When we think of the recent epidemics in Africa, it is of course Ebola that comes to mind. Its virulent nature, its initial lack of a vaccine and treatment, but also its shocking nature for the populations of the affected countries, has left its mark on people's minds. If there is one thing that we have learned from this episode, it is the indispensability of the multi-disciplinary nature of the actors who have joined forces to combat the epidemic. As microbiology researcher Professor Philippe Sansonetti explains, "This is probably the first disease where field interventions have involved doctors, epidemiologists as well as sociologists and anthropologists. This made it possible to identify very precisely the areas and sources of contamination. In particular the funeral events, the situations of traditional groupings which, perhaps, would have gone unnoticed in other circumstances".
Cumulative confirmed cases of
COVID-19 on 31 March 2020
Source: WHO Africa Dashboard
As the African continent is now affected by the COVID-19 pandemic, which has already infected more than 4,000 people and caused the death of some 100 across the continent, it is striking that the lessons learned from the Ebola crisis do not seem to guide most of the discussions in ministries and among donors, who seem mainly focused on the medical response. The challenges to the health system are obvious: it is reasonable to assume that capacity for emergency management, coordination of intensive care, numbers of health workers, and equipment is insufficient. This capacity has been shown to be inadequate in some countries that have, seemingly, the best-performing health systems.
But beyond the challenge for health systems, which we know will not be able to respond adequately if COVID-19 spreads, the lessons of Ebola also teach us important lessons about priority subjects such as the protection of health workers, the limits of biomedical approaches, which often create great social tension between populations and health-care services, the role of the media and the difficulty of communicating in an appropriate and effective way, and relative confidence in the health system. Added to all this are issues related to the continuity of care for chronic patients, who are known to be the first victims of these epidemic phenomena.
Protection of medical staff
In Europe, healthcare workers are paying a heavy price in the fight against COVID-19: in Italy, 4824 professionals have been infected as of March 24, 5400 in Spain (representing 14% of that country’s total infections), and in France, the Minister of health announced 600 new infections among health professionals last week. This is due to the virulence of the transmission of this particular coronavirus, but also to the inadequacy of the protective measures available: too few masks, which have to be recycled, no more double protection, the unavailability of face shields, and so on. Many health workers have denounced this situation and testified they were working unprotected, with fear of being contaminated.
During the last Ebola epidemic in West Africa between 2014 and 2016, 891 healthcare workers died from the virus out of the 10,000 people who died, i.e. 9% of the total. One remembers the long and important disputes about the outfits and protections used to care for the sick. Without going into this long debate, it is clear that the protection of the carers, who are few in number to begin with, as well as the protection of the community actors who will be involved in the activities we will describe below, is essential. These community actors were systematically forgotten in the response to Ebola, denying their important role in awareness and prevention activities, and denying their needs, in terms of protection, and psychological and social support.
We do not know whether today, in the needs assessments made by the Ministries of Health of countries that have submitted plans to the Global Fund for additional funding, these needs have been fully taken into account, and whether the staff of community-based organizations can count on the protections that will be put in place for health workers.
Bio-secure approaches and their limitations
Countries that have been able to respond rapidly and relatively effectively to the COVID-19 epidemic have all applied the same strategies: systematic and large-scale population testing with very rapid isolation of positive cases, and containment measures such as quarantine and self-isolation. The difficulty of the French, Italians or Americans to respect the prevention instructions as soon as they were put in place (social distancing, and later on containment) was obvious. And all this while sources of information on modes of transmission, recognition of symptoms, actions to take, etc. were widely accessible and understandable by all.
The socio-anthropological work carried out at the time of the Ebola crisis clearly showed to what extent bio-security approaches, based on medical knowledge, and the dissemination of information through traditional channels, were not effective. The local reinterpretation of national decisions and international WHO guidelines thwarted these plans, to the extent that interventions by health workers and community agents met with strong resistance from the population and in some cases their refusal to be treated. Among the most unpopular measures: the isolation of patients, some of whom were not seen alive again after being placed in isolation, the evacuation of bodies and the impossibility of organizing funerals, authoritarian modes of disinfection and, in front of the whole neighbourhood, the disinfection of the homes of infected people, and compulsory screening linked to the study of the chain of transmission, all of which caused misunderstanding, fear and stigma among some communities.
