Initial thoughts on the psychosocial consequences of the COVID-19 pandemic in French-speaking sub-Saharan Africa​​​​​​​

  • Pr Jacques Barrier, MD

  • Editorial
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Introduction: an investigation into the region’s perspectives on the disease has been started quickly but is unfortunately hampered by curfew or lockdown measures. How to best interview this population? Some researchers may have started, possibly via telephone. In the urgency linked to the emergency, we present these initial thoughts freely shared by the through interviews with various investigators and hope to be able to offer meaningful results quickly. These will be updated on a weekly basis.

Current situation

1 - On March 29th, the epidemic has not yet reached a major level, although 39 African countries are affected with a significant daily increase in the number of cases, in connection with the high contagiousness of the coronavirus. On March 28th, 150 cases were identified in Ivory Coast and 113 positive cases in Cameroon. 3 deaths, 2 recoveries, 24 cases in Madagascar and 6 in Benin 2 days earlier. On March 29th Mali had 18 cases including 1 death (patient arrived dead at the hospital).

Apart from South Africa where the epidemic has become more widespread, the number of declared deaths seems rather low (possiby related to the youth of the population?). These data only refer to tested cases and are merely an indirect reflection of the real prevalence.

2 - The vast majority, if not all citizens are informed (television, internet, mobile phones). Panic among part of the population (rumors, social networks seeking people to blame – mainly the elite, those who travel, foreigners to the point of advocating ostracism...). For example, social networks may convey the idea that after slavery and colonization, those responsible want to finish [Africa] off with COVID-19. This is referred to as "colonization and coronation" (sic). Fake news is on the increase; some European sources are relayed in Africa even though they had been debunked in France (eg, the responsibility of Pasteur Institute in creating the viral infection in order to sell vaccines). In Gabon, the hypothesis of biological engineering is evoked even in educated circles. In Mali, rumor has it that the virus was created by mistake or even intentionally by China or the USA, in the context of current political issues between these two countries. This type of rhetoric is unfortunately common in situations of public disasters (emblematic scapegoat theory). Generally speaking, strong social tensions will emerge, especially out of fear for the future. We can already see very occasional rebellions and looting requiring more or less violent military or police interventions. The coming period seems risky.

3 - The organization of lockdown is difficult in many countries. A number of countries decided early to close schools and universities (eg, early March in Senegal). Apparently, curfews and lockdown are relatively well accepted in wealthy areas; they are often refused in populous areas because living in close proximity is essential for people in Africa. In popular cultures of touching and intimate contact, how can a certain distance between people be respected, especially when the refusal of contact is seen as an insult? When we eat from the same dish, close together? When we think that the isolated individual is in danger and that only the group can offer safety? However, it should be noted that regions that have experienced previous epidemics (eg, cholera) adapt more easily to this lockdown or to a curfew.

Public transport, which is indispensable to the majority of Africans for all travel (buses, bush taxis), poses a real problem of physical distancing. While there may be absolute bans on travel outside cities, or on certain major roads, urban transport poses an incomprehensible problem with regard to the difficulties of everyday life (a point noted by most interviewees).

4 - Returning to the village: as long as it is still possible, as long as the roads have remained open, movements of large numbers have been observed from the large, densely populated cities (eg, Abidjan when the lockdown was announced) to villages of origin (one can imagine the potential spread of the virus...). It is not simply a desire for nature, or for better subsistence or even survival, because returning to the village, to the community of origin, to the family, has always been important in African culture when an existential, personal or group problem arises. It allows for the possibility of making contact with the Elders, the wise men who guide decisions in the community.

5 - Strong beliefs for many Africans: the virus is part of the world of the invisible... Evil, disease, malfeasance must find responsibility either in the visible world (society, the environment) but sometimes also in the invisible world (where God, the spirits, the ancestors are). An explanatory system is absolutely necessary. This invisible world is important in the imagination and in myths. It is said in Mali that "it is God who gives sickness as well as death", even while the majority of imams and traditionalists respect official recommendations. However, it is noted that religious gatherings persist: Christians with the many so-called "revival" churches, Muslims (for example, the holy places where marabouts of brotherhoods officiate, sometimes with major festivals), animists (ritual festivals, brotherhoods of Donsow hunters in Mande country). Note a recent video where we see a charismatic ceremony in which the celebrant successively touches the faces of all his faithful with the same cloth. The ceremony aims to ward off evil by invoking the coronavirus... In different ethnic groups, the various initiation or other traditional ceremonies are not postponed because "the ancestors are more important than the disease". But in Senufo country (Ivory Coast), we were told that the Poro ceremony was postponed.

