Mental health, COVID-19 and primary healthcare in Guinea : a tale of stigma and solidarity

Click here to read the French Version of this COVID-19 In Guinea Blog

The daily coronavirus figures in Guinea make no mention of the socio-professional category of infected people. However, healthcare workers are at increased risk of contracting and spreading the virus.

This blog is an update of our posts published in April and May 2020 in BMJ Global Health and is once again written by two witnesses on the frontline of the fight against COVID-19 in Guinea.

From 4 May to 4 June 2020, the number of confirmed cases increased from 1710 to 3991, the death toll rose from 9 to 23, and the number of recovered cases went from 1450 to 2512. During the same period, the tougher confinement measures led to violence and the death of six protesters in the suburbs of Conakry. In its statement of 22 May, the Scientific Council pointed out the weaknesses in the response mechanism, particularly an almost exclusive centralisation and concentration of efforts on the medical aspects of the disease. The fact that Conakry no longer has a monopoly on infections, means that many key actors want to play a role in the response efforts. Corona has spread to other cities and neither the health facilities, businesses nor the main prison have been spared. The latter has even set up its own treatment centre. The Hafia Minière community health centre has followed suit. The centre operates in a working-class district of Conakry and is run by the “Fraternité Médicale Guinée (FMG)”, a primary healthcare development NGO. Between the NGO’s HQ and the health centre lies a courtyard where a borehole was installed which provides clean drinking water to the hospital, the patients and the staff. However, the neighbourhood also uses the well, making the courtyard a meeting place for patients, health workers and residents.

This health facility not only handles the medical problems of patients from the catchment area, but also monitors 500 patients on ARVs, 450 on TB treatment and more than 2000 with epilepsy and mental disorders. The centre’s on-site or mobile services are used by about 2348 sex workers, 233 men who have sex with men (MSM), 23 drug users and 531 prisoners use. Furthermore, vaccinations for children and pregnant women are administered daily and on average 40 deliveries per month are performed.

The measures put in place during the Ebola outbreak were reactivated when the first cases of COVID-19 were registered in Conakry, including general hand washing with chlorinated water and temperature measurement on entering the premises. Social distancing, one of the measures to slow the spread of the virus, was introduced later. To deal with crowding on busy days, additional benches were installed in the waiting room, and new reception and triage areas were set up. As the number of cases increased dramatically in Conakry, the health centre attendance went down for common ailments (curative consultations and care, vaccinations, laboratory tests and care for specific categories such as sex workers and MSM). HIV, tuberculosis and epilepsy patients and people with mental problems kept to their usual schedule probably because of their long relationship with the health staff, the mutual trust, the exclusivity, and the free care.

On 9 May, a health worker, tested on 5 May, was confirmed positive for COVID-19. On 11 May, 72 people including care providers, administrators, trainees, volunteers, and some casual workers were also tested. On 15 and 16 May the results indicated 11 positive cases which were hospitalised in 3 different treatment centres in Conakry. One negative case of this sample developed anosmia and a cough on 16 May and was confined to the Donka treatment centre where he was retested. While awaiting the results of his test, he was treated with chloroquine and azithromycin (protocol used in Guinea) and was confirmed positive on 19 May, which brings the number of cases among health centre staff to 13. The Hafia Minière health centre has set up a monitoring scheme for all staff, their family, and contacts, like the one for the National Health Security Agency teams. So far only 4 spouses or relatives tested positive during the two weeks that followed the hospital admission of the 13th patient.

The Hafia Minière Health Centre is one of the few centres of the Guinean health system that deals with mental health issues at the primary care level.

Since the screening of the first case to the announcement of the result, the collective screening sessions, the long wait for the results and their announcement, the stress associated with being hospitalised, the testing of spouses and relatives of positive cases and again the announcement of the results, we saw a lot of fear, stress, anxiety, irritation, tension, isolation, self-isolation in the health centre and at home, tears and sometimes joy when the result was negative during this period. We discovered implicit and explicit stigma in the workplace but also a wave of solidarity towards the patients, first locally, then nationally and later internationally
(https://blogs.bmj.com/bmjgh/2020/05/12/covid-19-in-guinea-the-first-line-of-health-care-in-south-and-north-get-ready-for-action/). As soon as the first case was confirmed, FMG set up a solidarity fund to support hospitalised health workers and their families. The fund will prove its worth and help purchase medicines for patients with co-morbidities, supply food made according to the wishes of the patients and provide support to their families.

Although the Hafia Minière’s health centre offers mental care, we detected signs of implicit stigmatization among health staff in both words and attitudes. Instead of the recommended social distancing, we sometimes witnessed avoidance behaviour and comments such as: “Where did they get this disease?; How did they get infected?; Did he/she have contact with these people?; Did that person come near me?; Don’t go near that one; Don’t go upstairs; Don’t go to that office; I no longer go to the health centre, what about you? How can you stay open when you had cases? I don’t want people to find out that I tested positive. Please don’t tell my colleagues that someone in my family tested positive.».

On the other hand, we were struck by the acts of compassion and solidarity such as comforting phone calls, support to patients in treatment centres and test sites, putting one’s own means of transport at the disposal of someone in need, bringing patients’ personal belongings to the treatment centre, visiting the children of hospitalised colleagues, bringing together caregivers in treatment centres with patients, providing meals to patients in hospital and to their families at home, adding credit to mobile phones, providing information to families about their parents’ health status, psychological support, respect of ethics in relation to confidentiality and the willingness of patients and their families to disclose their HIV status during the COVID-19 pandemic, the set-up of a Solidarity Fund and the collection of funds. The proceeds of the Solidarity Fund will be used fairly: e.g. those with comorbidities will get help with medicines not covered by the treatment centres, those who have dependent children at home receive support according to their needs. All staff, whether employees with an employment contract, trainees, or workers, will get support to meet their needs and without discrimination.

While the epidemic has a significant impact on the mental health of infected patients, the solidarity that originated in this epidemic shows the proximity of health centres to the populations they serve, is proof of the relevance of the health teams and the centre and the significance of local groups and associations.

While the epidemic has a significant impact on the mental health of those affected, the solidarity it creates is an expression of the symbol of the proximity of health centres to the populations they serve, proof of the relevance of the team in an institution and the spirit of community life.

The epidemic and the misery it entails results in a myriad of feelings going from fear and the resulting stigmatisation on the one hand to solidarity that sprouts from compassion, pity and a sense of belonging.

For the Hafia Minière health centre the epidemic has been an intense experience that has made healthcare providers question their emotions, feelings, and position in the workplace, not as a professionals per se but as a ‘normal’ human being.

About the authors

Abdoulaye Sow is a general practitioner, public health expert and director of the Guinean NGO Fraternité Médicale Guinée. He is supporting first line healthcare services and involved in the training of family doctors in Guinea.

Bart Criel is a medical doctor and currently professor at the Public Health Department of the Institute of Tropical Medicine Antwerp, Belgium.

Conflict of Interests: None

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