Communities and COVID-19: Perspectives from a Health Promotion Expert
By Glenn Laverack, PhD
The current COVID-19 coronavirus pandemic is the largest since the “Spanish flu” 100 years ago and possibly the largest public health intervention ever. Until an effective vaccine or treatment becomes available, the coronavirus can only be stopped by giving people greater control over their lives, individually and collectively, and globally. The first enemy in an infectious disease epidemic is time. Most governments have reacted quickly to enforce containment measures and use communication and moral persuasion to influence individual risk behaviors such as social distancing. The response to the epidemic has been driven by data, tough political decisions and, to some extent, what works in public health. In truth, we have underestimated the COVID-19 which has overwhelmed health systems and pushed hard-working health professionals to their limits. The pressure revealed gaps in risk communication, community participation, protective gear, intensive care and testing.
In an infectious disease outbreak, the first enemy is time
COVID-19 is “Disease X”, a relatively unknown pathogen leading to a pandemic, originating from a zoonotic virus and with a high infection rate. Similar outbreaks include Severe Acute Respiratory Syndrome (SARS) in 2002 and Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in 2018. All have occurred in Asia and have resulted from the sale and preparation of ” wild animals in unregulated and / or unsanitary conditions, creating an opportunity for the transmission of a virus (Laverack, 2018). Why have international public health authorities continued to allow these conditions to persist? The real surprise about COVID-19 has been the rapid spread and severity, leaving us unable to predict how it will develop in societies. The nature of COVID-19 has created a sense of fear and a need for urgent and unprecedented action. Some decisions will leave behind lasting human and economic costs that will be deeply felt in society. Next time, if we can choose, will we want to use such drastic measures to stop the epidemic or will we choose to use a more nuanced public health response?
COVID-19 will leave behind lasting human and economic costs that will be deeply felt
There is no single model of communication and community engagement during a pandemic. Each country must develop its own approach according to the strengths and weaknesses of its socio-cultural, political, economic, infrastructural and historical context. Some socio-cultural contexts, for example, can tolerate long-term confinements while others will resist, especially as life becomes increasingly difficult. What works in some countries should be treated with caution as it may not be possible to replicate it in other countries.
Each country should develop its own approach for community engagement and communication based on its strengths and weaknesses.
Governments have not widely used community-centered approaches, although there is no excuse for not actively involving people in an outbreak response. Emphasis was placed on individual compliance and, in particular, on strict population control measures. Health promotion plays an important role in changing behaviors such as hand washing as well as in strengthening community participation. Communities can monitor the daily movements of people in a given location such as a neighborhood, village or across borders. Community self-management can ensure that containment requirements are met by helping others understand the consequences of their actions and report violations or suspected cases (Laverack & Manoncourt, 2015). Closures are more likely to be successful if people are allowed to take more control and responsibility and are motivated by a sense of selflessness, rather than by imposing penalties for violations. During the Ebola virus disease outbreak in West Africa, non-compliant behaviors were observed during closures, sometimes exacerbated by poor service delivery, poor information flow and lack of government support vulnerable people. The situation worsened as closures continued, often in specific localities, and attempts by security forces to coerce communities into compliance were counterproductive and led to mistrust and escalation of resistance. (Laverack, 2018, chapter 9).
There is no excuse not to actively involve communities in an outbreak response
The protection of vulnerable people in society was not fully addressed during the pandemic, including refugees and migrants, the socially isolated, the homeless, the elderly in residence, the mentally ill and women and children exposed to domestic violence. Vulnerable people who suffer from inequalities will be most affected by COVID-19. Likewise, countries with the greatest inequalities will potentially be more affected by COVID-19. Overcrowded and slum conditions with insufficient water supply and poor sanitation and high population density deny the possibility of good hygiene and social distancing. Local administrative and enforcement authorities, health agencies and communities must work together to deal with an epidemic, but little progress has been made on how to reach slum communities, without a clear strategy for cooperation, engagement and communication (Laverack, 2018a).
Vulnerable people and victims of inequalities will be hit hardest by COVID-19
The mobilization of volunteers during the pandemic by nongovernmental agencies, universities and community organizations provided much needed support, for example, providing essential items, making face masks and screening vulnerable people. The usual social support network of friends and family is severed during a lockdown, and residents of buildings, neighborhoods and villages have had to help each other. However, altruism was not universal, some localities being better organized and more united than others. Advance planning and the support of community organizations and voluntary support networks by the government is a good practice as it provides a link between those affected by COVID-19 and services. However, support must be systematic to ensure that all vulnerable people are helped during an outbreak.
Governments should use a systematic approach to help vulnerable people during an epidemic
Health promotion activities must be maintained during a pandemic to support a healthy physical, mental and spiritual lifestyle, especially during lockdown. Places of worship have been closed, despite the ease of social distancing, and people lead stressful, sedentary lives. Promoting a healthy lifestyle would include reinforced messages about healthy eating and activity levels, stress reduction, and the safe use of alcohol and tobacco in the home. It is also important that information is made available on ongoing prevention programs such as immunization and testing and on online and telephone services to deal with stress and domestic violence. In West Africa, untreated malaria cases and unvaccinated children against diseases such as measles are estimated to have killed more people than the true outbreak of Ebola virus disease (Roberts, 2015) . Health promotion messages can also help counter misinformation and rumors, reduce stigma, and reduce public mistrust of public health services.
Health promotion activities should be maintained during confinement to support a healthy physical, mental and spiritual lifestyle
Communities must be an integral part of an outbreak response, including during the exit strategy from lockdowns. Everyone must be actively involved for the response to be successful. Community engagement and communication are two important approaches that can give people more control over their lives and health. However, communities and community organizations must be provided with government resources to strengthen social networks and local capacity to cope with an epidemic. Failure to do so is debatable and the reasons for not actively involving communities in a response to the epidemic should be assessed, including any assumptions about weak local skills and the lack of trust between government and civil society.
Glenn Laverack, Visiting Professor, Department of Sociology and Social Research, University of Trento, Italy
Laverack, G. (2018) Health promotion in epidemics and health emergencies. Boca Raton, Florida. CRC Press. Taylor & Francis Group.
Laverack, G. (2018a) Blacker than Black: Failing to reach slum communities during epidemics. Infect Dis Immunity. Vol 1 (1): 4-6.
Laverack, G. and Manoncourt, E. (2015) Key experiences of community engagement and social mobilization in the Ebola response. Global health promotion. 1757-9759. Vol (0): 1-4.
Roberts, L. (2015). As Ebola subsides, a new threat. Science 347 (6227): 1189.