Dealing with an epidemic: preparing for the worst and hoping for the best.
This article looks at the risk for Small Island Developing States when faced with pandemics — the case of Mauritius.
Small island developing states (SIDS) like Mauritius have unique characteristics. They are a group of 58 island nations geographically dispersed but facing similar social and environmental challenges in view of their population size and fragile ecosystem. In addition, some tend to be particularly at risk from rising sea level, as in the case of Maldives and the Marshall Islands where over 95% of land lies within 5 meters above sea level.
This year marks the 100th anniversary of the 1918–1919 global influenza pandemic, which infected 500 million people and claimed more than 50 million lives. Since 1918, there have been further pandemics and while today influenza remains a global threat, numerous viruses which were previously only heard of on the big screen were all of a sudden, a reality we had to fight. The 2014 Ebola crisis in Africa (DRC, Sierra Leone and Liberia) was followed by Zika, Yellow Fever (Brazil) and the Nipah virus (South India). What has changed surely is that the world woke up to the impact of globalization on outbreaks. After all, if the world is now smaller for human beings it has also become smaller for viruses. The panic that followed brought massive political mobilization. The UN Security Council declared Ebola a threat to international peace and security, flights were cancelled, mining operations were slowed or stopped, and trade slowed to a trickle. This did not prevent the deaths of some 11,000 and major economic loss.
The short-term (2014) impact of Ebola on output was estimated to be 2.1 percentage points of GDP gross domestic product (GDP) in Guinea; 3.4 pp of GDP in and 3.3 pp of GDP in Sierra Leone with a combined forgone output for these three countries corresponding to US$359 million in 2013 prices. By 2015, the World Bank had estimated a $2.2 billion GDP loss by the three countries. WHO and other international organizations have stressed the importance of being able to contain an outbreak but key to this as was revealed the recent Nipah outbreak are: the level of education of the population, effectiveness of the health institutions to distribute medicines, vaccines and treat patients, deployment of healthcare personnel, the ability to quarantine potential carriers and patients; and effective decision making process. If these are the critical success factors are we ready to deal with an epidemic?
Mauritius, as a SIDS, has several strong advantages — certainly our educated population is behind our success in eradicating malaria, controlling TB and HIV. And the recent plague and measles outbreaks triggered a positive response from our healthcare system. But these are diseases which as Donald Rumsfeld would frame it are the known knowns. Cholera, Malaria, Dengue and Smallpox have been studied and treated for centuries. The first epidemic of Cholera on the island was reported in 1775 and wiped out a population equivalent to that of Port-Louis whilst Malarial fever made its first appearance in 1865. The threat is not likely to come from our “known known’s” but rather from the known unknowns. As Robin Cook puts it in his medical thriller “the worst thing about disease is the uncertainty. Humans are capable of adapting to anything as long as they know”.
In an increasingly connected world and with more than a million tourists visiting every year, is Mauritius ready to deal with an outbreak? Certainly, we have strong pillars in the existing healthcare infrastructure. The State of Kerala is over 15,000 sq miles with a population of 34.8 million. Its leaders pointed out that to contain the Nipah virus, which has no vaccine as of date and leaves only 25% survival rate, they quarantined the patients. Given our population density, should an outbreak occur we might have to quarantine the whole country. Quarantine on an island is seemingly an easier thing to do than in the case of DRC but the economic impact will be disastrous — no flights, no trade and no imports. For a country heavily reliant on tourism, imports including food, and services, this is a hellish scenario.
When a crisis hits any country, the population will default to government for leadership. The Prime Minister’s Office no doubt has a crisis protocol in place for disaster management that becomes activated with cyclones or other natural calamities. We have yet to test this disaster management team in times of pandemics. Several issues are raised by Laurent Musango, the WHO Representative in Mauritius, in his 2017 Country Report. While the report highlights the positive response to cases of plague and measles, it also points out the need to strengthen our surveillance mechanism; the intensive red tape of government institutions; the inefficient allocation of resources; and the lack of coordination amongst stakeholders.
The weakness of our health institutions has always been under the microscope. It was the case when Dr Anderson published his doctoral thesis on Epidemics of Mauritius in 1918, it is the case still with the 2017 WHO Country report. And there is no doubt that the first obligation of any government in times of crisis is to protect its population. However, Mauritius has the potential to demarcate itself from other SIDS in how it reacts to pandemics. The Coalition for Epidemic Preparedness Innovations was set up by the WHO in the aftermath of the Ebola crisis to look into the very same weaknesses pointed out by Musango. In addition to an innovative partnership between public, private and non-profit organizations, they seek to promote the use of technology to detect and fight the next pandemic. Mauritius is a very connected society with some 63% of the population being internet subscribers and more than 1.8 million mobile phones subscriptions. We are able to access information faster and relay data to policy makers in real time. Kenya is already using cell phone data mining to track Malaria and strengthen its surveillance and monitoring mechanism. Technology cannot prevent an epidemic but it can provide real time monitoring and surveillance, educate, and empower healthcare personnel to take actions that would significantly reduce the impact on the island.
The world today remains vulnerable and pandemic preparedness financing often is not a budget priority in countries facing resource constraints. The World Bank has pointed out in a recent report (2017) that most countries are not prepared to face the next pandemic and that expected annual losses arising from pandemics as a share of national GDP is estimated to be $ 132 million. Mauritius has not yet embarked on the Joint External Evaluation exercise which is a voluntary assessment of a country’s capacity to prevent, detect and rapidly respond to public health risks. Islands have a track record of surviving through disasters. However, Mauritius will gain from showing to the world that it is not only focused on achieving economic goals but can also win any battle against future disease outbreaks by preparing for the worse but hoping for the best.
A new outbreak centered on a densely populated area of DRC was declared about a week ago. Out of the 43 people believed to have been infected in North Kivu province, 36 have died. Sixteen of the cases were confirmed to be Ebola.
Ashveena Gajeelee is a research fellow at Harvard Law School. She is a public policy specialist and has a strong research interest in global health norms and how regulatory policy impacts access to medicine and health equity.
