COVID19 Public Health Crisis: what could Welsh partnerships do?
Kathrin Thomas and Sue Walters
“My family are going to die of hunger before we die of coronavirus” “I have been forced to stay at home to die of starvation” We have heard similar heart-breaking words from several of our African colleagues in our Welsh international partnerships. These partnerships are long term and rooted in friendships and mutual learning. So, what do we do now, when we are still trying to understand our own new reality because of this pandemic?
Coronavirus is circling the globe, hitting one country after another, with Sub Saharan Africa some weeks behind Europe. Everywhere, ways of life are being disrupted and changed forever.
We all know that the wider determinants of health are more important than health care services in deciding how long you live and the quality of your life. COVID19 will kill a variable, and relatively small, proportion of the population in each country, but the societal changes it brings will affect the health of everyone for a long time to come. In Africa, the economic disaster could kill more people than the virus and make life much tougher for many than it already is.
How this virus is moving across the globe is presenting us with many lessons. There are factors that affect transmission of the virus, and factors that make some people more vulnerable to getting very sick or dying if infected by the virus. These are variable from one country to another, and between communities within countries.
In Africa, the way the virus transmits is likely to be different because of the different ways that people travel between countries and communities. The basic prevention measures of hand hygiene, physical distancing, avoiding gatherings and shielding all present challenges. In particular, the use of distancing to the point of lockdowns is not sustainable for very long in fragile economies where people do not have savings or social protection. The density of large slum cities may speed up transmission, while isolated rural communities may be more protected
COVID19 is usually a mild illness that can be managed at home. In countries affected so far, it appears that about 20% of people get sicker and need health care. About 5% need critical care and up to 2% may die. However, this data is not yet available for Africa and may turn out to be quite different. Age is by far the biggest risk factor for severe illness and death. African countries generally have much younger populations, for example the median age in the UK is 40.5 and in Uganda is 15.8.
As the virus is most lethal to people over 60, this is a relatively smaller proportion of the population in most African countries. However, many younger people have co- morbidities such as obesity, diabetes, hypertension, and cardiovascular disease which do increase risk considerably. HIV infection so far appears to be less of a risk factor, unless for people who are not on ARVs and with low CD4 counts.
The pandemic has shown up global inequities and hit the poorest and most vulnerable everywhere, and no doubt this will happen in many African countries too, undoing decades of development.
Existing health services are fragile. A big concern is that lifesaving public health and primary care services will become inaccessible and even less adequate because of the multiple effects of the pandemic. Reduced childhood vaccination rates leading to rising infant mortality and reduced access to maternal health care leading to increased maternal mortality. Often maintaining essential services is as important for your partners as any new intervention for COVID19
Here, we want to focus on what partnerships could do to help each other deal with the direct and short-term impacts on health in sub Saharan African countries.
1. Share experience
Often the greatest support for people in a crisis are those around them or people that have been through a similar experience. Facing challenges together builds bonds, the pandemic is an opportunity to be there for each other and understand more about each other. Listen carefully to understand their main concerns and ask what ideas they have and discuss how they could address them. Sometimes we cannot solve the problems people are facing but we should never underestimate the power of listening and acknowledging their difficulties
2. Find out what’s going on
Many people in your organisation will have small pieces of the jigsaw. Ask what they are hearing and what challenges they are facing Find out the media outlets your partners and the local population are using to get their news and use these to understand what information is circulating locally. To understand the situation better, include a shared document where people can add their information: time and source of information are key to making this information valuable.
Communicate: this is now easier than ever through tools such as WhatsApp, Telegram, Zoom, Teams and others. Consider recording this in one of the many document sharing tools online such as Google Docs and Trello.
Check these sites for up to date information about the pandemic in Africa
- Your partner’s Government website
- Africa Centre for Disease Control, who have data and resources
- WHO Afro, lots of resources and guidance and country specific links
- IANPHI have a page for each country’s guidance
- A good source for global data and analysis is Our World in Data COVID pages
- Contact the Hub Cymru Africa team for information and to connect with others doing similar work: they have set up WhatsApp groups for Southern, West and East Africa.
- To understand the situ
3. Ask your partners what they need now and in the next few months
Suggest to your partners in Africa that they keep a list of what needs there are in the community they serve, the scale of each and what they would need to address each one. This will help them prioritise the needs of their community. If someone in country or abroad offers some help, they can be clear about what they need to have the biggest impact. The best help will often be to address the pressure points that are most acute. Ask your partners what they think you can help with now and in 3 months, and in longer term. Revisit these questions periodically as priorities may well change over time.
4. Information and guidance:
Do they want any specific information and guidance? What audience is this aimed at and how best to reach them?
Claim the space Encouraging the partners you work with in Africa to provide only good reliable information, even if it is just passing on key WHO or government messages and explaining what is not known can be very useful. In any disaster or crisis people want information, if there is nothing from reputable sources, the rumours and false information will fill the void, so it is good to find out how people get their news and use these channels to get key messages out there. If you would like any more information, or find a health link active in your country, please contact the Wales and Africa Health Links Network
Public awareness raising material
- WHO’s WhatsApp number is a great example of this, it sends information direct to people’s mobile phones, such as images of key WHO messages in a form that works in black and white and that takes little ink if they choose to print it out. Send “hi” to +41225017596
- General WHO Messages/Posters on the virus
- Children’s Colouring page explaining the virus and how to control its spread
Myth busting resources
Guidance and training for health workers
- WHO is the first place to look
- Africa CDC has data, guidance and interactive resources such as webinars
- The Lancet has an excellent global COVID19 resource centre
- openWHO offers free online training
- The NHS is offering all COVID related eLearning as open access for all
- The London School of Hygiene and Tropical Medicine offers guidance, modelling and training
Many Countries now recommend or insist people cover their nose and mouth when in public places. This is currently not recommended by WHO or Africa CDC as they believe there is insufficient evidence of its effectiveness as a public health measure. Radio 4’s Inside Science with Trisha Greenhalgh, Professor of Primary Care Health Services at Oxford University, talks about the use of homemade masks you can listen here , the link to University College London’s makers page that is mentioned is here
How to make a homemade mask: Here are simple instructions on how to make a bandana mask in 1-minute video from Dr Jerome Adams, USA Surgeon General . And here are the CDC simple instructions on sewing or making cloth masks. The website Masks4All also has information and how to sew a cloth mask instruction.
