There was a sense of hope and a feeling of victory when we saw the numbers of COVID-19 cases drop in Mauritania. However, shortly afterwards the situation changed drastically and the old proverb ” don’t sell the bear’s skin before you have caught the bear ” came to mind.
Between 13 March, the date on which the first case was confirmed, and 29 April, the country reported only 8 cases and 1 single death. Mauritania thus took its place among the nations that had successfully managed the pandemic. But since 12 May, the number of COVID-19 cases has been rising exponentially, sometimes reaching peaks of 102 cases and up to 6 deaths per day. On 8 June, the country had 1,104 confirmed cases, including 59 deaths and 119 cured. At this point in time, 10 out of 13 regions are affected.
The capital Nouakchott is particularly hard hit with 82% of the reported cases. The figures show that health workers account for 10%.
Mauritania’s initial containment measures included the closure of land and air borders, a ban on traffic between cities and wilayas (regions), the closure of mosques and public places, a systematic screening at border crossings, quarantine for returning travellers and the set-up of COVID-19 treatment centres in the capital. After a while, the government relaxed these measures and opted for a control strategy to minimise the spread of the virus. The various directorates at the Ministry of Health continued the response preparations with a focus on the management of patients in hospitals, the training of health workers and the detection and monitoring of suspected cases. Student doctors were recruited to support the medical teams responsible for the follow-up of cases.
Why didn’t the initial response strategy work?
The first response was effective in halting imported cases, but action against the spread within the communities was never really considered because this also depends on the willingness of the population to respect the containment measures.
A large segment of the population remained convinced that this virus did not exist: “all this is just a conspiracy from elsewhere”. Information on social media about the conditions in which quarantined suspected COVID-19 cases were kept, made matters worse and did nothing to heal the breach of trust between the community and the authorities.
For various reasons, the training of health care providers in the capital has lagged behind the rest of the country. Furthermore, the weak respect of preventive measures (wearing gloves, masks, etc.) by health workers and the lack of an effective triage system, has inevitably contributed to the rise of COVID-19 cases among health workers and indirectly among the patients they treat. This in turn has implications for the management of chronic cases, which run an even greater risk.
Were the containment measures taken too early to be effective? Yet, across the world, a rapid response and lockdown have proved their effectiveness in countries that managed to curb the pandemic. Another important factor is the resilience of the system to adapt and respond efficiently, when faced with a stressful event. The weakness of the health system in Mauritania and many sub-Saharan countries seems obvious.
The new strategy, partly the result of the implosion of COVID-19 cases, is to follow up on asymptomatic cases at home because health centres no longer have enough beds and space to manage all cases. This approach can be risky given the public’s behaviour towards containment measures, their convictions and their habit of visiting sick relatives at home or just have a tea together.
Mauritania has currently entered the phase of community transmission. The country has low screening capacity and there is uncertainty about the procedures which results in patients travelling back-and-forth between health centres, leading to a further spread of the virus.
Deaths related to COVID-19 are as disturbing as the number of cases. Many of these deaths were confirmed post-mortem, some of them at home. The question is whether the virus killed these people, or did they die as a result of another associated pathology?
It is high time to not only reflect on the current public distrust towards health structures, the convictions and the fake news and the weak capacity of our health system but to also propose a strategy fit to the context and acceptable to the people. We urgently need to help youth and women’s associations to organise awareness campaigns and start a dialogue with communities to effectively fight against COVID-19.
Yahya Gnokane is a medical doctor and a health services organisation expert working in the AI-PASS program as a technical assistant in the district of Babade.
Kirsten Accoe is a midwife and public health expert. She is faculty of the Public Health Department of the Institute of Tropical Medicine Antwerp since 2018 and in charge of the scientific follow-up of the AI-PASS program in the Bababé district.
Bart Criel is a medical doctor and currently professor at the Public Health Department of the Institute of Tropical Medicine Antwerp, Belgium. He is coordinating the overall scientific follow-up of the AI-PASS programme.
Enabel is the Belgian development agency and in charge of the implementation of the AI-PASS programme via a contractual arrangement with the European Commission and currently supports the Mauritania government in controlling the COVID pandemic in the framework of the 11th European Development Fund (FED). Enabel has sub-contracted the scientific follow-up of the AI-PASS programme to the Department of Public Health of the Institute of Tropical Medicine Antwerp. In order to contain the occurrence of possible conflicts of interest, the three authors remained at all times critically reflective of their position in the AI-PASS programme.