(Photo by Jiří Humpolíček, CC BY-SA 2.5)
Scabies, lice, and bedbugs don’t care if we’re in the midst of a COVID-19 pandemic.
But some of the strategies we’ve been using to prevent COVID-19 transmission in shelter are relevant to these other, longstanding public health threats.
In a previous article, I described how Bethesda Project’s Church Shelter Program has been using a form of community-based surveillance (CBS) in response to COVID-19. Recently, I took a closer look at CBS initiatives in Cuba, Uganda, and Ecuador to learn how other communities in resource-limited settings creatively and effectively respond to disease outbreaks. Then, using some of their best practices, I designed a community-based model of pest prevention for use in our shelter.
In this article, I’ll share what I learned and say more about this model (which is flexible enough to be used in other shelters or congregate settings).
The 1978 Alma-Ata declaration of the World Health Organization states that “governments have a responsibility for the health of their people”. I’ve written before about how the Church Shelter Program operates with a “governance” rather than a “management” paradigm, so we hold ourselves accountable to this statement. What it means to us is that shelter staff have a responsibility to proactively protect our guests from diseases associated with shelter settings.
In the context of pests such as scabies, lice and bed bugs, it means that we proactively work to prevent outbreaks and swiftly address them if they do occur. To ignore such an outbreak, or claim that the affected guests are responsible for dealing with it on their own, would be a violation of their right to health and of our responsibility as shelter providers.
At the same time, it also matters to give members of the shelter community the opportunity to design and participate in public health measures intended to benefit them.
The effectiveness of community participatory involvement in public health initiatives
Cuba happens to have a long history of community involvement in public health efforts, as described by Dr. Linda M. Whiteford and Dr. Laurence G. Branch in Primary Health Care in Cuba: The Other Revolution (2009). For example, in the 1960s the Cuban government successfully trained ordinary citizens to administer vaccines for measles, chicken pox, and polio, which enabled widespread vaccination campaigns to rapidly occur across the island.
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Following an outbreak of dengue fever in the early 1980s, Cuba took a similar approach. Neighborhood brigades composed of ordinary citizens were trained to recognize and remove the plants that are hosts for the Aedes egypti mosquito (the vector responsible for transmitting dengue fever to humans). The brigades patrolled their communities — even going into their neighbors’ yards — to remove plants, pick up trash, spray insecticide, and eliminate standing water that could serve as breeding grounds for mosquitos. Within four months, Cuba had ended the outbreak.
This approach also proved valuable during the emergence of Zika virus. In a 2017 article published in The American Journal of Tropical Medicine and Hygiene, researchers noted that at a time when Brazil had 200,465 cases of Zika, Colombia had 95,793, Venezuela had 58,591, Martinique had 36,445, and Honduras had 31,468, Cuba had just 3 cases. They attribute Cuba’s success with limiting Zika transmission to the country’s culture of active community participation in mosquito control efforts.
In a 2018 article in the journal Nature, Sara Reardon describes how even before any cases of Zika were detected on the island, Cuba dispatched soldiers to begin spraying homes with insecticide, health workers conducted surveillance for mosquito larvae near water sources, and medical officials went door-to-door to conduct symptom screenings. And yet, Reardon is also clear that Cuba’s success here was “largely because of such intensive measures by ordinary citizens,” people who did not have advanced or medical degrees.
Uganda took a similar approach in its Guinea Worm Eradication Program, established 1991 as a collaboration between the Ugandan Ministry of Health, The Carter Center, and UNICEF. Guinea worm disease is a parasitic infection that is transmitted when humans consume water contaminated with guinea worm larvae. In 1991, at the start of the eradication effort, Uganda registered over 126,000 cases. By 2004, the disease had been eliminated within its borders.