5. Supporting public health and health services
How could we help health workers protect themselves? How can they care for the wellbeing and morale of each other? How can we help public health and health care services?
- Personal Protective Equipment (PPE) Globally, demand for the PPE recommended by the WHO is far outstripping supply, so it is very difficult for small scale partnerships to help partners to purchase this. However, some PPE can be made locally with some creativity, in particular face shields. For the Love of Scrubs (spontaneous community response to NHS shortages) Visor Army (spontaneous community response to NHS shortages)
- Training: supporting local training, for example reimbursing the costs of training community health workers about COIVD19 to cascade to communities, or moving existing training online or developing new training, either recorded or live
- Transport: lockdowns have stopped much public transport and private vehicles from carrying others. Funding for alternative forms of transport for people to access health facilities, or help with giving people access to health information by phone or information leaflets.
- Social Distancing in Health Care Facilities: discuss with partners ways they could reduce contact between people, can crowded waiting rooms be reduced by giving people a time to attend, or moving the waiting room outside (weather permitting), so the distance between seats can be increased and fresh air circulates. Can floor markings be used or one way systems to reduce proximity to one another.
- WASH: access to handwashing is even more critical, so any WASH project that can be adapted or started would surely have an impact. Providing money and information for soap and hand sanitiser. See Sanitation and Water for All for resources, how to build a tippy tap for handwashing, for patients and visitors outside health facilities in English and several different African languages, and WHO guidance on how to make hand sanitiser
- Materials: money for stationary, megaphones, data, printing or whatever supports delivery
6. Mitigating hardship
What can you help them do about social protection measures (e.g. protecting jobs, preventing poverty)? What would help your partners to mitigate the impact on communities? Can you fundraise and send money safely to your partners?
- Keeping partner employees in their jobs, maintaining wages
- Financial support for those in forced quarantine or isolation, unable to work
- Hardship funds run by local organisations and NGOs, such as faith based organisations or local schools
- School children will be more at risk of abuse and neglect, supporting outreach to keep them visible
- Providing money for data to allow people to keep in touch and get help and information
8. Taking new action: deciding what to do
Precautionary Principle The virus is novel so there are a lot of unknowns. Think about what unintended consequences there could be, and for whom. Some actions may harm some groups and benefit others. If you are not sure, you should err on the side of caution: this could be not doing something but also doing something that has very little risk that may have a big benefit — for example the precautionary principle is being used in some places to insist on the use of face coverings in public because the evidence is still emerging
When considering how to respond there are two different types of evaluation
a. Weighing up whether or not to do something do you test for the virus, set up isolation centres, lockdown the country. Does the benefit out way the cost, not just financial but in ill health, disempowerment of communities etc. Just because one country has done something and it worked, doesn’t mean it is good for another country. Take lockdown, it has been credited with effectively reducing the peak of virus cases in Wales, so the National Health Service (NHS) has not been overwhelmed. In a country with very limited capacity to treat seriously ill people. Where the state is not able to financially support many citizens through long periods of unemployment, the harm caused by lockdown may outweigh the benefit
b. Choosing how to spread resources between a variety of options, When there are many options that can provide a significant benefit, the choice is how to distribute limited resources to achieve the maximum benefit. The high impact low cost solutions are the obvious ones for us to start with.
9. Review your current projects
You will not be able to visit for many months, so how else can you deliver the objectives? Do you need to switch to something different? Discuss with your funder and just do it
10. Fund raise for your partners or for other organisations
If you cannot repurpose your existing funding sources, you can consider raising more funds for your projects or towards larger funds(for example the WHO COVID19 Solidarity Response Fund)
Keep checking the Hub Cymru Africa website for funding advice or contact a Development Officer
11. Consider longer term goals and objectives:
what will you need to do differently in the longer term?
We will explore this in more detail in a further item
Meeting people’s basic needs is likely to be more difficult and costly during the crisis. Resources to ensure food supplies, fair and just policing, burial of the dead, maintenance of water and electricity supplies and ensuring access to medicines, should not be underestimated as a breakdown in these systems could claim more lives than the virus. Helping keep things going doesn’t sound exciting and may not be very attractive to your sponsors but it may be the most impactful thing you can do.
We are small organisations with very limited resources, but we are committed to partnership working in the long term. We have to adapt what we are doing and how we do it, and have to learn with our partners how to cope with this new world
Sue Walters BSc MSc CEnvH is a Chartered Environmental Health Practitioner with an MSc in Crisis and Disaster Management. She has expertise in health and safety, food safety, WASH (water, sanitation and hygiene) and control of infectious diseases
Kathrin Thomas MBChB MRCGP FFPH is a General Practitioner and Consultant in Public Health. She is the Chair of the Betsi Quthing Health Partnership and also the Chair of the Wales and Africa Health Links Network