instead have been spent on providing and reinforcing accurate and useful information; information such as exactly how the disease is transmitted, explanation of the protocols used in measuring progress of the outbreak, and the meaning of terms -- confirmed cases vs suspected cases vs reported cases. Outlines of the preparedness, response and recovery plans which would be used in the event of an outbreak could also be communicated to develop public confidence in the country's preparedness.
Rumour control is important in the management of any crisis. I keep hearing from all sectors of society that the spread of the disease is so rapid that it cannot be due (solely) to mosquitoes. There are some truly wild stories on the origins of the outbreak making the rounds. These rumours could have been prevented or reduced if models which can predict the progress of the outbreak had been employed and the results of the modelling presented to the public. Having a forecast upfront of the likely rate and pattern of spread, and likely numbers of persons to be affected, not only allows planning, but also builds credibility. Belatedly we are hearing forecasts that between 30 and 60 or 70 per cent of the population could be affected. Imagine how useful that information would have been six months ago. Businesses and schools could have put in place plans for reduced numbers of staff. Schools could also have planned for the care of children who fall ill at school. Importantly, the speculation on why so many people are becoming ill so quickly and charges of a cover-up would have been forestalled.
Once cases were detected, regular updates could have been given, containing information such as communities which have been impacted, numbers of reported cases, numbers of confirmed cases, an estimate of the number of people likely to have been impacted, health facilities with heaviest caseloads, impact on the medical community, schedules for fogging, and other response activities.
In any crisis communication campaign the messenger is as important as the message. Trust and credibility are critical elements in the acceptance of messages by the public. Careful consideration should be given as to who delivers what part of the message. A unified message is also important. It would have been ideal if Government and Opposition could have spoken with the same voice; MPs and councillors of whatever party colour reinforcing the messages of the lead agency -- the Ministry of Health.
The financial situation of the Government is an inescapable, but not insurmountable reality. Some costs of the communication campaign could have been defrayed by partnerships with businesses through advertising. Other businesses may well have contributed material for community clean-ups. In any event, had the ex ante approach been taken, the money being spent would have derived greater benefits.
The public discourse surrounding CHIKV suggests that the public is not confident in the ability of the authorities to manage a more serious threat. Events such as the CHIKV outbreak provide the opportunity for rehearsal and learning. Standard practice calls for a review of the event by the authorities, and improvement of plans and capabilities based on the lessons from the analysis. Let us take the opportunity; the next outbreak may be much more dangerous.
Dr Barbara Carby is the director of the Disaster Risk Reduction Centre at the University of the West Indies. Comments: firstname.lastname@example.org