This week we have the lovely Dr Kerry Greenan, a GP trainee from London, who has written a post on her experience working with a Non-Governmental Organisation (NGO) in Zambia. If you also wish to write for the blog, please contact me with an outline of your idea – mentoring and feedback given.

The Zambian government’s response to the COVID-19 pandemic has been swift – when I arrived in early February to work for On-Call Africa, (a UK-run medical outreach charity based in the southern province) just shortly after the first two cases were confirmed in the UK, I had to undergo screening at the airport consisting of a temperature check and symptom questionnaire. On 25^th March, when there were just two confirmed cases in Zambia, closures of schools and public places such as restaurants were announced and restrictions put on travel into and out of the country with mandatory quarantine (something that the UK is only just implementing now). Face-masks are now compulsory in supermarkets. At the time of writing, there have been 446 confirmed cases of COVID-19 in Zambia, with seven deaths. These have mostly been confined to Lusaka, the country’s capital, with few outbreaks elsewhere which have been rapidly contained. So far, Zambia appears to be managing the pandemic well.

However, there are still a number of reasons to be worried for Zambia’s rural communities. It is becoming increasingly clear in this global pandemic that those being hit hardest are the poorest and most vulnerable, and those who attend On-Call Africa’s outreach clinics certainly fall into this category. The population is incredibly geographically dispersed: the vast majority of people live more than 5km from their nearest rural health centre, often with no means of transport through poor quality roads (something I can attest to having spent a significant amount of time stuck in the mud trying to reach clinics!). Although this remoteness from urban areas offers some protection from the virus, it also makes accessing healthcare problematic should severe symptoms develop. Mobile phone signal is generally poor in these areas and there is no access to television or internet services, meaning that public health announcements are unlikely to be widely heard. Like most countries, there is a COVID helpline to call for advice, but when most people don’t have phones or reliable signal, this will be of limited value. Within the villages themselves, people live in very close quarters: I can’t imagine how the social distancing and self-isolation behaviours that we are slowly becoming accustomed to throughout Europe will be possible. Zambia has recently suffered its worst drought for decades meaning that levels of famine and malnutrition are high: at a time when we are encouraging people throughout the world to stay home, we are likely to see an increase in travel as people unavoidably go out to work during the harvest season to provide food for themselves and their families. Combine this with the high rates of HIV and TB, and there is clear potential for rapid spread of the virus with a high proportion of severe and critical cases. I think of how many conversations I’ve had recently with my patients in the UK about increasing anxiety and struggles with lockdown restrictions, but in Zambia the threat of COVID-19 sweeping through communities who already have so much hardship to contend with and such limited ways to protect themselves must feel completely overwhelming.

On-Call Africa is a charity providing medical outreach clinics to some of the most remote areas of Zambia’s southern province, as well as training community health workers (CHWs) and providing health education. The aim is to sustainably improve access to healthcare for these communities, who often have low levels of health literacy and lack access to basic amenities such as safe drinking water.  One of the first difficult decisions taken by the charity in response to the pandemic was to actually stop running clinics given the dangers of transmitting the virus into the villages  – for me this meant returning home seven weeks earlier than planned, something which I was obviously devastated about: in some ways it felt as though we were abandoning the communities when they were at their most vulnerable. On a more personal level, I had loved working in Zambia, and this was also a premature end to a trip which I had been planning and looking forward to for over a year (the cancellation of my highly anticipated post-placement safari was a particular blow). One of the reasons I was initially interested in becoming involved with On-Call Africa was their ethos around long-term improvements in healthcare and having an exit plan for the villages they work in, rather than just providing a temporary fix. With this in mind, the CHW training program and health education initiatives are equally if not more important than running the outreach clinics, and realising I can still remain involved in these activities from the UK is some consolation (as well as the hope that I might one day get to return once the current pandemic eases)!

Like many developing countries, Zambia relies on CHWs (who are often volunteers) for delivery of essential healthcare services in rural communities. Many of the patients I saw had no access to a doctor outside of our monthly clinic, and so CHWs are usually the first port of call when they are unwell. They play a number of key roles alongside rural health centres – for example, On-Call Africa provides training in basic general medical assessment and treatment while other NGOs or government services employ CHWs in specific roles, such as identifying and treating patients with TB or malaria. With many NGOs reducing travel into rural areas, the risk of spreading COVID-19 has to be balanced against the risk of withdrawing essential services and thereby increasing deaths from other treatable diseases. We know from previous pandemics like the Ebola crisis that there were a huge number of indirect deaths from other causes as already fragile healthcare systems became overwhelmed and resources diverted away. This issue is exacerbated when multiple organisations work separately on different projects; without coordination and collaboration between different organisations, the community response to COVID-19 could be chaotic and fragmented.

Without an established primary care system, responsibility for maintaining healthcare services in rural communities will ultimately fall to CHWs. I became part of the COVID-19 Community Health Protocols Working Group so that I could continue supporting our CHWs, having worked closely with many of them during my time in Zambia. Working across NGOs and together with the Ministry of Health to develop national protocols, we wanted to ensure that they are able to safely continue providing essential healthcare services, as well as playing a vital part in identifying cases of COVID-19 and implementing measures to stop the spread throughout the villages. CHWs, often respected members of their societies, are well-placed to continue health education, dispel myths and rumours and distribute key public health messages about the pandemic, which otherwise may not get through. They will be the ones promoting social distancing, handwashing and as much isolation as possible for those with symptoms. In effect, they have huge value as community leaders, something already shown to have huge impact during the Ebola pandemic in Sierra Leone. I do however have my reservations about relying on CHWs: these are volunteer workers who are putting themselves at risk by continuing in these roles, often with limited PPE and senior support. Measures to protect them as much as possible are of course included in the guidance (recommendations for PPE, limitation of non-essential contact, no active contact-tracing of COVID-19) and I can’t see another obvious solution for the continuation of healthcare provision. Still, as medical professionals around the world are currently receiving an outpouring of gratitude from the public, I hope that dedication and commitment of community volunteers does not go unrecognised.

While creating protocols to be used by all organisations employing CHWs in Zambia allows consistency in the advice and guidelines being delivered, remote training and updates need to be taken into account. Tech platforms such as Medic Mobile are currently working to develop the protocols into online training guides, which will be accessible even in low signal zones and which can be updated as the situation inevitably evolves. They will enable CHWs to report cases of suspected COVID-19, allowing the government to keep track of the pandemic.

The development of Zambia’s community response has relied on huge cooperative efforts not only between various organisations in Zambia, but also between countries, with the Kenyan and Malawian Ministries of Health sharing their own CHW training resources for development. This is a global pandemic and sharing learning and resources between nations is the only way that we can overcome it. The COVID-19 pandemic has led to huge changes in the way we practise medicine, and conversations are starting about which of these changes could actually have a positive impact in a post-COVID world; there is real opportunity to reflect on and make changes to existing systems. Focus has been on rapid improvements and innovations in technology: remote access to healthcare would clearly be an advantage for Zambia’s CHWs and their rural communities and I hope this will continue in the long-term. But if I could pick one thing to keep once the pandemic has settled, it would be the spirit of collaboration: if NGOs can continue to work with common aims in parallel with each other and with governments of the countries they work in, we have a greater chance of actually improving healthcare systems in developing countries, and work towards reducing the huge health inequities that we currently see throughout the world. I really hope I get to return to Zambia one day, but I hope even more that we may see a time where the presence of NGOs is no longer needed.