James Shepherd-Barron

Disaster Management Consultant, Disaster Epidemiologist, Author, and Founder of The Aid Workers Union

EBOLA HAS MUCH TO TEACH US ABOUT THE MANAGEMENT OF COVID-19

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The author is an independent disaster management consultant and was the UK Government’s Humanitarian Health Adviser in Kinshasa during the Ebola epidemics of 2018 in the Democratic Republic of Congo. He was also special adviser to the Minister of Health in Sierra Leone during the Cholera epidemic of 2012 and Ebola epidemic of 2014.

It’s never too late to learn from a virus, especially a new zoonotic RNA virus to which we are all susceptible. These are some of the relevant non-clinical lessons learned from the various Ebola (EVD) outbreaks of 2014 in Sierra Leone and the Democratic Republic of Congo (DRC) in 2018.

Before we start, though, just a few words to put things in perspective. It’s not over until it’s over. At the moment, there are no vaccines to prevent us contracting C-19 and no therapeutic drugs to cure us once we have. Until such time there is a vaccine, the population reaches herd immunity, or the bug mutates to become benign, we will eventually all contract the disease; it’s just a matter of when[2]. Since lockdown cannot be sustained forever, we should expect at least three waves of infection between now and the end of 2021. And, as I was once told by an exhausted Congolese doctor who had not been paid for six months, “You can recover from being broke; the only thing you can’t recover from is being dead.”

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TIME TO PROTECT CASH

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Cash – physical currency – is a vital public good whose social utility in times of crisis deserves to be better recognised. It is time for aid agencies to protect it. The health of vulnerable populations around the world – the people international aid agencies exist to protect – should not be put at risk by advising them to use only cashless forms of payment or systems which are not disaster-resilient. In fact, to do so goes against the humanitarian principles of ‘do no harm’.

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IS CASH CONTAMINATED? Are Banknotes Vectors of Covid-19?

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Is it true that banknotes do not pose a risk of infection for the public?

According to Cash Essentials, Bundesbank executive board member Johannes Beermann certainly thinks so and has indicated that the risk of picking up coronavirus from handling cash is extremely minimal. “Banknotes and coins do not pose a particular risk of infection for the public,” he said.

And he is right.

Banknotes do not seem to play a major part in what epidemiologists call ‘the chain of transmission’. If they did, incidence of C-19 infection would be much higher. And the way they are made, with their polymer substrates, anti-microbial inks and surfactant varnishes, means that they don’t lend themselves to the transmission of pathogens.

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INFORMATION MANAGEMENT: The C-19 Dashboard

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At his first daily press briefing on 30 March 2020, Dominic Raab, the UK Foreign Secretary, referred assembled journalists to the “latest update from our COBRA Coronavirus Dashboard.” He then spent much of the next 40 minutes providing imprecise answers to very precise questions. Much of what he said sounded like spin, not evidence-based decision making. Speaking from behind a podium emblazoned with what is in effect a political slogan rather than a public health message, perhaps the fact that listening to random government ministers speaking to ‘core press lines’ as if voicing over a Hovis bread commercial is the best we should expect.

But one mis-spoken word, one garbled sentiment in such panicky times gives a sense that our leaders are all at sea, floundering in a rip-tide of ad-libbed condescension. And in a frightened world certain only of uncertainty, this steadily but surely erodes trust in those who purport to protect us; a situation not helped by an over-zealous Police service quite demonstrably interpreting well-meaning government guidance with their own Orwellian brand of wooden-brained, judgmental heavy-handedness. A Police state and the wholesale infringement of civil liberties it implies in an era of ‘lockdowns’ and social isolationism is not where any of us want to be, or want to go.

A lot of this is down to wooly communications. OK, in the early stages of the C-19 response the government was trying to nudge us into changing our behaviour by politely suggesting we exercise outdoors only once a day. It became clear that the public had misinterpreted this nudge and had driven in their tens of thousands to walk in Derbyshire’s Peak District, it became clear that the type of dictatorial clarity introduced early on by the French was needed. In France, an ‘attestation’ was needed before leaving the home, one of the criteria permitting such action being ‘daily exercise in the vicinity of the home.’ This clarification was later added to the UK government’s advice.

But we British pride ourselves on our libertarian laissez-fair attitude and resent being told how to behave by the state. Knowing this, and well aware that indefinite lockdowns implode through the weight of their own boredom, tension and loneliness, the government has been careful to take a nuanced approach to the way mass behaviour change is invoked. This also makes good epidemiological sense as to go into lockdown too early – or too late, for that matter – risks causing more problems than it cures.

For a country to succumb in the way the UK meekly has to dictatorial diktat involves high levels of trust in organs of the state, particularly the Prime Minister’s Office. Squander this trust and public sentiment spirals downhill extremely rapidly. We learned this lesson time and again during the Ebola epidemics in Africa over the past decade.

