Africa is bracing itself for COVID-19. The first deaths have been identified in Nigeria, Zimbabwe, DR Congo, and South Africa. Many countries have opted for the most severe scenario: lockdown. What needs to be done to prevent a catastrophe? What can Cordaid do? Interview with our Health Systems Expert Jos Dusseljee. “Viruses that pose a global threat require a global response – in each country where those viruses exist or break out.”
(Patient in the emergency ward of the healthcare center in Serbo (Jimma, Ethiopia). The center is one 68 health facilities of Cordaid’s results-based financing programme in the Jimma area. © Cordaid/Frank van Lierde)
How vulnerable are the health systems in fragile countries like South Sudan, the Central African Republic, and the Democratic Republic of Congo to the threat of COVID-19?
Extremely vulnerable. Healthcare is underdeveloped, underfinanced, understaffed, and protective equipment is unavailable. The fragile countries in which Cordaid works are barely prepared for normal health challenges, much less for the corona crisis – and that crisis is coming.
Until recently, African countries appeared to have been spared from COVID-19, why is that?
We don’t know yet. Several factors could have played a role. People travel less between and within countries in Africa. People take less holidays. There is an enormous lack of equipment needed to recognize and test for COVID-19. It has been said that the warm climate prevents the spread of COVID-19, but that hasn’t been proven. In any case, the virus has arrived and is spreading itself throughout Africa.
Countries in Africa differ enormously. Healthcare in South Africa or Kenya is much more developed than in South Sudan. Are those countries less vulnerable?
While it’s true that South Africa’s healthcare system is more developed, society there is enormously unequal and the poor lack access to adequate care. Kenya also has huge “pockets of poverty”. Countries like South Africa, Nigeria, and Kenya, that have stronger healthcare systems, are also much more integrated into the world economy, meaning COVID-19 will spread there sooner. While the virus doesn’t discriminate, it’s clear that economically and in terms of health, the poorest part of the population will bear the most severe consequences of a pandemic. They have nothing to fall back on. In South Sudan and the Central African Republic, that means almost the entire country. In South Africa, it means a large share of the population.
Do you think the virus will spread more in Africa than in Europe? What would be the consequences?
If I knew that I would be up for a prize. Virologists would be able to answer that question better than I can. But when I feel pessimistic, I fear for the worst. There is little to no IC capacity in most of the countries in which Cordaid works. Often that capacity exists only in the capital city. There is only one hospital with an IC unit in Zimbabwe, whose healthcare system is relatively more developed than, for example, that of the Central African Republic.
Zimbabwe has 14.5 million inhabitants. If COVID-19-specific care starts to place a burden on healthcare in Africa, then, just like here in the Netherlands, capacity will be removed from regular healthcare, which is already so weak. Think of maternity care and childcare, vaccination programs… If COVID-19 responses will weaken those basic, life-saving healthcare services, that will be a disaster on top of a disaster.
“Lockdowns should have been combined with adequate care and measures to enable people to survive those lockdowns.”
In the Netherlands, restrictions on public life have been ramped up progressively over the past weeks. By contrast, some African countries went into lockdown after the first confirmed cases – immediately opting for the most severe measures. Whether those measures will work remains to be seen. Social distancing is barely possible in many African countries. Housing is cramped and the inability for many people to be self-sufficient for days or weeks on end makes keeping distance difficult. In many countries, there is no social safety net, outside of a few elite neighborhoods in capital cities. If the lockdowns continue, we will see famines.
What should they have done?
Lockdowns should have been combined with adequate care and measures to enable people to survive those lockdowns. Choosing between lockdown or not, especially in fragile countries, is often choosing between the lesser of two evils. If a country does lock down, the government – even with limited resources – must do everything in its power to increase societal resilience.
Extremely fragile countries cannot do this on their own. That’s why global efforts to strengthen health systems and community resilience are so important. If we don’t take action, we will be left with a global problem. Viruses that can pose a global threat require a global response – in each country where those viruses exist or break out. If we don’t defeat COVID-19 in Africa, it will continue to torment the world, as Ethiopian Prime Minister Abiy Ahmed wrote recently. Herd immunity and protection requires a global approach – it’s about global health security.
What lessons have we learned from countering the Ebola epidemic in Sierra Leone and Liberia?
That Ebola epidemic was concentrated in a region counting about 2 million people on the borders of Sierra Leone, Liberia and Guinea-Conakry, the setting of a bloody conflict only 10 years earlier. Ebola’s mortality rate is nearly 40%. These characteristics don’t compare to COVID-19. Still, there are valuable lessons to be taken from the response then. At the time, the efforts to combat Ebola were taken over almost entirely by the international community. Aid works flown in from abroad were viewed with suspicion by local communities: foreign aid workers brought the disease with them or were profiting off its spread. That degree of suspicion made combating the spread of Ebola very challenging.
The important lesson the WHO took from that situation was that they should have sent anthropologists alongside doctors and aid workers. Instead of taking over the entire local health system, they should have worked more closely with local communities and healthcare workers, leaving local health structures intact. You need to understand and to adapt interventions to the beliefs, frustrations, and fears people have.
