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Between denial and fears about COVID-19 in Haiti, health promotion on the front line

Health promoters play a key role in responding to people’s concerns in the face of COVID-19 and encourage them to seek timely health care.  Nathalie Destiné Charles, MSF Health Promotion Team Supervisor in Martissant  and Julie Rolinet, MSF Health Promotion Manager in Port-au-Prince describe MSF efforts to increase community engagement with the aim of promoting preventive measures to limit the spread of the disease but also to address rumors and reduce stigmatization.

A health promoter in Martissant , Port-Au-Prince, Haiti © MSF/Lunos Saint-Brave

In Haiti, there have been many rumors since the start of the COVID-19 epidemic. One of the most widespread rumors is that a fatal injection is administered in hospitals to increase the number of deaths linked to the epidemic, in order to receive more international aid. Another is that health facilities are testing a vaccine for the coronavirus on people without their knowledge. We work day after day to counteract rumors and provide correct and factual information to the public as part of the health promotion team for Médecins Sans Frontières (MSF) in Port-au-Prince. But some beliefs are hard to change. At the MSF emergency center in Martissant, a commune in the capital, patients have become more reluctant to receive an injection when necessary, and sometimes they refuse it.

On the street, people often tell us that they would rather die at home than go to the hospital. Beyond the distrust it shows of institutions, this is a very worrying trend as it affects health-seeking behavior. At the COVID-19 care center opened by MSF in the commune of Drouillard in Port-au-Prince, we note that people tend to delay treatment and arrive in serious or even critical condition. Out of 132 patients admitted to the center between mid-May and mid-June, 12 died on arrival or within the first 24 hours.

Many of the people we meet express contradictory things about COVID-19. On one hand, they don't believe in it but at the same time they fear it. Some fear that the health system, already fragile in Haiti, cannot cope with such an epidemic. Indeed, the repercussions of COVID-19 are increasingly evident in the general health system. Several health facilities in Port-au-Prince have already been forced to totally or partially suspend their activities due to the lack of protective equipment or capacity to set up triage and isolation in order to ensure patients’ and staff safety.

A health promoter speaks to a community member in Martissant

MSF health promoters are raising awareness on preventive measures related to COVID-19 in Martissant, a commune of the capital town Port-au-Prince which is known as one of the most densely populated area in the world. [© MSF/Lunos Saint-Brave ]

Fear and stigma are linked: for fear of being infected, people do not want a sick person near them. It is a means of protection. This is why before the opening of our COVID-19 care center in Drouillard, MSF health promotion teams went to see the community leaders and neighbors to listen to their concerns and try to answer them. They were also invited to visit the structure before it opened to understand the path that patients take and to see all the precautionary measures in place to avoid contamination.

Denial of the disease, however, is likely linked to the fact that the number of deaths officially registered in the country remains low so far, compared to what can be observed in other countries. In some neighborhoods, residents tell us about an "epidemic of fever" affecting a large part of the population, but they do not see it as COVID-19.

Because of COVID-19, we can't organize large gatherings to share health information. So instead we adapted our methods and encouraged training and awareness-raising in small groups. For training on COVID-19, we targeted certain key groups such as community liaisons, school directors and neighborhood associations. We have already trained more than 120 people, which is the basis of our community engagement. Then they can further share the information with those around them to help people protect themselves from the virus.

We have also strengthened our door-to-door activities to make residents aware of the existence of the disease, the preventive measures to adopt and the need to go for treatment before it is too late. Inevitably, we manage to educate fewer people than if we could have large gatherings, but we have more in-depth discussions with each person. In the current context, where there are a lot of rumors circulating, this exchange is fundamental because it allows us to understand people's concerns, and it  allows them to ask questions. It is when people ask themselves questions without finding adequate answers that rumors have a place to spread.

If everyone understands how the disease works and is transmitted, it allows everyone to identify the situations most at risk in their daily lives and to take precautions according to their situation. Preventive measures such as wearing a mask, physical distancing, or even handwashing are very difficult for part of the population in Haiti. They may have to choose between feeding their kids or buying a mask, or they may not have adequate access to water or soap. Physical distancing is very difficult in a neighborhood like Martissant which has one of the highest population densities in the world. Together with the local people, we try to think of alternatives adapted to their living conditions such as collective handwashing points, for example.

The fact that MSF has been present in Haiti for almost 30 years and provides free healthcare, especially in very difficult areas of Port-au-Prince, which are known for their insecurity, has allowed us to create a solid relationship of trust with the population. When dealing with rumors, trust is an asset. As health promoters, our role is to actively listen and speak with the people in the communities where we work, to preserve this bond of trust.

Keywords

COVID-19 Coronavirus

Most of the world's countries have reported cases of coronavirus disease COVID-19 and MSF teams in over 70 countries are now racing to respond to the pandemic.  

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