6 - The hope expressed by the population for the life-saving drug hydroxychloroquine or chloroquine is reported in three countries. This drug, well known in Africa (as an antimalarial), becomes symbolic here and French scientific discussions on this subject stir debate or irritate. The drug is already much sought after in pharmacies, which are already reporting shortages (source: Bamako). Traditional healers are also offering natural treatments (examples from Gabon).

7 - Respect for Elders, bearers of the word and masters of custom and palaver. They are the ones who are threatened. Will their wisdom resist fear? Following the Elders’s advice is real in some countries but the effects can contradict official guidance. For example, people over 60 years old are invited to stop travelling in Benin, which is a good measure. But funerals cannot be avoided (importance of the ancestral rite "the Ancestors are more important than disease") which poses a major problem (lack of social distancing, contact with the dead). Proximity should of course be avoided at the end of life and during funerals; we have seen that this is often not possible with Ebola infection. It should be noted that decisions to limit the number of people allowed at a funeral could be made (eg, a limit of 20 in Côte d'Ivoire, which is already a relatively large number).

8 - Economic fear in countries where the economy is predominantly informal or when nascent liberal or managed economies are growing. There are differences of opinion between political leaders who advocate safeguarding economic activity at all costs, taking a break, or rebuilding the economic system (sic). Some governments (eg, President P Talon in Benin, ORTB interview on 29 March) insist on the need to keep the economy alive because they are unlike Western states who can afford to put the economy on hold by organizing an extended containment until the end of the crisis. In practice, almost everywhere, village markets and large city markets persist because they are indispensable to the life and survival of populations. In some instances, symbolic measures can be applied without problems: here, before entering and leaving the shops, it is compulsory to wash one's hands, which is impossible in the markets.

Recommendations:

All participants indicate that there are similarities in the psychosocial reactions of the different French-speaking regions of Africa. The same determinants could be noted in countries successively affected by the pandemic, from Asia to Europe. However, there are specificities that need to be taken into account.

What is common with the international level is the objective media coverage of the crisis:

Only conclusive scientific facts should be disseminated to the population by the media, but this is not always easy because the novelty of this viral disease for which knowledge is constantly evolving, with sometimes divergent expert opinions.

The early amplification of misleading information (fake news) through social networks, especially from influential groups, urgently requires a specific communication plan (of "psychosocial detoxification") from national media. This requires the intervention of recognized scientific experts within academic institutions and public health administrations.

Education through local media and networks (barrier gestures and distancing) is also necessary. Call centers and specialized treatment centers are being set up (Senegal). This is the subject of discussions almost everywhere.

Political transparency is both desirable and desired by the populations. There is a temptation to camouflage the epidemic for a while (which Egypt and other countries seem to be doing). Reassure as far as possible about the technical means implemented for prevention and treatment (ICU beds, masks, gloves, diagnostic tests, etc.). This is a problem not specific to Africa. But what satisfactory solutions can be found in developing countries whose financial means are limited? How to direct and ensure international aid in a global crisis situation? How can NGOs with an established local presence act?

A point more specific to the study group awaiting the results:

a communication and action plan integrating African psychosocial aspects (inspired by foreign models, particularly Western or Asian) with an immediate mobilization of all potential actors, something not done in prior epidemics, including Ebola. The plan should target economic managers, including all professions, school and university managers, and not only in the field of health. Above all, traditional chiefs such as kings, village chiefs, clan elders and lineages, associations of traditional healers, religious leaders (Muslims, Christians, traditionalists) should not be forgotten. The aim is to define priorities with as strong a consensus as possible, and then to launch a strategic plan acceptable to the whole population in its diversity: to inform, reassure, and act to support the weakest.

Implementation is of course political. We know that there are different models for this type of general mobilization, such as the national strategic conference or the declination at all levels of responsibility starting from a national committee. The important thing is to succeed in explicitly taking into account the cultural dimension specific to each region.

In this context, defining a specific communication and protection strategy towards the Elders seems unavoidable. This must be worked out at the highest level and made public. Some evoke selective lockdown when it is difficult to achieve it globally.