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From 2014 to 2016, the Ebola epidemic claimed more than 11,000 lives in Sierra Leone, Guinea, and Liberia. Cholera has claimed nearly the same number of lives in Haiti since the 2010 earthquake. In devising the plans to claw back from the worst of these epidemics, governments and health care organizations have understood that hospital and clinic-based medicine would not be enough. So instead of relying only on traditional health care, they worked to implement social mobilization strategies and community-based care, efforts that directly and indirectly saved countless additional lives. Today, Rwanda is using similar practices and measures in order to combat COVID-19.
We are both front-line emergency physicians in Boston who have worked around the globe as doctors for the nonprofit Partners in Health. We have seen in Haiti, Sierra Leone, and Liberia how community-based care and true local engagement works, and how it helps individuals and communities survive crises. And now, amid the coronavirus crisis, we have realized that the United States, and other wealthy nations, must now follow suit in implementing community-based care. Doing so will help to defeat the virus more quickly.
From our combined experiences, we know three specific and immediate interventions that can help stop COVID-19 here in the U.S. They are easy and inexpensive, and each of us with our friends, family, and neighbors—both geographically close and those online—can work together to implement them quickly.
First, we need to broadcast essential health messages in ways people have access to hearing. When Ebola ravaged West Africa, the most effective messaging came from community health workers (often Ebola survivors themselves) who connected with their local communities for health education, social mobilization, and case detection. Additionally, trusted local leaders— teachers, nurses, midwives, priests, and imams—were engaged to share messages of social distancing and sanitation.
In the U.S., this means we must reach people through the mechanisms they already use routinely and trust. We live in a society where information is polarized and truth means different things to different people. Stopping COVID-19 as a country will be a function of stopping it first in each of our individual communities. This will require engaging the leaders of those communities in that effort—working on all sides of the aisle, with social influencers, religious leaders, community-based organizations, and respected community leaders, whether physically or virtually. Doing so takes the cliché of “thinking globally and acting locally” and actually puts it to work. With growing news about “open up” protests, it’s essential that trusted community members continue to message and reinforce the value of social distancing. A recent survey shows that the vast majority of Americans support social distancing restrictions. Yet, everyone needs to share and understand the same message of social distancing, caring for our neighbors, and getting tested when sick.
Secondly, we need people who are infected—or exposed to those who are infected—to stay isolated at home. We all know this by now. But we also need to realize that for those without ample resources, this is more challenging: For example, if you don’t have an extra bedroom, a spare bathroom, and a private car, or can’t order food delivery, safe isolation is nearly impossible to achieve. For this group of people, safe and appropriate quarantine can only occur with community intervention.
During Ebola, local communities came together to provide food, water, and supplies to families in quarantine. Through this neighborly action, families who were quite literally “cut off” (often with orange fencing erected around their yards) were cared for during their quarantine. Leveraging community-based mechanisms, the government of Rwanda is doing the same now during COVID-19 by feeding everyone during their quarantine, at established quarantine centers or at home during self-isolation. Why don’t we do the same? We have the resources, if we choose to recognize and deploy them.
In our hometowns here, we could do the same by providing a “quarantine box,” complete with food, soap, cleaning solutions, and other daily essentials to those in need. This can be organized by governments, or at a grassroots level by neighborhoods, local religious houses, sports teams, or other community organizations. The city of Boston has started a similar effort in the past week in Massachusetts, creating a volunteer program to support older, at-risk individuals in their communities. Importantly, these needed supports can be delivered to a doorstep to preserve social distancing and safety. Helping our neighbors safely quarantine is a double win: Those who are sick get the support they need, and we reduce transmission of the coronavirus in our communities, preventing future infections.
Finally, people won’t know they are infected or have been in contact with someone who has been infected until we expand testing and bring it directly into every neighborhood, particularly the poorest. Notably, stay-at-home orders exclude essential service workers who remain at high risk of contracting the virus. Many Americans have less flexible work, rely on weekly paychecks, and depend on public transportation. To allow potentially infectious people to keep their communities safe and avoid riding buses and trains to reach testing centers (or using ambulances to reach crowded emergency departments for testing alone), we must build capacity for community-based COVID-19 testing.
While this requires some organization, funding, and other inputs from state and local governments, history proves this is highly achievable with concerted community efforts. This is not dissimilar to social mobilization efforts that occur to run voting stations in all of our neighborhoods. We can do this to stop COVID-19.
In Haiti, during the cholera and diphtheria outbreaks, community health workers with short trainings were able to lead home-based vaccination campaigns, which helped quell both epidemics. In the cholera outbreak specifically, our community health worker team delivered doses of the vaccine to a rural community of 45,417 people, which led to a 65 percent reduction in disease. Right now, similar gains may be tallied against COVID-19 in America—across urban and rural communities—by making testing mobile and/or accessible near home.
Our global teams have seen the effectiveness of these grassroots social mobilization efforts in epidemics around the world in countries with far fewer resources than the U.S. Importantly, they’re not expensive, they’re highly scalable, and everyone can play a part. There’s really no time to wait.
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