* ‘People should not think that they are immune and will not be infected’
* ‘Mauritius has a good record of preparedness and rapid and effective response to many public health threats’
According to Wikipedia, public health has been defined as “the science and art of preventing disease”, prolonging life and improving quality of life through organized efforts and informed choices of society, organizations (public and private), communities and individuals. ‘Analyzing the determinants of health of a population and the threats it faces is the basis for public health. The public can be as small as a handful of people or as large as a village or an entire city; in the case of a pandemic it may encompass several continents.’ The results of numerous studies have indicated a very strong relationship between the health of a country’s population and economic growth. In this respect, a lot has been undertaken in Mauritius at the level of public health since decades, but these remain largely unknown to the people.
Dr Shahina Aboobakar has more than 35 years of work experience in the public health services in Mauritius, in both preventive and curative sections. She has worked in several capacities during her career, as Medical and Health Officer, Community Physician, NCD Coordinator, Regional Public Health Superintendent and finally as Director Health Services before retiring from Government service in 2018. Dr Aboobakar is a medical doctor with a Master’s Degree in Community Health from the University of New South Wales, Sydney and a Diplome d’Universitaire (DU) d’Epidémiologie Appliquée from the Mauritius Institute of Health and the Université Victor Segalen Bordeaux 2.
* It is only during times of crisis such as the present one that people hear about “Public Health”. What do you think should be done to maintain the visibility and highlight the importance of Public Health in normal or ‘inter-crisis’ times?
Public health is often considered as the “poor relation” of medicine in Mauritius, and it is the general but erroneous opinion of other specialties that there is not much work to be done in this field.
Public health is concerned with protecting the health of the entire population. In order to maintain the visibility and highlight the importance of Public Health, there should be major changes in the way public health services are organized, operated and governed in Mauritius.
* Should Public Health be considered a specialty on a par with other specialties? If so, what is the way to go about this, and can we learn from other countries in this respect?
Yes. Public Health is offered as a major at many international universities. In many countries Public Health graduates are employed by the government and state agencies, consulting firms, research organizations and universities. They can also be recruited by international health organizations such as the WHO, UNICEF and UNFPA among others.
* How can we incentivize medical graduates to specialize in it? Are there different branches that can be of relevance in light of the emergence of new infectious diseases?
Medical graduates can be encouraged to specialize in it as long as they are offered the same benefits as in other specialties. Some of the branches of Public Health which are relevant in the present context include Epidemiology & Biostatistics, Environmental Health Science, Social and Behavioral Sciences, and Disaster Management & Emergency Preparedness.
* Can you outline the evolution of the discipline up to the present?
The evolution of public health has been a continuing process through time with expanding scientific medical knowledge and experience. The need for an organized public health system for disease prevention and control grew as part of the development of community life, with its accompanying urbanization and social reforms.
At present, there are new public health threats, either replacing or existing along with non-communicable diseases such as diabetes, cardiovascular disease, cancers and mental illness. Additionally there is the threat of emerging and re-emerging diseases such as AIDS, SARS, Avian influenza and Covid-19, which demand new ways of preventing their potentially serious consequences to humanity. Additional threats include anti-microbial resistance and severe climate and ecological change.
* How far back in time do we have records about infectious diseases? What are the sources of historical material that are useful and required to research this aspect?
Epidemics of infectious diseases have been documented throughout history, with records of devastating epidemics of plague, smallpox, leprosy, tuberculosis, and syphilis going as far back as ancient Greece and Egypt.
The plague, or Black Death ((also known as the Pestilence, the Great Mortality, or the Plague), swept across Europe in 1345 and in the five years that followed killed 40 million people worldwide. The first recorded epidemic of smallpox was in 1350 BCE. Syphilis became epidemic in the 1490s as a highly contagious venereal disease in Spain, Italy, and France.
Useful material for research includes documents from the Centres of Disease Control, Atlanta (USA), the National Institutes of Health (USA), National Centre for Biotechnology Information of the National Library of Medcine (USA), the World Health Organisation and journal articles which can be accessed online.
* When did the terms epidemic and pandemic come into use, and what is the difference between the two? How do they differ from an endemic disease?
Epidemic is derived from Greek epi “upon or above” and demos “people”. After the non-medical use of the term epidemic by Homer, Sophocles, Plato, and Xenophon, Hippocrates gave it its medical meaning when he used it as the title of one of his famous treatises. Over centuries, the form and meaning of the term have evolved and changed. Its most recent semantic evolution dates from the last quarter of the 20th century.
An epidemic is the occurrence and rapid spread of a disease above what is normally expected in a population, whereas a pandemic is an epidemic that has spread over several countries or continents, crossing international boundaries and affecting a large number of people.
Endemic refers to the constant presence or the usual prevalence of a disease in a population within a geographic area.
Epidemics and pandemics differ from endemics in the sense that they are not always present in a population, but may occur from time to time, depending on factors favourable to their transmission.
* What are the major epidemics and pandemics that have taken place in the world and in Mauritius?
Epidemics and pandemics have ravaged humanity from prehistoric to modern times. One of the deadliest epidemics was that of Plague which affected many continents. The Black Death spread from Asia to Europe, from 1346-1353, killing about half of Europe’s population. The Great Plague of London between 1665-1666 killed 15% of the population of London, followed by the Great Plague of Marseilles from 1720-1723 and the Russian plague from 1770-1772.
