The COVID-19 situation in CAR
Caroline Chavaillaz Wandeler
Coordinatrice générale République Centrafricaine
General Coordinator Central African Republic
The first officially detected case of COVID-19 was in Bangui on 14 March. The patient had arrived in the country by air. Local transmission has now been confirmed. By 14 May, CAR had recorded 221 cases of COVID-19 (so far, 12 people have recovered; there have been no fatalities). Over 6000 people have been tested.
The relatively low number of cases merits some attention. In this regard it may be significant that the CAR initially lacked adequate materials for carrying out tests (it has received several donations since then). We have also observed that the screening unit in Béloko, on the border with Cameroon, has contributed to an extremely rapid increase in the figures. Note that Cameroon has been severely affected by the epidemic.
Since the first case was announced, the government of CAR has put measures in place to stop the spread of the virus (e.g. movement of people confined to certain routes, prohibition of large gatherings, closure of schools etc.).
We should mention that the border with Cameroon remains open, even though many cases of infection in CAR have their origin in Cameroon. The Douala-Bangui link is extremely important for bringing supplies to the capital of the CAR. Its closure would have severe consequences for the economy of the country.
There are vital economic and political issues at stake, in addition to those connected with healthcare. Closing the Douala-Bangui link could politically de-stabilize the country and trigger protests, possibly of a violent nature, if people are deprived of essential goods.
The Car has however closed its frontiers to commercial air travel, in line with most of its neighbours. This situation is further isolating an already-isolated country. There are direct impacts on the work of humanitarian personnel on the ground. Relieving teams is already very difficult. The situation is causing extra stress and fatigue.
Several of our colleagues here on the ground are approaching the end of their missions but have no idea when they’ll be able to leave. Similarly, those designated to relieve them are finding it difficult to get here. The situation gets even more complex depending on the nationality of personnel. We’ve also spent a lot of time managing this situation in liaison with HQ.
I myself ended up stranded in Europe. I was unable to return to Bangui after my leave of absence. I’ve had no option but to work remotely with the teams remaining in the field. I won’t deny this situation has not always been easy, for distance does not facilitate communication, and the problem is compounded by the quality of the connection, which fails regularly.
The European Union officially opened its first humanitarian airlift to CAR on 8 May. So I managed to get back to Bangui on this plane (we also brought supplies). Much work went into organizing this flight, and many people worked to make sure everything went smoothly. As indeed was the case.
On our arrival, all passengers were tested for COVID-19. We also had to observe a quarantine of 21 days. So I’m speaking to you from the room where I’m confined. The isolation procedure will be the same for the next expatriate personnel to arrive. But the situation also affects the deployment of our activities.
Why was CAR chosen as the first destination of the airlift? Because the COVID-19 crisis risks intensifying aid requirements across the board. The Central African Republic has enormous needs, and not only in healthcare. CAR has around 4.6 million inhabitants, and it’s estimated in 2020 that around half the population is in need of healthcare-related aid.
The country is also at risk from no fewer than 9 epidemics (cholera, meningitis, measles/whooping cough/tetanus, rabies, monkey pox, malaria, Ebola) in addition to COVID-19. Acute malnutrition continues to be a major public health issue.
CAR is ill-equipped to tackle COVID-19. At the start of the crisis, the country’s health ministry designated one hospital for receiving COVID-19 patients. This hospital has 14 beds. Ventilators are almost non-existent in the country (between health ministry and NGOs, there are perhaps ten). The health ministry is still deliberating on the creation of a second Covid reception point.
The country has a limited supply of test kits and significant shortages of personal protective equipment. Therefore it’s crucial for Médecins du Monde as a provider of healthcare to work with the health authorities of CAR in the fight against coronavirus.
So we’ve decided to set up prevention activities in 5 health clinics on the periphery of Bangui. The clinics selected are located on the two principal arteries leading out of the capital city in the direction of the provinces. Both arteries are very busy, and the risk of propagation of the virus is high (Bangui is the principal epicentre of the virus).
The main objective of this intervention is to assist the local healthcare system in preparing for, limiting the spread of, and tackling the COVID-19 epidemic. This means keeping the health clinics operating as normally as possible despite the epidemic, while preventing them from becoming nodes in the propagation of the virus.
This is how we’ll be assisting the local health authorities: for example we plan to train personnel in communication skills and the identification of COVID-19 symptoms, help in the construction of an isolation area, install hand wash stations, and provide supplies for disinfecting health clinics.
We also plan to organize community mobilization, in conjunction with our mobilizers and local community agencies, to inform people of the preventive actions they can take in their everyday lives, and what to do in the event they develop symptoms.
We won’t be acting alone in this project. We’ll be working in consortium with Humanité & Inclusion and Solidarités International. This is the first project in the SYNERGIES scheme, an inter-NGO emergency response mechanism whose members include MdM, Solidarités, H&I and Première Urgence, which is not a member of the consortium.
