Nene Morisho Mwana Biningo
The Covid-19 pandemic has rapidly spread across the world and has become a global public health threat. As of January 10, 2022, the DRC has officially recorded 8,719 Covid-19-positive cases and 1,225 deaths, representing a case-fatality rate of approximately 1.4%[i]. The province of North Kivu and in particular the city of Goma is the second most affected by this pandemic in DRC after Kinshasa. Butembo and Beni are also affected by the pandemic, as there are important exchanges between these cities and Goma. In addition, Beni and Butembo are linked to Uganda through the Kasindi border, which is one of the most important entry points to the DRC.
In Beni and Butembo, the Covid-19 pandemic has replaced the Ebola epidemic in Eastern DRC, a disease that has decimated entire families. This Ebola outbreak, which was declared over in 2020, showed how the response to infectious disease outbreaks crucially depends on people's trust in political and public health authorities. Two years later, the country, like the rest of the world, is still struggling with the Covid-19 pandemic. Today, mistrust is recognized globally as a central challenge in the response to the Covid-19 pandemic.
We urgently need to learn how to explore the patterns of mistrust that we have seen in past Ebola outbreaks, over the last two years of living through the Covid-19 pandemic, and may experience again in future infectious disease outbreaks.
The following observations about mistrust in the Covid-19 pandemic in North Kivu are critical for exploring how mistrust is articulated and reinforced in the domain of Covid-19 testing.
According to the discussions that our research team had with different segments of the population (religious leaders, administrative authorities, youth, etc.) how people experienced the response to Covid-19 made them skeptical about the existence of the disease. Similar to the behavior of responders in the Ebola epidemic, which eventually led the population revolt against the response and doubt the very existence of the disease, certain practices are undermining the response to the Covid-19 pandemic
The following points provide an analysis of these practices.
- In the understanding of many inhabitants of Beni and Butembo, rapid tests are inaccurate and do not give the real results. For them, only PCR tests provide reliable results. Interviewees say that have this understanding from the doctors and nurses who are in charge of doing the PCR test. The fact that public health experts who are supposed to know better than anyone discredit the effectiveness of the various tests can only create doubts in the population about this system.
- Stigmatization of patients and the whole family: affected families are seen by their neighbors as seeking financial or material support from NGOs. This is a legacy of the Ebola response where families of the sick received support from NGOs (mostly food support). As one informant put it „our children in the neighborhood were criticized by their friends, saying that they were looking for money by declaring themselves positive for covid 19“. Another informant told us “even our church members thought we were lying about my illness, to get money.”This stigmatization is reminiscent of the mistrust in the Ebola epidemic which creates an environment that is not conducive for fighting the pandemic.
- Lack of trust in hospitals in the same city: A common experience is that test results of one hospital are not accepted by another hospital. Patients who are transferred from one hospital to another have been required to repeat a Covid-19 test, which sometimes turns out to be negative, when it was positive in the first hospital. In Butembo, for example, results from the Kyangike Health Center were refused at the Kitatumba General Hospital.Moreover, tests performed in the one towns are not accepted in other towns. For example, a pastor interviewed in Butembo confirmed that the results of the test he had done in Butembo were not accepted in Goma, such that he was forced to undergo another test. The rejection of tests results is remarkable as Butembo and Goma are cities of the same health district and are in the same country. It goes without saying that this practice has contributed to reinforcing the population's doubt about the existence of the disease. In Butembo, as in Beni, the population considers it as a business opportunity for the political and health authorities.
- The high price of the test leads to mistrust of the disease. Even religious leaders do not believe in it.For example, some interviewees feel that it is incomprehensible that the cost of testing for certain diseases more serious than Covid-19 is less expensive than that of Covid-19. It is clear that not enough awareness has been raised to explain the merits of the test and the factors behind its relatively high cost.
- Some people also feel that their experience of Covid-19 tests is not good: the waiting time in hospitals for taking a test is long, the waiting time for the results (48 hours) is also long, the discomforting experience of nasal or throat swabs also leads to rejection of the test.
- The high cost of the Covid-19 test leads people to say that it is a disease of the rich.These costs seriously affect people’s mobility and their commercial activities. The costs of $40 limits the movement of people in and out of the country. Consequently, commercial activities are limited, too. In view of the poverty in the region, charging $40 for a test is inconceivable for a population for whom this amount is the full capital for starting a business. Even civil servants and private sector workers may not have a salary of US$40 per month. The cost of testing, excluding a large part of the population from testing, has given rise to the conclusion that it is a disease of the rich. Moreover, when the DELTA variant spread throughout the country, inhabitants in both cities observed that only wealthy men and women were affected by the disease who could afford to be tested and treated. People are asking skeptically why Covid-19 only affects those who are able to pay to be cured! this remains an inextricable paradox in the collective imagination in this part of North Kivu province.
From the above, it appears that four important elements contribute to the lack of confidence in the Covid-19 response system, and in particular in Covid-19 tests. These include: the high costs of testing, which varies from city to city; the different types of tests available, some of which are not accepted everywhere; poor communication about the disease; and the stigmatization of people who test positive. With a few differences, these elements are almost similar to those observed during the Ebola response, which fueled the population's resistance to the response.
- It indicates that some of the lessons learned during the Ebola response are not yet sufficiently capitalized by the response to the Covid-19 pandemic. It is therefore important that an effort to identify the strengths and weaknesses (lessons learned) during the response to Ebola be made by the actors involved in the response to Covid-19.
- Numerous studies on this subject exist, including the one by Nene et al (2020) and Songi et al (2020) – Awareness-raising and training of response actors must be done to ensure that these lessons learned are understood by all and that mistakes made in the Ebola response will be avoided during the course of the response against Covid-19 pandemic.
[i] https://reliefweb.int/report/democratic-republic-congo/covid19-rdc-r-publique-d-mocratique-du-congo-mise-jour-0
Morisho, Nene, Josepha Kalubi, Sung-Joon Park, and Martin Doevenspeck. 2020. “Same but Different? A Comparison of Ebola Virus Disease and Covid-19 After the Ebola Epidemic in Eastern DRC (2018–20).” African Arguments https://africanarguments.org/2020/04/24/same-but-different-a-comparison-of-ebola-virus-disease-and-covid-19-after-the-ebola-epidemic-in-eastern-drc-2018-20/
Park, Sung-Joon, Hannah Brown, Kennedy Wema Muhindo, Matthias Borchert, Nina Gobat, Nina Gobat, Nene Morisho. [under review]. “‚Ebola is a business‘: An analysis of the atmosphere of mistrust in the tenth Ebola epidemic in the DRC.” Critical Public Health