Credibility in an era of social media and instant communications depends on factual information clearly, consistently and coherently explained. Where facts are hard to come by, then explanations of the assumptions behind the analysis will do. The public are not easily fooled. Any sense that science has been interfered with by politics or that unpalatable truths have been dumbed down or politically spun quickly undermines the nation’s trust in the capacity and capability of its leaders. In the final analysis, anything other than clear-eyed realism and total transparency results not just in a loss of credibility, but unnecessary loss of life. This is why Governor Cuomo is doing so well in New York.

As we gird ourselves for the acceleration of this epidemic to its late-April peak, trust in government is wavering. This is largely because, as Giles Whittell of Tortoise Media put it on 30 March 2020, “Governments are generally underperforming as purveyors of reliable information on the pandemic.”

What could they do better?

In Sierra Leone, three months after the Ebola outbreak was declared and one week after a national state of emergency was announced, the national ‘Ebola Operations Centre’ established to manage the extensive control measures needed consisted of little more than two flip-charts, one without paper, and a pile of pens strewn across a dusty table. There was nothing to show that this small room, crowded with empty chairs, was an ‘operations centre’ for anything, let alone an unfolding national calamity. There were no maps and no organigrams on the wall to show who was responsible for doing what, where, and when. There were no graphics charting the progress of the disease or of the measures underway to control it.

The World Health Organization has come a long way since then and by the time of the 2018 outbreaks in DRC had designed an operational template for enhanced coordination and control, including on how to report on what they call KPI’s or Key Performance Indicators. As with the COBRA C-19 Secretariat in London, the Emergency Operations Centre in Kinshasa would gather data from the affected area and from all over the world, compile it into 13 response areas (each with specialist ministry committees), interrogate the data, make their collective analysis, and report their findings to the Minister of Health at 2 pm every day. Rarely did anybody agree on anything. Heated discussions between doctors, epidemiologists, statisticians, logisticians and bureaucrats, both in the room and down the line from all over the world, would ebb and flow in this seething cauldron all morning, ending up as one coherent, easily readable dashboard in time to brief the minister who, one hour later, would brief the world.

Such a ‘management system’ exists. What it should look like is outlined in the ‘World Health Organization Framework for a Public Health Operations Centre’. Produced on the back of lessons learned from countless outbreaks around the world over decades, it has been designed by information managers who know how to present qualitative and quantitative data in easily understandable form. It does not need to be re-invented. It includes data on what UN disaster managers call “4W (who, what, where, and when) mapping” combined with health information management data on aspects such as hospital capacity, bed occupancy, laboratory diagnostics, case management, contact tracing, disease surveillance, supply chain management and human resourcing. Lots of numbers are then transformed into easy-to-understand graphics and supplemented with time-lapse maps to create a single gateway into what is going on in real time. The World Health Organization’s dashboard covers one entire wall of its Emergency Operations Centre in Geneva.

Tracking operational outcomes against KPIs, together with an explanation of what is being done to address shortcomings, is useful for both downstream operational planning and upstream accountability and is a standard operating procedure in international disaster responses, as is regular gap analysis. Reflecting operational performance against pre-determined criteria and benchmarks is critical, not just for strategic oversight and programme adjustment but for better integrating risk communication and community engagement into the overall response … a frequent shortcoming in outbreak responses up until now.

If the British government is using such a dashboard – and it is – then all it has to do is show it to the world, warts and all. When numbers are noisy and the data flaky, all the specialists and the politicians have to do is explain the assumptions behind why they have made the decisions they have. Every sentence is vital; every word critical. There is no room for mis-speaking in such a febrile atmosphere.

Providing such clarity in all its gory detail might confuse – or even upset – some of the public some of the time, but it would stop the media filling in the gaps with its own muddled and simplistic interpretation, much of it designed for effect rather than information. This is why, for example, we consistently hear about ‘how many people died yesterday’ rather than how many died as a percentage of the laboratory-confirmed caseload or whether the rate at which these deaths occurred is accelerating or decelerating, or is above or below that which was expected. Key statistics such as Case Fatality Ratios and explanations on why ‘mortality rates’ are different are not presented at all.

With a dashboard we could see the evidence for ourselves and draw our own conclusions. We could see when the government expects transmission or mortality to peak and when herd immunity might be achieved. From this panoply of graphs and graphics we can deduce our own patterns and work out for ourselves how to plan our lives in the new normal of limbo, lack of livelihood, and lockdown. We neither need nor want to be patronised. We just demand to be informed.

© James Shepherd-Barron

31 March 2020

COVID-19: Is the gain worth the pain?

