By our correspondent in Male’

“On the day after the committee meeting the fever notched another small advance. It even found the way into the papers, but discreetly; only a few brief references to it were made. On the following day, however, Rieux observed that small official notices had been just put up about the town, though in places where they would not attract much attention. It was hard to find in these notices any indication that the authorities were facing the situation squarely. The measures enjoined were far from Draconian and one had the feeling that many concessions had been made to a desire not to alarm the public. The instructions began with a bald statement that a few cases of malignant fever had been reported in Oran; it was not possible as yet to say if this fever was contagious.”
Albert Camus, The Plague.

An outbreak of Chikungunya was reported in northern areas of India as early as February 2006, shortly after an alarming outbreak brought worldwide attention to the disease in La Réunion. Our health authorities failed to notice this alarming trend in our neighbouring country, or even if they did notice, they kept silent.

The government of Maldives did not react to an outbreak of Chikungunya in Kerela state in India in October 2006. The affected areas in Kerela included Trivandrum or Thiruvananthapuram, which is the most popular Indian destination among Maldivians going there for medical treatment and vacation. Daily flights between Trivandrum and Male’ carry Indian workers and travelers and Maldivians. It may be a matter of a few days for a disease to reach the Maldives from Trivandrum. Any outbreak of a disease in that part of India should have been taken as a serious issue.

When an unusual fever started spreading in the Maldives with symptoms of Chikungunya, the government was once again slow to react.

The government of Maldives failed to act according to WHO best practices for communicating with the public during an outbreak. Report of the WHO Expert Consultation on Outbreak Communications held in Singapore, 21-23 September 2004 cautions against such irresponsible behaviour by the authorities.

At the other extreme, outbreak control can be severely impeded when political authorities, motivated by economic rather than public health concerns, decide to withhold information about an outbreak, downplay its significance, or conceal it altogether. Such a position, which has been all too common in the past, can endanger international as well as national health when the disease has features – non-specific early symptoms or a long incubation period – that allow it to be carried abroad by international air travellers.

An article about Chikungunya in Haveeru explains to some extent how our authorities were dealing with the outbreak. However, this article fails to mention that there were cases of Chikungunya even prior to November 2006 and that the authorities downplayed the significance of that and made no attempt to either identify the disease or even if they had identified it, did not announce it to the public.

When reports of an anomalous fever spreading throughout Maldives first emerged in November, the DPH issued another warning about pretty much said that they had no idea what the new disease was. By the first week of December rumours had begun that the new viral fever was in fact Chikungunya, and the number of people who had come down with it was increasing rapidly. The DPH then sent some blood samples abroad, collected from throughout the country, to test whether they were dealing with Chikungunya. Prior to that Maldives had been seeing increasing numbers of people contacting Dengue fever and there had even been some fatalities from the disease. During the third week of December a four year old died in Faafu atoll Feeali, and although there was no way to confirm it, due to lack the necessary equipment in the island, the Health Center believed that the child had died of Dengue fever. But the symptoms that were being seen were different from Dengue and the DPH needed to find out for sure what they were exactly dealing with. On 25th of December, the DPH finally revealed that the results had confirmed that the anomalous fever was indeed Chikungunya.

Opposition media websites Minivan News and Dhivehi Observer reported the outbreak earlier than the official announcement.

Minivan News report of 23 December 2006 correctly implied that the government was playing down the urgency of the matter because the outbreak may have negative impacts on the tourism industry.

Despite the government’s warning, some have expressed fear that the Department of Public Health and the Health Ministry are “playing down” the incident and do not realise the serious of the matter.

They blame the government’s actions largely on the tourism industry. If tourists are alarmed the will not travel to the Maldives and consequently, the country will loose money.

The authorities should have realized that this is the age of the Internet and it would be rather foolish to try to cover up what was happening. Indeed, many travel information and advice websites now the carry the news that there is an outbreak of Chikungunya in Maldives. WHO has identified this trend in their report:

Conditions in the 21st century’s highly mobile, interdependent, and interconnected society may have changed some of the rules for outbreak communication. Under these conditions, it is increasingly difficult to think of an outbreak as having merely national or local significance given the increased opportunities for spread by air travellers and the potential consequences for distant economies. The democratizing power of rapid electronic access to information may also have changed the rules. In the information age, it has become increasingly difficult to cover up an outbreak – media coverage can make outbreaks too big to hide. In the final analysis, truth will prevail: rumours and their investigation by the media will eventually uncover the facts even when the authorities attempt to conceal them. When disclosing information, making information about an outbreak public locally is now equivalent to making it public globally.

From the available media information it seems that blood samples were not sent abroad for testing even by the end of November.

Doctors announced on Tuesday that there is currently a viral fever with new properties.

Some of the doctors at Indira Gandhi Memorial Hospital said that the symptoms of the new virus included high fever, headaches, aches in joints and muscles, dizziness and nausea, weakness, and outbreak of pimples. Some doctors said that these were the symptoms of Chicken Gunya, spread through mosquitoes in neighbouring countries.

“There is a viral fever with unusual symptoms,” said a senior doctor at IGMH, Dr. Ahmed Raazee. “However, we have as of yet been unable to diagnose what this particular viral fever is. We would need to conduct a serology test in order to find out what disease this is.”

According to IGMH Director of Medical Administration Dr. Fathmath Mohamed Didi, the blood samples necessary for the tests to identify the disease are being collected. The samples are to be sent abroad to be tested.

