Commentary: Grassroots health surveillance can help detect new outbreaks of COVID-19 and other illnesses

To answer that question, global health experts should pay more attention to successful grassroots efforts to combat disease.

CASES OF EFFECTIVE COMMUNITY SURVEILLANCE

Consider the fight against onchocerciasis, or river blindness.

In the 1970s, it was led by World Bank President Robert McNamara, Merck CEO Roy Vagelos, and WHO Director-General Halfdan Mahler. But over time, a bottom-up strategy whereby almost a half-million village community health workers owned the problem, proved more effective.

A 1994-95 multi-country study showed that when communities are responsible for organising their own distribution of ivermectin (the drug that treats onchocerciasis), coverage is higher than when the health system delivers the drug.

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Another report by the Carter Center highlights the role that kinship and local networks play in tackling this disease.

Similarly, the Bombay Leprosy Project is a longstanding programme in Mumbai’s largest slums, such as Dharavi.

Community volunteers, trained by paramedical workers, conduct door-to-door surveys among the population in order to detect new cases.

During the pandemic, it has been one of the most effective channels for delivering personal protective equipment (PPE), healthcare, food, and now COVID-19 vaccinations to the poorest of the poor in areas where the Maharashtra state and federal governments are essentially absent.

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REBUILDING NATIONAL RESILIENCE

The importance of bottom-up initiatives in responding to the pandemic is not limited to developing countries.

The United Kingdom’s government invested heavily in a centralised national COVID-19 test-and-trace service. But evidence suggests that even relatively underfunded local schemes performed better, leading the government to rethink its approach.

Increased efficacy is not the only reason to consider a grassroots strategy.

Politically, many countries – perhaps scarred by their experience of trade blockages at the outset of the pandemic, the worldwide scramble for PPE supplies, and vaccine nationalism – are currently more focused on national resilience than global commitments.

A new emphasis on local resilience may therefore find a much more receptive audience in communities around the world.

One of the shortcomings of international health regulations during the COVID-19 pandemic has been the failure to prepare, provide, and coordinate adequate resources at the country level. A bottom-up approach could change this.

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FUNDING EARLY WARNING FOR OUTBREAKS

Moreover, investments in community-level health-surveillance capacity will likely be key to tackling this and future pandemics. Here, the right financial incentives are crucial.

Rural smallholders in Africa and Asia will be the first to know when some of their chickens or ducks seem sick – possibly with an avian influenza virus that could trigger a human pandemic.

But if farmers who report a disease outbreak face the prospect of culling their entire flock without receiving adequate compensation, they may well decide not to share the information.

Likewise, as Stefan Dercon of the University of Oxford has argued, investing in the reach and quality of community health care and in health workers’ protection is vital to ensure the continuation of basic medical services.

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These include vaccination, provision of antiretrovirals, supplementary feeding, maternal health, bed net distribution, and malaria treatment. Community health workers are also essential for shielding the most vulnerable in densely populated areas, and for tracking and controlling disease.

Such bottom-up approaches will require government support, including financing of local efforts. Any backing may need to be anchored in law to be sustainable, as was the case with the funding of Brazil’s public health research institution Fiocruz in the early 20th century.

Such statutes may protect organisations from attempts to reduce budget allocations or finance other programmes at their expense.

Historically, global health and environmental cooperation has reflected various combinations of top-down and bottom-up measures.

While the 1987 Montreal Protocol to protect the ozone layer was an example of top-down regulation, the 2015 Paris climate agreement resulted from a much longer process involving communities, cities, and countries around the world.

Academic studies and research by hundreds of universities, institutes, and scientists, and early initiatives by mayors and individual communities, greatly heightened grassroots awareness and commitments from families, schools, local media, municipalities, and regional administrators.

In the end, even the best bottom-up disease-control efforts risk being thwarted by international failures to ensure access to PPE, genetic sequencing, or vaccines. But policymakers must not neglect local-level healthcare.

To be better prepared for future pandemics, our top-down models and agreements must shape responses that are grounded firmly in local communities and value their engagement, risk ownership, and anxieties.

Ngaire Woods is Dean of the Blavatnik School of Government at the University of Oxford. Ok Pannenborg is a former chief health adviser and chief health scientist at the World Bank.