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Summary

If it works, the UK Government’s Covid-19 (C-19)[1] control strategy will cost over £300 billion and save half a million lives, most of them elderly. According to the International Monetary Fund, this level of expenditure will tip the country into recession and require levels of domestic borrowing not seen since the Second World War. Younger generations fear that it is they that will be left paying the price. Whether they deem this price worth paying depends on what value they are prepared to put on human life.

On the basis that each British citizen’s life is valued at somewhere between £5 – £9 million, that each life-year saved is consequently worth about £248,000 and that each victim loses an average of 14.6 life-years from C-19, this article argues that the price is worth paying. At least, for now.

“Yes, there is a high price to pay. But how do you put a price on life?”

(Michael Gove, UK Minister of State, 29 March 2020)

Over the longer-term, Britain’s youth might instead ponder the social and political, rather than economic, ‘price’ involved and prepare to drive a new agenda for change which re-engineers democracy, re-defines civil liberties, puts Climate Change front and centre, and ensures redistribution of wealth through enlightened corporate responsibility.

Whether the “world’s beauty will be revealed afresh” is in their hands.   

Introduction

The UK Government’s C-19 suppression strategy and its demands for extensive country-wide social isolation and ramping up of NHS critical care capacity may result in between 35,000 and 70,000 excess deaths[2] across the country by the end of December 2020 (University College London). This is in addition to the 30,000 that would die anyway from Acute Respiratory Infections such as seasonal Flu (Public Health England). Against the number of premature deaths predicted by ‘zero option’ (do nothing) modelling where up to 560,000 UK citizens would die (Imperial College) this represents the saving of around half a million lives.

However, this will come at great social and economic cost, leaving some to wonder whether such draconian disease control measures are worthwhile? Could the social and economic consequences of the virus be deadlier than the virus itself?

The answer, at least over the short term, appears to be ‘No’. The saving of 500,000 lives is deemed to be worth the billions of pounds committed by the UK Government. But how was that conclusion reached? And in what context does it hold good when the question has yet to be tested against society’s assumption that “every life is priceless” when, from a risk management perspective, they are not?

With the peak of transmission estimated to be in late May / early June, estimates of predicted mortality remain uncertain. But one aspect is crystal clear: The length of the epidemic and the numbers that die are, to a major degree, dependent of the public’s psychological resilience and their ability to break the chain of transmission through sustaining physical distancing from one another for at least three months, possibly longer.

Much clearer is that the strategy now underway will tip the global economy into recession. Most of this money will need to be borrowed now and repaid by future generations.

Are those future generations, some of whom are not yet born, willing to pay such a price, especially when most of those who die are elderly men with pre-existing chronic illnesses (co-morbidities) and who, according to some public sentiments, “only have a few years left anyway”? After all, as the Chief Economist of the UN’s World Food Programme recently put it, “There is only so long an economy can be locked down without inflicting lasting damage.”

The ‘damage’ he is referring to is not measured in short-term mortality alone – a few years from now this disease will be endemic and treated much the same as seasonal Flu or a common cold is – but the long-term consequences of global economic shut-down.

To answer this question, we need to know how much a life saved – or, more specifically, a life-year gained – is worth to society. Only later on, will we need to know what the potential social, economic and political benefits might be in terms of, say, climate change, democratic accountability, and corporate responsibility.

The Humanitarian Dilemma

Whatever control strategy is applied to the C-19 pandemic, two things are clear: A lot of people will die prematurely – many unnecessarily – and the social and economic cost will be enormous. Leaving aside the ethical considerations, society is faced with the same ‘humanitarian dilemma’ faced by disaster managers when coordinating responses to international calamities where resources are never enough, the data unreliable, and uncertainty the norm: Is the predicted gain in terms of avoidable deaths averted by any one intervention ‘worth it’ in terms of the financial cost involved? How does one balance the cost of the prevention against reducing the risk of a premature death that may never happen? If there are not enough resources to do both, is it more cost-effective to improve access to safe water in a cholera epidemic or vaccinate the children? Is it better to distribute the full value of cash grant required to keep a family in Northern Syria alive to half the families that need it, or half the amount to all the families?

The answer to ethical conundrums like these are not as difficult to work out as they appear, and, although away from public view, disaster managers make such life-and-death decisions all the time. So do insurance companies, government transport departments and NHS economists. Each uses a form of cost-benefit analysis (CBA) to help in their decision-making. And each involves the difficult moral question of how to value human life.

The Value of a Life

Although the concept of placing a monetary value on human life is controversial, the ability to do so is essential when making informed and rational decisions on resource allocations. Understandably, for ethical, religious or philosophical reasons, many people oppose valuation of something commonly perceived as priceless and argue that no monetary figure could possibly compensate entirely for the loss of a human life.

