1990: Cholera campaign -- lessons learned

Consortium of Universities Estela Roeder

Cholera in the Americas• The return of cholera to the Americas in 1991 marked

the beginning of the first epidemic of this disease in the 20th century, with almost 400,000 cases and a death toll of 4,093 in the first year, giving the warning signal with regard to surveillance for the control of this pandemic, which had been the scourge of mankind for centuries.

• In January 1991, Vibrio cholerae 01 was detected in a coastal village of Peru, signalling the arrival of the seventh cholera pandemic to Latin America. By 2000, the epidemic had reached 21 of the 35 countries in the Region of the Americas.

• The following case history, prepared by Lic. Estela Roeder, Head of Communications of the Peruvian Ministry of Health at the time, presents the context, strategies, analyses and lessons learned from this cholera episode.

Why do epidemics occur?

Epidemics have different causes and effects in different regions / countries, depending on:a) Level of economic developmentb) Educational levelc) Cultural aspects: habits, customs d) Government policies on health and the environment

An epidemic shows up the living conditions

The early 1990s

• When the epidemic broke out, the Peruvian government had been in office for 6 months.

• Peru was going through an acute economic crisis, in view of the negative results of the former administration.

• Outside Peru, a new war was starting: the Gulf War (Irak invaded Kuwait).

Cholera in Peru

• The Minister of Health was a person with technical and professional prestige at the international level.

• He had a team of qualified officials• There was a desire to change things in the Ministry• Institutional expectations were great• The people of Peru were demanding better health

services (quality of health care, resources, and infrastructure)

• NGOs were leaders in the topic

Cholera in Peru (Continued)

• In January 1991, the summer campaign for the control of diarrheal diseases (high infant mortality rate) had just been approved and was to be launched in February/March

• Basic sanitation conditions were precarious: more than half the population of Peru did not have piped drinking water and had no drainage system

• Health education was not developed• The reorganization process in the Ministry

of Health was incipient

How the cholera arrived

• The cholera in Peru was part of the seventh world pandemic. Asian countries had the highest incidence.

• Peru’s health personnel had experience managing diarrheal diseases with oral rehydration salts (“life-saving packets”; community Oral Rehydration centers; health education), but they knew nothing about cholera.

How the cholera arrived (Continued)• At the end of January, a few adults (men

and women) in Chancay, north of Lima, showed signs of acute diarrhea.

• At the beginning of February, the cases multiplied massively

• The Minister of Health was on an official mission outside the country

• The media started publishing headlines on the topic. Pressure by the media.

• On February 4, the Director of the National Health Institute announced to the country the presence of cholera (with the consent of the President of Peru)

A campaign is approved

• The campaign was called a “stop cholera” campaign, because of the emergency situation (thousands of cases)

• The Communications Bureau of the Ministry of Health assumed responsibility for the campaign

• International cooperation arranged to support the informational/educational activities with technical assistance (rather than financial)

• NGOs and social organizations offered their help

• The mass media offered free spaces

The strategiesInstitutional• National Committee (Command) for the

Fight against Cholera (Communications Bureau participates)

• Daily press releases approved by the Ministry and the Committee. Selection of the informational and educational topics in keeping with the process of the epidemic (Epidemiology Room)

• Selection of official spokespersons• Media cooperate in the reception and

delivery of funds / donations

The strategies (Continued)

Alliances• With the other Ministries (competition)• With the municipalities• With NGOs (reproduction of

communication material and products)• With community-based organizations• With cooperation agencies• With the media

Communication tasks

• Design basic and secondary messages• Work closely with the media• Appoint recognized spokespersons

(decision of the Ministry)• Use clear, simple statements (consensus)• Produce informational material (posters,

flyers, banners)• Prepare graphic arts for posters for the

NGOs

Communication tasks (Continued)

• Produce a video spot with the basic messages (Institute for Research on Nutrition / Banco de Crédito)

• Produce a radio spot for all radio stations throughout the country

• Print information sheets for journalists• Prepare graphic arts for the newspapers • Invite journalists to key events

Main messages

1. Wash your hands 2. Boil your water3. Eat cooked food

Campaign motto:

LET’S STOP THE CHOLERA!

SWOT Analysis

STRENGTHS• Immediate decisions were taken to

prepare the health services • The health personnel participated

actively• Institutions and companies gave their

support• Cooperation agencies congratulated

Peru on its handling of the situation

SWOT Analysis (Continued)

STRENGTHS• A “stop cholera” campaign was

designed and implemented successfully• The media played a key role publishing

the official press releases and informing about measures for prevention and control

SWOT Analysis (Continued)

WEAKNESSES• The President kept quiet at the

beginning and then assumed a contradictory discourse (“The War of the Cebiche”)

• The other ministries started to compete with the Ministry of Health (Agriculture, Fisheries . . .)

• There appeared “experts” outside the Ministry of Health

SWOT Analysis (Continued)

WEAKNESSES• The recommendation not to eat raw fish

was made without coordinating with the fisheries sector

• Initial inaccurate information (boil water for 15 minutes)

• Wave of social protests (using gas / kerosene to boil the water; not being able to go to the beach; tourism restricted)

SWOT Analysis (Continued)

OPPORTUNITIES• Create an image of credibility in a

situation of threat to public health• Re-structure the health system

(emergencies)• Generate institutional philosophy and

commitment• Propose medium- and long-term

programs for basic sanitation

SWOT Analysis (Continued)

THREATS• Cholera might remain• Loss of prestige at the international

level (exports)• Growth of social protest• Intensification of poverty• Delaying of other institutional priorities

(decentralization)

Lessons learned

BAD THINGS

• Contradictions at the government level• Latrines installed throughout the

country• The population was frightened

Lessons learned (Continued)

GOOD THINGS• Deaths of hundreds of thousands of

Peruvians were prevented• Social deficiencies were brought into

evidence• Health personnel acted with a great

sense of responsibility• Civil society had an active participation• The media played an educating role

rather than indulging in sensationalism

Communicationally speaking

• The three basic messages were assumed• The population changed its behavior• Greater importance was attached to

communication (more support / resources)• The “stop cholera” campaign was a

prologue to the educational campaign for 1991

• It was a starting point for the development of new health communication models