A 2006 article published in the American Journal of Tropical Medicine and Hygiene describes one community-based approach that helped achieve this outcome: Elderly men in local communities were recruited to act as “pond caretakers.” These were typically men who were respected by their peers and who were too old to engage in farm work, but who were fully capable of monitoring the community’s water supply to ensure it was not contaminated with guinea worm larvae.
The pond caretakers gathered water for visitors, provided filter straws to individuals who came to drink from the ponds directly, and created fences or barriers around the ponds.
Clearly, community involvement makes a difference — but is it actually necessary?
Yes, it is.
The Cuban Minister of Health may know the species of plants that are hosts for the Aedes egypti mosquito, but she doesn’t know whether or not those plants are growing in your yard, let alone where in the yard — but you do, and your neighbor certainly does. The Ugandan Minister of Health may know that guinea worm disease is transmitted by water, but he doesn’t know where every single pond in your community is — but you do, and your neighbors certainly do as well.
Specialists, experts, and clinicians have an important role to play in designing and coordinating public health responses, but effective on-the-ground implementation depends on communities themselves.
Dr. Whiteford explores this point in depth in her book Community Participatory Involvement (2015), which describes lessons learned from a community-based intervention to contain a cholera epidemic in rural Ecuador.
Local experiences and knowledge were crucial to the success of the intervention because while the methods to address cholera may be simple — i.e. boiling water and handwashing — their implementation was not.
In certain parts of Ecuador at the time, many households did not have plumbing. Boiling water to purify it meant having to get extra wood or charcoal, which households could not afford. Asking people to wash their hands more often meant having to manually transport more water from the river to the household.
Meanwhile, the use of the soap created a new set of problems. For example, like many people in water-scarce communities, people in this region used one container of water for cooking, rising dishes, washing hands, and then finally feeding livestock. However, the soap altered the taste of the water and the livestock refused to drink it, which threatened the families’ livelihood.
It was only by including community members in the response to cholera that researchers were able to effectively navigate these obstacles.
The Church Shelter Program’s community-based pest prevention model
With the insights and experiences from Cuba, Uganda and Ecuador in mind, here is what my model of community-based pest prevention in emergency shelter looks like.
Shelter guests will be the first to recognize or suspect that an outbreak of pests — let’s say, bedbugs—is occurring because they are the ones who sleep in the shelter. This also means they are well-positioned to report suspected outbreaks early on.
Within the shelter community, peers have unique levels of social capital, legitimacy, and trust amongst each other. In addition, they also have local knowledge that is important for addressing bed bugs. For example, they know which mattress covers have tears, which sleeping mats are beginning to fray, where the cracks in the walls are, which person is hiding stashes of clutter, which guys have bites on their arms, etc.
These are crucial details that mean the difference between containing a bedbug outbreak or not.
To make use of the social capital, insights, and knowledge of the shelter community, we need to create a culture of community-based pest prevention. To do that, shelter staff and guests collaborate to select a small subset of guests who are recognized for consistently stepping up to help with cleaning, housekeeping, etc. These are individuals who are attentive, observant, respected by their peers, and who place a high value on cleanliness.
These individuals are then invited to act as “pest monitors” who will inspect the shelter’s beds, cots, or sleeping mats every day for signs of bedbugs. The monitors will be trained in the basic biology of bedbugs, indicators of infestations, and risk factors for infestation.
Shelter staff and guests will then collaborate to decide on a range of early intervention measures that the monitors will have the autonomy to apply (i.e. laundering bedding and clothes, treating furniture with a portable steam cleaner; vacuuming bed seams, etc.).
As I wrote in a previous column, the long-term solution to disease outbreaks in shelter is to ensure that there is no need for shelters in the first place. Providing people with safe, adequate, affordable housing, perhaps with support services, is the best way to reduce their risk of contracting a contagious disease in congregate settings.
But, while we do have shelters and while people are residing in them, we have a responsibility to keep them clean and safe. One of the most powerful and effective ways we can do that is to involve shelter guests themselves in the public health interventions designed for these settings.
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