Alice Desclaux describes well how anthropologists were then, belatedly, asked to deploy, and “to understand the perceptions and attitudes of the populations, to identify opinion leaders and 'allies' for communication, to suggest appropriate messages, and to support the constitution of local Ebola control committees in order to facilitate the deployment of health interventions and to promote community participation in the response (...). This work, which is specific to local micro-social settings, requires rapid response – before social tensions escalate into conflict, which is important in view of the large number of sites involved.”
Isn't it also the role of community-based organizations (CBOs) to raise needs, to adapt the discourse imported from the medical environment so that communities can better understand it, and to support local-ownership approaches?
Confidence in the health-care system
Another key factor in the fight against COVID-19 will come from the confidence that the population places in its health system, and in the instructions given by the political authorities. What is at stake goes well beyond the simple framework of the epidemic, and refers to many other subjects, among which are the following:
- The memory of how other crises of any kind – health, security or natural disaster – have been managed, and how the government of the day has dealt with them. Were they transparent and honest? Did they take into account the real needs of the population and protect them? Did they put in place the necessary mechanisms to anticipate future crises?
- Confidence in the ‘biomedical’ health system: The writings of social anthropologists have clearly shown how, in parallel with research on the determinants of Ebola-virus transmission, popular interpretations based on "ethnic" references emerged and conditioned the behaviour of populations, particularly in rural areas. It is to be feared that in the case of COVID-19, in the absence of a good knowledge of the associations, misunderstandings, or rumors linked to this virus imported from Asia, then from Europe through travellers, multiple and mostly erroneous interpretations are possible. Already, writings have circulated on social networks, which have questioned Chinese interests on the African continent and seen in the virus a translation of the ‘Asian giant’'s desire to weaken the continent for future negotiations.
- Finally, of course, this confidence depends on the effectiveness of the health system in meeting the needs of patients. We know that the first response sought, especially but not only in rural areas, is from traditional practitioners. This is due to the poor quality of medical services in health facilities, most often combined with exorbitant costs for the patient, who sometimes pays more than half of the bill. All this causes a breach in the trust that people have in the health services of the formal system.
Consequences far beyond the epidemic itself
We can already see that a health crisis such as the one we are going through today jeopardizes all the foundations of society, beyond the lives lost. On the one hand, the entire economic system is being affected, and in the countries of Africa (and many others in Asia and Latin America), these are economies that operate partly informally. For these, solutions such as teleworking, and the whole digital economy linked to online shopping – even if it’s just for food – are unthinkable on a large scale, and inaccessible to the majority of the population. All measures aimed at containment, curfews and closures of places where people gather require the partial or complete cessation of activities of the majority of the population of the African continent. In countries where people earn on a daily basis, in cash, and where everyone buys products sold in markets in just the small quantities they can afford, supply under the conditions of containment will be one of the main challenges. There is concern on the part of civil society and the populations themselves that very soon the most vulnerable people and groups will no longer be supplied and will be further impoverished.
This situation, coupled with the concern about the spread of COVID-19, is conducive to the social disorder that is now visible in some European cities. Police forces and sometimes the army are called upon to enforce the quarantine, and these images have led some journalists to say that we must be vigilant about our fundamental freedoms. The confinement, social distancing, and volatile nature of COVID-19 itself together lead to a series of unexpected reactions that are conducive to calling social cohesion into question: depending on people’s circumstances, they will be able to withstand containment measures better or worse than others. For some people will have easier access to screening tests, will be treated under the best conditions and will be least affected by the logistics of containment. Others, who lack the technological means, and have no cash or savings once their work ceases (in reality 95% of the informal economy such as restaurants, cafés, non-essential services) will have much greater difficulty in coping.