Our mobile clinic will also be playing its part in the fight against COVID-19. We’ve received additional funding which will allow us to strengthen our team and offer COVID-19 prevention activities in the zones of intervention.
Coordination with the health ministry and other actors present in CAR is an essential condition for the success of our actions. So we’ll be participating as actively as possible in the different coordination committees appointed as part of the COVID-19 response.
We are in regular contact with the local healthcare cluster and health authorities to make sure our projects address the most urgent needs while operating as part of a global response. It’s not easy. There are many challenges, but we keep doing our best.
MDM action against COVID-19 in Kinshasa
Didier Cannet
Responsable de mission Kinshasa République du Congo
Head of Mission Kinshasa (Democratic Republic of the Congo)
Africa – the context
• While death tolls keep rising in the United States (over 80,000 fatalities) and Europe (over 150,000 fatalities), the figures for Africa are lower than expected. To date, the continent has recorded 69,000 cases of infection and just over 2,400 deaths.
• Yet when the epidemic began, specialists feared a catastrophe in Africa, where healthcare infrastructure is rudimentary in many places.
• Death tolls have been highest in Egypt (10,000), South Africa (12,000), CAR (221), Nigeria (4971), Ghana (5000) and Sahel/DRC (1200, mainly in Kinshasa) – and these countries were already struggling with other epidemics.
• For many specialists, the limited spread of the virus in Africa is a multi-factorial phenomenon which can be explained by young populations, collective immunity, and rapid confinement and isolation measures.
Democratic Republic of the Congo
The Democratic Republic of the Congo is a huge and diverse country. It is over four times the size of France and, despite the poverty of its population, rich in mineral resources. It ranked 179th out of 189 in the Human Development Index in 2019.
• 1st case: mid-March in Kinshasa, imported. A further 1200 cases and 50 deaths have been recorded since then, mainly in Kinshasa and its expatriate quarter of Gombe. Infection rates are probably much higher, as PCR test kits are in short supply.
Unfavourable factors:
• A mega-city of over 12 million inhabitants, afflicted by overpopulation and extreme population density, poverty, malnutrition, multiple infectious diseases, violence.
• War and collapse of public administration infrastructure, especially healthcare, with few hospitals, few ventilators and few life support machines.
Favourable factors:
• 18 March: government measures against Covid-19 (see attached document), closure of frontiers with isolation of Kinshasa and Gombe, closure of schools, places of worship and restaurants, prohibition on gatherings of over 20 people.
• Prior experience – in Africa and the DRC in particular – in the fight against epidemics; cholera, Ebola, sleeping sickness, measles, malaria, HIV
• The leader of the Covid-19 response in the DRC is professor Jean-Jacques Muyembe, who earlier led the successful fight against Ebola.
• The country’s public and community healthcare culture provides a sound platform for our own actions.
• Priority healthcare; prevention better than cure – all doctors and nurses are trained in a public healthcare and prevention culture, unlike in France.
Covid action in Kinshasa as part of the post-acute and rehabilitation programme funded by Packard
• MDM has been present in DRC since the “turned back” of Shaba 94 et street children et street girls 1999 , Return to Tanganyika since 1 year and already there in two zones since 2013 with the SRH programme currently funded by the Packard Foundation.
• The Covid containment strategy is articulated over three fronts of action:
1. Community action: awareness & communication -> reporting the correct information on the sickness, its forms of transmission, prevention (face masks, hand washing, disinfectant gel etc.), shattering myths/false beliefs in the 2 healthcare zones and the health centres, support for health centres;
with our partner, AFIAMAMA: raising community awareness
2. Reinforced epidemiological surveillance and referral/escalation of alerts, with 83 RECO (leaders, neighbourhood representatives etc.) receiving training as community advisors
3. Action in healthcare establishments – detecting cases and “ICP”: Covid-19 Infection Control and Prevention -> reinforcement of hygiene measures in assisted health centres.
ICP assistance for health centres (patient circuit, implementation of hygiene measures, installation of ICP equipment, treatment assistance for symptom-based admission of mild to moderate cases
Assistance for referring cases to the authorities responsible for handling Covid-19
Action is taken in coordination with other partners and actors in the zone of intervention. Thanks to Packard, we launched our action as early as mid-April in two healthcare zones, Selembao and Kingabwa, covering 4 health districts.
The number of cases has been rising in the last few days (12 cases in Selembao and 21 in Kingabwa), and we must act rapidly to gain time and territory on the pandemic.