Nevertheless, comparing different options requires a common metric against which to measure impact. Usually, this is money. This immediately poses a challenge to planners as it requires a value be put on the direct effects on people vis-à-vis ill-health, injury and death. The UK’s Department of Transport uses a Value of Statistical Life (VSL). Disaster managers in the World Health Organization use Quality Adjusted Life Years (QALYs). Others use ‘Micromorts’ or ‘Judgement Values’ (J-values). Underpinning each approach are the triple concepts of life expectancy, earning potential and quality of life where a monetary value on future years of life is calculated based on discounted income (e.g GDP per head) and work-life balance (the ratio of time spent working to time not spent working). This is part of the Calculus of Calamity[3].

Although many would argue that the value they place on their life is infinite, reality reveals that this is not the case. There are limits to the amount we are prepared to pay for marginal increases in longevity – for example, to have expensive safety features fitted in our cars – and increases in occupational risk of death are often acceptable if the monetary compensation is substantial enough, as evidenced by the existence of ‘hazard pay’.

Another challenge is that most people have great difficulty in understanding the varying levels of risk to which they’re exposed. This is especially true when the impact is intangible and far off, as it is with a deadly pandemic like C-19. Yet another is that any attempt to put a figure on the value of human life has to take age and disability into account. Most people agree that it’s reasonable to suggest that the life of a new-born baby should carry a far higher value than that of someone in their eighties. Equally, people usually recognise that a double amputation might save the life of the patient but that this would mean additional years of life gained would be subject to a greatly reduced quality of life.

To accommodate such value judgements, health professionals and disaster managers use something called a ‘statistical life year’ (SLY) when making life and death decisions. Improved life expectancy in terms of ‘life years’ is a much better characterisation of the benefits to be gained by mitigating risk than ‘lives saved’. This is because, in fact, nobody’s life can ever be saved: the best that can be done is to return an individual’s life expectancy back to what it was before the hazard occurred. The SLY calculates the value to each individual of one additional year of healthy life gained by a particular intervention, adjusted for disability.

In the UK, where each citizen’s lifetime value to society is estimated to be worth between £5 – £9 million, the SLY value is estimated to be £248,209 (Thomas, 23 March 2020). This analysis is informed in part by a well-known economic effect called ‘The Preston Curve’ which demonstrates that we get to die earlier as we grow poorer[4] (Preston, 1975).

This implies that the government would be justified in spending about a quarter of a million pounds on any intervention that would extend a single citizen’s life expectancy by one year. With each victim losing 14.6 life-years on average and, in the best case, 500,000 lives being saved, the cost of control measures must be lower than £1.8 trillion … which, at the moment, they are[5].

C-19 as a Natural Hazard

Dividing the cost of the intervention by the aggregated number of life-years expected to be gained by the intervention allows disaster managers to calculate the relative risk of each intervention without having to bring unnecessary value judgements into the equation. Assessing cost-benefits in this way allows railway safety to be put on the same footing as medical treatments, natural hazard risk reduction and public health.

In this sense, our response to the C-19 pandemic is no different to our response to natural hazards such as Earthquakes or Tsunami; various response options, each with different risk parameters and expected outcomes, have different social, political and economic costs against which the short- and long-term implications on life expectancy and quality of life have to be considered.

All options have to be considered against the ‘Zero Option’, the ‘business as usual’ counterfactual of doing nothing. In the UK, modelling suggests this would lead to the C-19 epidemic peaking in late May/early June and being over by September 2020. But this would lead to roughly 550,000 lives being lost i.e a loss of life comparable to that suffered by the UK throughout the entire course of the Second World War.

Other options are equally unenviable. For example:

A 12-month lockdown during which fully equipped hospital capacity was prepared, followed by an additional four-month shutdown a few months later could cut fatalities by two thirds.

A 12-month lockdown during which a vaccine was developed and a large-scale immunisation programme was carried out would reduce fatalities to less than the average toll on people caused by seasonal influenza each year i.e about 13,000 premature deaths, being less than the average number of 17,000 influenza-related deaths in the UK per year (Public Health England, 2019).

Cost to Society

Meanwhile, the constraint which all but the ‘zero option’ have to consider is that C-19 countermeasures should not decrease GDP per head so much that the UK population as a whole loses more life-years than it gains from such measures. Public health protection schemes should not be put in place if their costs are large enough to cause the nation’s economic output to fall so significantly that it will cause more loss of life and if the scheme had never been implemented in the first place.

It is likely that a recession resulting in a general fall in economic output of 6.4% per person over a prolonged period would cost more life-years than would be restored by current and future C-19 countermeasures. This observation is based on comparisons from the economic recession of 2008-2009 where GDP per head fell by 6% and did not recover until 2015, and its negative impact on life expectancy. Under the scenarios mentioned above, modelling suggests that each victim suffers about 14.6 life-years (years of healthy life) lost.