Reflection on the role of civil society in the COVID-crisis 19
The purpose of this article is not to list the problems that African countries will face in the coming days. The images of what is happening in Europe and the United States have travelled around the world, and everyone is wondering how best to anticipate the dramatic consequences we have listed before.
What strikes me, however, is how little account has been taken of civil society in the management of this crisis. One only has to read the declarations of the main donors, technical and financial partners, ministries and governments, to see that the main subjects remain economic and biomedical, as if we could analyse the situation of populations by compartmentalising their problems: their health, their means of survival, their security... we make the same mistake again and again: not to ask the populations, and civil society organizations, what their needs are and how best to reconcile health imperatives (protective and preventive actions and containment) with an economic, cultural and social reality that produces its own constraints. There is an urgent need to work with the communities and to devise a local response, coming from the communities themselves, in order to avoid sinking into the crisis.
In its regular communications on COVID-19, the Global Fund, which has otherwise been remarkably flexible and quick in its response to COVID, hardly ever mentions CSOs. The main activities that the Global Fund is willing to fund, of course, cover supplies, laboratory systems, protective equipment for health workers, and community health workers. But there is no mention of CSOs, some of which provide services to patients (testing and treatment), and others that are important vehicles for advocacy, anti-discrimination, community mobilization, and monitoring the quality and availability of services.
Civil society organizations in West and Central Africa, if supported by strong organizations (such as Médecins sans Frontières, Action Contre la Faim, the Red Cross, Alima), and public and private actors to strengthen logistics, will be able to respond to supply needs in neighbourhoods and villages. They are also able to set up networks of mutual aid, information and education on the most essential preventive actions (while ensuring access to water and soap).
Organizations involved in the fight against epidemics already know which patients are most at risk. It is known that in addition to the victims of COVID-19, many patients are at risk of having their treatment for other conditions interrupted for many reasons: stock-outs in pharmacies (the country has closed its land and air borders, stocks are therefore difficult to renew), desertion of health facilities by health personnel who do not feel protected or who will be affected by the virus, difficulty for patients to travel long distances in the absence of public transport or taxis, among others.
Here again, a coordinated system for renewing prescriptions for a period of six months (if stocks allow), and the distribution of HIV and tuberculosis treatments by community-based organizations would be a good option. With regard to malaria control, chemo-prophylaxis campaigns, and activities such as indoor residual spraying must continue, along with an urgency to think about how to protect the teams undertaking that work.
Finally, it is up to civil society to take over from the State to reduce the social divide that will inevitably widen between those who have the means to resist the containment measures and the others, between towns and the countryside, between those who can read and have access to information and those who do not.
We can never be too wary of the traces left by these kinds of crises: in Europe, we fear the post-COVID-19 era. In France, complaints before the criminal courts are raining down on members of the government, political parties are tearing themselves apart after a union that lasted barely 3 weeks, specialists and scientists are expressing their disagreements publicly. We will have to wait months or even years to measure the full extent of this crisis. In Guinea, anthropologists have observed the phenomena of discrimination and social rejection of patients affected by the virus, their difficulties in returning to their villages, for which specific rituals of "social reintegration" have had to be developed by communities, and a range of psychosocial consequences for families.
This is why it is important for all countries to involve CSOs from the very first debates on the response strategy to COVID-19. CSOs should be part of countries’ health ministries’ response committee, but also integrated into the work of other ministries such as the ministry of the interior (or its equivalent), family protection, education, budget and maybe decentralisation. CSOs must be the subject of attention from donors who can make funds available to them to share accurate information, implement awareness raising, prevention information and activities, food and treatment distribution, and social-linkage activities.
The Global Fund, whose commitment to civil society is long-standing and has borne fruit with the creation of civil-society platforms, can and must set an example by funding these activities, and by making its advocacy strength available to CSOs to help them establish themselves as a key player in the national response in African countries. It must also commit to engage other major health donors, such as GAVI, the Bill and Melinda Gates Foundation, and the World Bank, and lead the discussion to encourage them to do the same.