Masks can save lives in areas with little access to vaccines. A program with origins in Yale SOM research gets them to sometimes isolated rural areas and encourages their use. It has reached 100 million people in Bangladesh and other countries in South Asia with a boost from Hanesbrands Inc. and critical support from local governments.
By Karen Guzman
A research-based initiative launched by Yale SOM faculty to promote the use of face masks in the developing world is gaining ground, thanks to burgeoning relationships with governmental officials and non-government implementers in the targeted nations, and boosted by a donation of 80 million masks from Hanesbrand, Inc.
“We’re seeing the program adopted on a larger scale, especially in difficult to reach rural regions of Bangladesh,” said Ahmed Mushfiq Mobarak, professor of economics. “The generous contribution from Hanes, and buy-in from local governments, is enormously helpful.”
Since the beginning of the COVID-19 pandemic, Mobarak has been among a team of researchers studying how to address the crisis in the developing world, especially South Asia. His research on mask implementation, co-authored with his Yale SOM colleague Jason Abaluck and other scholars, gave birth to mask campaigns now in place in Bangladesh, Nepal, Pakistan, India and parts of Latin America.
Their study showed that a “cocktail” of four interventions together substantially increased mask usage. The elements include no-cost masks delivered to people door-to-door; offering information on the benefits of masks; reinforcement of mask-wearing; and modeling and endorsement by trusted local leaders.
To reinforce these key elements, Mobarak and his team—which includes researchers from Stanford Medical School and the NGO Innovations for Poverty Action (IPA)—created an acronym mnemonic: NORM.
“This is an evidence-based program based on randomized control trials,” Mobarak said. “It’s been a challenge, but within a couple of months, partnerships were in place to reach 100 million people.”
The Yale/IPA/Stanford research team has expanded and is now providing technical assistance to government partners facilitating large-scale implementation of the NORM model. The team made an early presentation to Hanes, encouraging the company’s mask donations, assisting with the logistics of their global transport, and organizing fundraisers to cover shipping costs.
Jerry Cook, Hanesbrands’ vice president for government and trade relations, said the company has already donated 34 million masks to India, and is now branching out with donations to Pakistan, Nepal, and Bangladesh to facilitate implementation of the NORM model. In total, Hanesbrands has donated more than 110 million masks, to date.
“It’s our way of trying to help people deal with this terrible reality,” Cook said. “We’re grateful that we’re able to be part of this effort.”
In Bangladesh, NORM has partnered with BRAC, a Dhaka-based international NGO. Working with government officials, BRAC has spearheaded the effort to distribute masks and educate people about the pandemic. More than 81 million people are being reached through this programming.
As BRAC’s COVID-19 Response Program coordinator in Bangladesh, Imran Ahmed Chowdhury has worked with NORM to direct efforts. “Coordinating with government agencies both at local and central level has been critical,” Chowdhury said. Distribution has included homes, as well as community “hotspots” like bus stations, mosques, malls, and markets.
Even during the Eid-ul-Azha, when restrictions on movement are eased to allow ease of homebound journeys, BRAC volunteers continued their work in the field providing free masks. BRAC is also counting on endorsements from local community and government leaders, mosque imams, and other community influencers for support in creating an environment that enables best practices.
Support from community and religious leaders has been crucial, said Tanjila Mazumder Drishti, senior manager for advocacy, knowledge, communication, and partnership management at BRAC. “It’s working really well,” she said. “We’re fighting a global crisis with a local solution by empowering local people to lead the behavioral change.”
In Pakistan, Mobarak reached out to Maha Rehman, director of policy at Mahbub-ul-Haq Research Centre at LUMS, to form a coalition. Rehman has been instrumental in adapting Bangladesh’s largely rural village distribution model.
“The model was already very actionable,” Rehman said. “It just needed to be adapted for a big city like Lahore.” A comprehensive outreach strategy—including postal packages, flag marches, and city-wide marketing material—was deployed all over the city. Support from local influencers, celebrities, social media, and a June 30 launch event with the health minister of Punjab, the postmaster general and commissioner of Lahore all played a role. Lahore’s city-wide campaign has already reached 5 million people, and the country’s federal coordinating body on COVID, the National Command Operation Centre, has suggested that this intervention should be replicated across the country.
Captain (R) Muhammad Usman, commissioner of Lahore, said that new challenges are arising for governments across the globe as the pandemic evolves.
“When the NORM Model was introduced to us, we reached out to key stakeholders and partners who helped us implement the model,” Usman said. “The #LahoreWearsMasks campaign was launched. Results have been very encouraging, and the model has even been endorsed by NCOC, the highest body overseeing COVID in the country. Knowledge-sharing and replication of the campaign across borders speaks for the maturity, scientific, and administrative perfection of this model. We are already looking at launching #LahoreGetsVaccinated in partnership with the research team.”
Nepal’s Covid-19 Crisis Management Center (CCMC) has agreed to support NORM. “We are hopeful that the NORM model will benefit urban and rural communities by encouraging mask-wearing, especially in mitigating the effects of the possible third wave of COVID-19 in Nepal,” said Brigadier Gen. Dr. Arun Neupane, who heads the medical division of the center.
The Bill & Melinda Gates Foundation has donated to efforts in Nepal. “We’re glad to see the NORM project is now partnering with the Covid-19 Rapid Action Task Force Alliance for a national-level campaign,” said Roshan Raj Shrestha, Gates Foundation’s deputy director of Global Growth and Opportunity for Water, Sanitation, and Hygiene. “We’re happy to be part of this program and are hoping to get full support from the government and development agencies in this critical mission.”
The NORM project is also now branching into Latin America, where initiatives in Mexico, Uruguay, and Peru are being explored, according to Jose Pinilla, policy manager at Innovations for Poverty Action.
“We partnered with Uruguayan Senator Carmen Sanguinetti, and we adapted the tools we had used in the original study to collect systematic data on mask-wearing around Montevideo, supported by the Inter-American Development Bank (IADB),” Pinilla said. “We have also been supporting the state government of Guanajuato, Mexico, as it works on a plan to encourage mask-wearing.”
Two recent Yale SOM graduates are also part of the NORM project campaign. Janani Rajashekar ’21 is assisting Mobarak as a “scale-up coordinator,” organizing delivery of resources, as well as communication and coordination with potential partners. Preeti Adhikary ’21 is the Nepal and social media lead for the NORM campaign. Adhikary’s mother contracted COVID-19 in February 2021 and survived after three weeks in the intensive care unit. “For me, COVID feels so personal,” Adhikary said. “When the second wave was starting in Asia, I really wanted to contribute to the fight against it.”