“Debunk false stories and combat disinformation. Clear, certifiable and correct information will prevent irrational fears. To do so, we need to train people in villages and cities and let them do the awareness-raising.”
Most importantly, you need to ensure that people continue using primary health services in their villages and towns. If maternity and childcare, vaccine programmes, and efforts to combat AIDS, tuberculosis and malaria decrease or even stop because a virus like Ebola or COVID-19 paralyzes primary healthcare, the ultimate effect of virus prevention is far worse than the scourge itself.
How can Cordaid help to prevent that from happening?
Cordaid has a systemic approach. We don’t combat one disease or virus or focus on one target group. Instead, we strengthen existing health systems in their entirety. If those systems are better equipped as a whole, they will also be better prepared to prevent and combat viruses like COVID-19. We work to increase local inhabitants’ and patients’ input into how healthcare is provided and health systems are organized. We enhance cooperation between local communities and healthcare centers and clinics, especially in health awareness-raising campaigns. I think these ingredients help to better combat COVID-19 and prevent major outbreaks in comparison to how Ebola was fought.
A second facet of Cordaid’s approach that might work well for a COVID-19 crisis in Africa is that, aside from health programming, we also support small businesses and entrepreneurs, enabling them to provide sustenance for themselves and their families – giving them a small but crucial buffer. Before locking down a country, we need to strengthen public health systems and increase economic resilience. Cordaid has been doing that for years.
How do you ensure that the hundreds of clinics and health centers that Cordaid works with are prepared for COVID-19?
The first priority: protect your employees, offer protective equipment, make sure staff can operate safely, and ensure patients can continue to use basic healthcare facilities. We’re working night and day to enable those basic conditions, as much as possible given worldwide restrictions on travel.
Second priority: debunk false stories and combat disinformation. Clear, certifiable and correct information will prevent irrational fears. To do so, we need to train people in villages and cities and let them do the awareness-raising. If they can’t do it in person, they can do it over the phone or the radio. Or, if schools aren’t closed – as they are in DR Congo – instruct students, so that they can pass that knowledge on to their families. The WHO and UNICEF are working to produce instructional materials that can be used across the globe.
Third, as I said before: strengthen the existing health systems. Make sure that there is enough personnel, that medical supplies are supplemented on time. And, importantly, make sure that combating COVID-19 doesn’t undermine basic healthcare.
Can we integrate efforts to combat COVID-19 in our existing Results-Based Financing (RBF) health programs in fragile African countries?
Yes – very well, in fact. In our RBF programs, we pay for results – which have been agreed upon in advance – in maternity care, childcare and a host of other medical services. We can easily expand that system to include indicators related to combating COVID-19. In that way, we can temporarily supplement the low wages paid by governments to healthcare staff that is treating COVID-19 patients. We can reward health centers and clinics that instruct, train and protect their staff. The WHO is coordinating with national governments to deliver masks and protective equipment throughout Africa. We want to help out to fill any gaps that arise, particularly in distribution as we work with health centers in the most remote areas of inaccessible regions.
Elderly people are most vulnerable to COVID-19. Is that the also, or more so, the case in fragile African countries?
The health risks are more severe in these countries, regardless of age. So elderly people are even more vulnerable to COVID-19 there. Besides the elderly, millions of people suffer from HIV/AIDS, tuberculosis and malaria. Their resistance is weak. And then there are minority groups: children, young girls, those who are marginalized because of their sexual orientation or ethnicity. Vulnerable people are always most at risk, especially with a pandemic spreading. Providing care for the most vulnerable groups should always be prioritized. Donors like the Global Fund give us resources to continue providing care for HIV, tuberculosis and malaria patients – and to protect them from COVID-19.
Don’t forget also that demographics in Africa are vastly different than in Europe. Only 5% of the population in South Sudan or the Central African Republic is over 70. In many countries in Africa, over 60% of the population is under 30 – Europe is much older in comparison. More young people means more resistance to COVID-19. On top of that, we could involve those young people, many of whom are out of work, in combating the spread of the virus. We could train them to instruct others: in our Sexual and Reproductive Health programs, young people already play an active role. We see how well that works.
“The most important thing for us is to continue with what we were doing: not only preventing basic health services from collapsing but improving them.”
Besides, the situation of elderly people in Africa and Europe is totally different. I have yet to see a home for the elderly in the countries in which Cordaid works. In Europe, we protect the elderly by isolating them. In Africa, the elderly live in constant proximity to young people. It might offer them the herd immunity that the Netherlands strives for.
In which countries will Cordaid work to prevent the spread of COVID-19?
We’re working to integrate COVID-19 protection into all our ongoing health programs, in Central Africa Republic, DR Congo, South Sudan, Ethiopia, Zimbabwe. But the most important thing for us is to continue with what we were doing: not only preventing basic health services from collapsing but improving them. Only by doing that will we be able to reduce maternal mortality, help children survive their childhood years, and enable people to survive treatable diseases.
(Interview by Frank van Lierde, Cordaid corporate journalist. Translated by Steven Lanting)