The Mining Industry Role in Emerging Infectious Diseases Preparedness and Response “Outside the Fence”

Emerging Infectious Diseases (EIDs) such as Ebola are a signifi cant threat to global health. It is unclear whether the mining industry has adequately considered EID risks, and more generally the challenge of communicable diseases.


Introduction
Emerging Infectious Diseases (EIDs) remain a signifi cant threat to global health. The scale and frequency of outbreaks have increased since the beginning of the 21st century [1], and pose a major cost to the global economy [2]. Of all EID outbreaks, 60% are zoonotic, and 72% of those are transmitted by wildlife [1].
The mining industry often operates in areas where public health systems and control of communicable diseases are weak. In addition, mining operations can contribute to the risk of EID emergence through altering land use and humananimal interaction [3][4][5][6][7][8][9]. Consequently, mining companies and their surrounding communities are especially vulnerable to EIDs. For example, the West African Ebola outbreak resulted in a signifi cant downturn in mining activities, as the planned expansion of projects was halted, the production of several mining companies was reduced, and some companies ceased their operations altogether (e.g. China Union) [10]. The Ebola experience highlighted both the vulnerability of the private sector to disease outbreaks and its potential to play a role in combatting future outbreaks. Following these events, there have been calls for more rigorous implementation of the International Health Regulations, and better collaboration between public and private sectors [11].
Against this backdrop, understanding the private sector's role and how it can fi t in with the public sector is critically important. The objective of this qualitative study was to explore the acceptability of implementing measures to assess and mitigate the risk of EIDs in the mining industry. Taking current practices and the perceptions of sector employees into account through this study, we have made several recommendations as to how the potential of the mining sector can be better harnessed to prevent and respond to future EID outbreaks, including linking with the public sector. Citation: Llamas

Methods
A qualitative approach was chosen; these methods are well suited to examining people's perceptions of and attitudes toward new topics, as well as for understanding how local contexts can infl uence policy implementation [12].

Study setting
The study was conducted with four international mining companies operating in Katanga. These four mining companies work in partnership with international organisations working under the Infectious Diseases Risk Assessment and Management (1) (IDRAM) initiative. The IDRAM initiative is intended to facilitate dialogue between the extractive industry and international development actors, fi nance institutions, national governments and public health stakeholders in order to better understand the risks of EIDs associated with the activities of the extractive industry.

Sampling
The four mining companies were part of the aforementioned partnership; these were selected to include companies of different sizes, stages of the project cycle, management structure, and headquarters location. We recruited 3-4 employees per company using purposive and snowball sampling. The aim when sampling was to include respondents whose responsibilities and experiences allowed us to investigate a range of perceptions towards EIDs prevention and mitigation management strategies. This range of responsibilities and experience was refl ected in the sample, which included: International directors (n=3) who were responsible for policy formulation and adoption, setting standards and regulations, allocating resources and promoting international collaboration.
Staff on site (n=15) who were in charge of the day to day camp management and providing health services. This entailed implementing policy, upholding regulations, establishing operational norms, infrastructure maintenance, food safety and security, waste and water management, biodiversity maintenance, safety enforcement, workers' and community's health, and responding to outbreaks. A breakdown of respondents by type of role is included below ( Table 1).

Data collection
Semi-structured telephone interviews were used to collect data. Participants were asked about current IPC measures at their mining-site, as well as their views on the barriers and facilitators to introducing new IPC measures. All interviews were carried out in English, lasting between 30-60 minutes, and were digitally recorded. Notes were taken in the absence of permission to record.

Data analysis
Transcripts were analysed by the research team using thematic and comparative analysis. Deviant cases were analysed to maximise the rigour of analysis [12], and interpretation disagreements were resolved by consensus. Interview results were triangulated with fi ndings from a fi eld visit conducted by the research team, and focused on comparing participants' reports on current IPC measures with observed practices at mining sites.

Ethics
The study was approved by FHI 360 and Lubumbashi University ethical review boards. Respondents received information about the study and they provided informed consent.

Existing IPC measures
Our results indicate that the mining companies studied had good IPC measures in place "inside the fence"; that is, within the area controlled by the mining company. Broadly, these included measures to limit contact between humans and animals to avoid disease transmission, and measures to promote worker and community health in order to reduce the risk of EIDs occurring. For example, workers' accommodation and camp facilities were kept clean, rubbish was collected regularly, and food was kept in locked containers to avoid attracting nuisance animals. Safe food and water were available in camp and kitchen staff were regularly tested for infectious diseases. Hunting was strictly forbidden, whilst adequate nutrition for workers was ensured and efforts were made to preserve the little biodiversity remaining in the locality.
Simultaneously, respondents were aware of the vulnerability of mining-sites to the external environment in which they operated ("outside the fence"). Respondents considered the main source of risks to be located within the surrounding communities, where conditions were ideal for outbreaks due to weak health systems, poor infrastructure, poverty, and population movement and growth.  The environment "outside the fence" had negative implications for workers' health and reduced the overall effi ciency of the mining operation. For respondents, investing in developing health programmes in community settings and preventing workers from falling sick made "economic sense". As one respondent put it: Run of the mill exposures to diff erent infectious diseases do cost the company a lot of money. From a fi nancial aspect you can't aff ord the company to lose continuously hours and hours of man hours because of curable diseases. [Interview 4.2 Camp Manager] According to respondents, mines not only invested in IPC measures to reduce the sickness rate among workers and thus improve the bottom line, but also in order to meet international industry standards and corporate social responsibility (CSR) commitments. Respondents mentioned adherence to international standards and CSR as an important factor in their company's approach to health programming, which exceeded "anything that [was] demanded under the mining agreements with the Congolese government". Compliance with regulations and standards was driven by both company performance and reputation. The latter was particularly important for international companies listed on stock exchanges in developed countries and dependant on international capital.