COVID-19 : Tanganykia province Emergency Programme
Sodéha Hien
Coordinateur terrain Tanganyika (République démocratique du Congo)
Field coordinator Tanganyika (Democratic Republic of the Congo)
A brief introduction to our mission in DRC/Tanganyika province:
Médecins du Monde has been active in the DRC for over 10 years, and has implemented various healthcare programmes in the country. At present, two MdM sections operate in DRC: MdM Belgique and ourselves.
In terms of active programmes, at present we run a sexual and reproductive health programme in the capital city, Kinshasa. Other programmes for Kinshasa are in the pipeline but Didier will examine these in more detail in the Focus on response actions in Kinshasa.
In May 2019 we opened a base in the province of Tanganyika as part of an emergency response programme addressing the health needs of the populations of this province, which has been badly affected by the inter-ethnic conflict (between Bantu and Pygmy, the two major ethnic groupings in the province) which has ravaged the zone since late 2016. What follows is an update on our interventions over the last year and the actions taken since the appearance of COVID-19 in Tanganyika province.
Our response in Tanganyika province : the context
Like the rest of the DRC, Tanganyika province has been mired in crisis for decades. The problems are many and inter-related:
• The security crisis (conflict between the two leading ethnic groups, presence of several armed groups and other armed militias in the province) which has caused significant population displacement, with people forced to flee their homes and leave all their means of subsistence behind.
• Food shortages: populations fleeing conflict zones produce no food.
• Internally displaced populations: in the first quarter of 2020, there were around 350,000 internally-displaced persons in the province, of which some 98,000 were living in conditions of terrible privation in the refugee camps around Kalemie.
• Epidemics: cholera and measles are now endemic. Ebola remains a threat, as cases in the provinces adjacent to Tanganyika have been reported.
All this occurs in a context of extreme and generalized poverty, while basic social services such as healthcare are almost non-existent or inoperative (looting/destruction during the conflicts, or lack of the resources needed for optimal operation). It’s in this complex context that we’ve launched our emergency response project to address the needs of the populations affected by the crisis and other emergencies in the province, operating 8 health centres and a referral structure for handling life-or-death emergencies and other cases with complications.
Outlines of the project being implemented:
We provide assistance to the healthcare structures on a global basis, helping provide free healthcare to the whole population, displaced and resident alike.
• We work to provide baseline healthcare services in the structures we support.
• We handle cases of Severe Acute Malnutrition on an out-patient basis, referring more complicated cases to the appropriate structures.
• We support sexual and reproductive health (SRH) services across the SRH spectrum, including provision of access to family planning and medical care for survivors of gender violence (and we face some tremendous challenges in this respect).
• In the present month of May we’ll be opening a fourth front of action in the form of a rapid emergency response structure across the whole province. Obviously this requires clearly-defined intervention and exit criteria for epidemic scenarios and other population movements.
One year into implementation of the initiative, the results have been quite encouraging.
• + 76,000 patients treated in health centres
• + 1200 special cases referred to the appropriate structures
• + 1600 undernourished children treated and recovered
Less than a year after beginning its intervention in the province, MdM is now recognized as a major health player in the province. Last September we were appointed co-leaders of the healthcare cluster (coordination of the healthcare aspect of humanitarian response) of the region we manage alongside the WHO. Thanks to this new role we are now actively involved in the fight against the new coronavirus.
Action by Médecins du Monde in the fight against COVID-19 in Tanganyika province:
Although cases of COVID-19 have been reported in seven provinces of the DRC (+1100 cases recorded to date), none have been officially reported in the province of Tanganyika. In terms of preparation, a contingency plan has been drawn up at provincial level, with the appointment of a provincial response committee. However, the ability of the province to manage the epidemic is severely limited (no cases have even been reported). The 10-bed unit designated for treating Covid patients lacks just about everything (medicines, medical supplies, even ventilators – it has none).
In addition to the measures taken at national level, the provincial government has taken steps to place the province in quarantine, a move which immediately affects other humanitarian activities – especially getting supplies to aid workers and the general population.
For us, the challenge is to keep the project on course while respecting the general principles defined by HQ for managing the epidemic as one among several, protecting the health of our beneficiaries and field teams and limiting the spread of the virus.
We therefore decided to:
• Reinforce preventive measures in all health centres and field work (issue of masks, handwashing facilities, printing awareness messages).
• Review certain activities in light of the need to follow the measures introduced by the government (community actions, more action for mass awareness, door-to-door option and inclusion of a message on COVID-19 in awareness-raising materials) and define patient trajectories in health centres.
• Support for provincial response coordination: donations of furniture/protective equipment, medical supplies and admission facilities in the designated treatment unit. With our support, this unit is now ready to admit Covid patients who do not exhibit complications.
• Coordination.
At present, all project activities are underway and comply with the measures introduced in this new context. However, as a major health player in the zone, MdM will be duty-bound to take action should the situation worsen, and we plan to mobilize more resources in this eventuality.