Scabies, lice and bed bugs don’t care if we’re in the middle of a COVID-19 pandemic.
However, some of the strategies we have used to prevent COVID-19 transmission in the shelter are relevant to these other long-standing public health threats.
In a previous article I described how Bethesda ProjectChurch’s Church Shelter Program uses some form of community surveillance (CBS) in response to COVID-19. Recently, I took a close look at CBS initiatives in Cuba, Uganda, and Ecuador to see how other communities are creatively and effectively responding to disease outbreaks in resource constrained environments. Then, using some of their best practices, I designed a community-based pest prevention model for use in our shelter.
In this article, I’ll share what I’ve learned and say more about this model (which is flexible enough to be used in other shelters or meeting environments).
The 1978 Alma-Ata Declaration of the World health organization states that “governments have a responsibility for the health of their people”. I have written before about how the Church Shelter program works with a “governance” paradigm rather than a “management” paradigm. Therefore we hold ourselves responsible for this statement. For us, this means that the employees of the animal shelter have a responsibility to proactively protect our guests from diseases associated with the establishment of the animal shelter.
When it comes to pests like scabies, lice, and bed bugs, it means we’re working proactively to prevent outbreaks and quickly control them when they occur. Ignoring such an outbreak or claiming that the guests concerned are responsible for dealing with it would be a violation of their right to health and our responsibility as accommodation providers.
At the same time, it is important to enable members of the animal shelter community to design and participate in public health activities that are intended to benefit them.
The effectiveness of community participation in public health initiatives
Cuba has a long history of community participation in public health efforts, as described by Dr. Linda M. Whiteford and Dr. Laurence G. Branch in the Primary Health Care in Cuba: The Other Revolution (2009). For example, in the 1960s, the Cuban government successfully trained ordinary citizens to administer vaccines against measles, chickenpox and polio, which enabled widespread vaccination campaigns across the island to be carried out quickly.
After a dengue outbreak in the early 1980s, Cuba took a similar approach. Neighborhood brigades, made up of ordinary citizens, were trained to identify and remove the plants that host the Aedes egypti mosquito (the vector responsible for transmitting dengue fever to humans). The brigades patrolled their communities – even in their neighbors’ courtyards – removing plants, picking up trash, spraying insecticides, and clearing up stagnant water that could act as breeding grounds for mosquitoes. Within four months, Cuba had ended the outbreak.
This approach also proved valuable during the emergence of the Zika virus. In an article published in 2017, published in The American Journal of Tropical Medicine and HygieneResearchers found 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 only had 3 cases. They attribute Cuba’s success in restricting the transmission of Zika to the country’s culture of actively participating in mosquito control.
In a 2018 article in the magazine nature, Sara Reardon describes how, even before cases of Zika were discovered on the island, Cuba dispatched soldiers to spray houses with insecticide, health workers monitored mosquito larvae near water sources, and medical officers went door-to-door to conduct symptom tests. Yet Reardon also realizes that Cuba’s success here “was largely due to such intense interventions by ordinary citizens,” people without advanced or medical degrees.
Uganda took a similar approach in its Guinea Worm Eradication Program, established in 1991 as a collaboration between the Ugandan Ministry of Health, The Carter Center, and UNICEF. Guinea worm disease is a parasitic infection that is spread when people consume water contaminated with guinea worm larvae. At the beginning of the eradication efforts, Uganda registered over 126,000 cases in 1991. By 2004 the disease was eliminated within its limits.
A 2006 article published in the American Journal of Tropical Medicine and Hygiene describes a community-based approach that contributed to this finding: older men in local communities were recruited to serve as “pond keepers.” These were usually men who were respected by their peers and too old to work on the farm but were able to monitor the community’s water supply to ensure it was not contaminated with guinea worm larvae.
The pond keepers collected water for the visitors, provided people who drank directly from the ponds with filter straws and erected fences or barriers around the ponds.
Community engagement makes a difference, of course – but is it really necessary?
Yes it is.
The Cuban Minister of Health may know the plant species that host the Aedes Egypti mosquito, but she doesn’t know whether or not these plants grow in your garden, let alone where in the garden – but you and your neighbors certainly do. The Ugandan Health Minister may know that Guinea worm disease is water-borne, but he doesn’t know where every single pond in your community is – but you and your neighbors certainly do too.
Specialists, experts and clinicians play an important role in shaping and coordinating public health interventions. However, effective local implementation depends on the communities themselves.
Dr. Whiteford examines this point in depth in her book Community participation (2015), which draws lessons from community intervention to contain a cholera epidemic in rural Ecuador.
Local experience and knowledge were critical to the success of the intervention because, while the methods of combating cholera may be simple – boiling water and hand washing – they are not.
In certain parts of Ecuador, many households had no plumbing at that time. Boiling water for cleaning meant sourcing extra wood or charcoal, which households could not afford. Asking people to wash their hands more often meant having to manually move more water from the river to the home.
In the meantime, the use of the soap created new problems. For example, like many people in arid communities, people in this region used a container of water for cooking, getting dishes up, washing hands and finally feeding cattle. However, the soap changed the taste of the water and the cattle refused to drink it, which threatened families’ livelihoods.
Only by engaging community members in responding to cholera have researchers been able to effectively overcome these obstacles.
The Church Shelter Program’s community-based pest prevention model
In light of the insights and experiences from Cuba, Uganda and Ecuador, my model of community-based pest prevention in emergency shelters looks like this.
Shelter guests will be the first to recognize or suspect an outbreak of pests – say bedbugs – is occurring because they are sleeping in the shelter. This also means they are well positioned to report suspected outbreaks early on.
Within the shelter community, peers have a unique level of social capital, legitimacy and mutual trust. In addition, they have local knowledge that is important for bed bug control. For example, they know which mattress covers have tears, which sleeping mats are starting to fray, where the cracks are in the walls, which person is hiding mess, which guys have bites on their arms, etc.
These are crucial details that will make the difference between a bedbug outbreak and not.
To harness the social capital, insights and knowledge of the shelter community, we need to create a community-based pest prevention culture. To this end, the shelter’s staff and guests work together to select a small subgroup of guests who are known to put a consistent effort into cleaning, cleaning, etc. These are individuals who are observant, observant, respected by their peers, and place a high value on cleanliness.
These people are then invited to act as “pest monitors”, checking the shelter’s beds, cribs, or sleeping mats for any signs of bedbugs every day. The monitors are trained in basic bedbug biology, infestation indicators, and risk factors for infestation.
The shelter’s staff and guests will then work together to decide on a range of early intervention measures that the monitors can apply (e.g. washing bedding and clothing, treating furniture with a portable steam cleaner; vacuuming bed seams, etc.).
As I wrote in a previous column, the long term solution to shelter disease outbreaks is to ensure that emergency shelter is not required at all. Providing safe, decent and affordable housing for people, possibly with support services, is the best way to reduce the risk of infectious disease in communities.
But while we have shelters and people live in them, we have a responsibility to keep them clean and safe. One of the most effective and effective ways to do this is to involve the guests of the shelter themselves in the public health interventions designed for these facilities.