Current macro-economic analysis suggests that planned countermeasures will severely dampen economic activity. Both the International Monetary Fund and the Centre for Economics and Business Research now predict that the pandemic will cause global GDP to decline twice as much as during the financial crisis of 2008. Furthermore, it raises the prospect of a 1930s-style recession. Such an outcome, if it were to come about, would cause a loss of life-years to the UK population that would far exceed the predicted toll under the ‘zero option’. It would be worse than doing nothing, in other words.

Thus HMG faces health and economic challenges of equal severity. It needs to institute reasonable countermeasures against C-19 but it needs, at the same time, to attempt to restrict the coming recession to not much worse than the 2008 financial crisis.

The Future

Whatever lies ahead, it is already becoming clear that the impact of C-19 will be deep and lasting; not just in the UK and Europe but in poorer and conflict-affected parts of the world which are woefully unprepared and lack the capacity to respond. Imperial College in London estimates that over 40 million people from such areas might die.

We can only hope that Alexander McCall-Smith was right when he said, “Our world, though diminished, will be much bigger, its beauty revealed afresh.”

© James Shepherd-Barron

30 March 2020

References

Thomas: J-Value assessment of how best to combat Covid-19; Unreviewed manuscript, 23 March 2020

Social Value UK: Valuation of a life, 9 June 2016

Ferguson et al: Impact of non-pharmaceutical interventions to reduce Covid-19 mortality and healthcare demand; Imperial College, 16 March 2020

[1] C-19 is the name given by WHO to the disease caused by the virus SARS-CoV-2

[2] Excess Deaths are those that occur over and above those that would occur anyway over the same period, based on previous data.

[3] Calculus of Calamity – A Stochastic Risk Optimisation Model for Managing Disasters; James Shepherd-Barron, KissyFish Books, 2019

[4] The Preston curve indicates that individuals born in richer countries, on average, can expect to live longer than those born in poor countries. However, the link between income and life expectancy flattens out. This means that at low levels of per capita income, further increases in income are associated with large gains in life expectancy, but at high levels of income, increased income has little associated change in life expectancy. In other words, if the relationship is interpreted as being causal, then there are diminishing returns to income in terms of life expectancy.

[5] UK Government control measures for the three months March-May 2020 inclusive are estimated at £320 billion

CASH & CORONA: What can the Cash Management industry do?

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Access to cash has always been critical to how we survive and recover from natural disasters. The Covid-19 pandemic is no different.

Unlike with a tsunami or earthquake, however, where the danger is clear and present, some people think that handling money and making payments can pose an invisible risk of disease transmission. This is why the Kenyan Government recently determined that “Cash-less financial transactions have to be further enabled to curb the risk of transmitting Covid-19 virus through banknotes and coins” and why the Peoples (Central) Bank of China disinfected and eventually replaced all its banknotes as the epidemic took hold in Wuhan.

In fact, neither measure was based on any epidemiological evidence, with both being driven by a combination of politics and sociology … which is understandable in a climate of uncertainty where sentiment is often as important as science.

This is not to suggest that banknotes don’t harbour infectious diseases; they do. But, as Mike Lee, CEO of the ATM Industry Association rightly points out, “Since people don’t usually sneeze or cough into their banknotes, it is disingenuous to single out cash as a medium of transmission as they harbour no more germs than any other plastic or paper surface.” It’s true. Cash, debit cards, ATM keypads and touchscreens are surfaces like any other and, when contaminated, act as vectors (fomites) of transmission. In this sense, says Bruce Renard, Executive Director of The National ATM Council in the US, “Money and ATMs pose no more risk to our health than mobile phones or doorknobs.”

So, knowing the passive role Cash, ATMs and Payment cards might be playing in Covid-19 transmission, what can industry bodies and financial service providers do to help society overcome this current crisis and break what the epidemiologists call ‘the chain of transmission’?

I would like to suggest six concrete things Banks, Credit Unions, ATM Deployers, and Card Companies could do, and do now:

Enable ATM screens to display key public health messages. Having talked to both the World Health Organisation in Geneva and the Centers for Disease Control in Atlanta, these, in order of priority, should be:

  • Wash Hands for 20 seconds using alcohol or soap and water.
  • Maintain a distance of at least 2 metres/yards between people.
  • Cough or Sneeze into your bent elbow.
  • Say hello without touching.
  • Avoid touching your face.
  • Reduce your social contacts by at least 75%.
  • Wipe off surfaces daily with soap or alcohol and leave to air dry.