Another lethal pandemic was that of Spanish Flu which, from 1918 to 1920, swept across the world in a matter of months and affected an estimated 500 million people. Another major pandemic in recent years is that of AIDS since 1981.
In 2009, a new strain of H1N1 virus infected as many as 1.4 billion people across the globe in one year and killed between 151,700 and 575,400 people.
The Ebola epidemic ravaged Guinea, Liberia and Sierra Leone in West Africa between 2014 and 2016, with 28,600 reported cases and 11,325 deaths. An epidemic of the newly emerged Zika virus appeared mainly in the South and Central American countries in 2015 and is still prevalent there.
Mauritius has had its share of epidemics. Malaria vectors were imported into Mauritius in the mid-1800s, and a violent epidemic occurred in 1867 followed by recurrent epidemics of malaria with high mortality during the next 100 years.
In 1889 the island was hit by smallpox and the infected patients were quarantined at Pointe aux Canonniers.
The first Spanish flu cases in Mauritius occurred in May 1918. It was a terrible catastrophe causing many deaths. An epidemic of Poliomyelitis occurred in the island in 1945.
The first case of AIDS in the Republic of Mauritius was notified in October 1987. An epidemic of Chikungunya, a disease never known in Mauritius, occurred in 2005 and 2006. Since then only imported cases have been reported. The Influenza H1N1 pandemic occurred in 2009.
Mauritius had several major outbreaks of dengue fever in 2009, 2014, 2015 and in 2018, which were due to local transmission of the disease by infected mosquitoes.
* What were their impacts on the health systems and on society at large?
Major epidemics and pandemics irrevocably change the social and economic fabric of society, causing short-term and long-term damage to economic growth. They also place a heavy burden on the health system.
* How did the authorities respond to them, and how effective were these responses?
The response of the Government to infectious disease outbreaks is critical for a country’s economy, its society, and its place in the global community.
Immediate public health measures were taken in accordance with established protocols.
Adequate resources were gathered to combat the prevailing disease.
Intersectoral collaboration was implemented to enlist the help of other government bodies and the private sector to put resources together to control the epidemic.
Sensitisation campaigns were strengthened at community level.
Help was sought from international bodies such as the WHO and the Indian Ocean Commission.
* Did these lead to the required policy changes so as to prepare for and pre-empt future occurrences?
Yes. Some of the policy changes included the following:
Preparedness and National Action Plans for different diseases were worked out and validated.
Rapid Response Teams were set up and trained at each regional hospital, and are currently functioning in the response to the present Covid-19 pandemic.
Laboratory capacity was strengthened and equipment was procured.
Capacity building of relevant staff was carried out.
The Communicable Disease Unit at the headquarters of the Ministry of Health and Wellness was strengthened.
Surveillance systems, in collaboration with the Indian Ocean Commission and WHO were set up and are still functional. The National Influenza Centre located in the Central Health Laboratory of Mauritius carries out surveillance for influenza and regularly sends specimens to the designated WHO GISRS (Global Influenza Surveillance and Response System) laboratory of the Influenza Collaborating Centre at Mill Hills, London.
* How does the current Covid-19 pandemic compare to the Spanish flu of 1918?
There is controversy over the origin of the Spanish flu virus, which may have originated in Spain, France or the USA, but there is no definite evidence of this. Covid-19 originated in Wuhan, China on 31 December 2019 probably in a wet market.
The spread of Covid-19 is wider than that of Spanish flu and affects almost all countries in the world whereas the 1918 influenza affected less than half of the countries.
The two pandemics largely differ in the population at risk. The mortality rate due to Spanish flu was higher in the 25-40 year olds, while Covid-19 mostly affects those over the age of 65, especially those with co-morbidities.
The two viral diseases kill via different mechanisms. Patients with Spanish flu mostly died due to secondary bacterial pneumonia, while those with Covid-19 die from an overactive immune response that results in multiple organ failure.
Both the Covid-19 and 1918 influenza pandemics have caused significant negative impacts on health systems and the global economy.
* We have seen that proper communication is very important in the management of such a major public health emergency. Do you have any suggestions for improvement to make in this regard?
Social mobilization and community participation are key components for sustainable prevention and control of infectious diseases. Civil society groups and inter-sectoral groups should be fully involved in health education, personal protection and law enforcement. Risk Communication is very important, and health care staff and the public should be fully informed about new and emerging infectious diseases through fact sheets and other modern communication strategies.
During the epidemics of Chikungunya and Influenza H1N1, our team at the headquarters of the MOH had prepared detailed fact sheets which were distributed to all doctors in the country. Teams went out to the community to explain the disease Chikungunya, about which there were many myths and misconceptions, and for door-to-door distribution of pamphlets and mosquito repellents.
* Clearly, coronavirus is not the last word in infections that mankind is going to face. How can we as a country be better prepared to face such threats?
Mauritius has a good record of preparedness and rapid and effective response to many public health threats in the past. This must be sustained and further advanced by fully implementing the International Health Regulations (IHR 2005) to strengthen core capacities so as to be better prepared and respond effectively to both known and unknown public health threats in the future.
* Do you have any message to the public at large for their present and future health security?
I would like to take this opportunity to request the readers of this newspaper and the public at large that they should heed the advice given to them concerning disease prevention and control. In the present pandemic, they should observe all precautions, use masks properly, wash their hands often, use sanitisers and maintain social distancing.
Covid-19 does not spare anyone and people should not think that they are immune and will not be infected. They are as susceptible as anybody.
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