Medical advisor]
An important fi nding is that mining companies had access to public health advice. Medical services in the mines had been issued with updated guidelines to manage potential Ebola cases by public health experts from ISOS. Public health experts were also drafted in to provide regular supervision or advice to local teams in specifi c circumstances. Thus, several respondents reported being well-supported and informed about new outbreak guidelines (e.g. Ebola).

Barriers to strengthening local health services
Whilst respondents agreed that strengthening the local health system was in everyone's interest, this motivation was moderated by respondents' concerns over fi nancial and feasibility issues. Health was neither considered core business nor expertise to the mining industry. Furthermore, respondents argued that mining companies were already providing more than local legislation currently requires and feared over-investing in community health programmes in case the Government relinquished responsibility altogether. For respondents, mining companies could not and should not replace government institutions, as ultimately it was the role of the state to provide services for communities.

I think people will say, 'Look, I'm here to mine, I'm not the government. I can't control, regulate, every animal and every person. People are responsible for themselves and there's the government here that should step up.' [Interview 5.3 Community development director]
Elaborating on this, other respondents noted that health issues were beyond their scope and expertise, which limited their involvement in EIDs control and prevention (e.g. health promotion).

Discussion
While we cannot make assumptions about the wider mining industry based solely on this study, our research has revealed important fi ndings. We found that companies were aware of the ways in which mining operations can increase transmission of infectious diseases and were already implementing a comprehensive package of IPC measures "inside the fence". Our respondents were also aware that mining companies remain vulnerable to disease outbreaks, mostly due to the conditions "outside the fence". The recognition of the impact of a high burden of infectious diseases "outside the fence" on the health of the workforce "inside the fence" and, consequently, on the profi tability of the mining operation, had contributed to the rationale for developing programmes to improve health and address infectious disease in the surrounding communities.
This fi nding is consistent with research elsewhere [13]. companies have generally tended to work individually, focusing on short-term fi xes rather than on sustainable improvements; for example by providing personal protective equipment or deploying logistical support, rather than strengthening the state health system) [17].
Overall, the potential contribution of the mining industry to EID preparedness and response has not yet been fully harnessed -neither in DRC nor elsewhere. This gap represents a wasted opportunity and several actions can be taken to encourage better coordination and cooperation between the mining industry and the public sector.
First, our results show that medical staff working for the mines had access to current guidelines and relevant information through ISOS (and other websites) and were already conducting some capacity building activities. Sharing information could be critical during an outbreak; local health workers in low-resource settings often lack up-to-date information and training, which negatively impacts on outbreak management. We suggest that longer term, coordinated investment in capacity building, such as joint training, should be conducted in partnership across mining companies and local health systems.
Second, mining companies could improve disease outbreak response and strengthen local health services by better sharing epidemiological data as has been done elsewhere [18,19]. Companies in our study reported that they already collect regular epidemiological data for the MOH. Our study could not determine how the MOH used this information, but given the weak infrastructure of the health system, it is likely that epidemiological data were not suffi ciently exploited to prepare for and respond to disease outbreaks. Often located in remote locations where health services tend to be minimal, mining companies could act as a sentinel surveillance system for diseases occurring "inside" and "outside" the fence.
Furthermore, the mining companies in our study appeared to have good access to surrounding communities through their workforce, dependants, and the existing support provided to community health programmes, and are thus in a good position to investigate rumours of disease outbreaks in the community.
Third, mining companies' access to communities puts them in a unique position to play a major role in disease outbreak management: during the Ebola outbreak communities' lack of trust in authorities, poor knowledge of the disease and sociocultural factors were all identifi ed as major drivers in spreading the epidemic, complicating the implementation of control interventions [20,21]. Mining companies could potentially provide more sustained support to local and international health authorities with effective community health promotion campaigns to encourage early referrals to care, adoption of preventive strategies and to address cultural practices that increase the transmission risk (e.g. burial practices).
However, the challenges of collaboration between the extractive industry and the public sector to strengthen health systems are substantial. Mining companies do not have the mandate, and neither are all suffi ciently large or wellresourced to take on such responsibility [17]. Consequently, our fourth recommendation is that a network should be established to pool resources and promote greater integration and coordination, comprising all relevant stakeholders: mining companies, MOHs, veterinary services, NGOs, WHO, research institutions, and UN bodies. Given the mining sector's uncertainty around intervening in communities and lack of trust in national health systems, combined with a desire to act unilaterally, establishing such a network could be complex.
[17]. Consequently a network would require clearly defi ned and agreed roles and responsibilities, raised awareness amongst staff at all levels, and the establishment of realistic plans to build capacity of health workers, health managers and public health staff. For example, mining companies operating in an area could share their fi nancial and human resources to improve laboratory capacity and effi cient sample processing to allow early disease diagnosis.
In conclusion, our study has indicated that while mining companies are currently aware of the risks of disease outbreaks, the potential contribution of the industry to EID preparedness and response has not yet been maximized. Although there are many actions that individual companies can take to reduce risk, collaboration between mining companies and other stakeholders (e.g. NGOs and the public sector) presents a win-win situation: effective partnerships have the potential to prevent and control future outbreaks in a coordinated, economical manner, in order to reduce loss of productivity and, most importantly, loss of lives.
Following the Ebola outbreak we face a signifi cant opportunity to change perceptions around the role of the private sector in public health, and it is one that we must work together to bring about.