Dr. Chris Dickey reports from Nepal, where he taught a J-Term course, Behavioral Communication Strategies for Global Epidemics
Dear Colleagues and Students:
The sudden forced migration of the Rohingya population in Myanmar to Cox’s Bazar in Bangladesh has created a major humanitarian emergency, with more than 700,000 impoverished, tired, and hungry individuals arriving to the camp in less than six months — often in waves of tens of thousands of people per day — in an area roughly the size of Central Park. Simply sheltering and feeding these individuals presents an enormous logistical challenge, but the public health emergency raises the bar to a new level. Already the camp has had to endure outbreaks of cholera, hepatitis E, pertussis, neonatal tetanus, and Japanese encephalitis, and UNICEF and WHO are currently battling major outbreaks of diphtheria and measles.
In Yemen, the proxy war between Saudi Arabia and Iran has cut off food and supplies to more than 20 million people, and the resulting infrastructure collapse, coupled with bombings of sewage treatment facilities, has resulted in the largest cholera outbreak in human history, with more than a million suspected cases (including more than 600,000 in children) and thousands of preventable deaths.
Wild-type polio is still a threat in Afghanistan and Pakistan, particularly at the borders where immunization efforts often fail because of migration and lack of coordination between those countries. Its ugly offspring, vaccine-derived poliovirus type 2 (cVDPV2), has resurfaced in Syria in areas formerly held hostage by ISIS, where immunization against polio stopped entirely along with the destruction of the sanitation systems there. This led to unvaccinated children being exposed to partially-attenuated virus in the places where vaccination continued.
These disease outbreaks -- like most others -- are due to a complex mix of biological, economic, environmental, socio-cultural, geographic, and political factors, and mitigating those risks will likely be impossible without considering their contextual contributions and interactions. In addition, it is critical to consider resource barriers (including availability and accessibility), socio-cultural barriers (acceptability of interventions), continuity barriers (so that interventions are there when needed), and quality barriers when trying to understand why an individual or community is at risk of preventable outbreaks like those described above.
I had the pleasure of teaching Behavioral Communication Strategies for Epidemics during January Term, which was designed to help students understand the complexity and bottlenecks in preventing outbreaks, and to evaluate theory- and data-driven behavior change communications as one of the many strategies available to reduce risk.
The class, which was developed in partnership with UNICEF Communications for Development (C4D), was completed in Kathmandu, Nepal and included 22 UNICEF professional staff, 21 GPH students, and two representatives from the government of Myanmar. The participants, who came from Afghanistan, Syria, Yemen, Nigeria, China, Pakistan, India, Nepal, Bangladesh, Cambodia, Indonesia, Lebanon, Uganda, Liberia, and the US, were grouped into eight teams to create innovative behavior change strategies for reducing the risk of disease outbreaks in the South Asia region and beyond. Each team was a blend of UNICEF field professionals, graduate students, and government staff. To encourage a systems approach, innovation, and a leveling of the playing field, every member of the team was assigned a role (epidemiologist; anthropologist; environmental scientist; monitoring and evaluation specialist; external communications specialist, or behavior change communications specialist) and the role was required to be different from each person’s expertise in real life.
Over seven intense and long days, under the guidance of Dr. Erma Manoncourt of M&D Consulting; Dr. Gillian SteelFisher of the Harvard Opinion Research Program; Dr. Theresa Jones of Anthrologica, and myself, the teams developed behavior change communications strategies that can be immediately implemented to reduce outbreak risks in Cox’s Bazar; Yemen; the Kakuma Refugee Camp in Kenya (for cholera); urban Yangon in Myanmar (cholera); Pakistan FATA Region (measles); the Afghanistan-Pakistan Border (polio); Syria (polio), and India (dengue). Strategies were presented to a panel of judges that included the course facilitators and Dr. Paul Sutter, the regional health advisor of UNICEF South Asia.
The winning team (pictured below right) included GPH students Emily Holzman, Anne Mattson, and Jessie Drescher, along with UNICEF colleagues from Cambodia, Nepal, and Yemen. The team developed a proposal to incorporate behavior change theory to help foster a sense of ownership among the Rohingya community in Cox’s Bazar. They benefited from the participation of UNICEF staff who have been working in Cox’s Bazar, and also from a presentation by the chiefs of health and communication for development at UNICEF Bangladesh -- both of whom are in Cox’s Bazar on a weekly, if not daily, basis. The team's intervention, which is intended to motivate camp participants to actively advocate for themselves and their community and to participate in prevention efforts (for example, by helping to build and maintain water and sanitation infrastructure), is likely to increase resilience -- especially in the face of anticipated shocks like the coming cyclone season -- and to reduce the risk of disease from multiple pathogens.
The judges were impressed by the team’s creativity and also its ability to incorporate concepts such as theories of behavior and behavior change; quantitative and qualitative data analysis; community-based participatory research; innovation; the systems approach, and bottleneck analysis.
The final ceremony and reception was keynoted by Jean Gough, regional director of UNICEF South Asia, who congratulated the teams for their innovative strategies and encouraged the students, field staff, and government staff to use their experience as a platform from which to create lasting change in the region.
UNICEF also viewed the course as an opportunity to identify and support GPH students who want to work in the field, and it’s already discussing internships with at least half of our students in the course.
Chris Dickey, DrPH, MBA
Clinical Associate Professor of Global Health
Director of Global Health