An even shorter version would be:

HANDS Wash them often
ELBOW Cough into it
FACE Don’t touch
SPACE Keep 1 metre apart
HOME Stay in if sick
CONTACTS Reduce face-to-face meetings by at least 75%

Each message could be accompanied by some text expanding on the reasons for each action point. They could appear singly or together, and in static or moving graphic form. A public messaging campaign similar to this was undertaken by the Government of Nepal after the Earthquake of 2016, where ATMs in Kathmandu provided details of where to obtain reconstruction grants and how to build back safer.

Place distance markers in the ATM lobby or on the pavement / sidewalk to clarify the minimum social distance. We are already used to seeing ‘safe distance’ markers on our roads.

Attach hand sanitiser dispensers to ATMs: To be replenished by the ATM owner or storekeeper.

Decontaminate internal and external ATM surfaces. ATM facias, touchscreens and electronic payment terminals should be regularly wiped down by operators and storekeepers, with a written record displayed nearby. This is no standard operating procedure in public toilets. Decontamination of an ATM’s internal workings by specialised engineers already takes place. This could be done more frequently, with a prominent sticker attached to the ATM saying when it had been done.

Include a ‘Make a Donation’ button in the user interface. This is already a default setting in many online payment schemes, so should not be too problematic from a software perspective. Suggested beneficiaries would require a locally appropriate menu of options but could include WHO’s Covid Fund (in support of less-developed countries) and the national Red Cross society.

Match any donation with a rebate on the interchange (or other) fee. This is not as difficult as it appears as, A) Fees levied by Money Transfer Agents are often temporarily waived for limited periods following natural disasters; and B) Loss of profit can be offset as a charitable donation under ‘social responsibility’ provisions.

If you like these proposals PLEASE share, don’t just ‘like’, as this will help nudge action.

If you have any other ideas on what the cash and cash management industries can do to help, please shout out to me at [email protected]

MOBILE PHONES & DISASTERS

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This is an excerpt from the book, Absolute Disasters which can be found on Amazon.

Mobile technology increases accuracy and compresses time. Nowhere is this more effectively employed than before, during, and after a natural disaster. Targeted messages can be sent to specific groups of people warning of impending calamity, for example, and then, after the event, data can be collected in real time allowing humanitarian action to be targeted at specific disaster-affected communities more quickly and more accurately than ever before by knowing who has been affected and where.

Mobile phones can now help determine with reasonable accuracy how many people are affected (or infected) and where they are.

In Bangladesh, bulk messages are sent warning of the likely scale, location, and timing of floods, storm-surges, tropical cyclones, and tsunami, together with instructions about where to seek shelter. The latter part of the message is tailored to each locality. Syed Ashraf of the country’s Disaster Management Bureau says that, “being localised, it is also much more accurate and gives advice relevant to the area which makes people trust it more”. Follow-up messages are sent regularly advising on preparedness measures to take.

But it’s not just about verbal or text communications. When delivering humanitarian aid to disaster-stricken areas, there is often a severe lack of basic information on the locations of the people in need of help, including the number of people who have left the disaster area. This seriously hampers efforts to deliver the right amount of supplies to the right places, even when sufficient resources are available. Using data supplied by mobile phone operators, it is now possible to determine with reasonable accuracy how many people are affected and where they are, even in remote areas with limited coverage. This technology was used successfully in the Pakistan floods of 2011. 

Mobile phones can also be used to predict how many people have been killed, injured, or trapped in an earthquake. When referenced against previous movement patterns, lack of movement of individual mobile phones within a particular cell zone after an earthquake indicates how many people may have been in a particular building at the time. Absence of use and the rate of signal decay due to flat batteries provides a further indication of how many may be trapped and possibly still alive.

Mobile phone tracking can also be employed to reduce the chance of disease outbreaks. During the response to Haiti’s cholera outbreak in late 2010 and Sierra Leone’s in late 2012, it was possible to know which areas had received people from the affected zone, and therefore which areas were at potentially increased risk of a new outbreak[i]. This, in turn, allowed for health messaging over public broadcast radio services to be targeted at particular areas alerting both the incomers and indigenous populations to the heightened risk and what to do to prevent the outbreak from spreading. There is no technical reason that such messaging could not have been targeted to the individuals concerned, although data protection concerns currently preclude this. Mobile technology has also revolutionised the way communicable diseases are monitored after disasters. Already, mobile phones have detected spreading pneumonias in Sri Lanka, and escalating diarrhoeal diseases in Tamil Nadu within a day of the disaster occurring.