“We need to conduct a viral test, which will be done abroad,” said Dr. Didi. “We need a certain amount of samples to be able to do that, and we are currently in the process of acquiring the samples.”

What is most revealing about the attitude of our health officials concerning this outbreak can be seen in the same Haveeru report of 29 November 2006:

A representative of the Department of Public Health said on Tuesday that the viral fever had spread to the islands in other atolls. However, the official said that the spreading of the diseases is not something to be concerned about.

“There is a certain amount of illness because of the rainy season,” said the DPH official. “The current count shows that around 284 people have been infected.”

We have reliable information that cases of Chikungunya were found in the Maldives even before November 2006. The government should have been alert since the outbreak in Kerela and the authorities should have sent blood samples for testing earlier than end of November. Chikungunya is not a new disease, even though it is new to the Maldives. Identification of the disease and prevention measures should not have taken weeks and months.

By mid-December it was too hard to ignore the disease. It was prevalent in various islands of Raa Atoll prompting the Maldivian Democratic Party to send a team there to investigate it. The disease also made quite an impact in the capital Male’. At last the silence was broken. The Department of Public Health confirmed that it was indeed Chikungunya. Haveeru report of 26 December 2006:

Tests done by sending blood samples abroad has confirmed the presence of Chikungunya, the Department of Public Health (DPH) has said on Monday.
An official of the Department said that due to recent outbreak of viral fever all over the country, the Department had sent blood samples from people all over the Maldives to be tested abroad, and that the results had confirmed the presence of Chikungunya and Dengue fever virus in some parts of the Maldives.

Confronted with a public outcry, more measures were introduced including the formation of a task force. Haveeru report of 28 December 2006:

A special task force to control the growing number of victims contacting the Dengue fever and Chikungunya has been formed by the Department of Public Health (DPH). The two kinds of fevers have become very widespread throughout Maldives. The DPH said that the Multi-sectoral Task Force has already held their first meeting.

The Task Force, which includes members from the Defence Ministry, Energy Ministry, Agriculture Ministry, Tourism Ministry, Public Infrastructure Ministry, Atolls Ministry, Health Ministry, the Information Ministry and the DPH, has already started work on controlling dengue fever and Chikungunya. In that regard, they had discussed the most effective ways to bring the mosquito population down, eliminate mosquito breeding grounds and also how to do it in a sustainable manner, before coming up with an action plan.

Haveeru report of 7 January 2007:

More than 3,500 cases of Chikungunya have been confirmed in Maldives in the past month alone, the Department of Public Health has revealed last Thursday. Like Dengue fever, Chikungunya is spread by mosquitoes and both diseases have been confirmed to be spreading rapidly throughout the Maldives.

The DPH also revealed that out of the 20,853 reported cases of those who had been diagnosed as having contacted diseases being spread by mosquitoes, 3,634 were confirmed as Chikungunya. Out of the 16,971 cases of viral fevers reported 248 were diagnosed as Dengue fever.

WHO reports that there is an outbreak of dengue in the Maldives since January 2006. This has not been controlled during the past year and even now healthcare facilities in rural villages are struggling to cope with patients suffering from dengue. It is pathetic that it took an outbreak of epidemic proportions to force DPH to combat mosquitoes, despite the presence of dengue in the country for over a year.

Three schools were closed at the beginning of academic year due to Chikungunya. Haveeru reported on 15 January 2007:

Even though the new academic year had begun yesterday the Education Ministry has announced that three schools will remain closed due to the spread of the viral fever, Chikungunya.

According to a statement given today by an Education Ministry official, schools in Haa Alif atoll Ihavandhoo, Meemu atoll Dhiggaru and Alif Alif atoll Himandhoo will remain closed for another week because lots of students as well as teachers were suffering from Chikungunya.

The psychological trauma to the patients as well as the social and economic toll is heavy. There is hardly a family without a patient suffering from Chikungunya. An epidemic can affect the productivity of a country and at this moment Chikungunya and dengue is doing that to the Maldives.

Even though tourist resorts where most of the visitors stay, have mosquito control measures in place, for sightseeing and shopping, some tourists tend to visit other islands, including Male’, where the disease can be found abundantly. The government of Maldives should realize that covering up the situation with a cloak of secrecy will make it more difficult to control the disease. If tourists are affected by the disease while they are in the Maldives it will cause more negative publicity if the tourists were not aware of the situation before they arrived. We can understand the mentality of the Maldivian government from the WHO report.

The political context further defines the communications challenge. Countries with a democratic tradition, in which politicians are elected and held accountable for their actions and the press enjoys full freedom, will be expected to issue reliable information about an outbreak and keep no secrets – or pay dearly if they do. More authoritarian governments may be less forthcoming with public information but will have the clout to enforce public compliance with control measures and can thus bring an outbreak under control with impressive speed, albeit frequently without regard for public sentiment or human rights. A political culture in which officials regularly collaborate with the media and know how to use them is more likely to maintain public confidence in an outbreak response than a political culture in which the media are distrusted and their work is suppressed.

WHO has outlined the following five critical practices as important when dealing with an outbreak: build trust; announce early; be transparent; respect public concerns; and plan in advance. The dictatorial government of Maldives has not respected these practices when dealing with the outbreak of Chikungunya. The authorities’ attitude is eroding any of the remaining public confidence in the healthcare system and discrediting an already unpopular regime.