COVID-19 in French-speaking sub-Saharan Africa. Part II – Recommendations

  • Pr Jacques Barrier
  • 10 Apr 2020

  • Editorial
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Pandemic Lockdown Reflections

As a first step, in the absence of specific vaccines at present, the objective is a pandemic mitigation strategy pending the disappearance of the virus or development of group immunity. The level of group immunity is not yet known, be it in Asia, Europe or America, let alone i in Africa, because it depends on genetic and environmental factors (the figure of 50 or 60% of affected subjects have been mentioned).

All public health experts and international organisations agree that total lockdown of the population (apart from certain essential activities) is the only way to effectively curb the pandemic. Africa's particular problem is on two levels: its demography (the youth of its population, therefore less concerned by the seriousness of COVID-19) and food survival in the context of a day to day informal economy.

Moreover, in order to take decisions, political transparency is desirable and expected by people. Decisions are taken on the basis of objective data: the fight against false or misleading information is unavoidable and is the subject of other work.

What can be done?

Noting the impossibility of an authoritarian global lockdown of sufficient duration to curb the pandemic, some people then evoke selective lockdown. It is possible on two levels:

Either the selective lockdown of areas in regions with well identified authority (for example cities, chiefdoms, provinces, constituent states of a country).

Or selective group lockdown, which concerns people at risk (of transmitting or receiving). This is indeed a pragmatic half-measure likely to be socially accepted in the long term.

Both levels can coexist in the same country.

Selective group lockdown is the one that has been put forward in this work:

Whom?

The risk of transmission: in the current absence of diagnostic tests accessible to all,  selective lockdown of non-symptomatic infected persons (healthy carriers) is impossible. With less important means, lockdown of symptomatic persons presumed to be COVID-19 can be organized.

The risk of reception: who is at risk?

  • All  studies put the elderly in the foreground, from the age of 60 onwards, for reasons of specific immune responses, what some people call "immuno-senescence".
  • In particular, the elderly with a high prevalence of comorbidities. It should be remembered that in Africa, these elderly people do not usually live in retirement homes or medico-social institutions. They are still within their families and therefore exposed to the likely contact of an often young, healthy or sick carrier in their homes. Taking this into account is delicate but indispensable.
  • Generally speaking, all persons with a heavy associated pathology which favours aggressive viral invasion and the disproportionate inflammatory reaction that may be responsible for high mortality. This background often makes them unable to endure the shock of intensive care hospitalisation when it is possible. Respiratory failure in all its forms is at the forefront. Various important comorbidities, especially if they are not controlled (especially type 2 diabetes, hypertension, heart failure, all cardiovascular diseases) and, it should be repeated, all the more so as age is advanced. Obesity is an aggravating factor. The high and rapidly increasing prevalence of these Non-Communicable Diseases is a major public health concern on the African continent, as highlighted by WHO.
  • Disabled, mentally ill and disadvantaged people in situations of extreme poverty must also receive special attention.
  • People infected with HIV? This is a quantitatively important population in Africa, of more than 25 million (according to WHO). There is not yet enough scientific data to confirm that people living with HIV are at greater risk of acquiring COVID-19 or that they will develop a more serious form of infection. But based on what is happening with other viruses, there is concern that the risk of a severe form is probably higher when CD4 counts are low (3). This is of course only a hypothesis and it is important to rapidly evaluate cohorts of patients combining HIV and COVID-19.

When?

In the context of the rapid spread of the epidemic, the sooner the better to organize lockdown. In the absence of expanded lockdown, selective lockdown is an option that should be quickly evaluated in areas where community contamination is beginning to take hold. Effective feedback will therefore be required (local actors have an essential role to play in this regard).  The decision is taken, but if possible with accompanying measures that will prevent undernourishment and consequently violent popular reaction.

How can this be done?

Selective lockdown has a better chance of working if it is understood and voluntary.

This requires a communication and action plan integrating African psychosocial aspects (by adapting foreign models, particularly Western or Asian), i.e. with a mobilisation of all potential actors, something that has not been done for other epidemics. This plan should target economic managers, all professions, school and university managers, not only in the healthcare field. Above all, traditional chiefs such as kings, village chiefs, elders of clans and lineages, associations and brotherhoods of traditional healers (traditional health practitioners) should not be forgotten. It is known that traditional health practitioners are the first port of call for primary health care (especially in the event of epidemics, especially in the local context where the conventional health system seems to be disarmed). Hunting brotherhoods in the Mande are unique in their roles in healing and local policing.

Religious leaders (Muslims, Christians, traditionalists) have a crucial role. Moreover, there is now a strong involvement of religious leaders after initial resistance and apocalyptic interpretations by some.

All media will be mobilized (radio, television, newspapers, internet, town criers, griots). Artists can play an important role as popular communication media.

The aim is to define the priorities as consensually as possible and then to launch a strategic plan acceptable to the whole population, in each sector defined, in its diversity: inform, reassure, act for the weakest.

Communication organized by these different actors must be reassuring, it is important to engage individual and collective responsibility, to act in the collective interest of the community. It is important to identify with them, the messages, ways and explanations in favour of an awareness of the need to protect oneself first, to protect one's family, one's community.

Let us insist on the fact that the lockdown of the elderly should be considered as a priority. In this context, defining a specific communication and protection strategy towards the elderly seems unavoidable. It must be reflected upon at the highest level (with traditional and religious leaders), organised together and displayed.

For HIV, the question remains unresolved. In practice, it is more difficult to organise, given the stigmatisation of these people, as various studies have shown.

Implementation

The focus group did not have the task of dealing with the technical context (health systems, operations including medical-hospital structuring). Obviously, the protection of caregivers is an absolute requirement.

The trigger for implementation is obviously political and at the national level.

For example, the decision to assess (rapid diagnostic tests) and isolate suspected persons arriving from abroad. This is easy at airports and ports but difficult at land borders which are porous due to lack of surveillance capacity.

We know that there are different models for this type of general mobilisation such as the national strategic conference or the roll out at all levels of responsibility from a national control committee. Medical and public health experts are important but the specific cultural dimension of each region (human and social scientists) must be explicitly taken into account.

Is it possible to combine in the same country, here selective lockdown measures by zones and elsewhere selective lockdown measures by groups? Why not, in the case of well-identified regions (e.g. cities, ethnic groups, chiefdoms, provinces, constituent states of a country) with a need for isolation and therefore strict limitation and control of movement, including the blocking of roads, in order to avoid contamination between these differently managed regions. The procedures are not simple but deserve to be studied. This problem should emerge at the crucial moment of lifting lockdown.

Accompanying measures are desirable, if not compulsory:

Lockdown is naturally associated with administrative closures (schools, universities, etc.). 

The closure of markets, shops and businesses: given the practical impossibilities of organisation and acceptance that we have seen, we could recommend a limited opening schedule, which would allow a strict closure under the control of security forces on alternate days. This type of decision must be carefully considered and the advantages and disadvantages must be assessed: the concentration or spread of attendance versus the possibility of strict and effective control of distance between customers and suppliers.

Furthermore, lockdown has undeniable psychological and even psychopathological consequences that require support from mental health specialists.

One of the major concerns of lockdown is related to the economic impact. The observation is that African States cannot survive in a sustainable way, if only for feeding their populations, so that bypass behaviours develop (just to survive…). Economic support measures seem difficult to implement in systems where the informal sector predominates.

This may be the setting up of a food bank with distribution of food vouchers for population groups in difficulty, but also an itinerant medical service.

NB: measures required when lifting lockdown could be the subject of further evaluation by the focus group.

Part I – Findings (psychosocial realities) and recommendations