The most basic tool, text messaging, is used to communicate with specific disaster-affected populations. Geo-SMS identifies phones in a specific area and sends out messages from relief agencies asking if help is required to those phones only. A reply triggers a menu of options they can choose from, such as: “Do you need: 1) First Aid, 2) Medications, 3) Transport, 4) Food, 5) Water, 6) Shelter (press the corresponding number)”. This system is also used for sending early warning alerts. In the case of a tsunami, for example, it is pointless and potentially counter-productive to send such messages to mobile phone subscribers living on hillsides above low-lying zones where violent ingress of water could be expected. Yet, at the same time, it is important to alert those who may be involved in the aftermath, such as hospital staff.

Absence of timely and accurate data following a natural disaster is one of the greatest obstacles to overcoming public health challenges as people struggle to survive. Less than a decade ago, a woman in premature labour brought on by the stress of a disaster’s aftermath would have had few options to access life-saving treatment if an emergency health clinic had not been set up nearby. But today, mobile telephone technology can help her obtain medical advice over the phone, alert a community midwife to her plight, or even ask a volunteer to get her to the nearest hospital.

Also, the time taken to record health information can be slow when health workers have only paper and pencil to record where suspected cholera cases live, which children have been vaccinated, or where vital supplies have been sent. Paper is cumbersome; it has to be carried, kept dry, and it has to be photocopied. And then the data has to be re-entered manually on some computer somewhere. All of this is inefficient, and takes time. Software such as EpiSurveyor which was developed by the UN and the Vodafone Technology Partnership as an open-source platform, is typical of the sort of technology that can be used to control supplies and monitor areas where outbreaks are suspected, as it is “much cheaper, faster, of better quality, and easier to do than pencil and paper”.

And finally, there is mobile cash transfer. In October 2011, the UN’s World Food Programme started using mobile telephones to facilitate cash transfers to 54,000 of the most food insecure people living in the Ivory Coast who lost their livelihoods during the political crisis earlier in the year, and who lacked the resources to buy their food in the local markets.

For the potential of mobile telephony to be unlocked in the ways described here, the service providers have to be involved. For reasons of data protection, they are unusually discreet in how they apply the algorithms needed, and with which national and/or international authorities they coordinate. Care also has to be taken in how apparently valid information is moderated, as the humanitarian sector is as prone to manipulation and hacking as anyone else. Dilemmas over the unprecedented level of information sharing facilitated by this technology have led to debates over how the humanitarian sector can most effectively harness the full potential of this technology while retaining a principled approach to disaster preparedness, response, and recovery.

[i]              Bengtsson et al: Improved response to disasters and outbreaks by tracking population movements with mobile phone network data – a post-earthquake geospatial study in Haiti; 2011 (doi:10.1371/journal.pmed. 1001083).

Chairing Conference-Calls

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Message from Faculty: “Please will all students engaging in on-line tutorials or meetings remember to attend wearing clothes.”

Chairing and taking part in conference-calls is quite different to other sorts of formal or informal meeting and is an art in itself. Because visual cues are usually absent, a different set of rules apply. This does not mean you may attend naked, but may mean, for example, interrupting speakers in a way that might be deemed offensive when in a ‘normal’ setting of being around a table. The Chair should not be afraid to mediate ‘robustly’, especially once it becomes clear that attention spans are very very short and that you are competing with e-mails and Facebook posts you cannot see. Just listen to any BBC Radio programme and you’ll quickly get to understand the dark art of strategic interruption.

Whether chairing or participating, the following tips for better conference-calls – and, for that matter, conducting BBC interviews – have proved useful in the past:


• Distribute important documents to participants well in advance, including a draft meeting agenda and overall statement outlining the purpose of the meeting. Do this via a platform like Googledocs.
• Set the time and date of the meeting making sure to make clear what time-zone is being used, and e-mail all attendees the passcode and conference access number in advance.
• Open up the meeting room five minutes early and jot down the name of participants as they come on-line.
• Start your meeting on time by reading out the list of those who have logged on, introduce yourself, and then ask if there is anyone else on-line who has not been mentioned.
• Clarify the purpose of the meeting and quickly run through the agenda to confirm that it suits everyone. Quite often, one or two participants will need to leave early and so will want various items brought forward. Having agreed any revisions, let everyone know how long the meeting is scheduled to take.
• Introduce late-comers at a logical break rather than as and when they enter.
• Participants should identify themselves by name and location each time before speaking.
• If disconnected, simply re-dial the conference access number and enter the passcode. There is no need for re-introduction.
• If any participant thinks a speaker is rambling on or repeating things already said, they should not be afraid to say so. Nobody will be offended.
• Enhance call quality and minimise background noise by muting your microphone when not speaking. Bandwidth limitations usually preclude using video. Put some ‘scotch’ tape over the camera just in case.
• If chairing, summarise action points and deadlines at the end of each agenda item rather than leaving it all to the end. Make sure everyone knows to whom the responsibility for each action has been delegated.
• Leave some time at the end of the meeting for any other business (AOB). However, note that some chairpersons prefer to suggest that AOB merely sets the agenda for the next meeting.
• Provide the web address where participants can see and exchange materials and request additional information.
• Close the meeting by deciding when the next one is to take place, and, if rotating the chair, who is to facilitate preparations and chair. It’s surprising how many times this is forgotten.
• After your meeting, circulate decisions and action items by e-mail to all attendees as well as other appropriate people.

DISEASE CONTROL: Cash is as important as Vaccines

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In this article, James Shepherd-Barron argues that DFID should put ‘cash management’ higher up the humanitarian agenda, especially when tackling epidemics.

In its video Digital Payments and the Ebola Crisis, the Better Than Cash Alliance outlines the benefits of using electronic cash transfers during the EVD epidemic response in West Africa 2014-2015[1]. Unlike other studies on the use of cash transfers in West Africa at the time which tend to focus on food security, their case study looked at payments to frontline health workers, specifically the challenge of ensuring they were properly paid for the risks they were taking.

Prior to the crisis, health workers had received their salaries intermittently and in cash which meant taking time off to travel long distances and at their own expense. Not only was this highly inefficient but it allegedly led to payments being stolen and being paid to the wrong recipient. Not surprisingly, this had a negative impact on staff morale which in turn led to strikes, significantly slowing disease control efforts.

When Sierra Leone’s Ministry of health began making transfers via e-wallets on mobile phones staff motivation increased markedly: strikes ceased (preventing the loss of over 800 working days), incorrect payments were reduced, and the government saved $10 million in the process. In addition to these immediate benefits, the video went on to outline the longer-term benefits of digital financial assistance, suggesting that, with proper investment in preparedness, significant social and financial benefits would accrue.

All of this makes a compelling case for strategic country-wide investment in digital transfer technology that goes way beyond outbreak control.

However, the video makes no mention of the fact that healthcare workers engaged on the frontline of the response still had to cash-out their salaries if they wanted to purchase anything. Nor does it mention that 93% of unconditional cash transfers in Sierra Leone and Liberia were made in physical currency as their respective Cash Working Groups had concluded that “with inadequate facilities and a limited number of service providers, the potential for e-transfers was in fact very limited and not a viable mechanism for reaching most beneficiaries.”[2]

Exactly the same scenario played out – and is still playing out – in the Ebola-affected areas of the Democratic Republic of Congo four years later.

Yes, there are challenges with cash. It can be expensive, logistically difficult to distribute, and sometimes insecure … though a study by Mercy Corps found that electronic transfers were more expensive overall if start-up costs were included[3]. In the middle of an Ebola outbreak, people think cash might even be a vector or fomite of transmission[4].

But digital payments have challenges, too, not least how low smartphone penetration, unstable electricity supply, poor mobile phone network coverage, weak Internet access, unreliable payment channels at point-of-sale (especially in rural areas), fragile phone-based apps, the increased risk of online fraud, and, perhaps most problematic of all, the tendency to foster indebtedness all inhibit takeup.

Since Ebola is a not a disease that can be eradicated like Smallpox or Polio, and is therefore here to stay, getting agreed remuneration regularly to frontline health workers is critical to staff morale and therefore critical to the effectiveness of outbreak response measures. International health actors have to put as much effort into this aspect of the response as they do into developing new technologies such as vaccines, drug therapies and state-of-the-art barrier care.

Those commercial companies who manage cash for society could play a more proactive role in working with donors, line ministries, financial institutions and telecoms companies to make sure frontline health get paid properly and have the option of being able to convert their salaries to cash if they so choose.

As the leading donor in DRC, DFID is well placed to catalyse this critical piece of the Ebola response effort and should put ‘cash management in crises’ higher up the agenda, not just for Ebola but for all diseases of epidemic potential. Failure to ensure that such an essential piece of the response  jigsaw is in place will not only increase the likelihood that the disease will spread across international borders faster, but that it will spread further.

[1] Ebola was identified in Liberia and Sierra Leone in March and May 2014 respectively. By early 2016, 28,616 people had been infected of whom over 11,310 had died. This crisis left not only death and devastation in its wake, but had severe long-term social and economic consequences.

[2] Frisetti: Harnessing Digital Technology for Cash Transfer Programming in the Ebola Response; CaLP, 2018

[source: http://www.cashlearning.org/news-and-events/news-and-events/post/478-harnessing-digital-technology-for-cash-transfer-programming-in-the-ebola-response (accessed 5 Dec 20190]

[3] Mercy Corps

[4] Shepherd-Barron: Potential mortality effects of paper currency during outbreaks of Ebola virus disease; Cash Essentials, May 2019 [source: https://www.cashessentials.org/cash-crises]