Interview with Renaud Piarroux, professor of medicine, researcher and head of the parasitology department at the Pitié-Salpêtrière hospital.
Défis Humanitaires : Would there be an African specificity of the Covid-19 as the curves that do not resemble those we know in France and in Europe, in the United States or in China would suggest? Would Africa be more resilient? Yet the WHO has alerted us to the risk of a hecatomb in Africa and one of its representatives recently declared that we have seen the propagation figures double in the last 4 days. What do you think about that?
Renaud Piarroux: What we can say about Africa is that the pandemic started there with a little delay and that it is spreading rather slower than elsewhere. The spread of a disease depends on the environment, depends on ecosystems. Whatever the disease, there is not the same spread in two different locations. For example, for a respiratory-transmitted disease, there will be a huge spread where people are crammed into the subway every day. If it’s cold, the number of cases tends to increase; if it’s warmer, it’s the other way around. So there may be a slightly different pattern in Africa, but that doesn’t mean that Africans are less susceptible. The good news is that the population is younger, so there should be fewer severe forms. But even if the epidemic curve rises more slowly, it doesn’t mean it’s not going to get higher. In fact, we don’t know how it’s going to change. Even if the progression is less spectacular, there’s no sign yet that it’s peaked. Since public health actions are more difficult to carry out, we can still remain concerned. We don’t know for sure, but we still have reason to be concerned.
I imagine that, in this case, the only thing to do is to strengthen preventive capacities and curative means, which are very weak or almost non-existent?
From a curative point of view, we don’t have much to offer; even if we had respirators, we would need teams around us, etc. What has been done in Paris is not feasible in Africa, even in a capital city. If there is not much to propose on the therapeutic level, on the other hand, there are tracks in terms of prevention. Confinement should not be proposed; it is not feasible in a poor country, but there are things that can be done, such as isolating the sick. This cannot be done without helping families who find themselves in difficulty because they have lost their livelihood, for example, and there are things that can be done to limit the damage.
I had a question about containment, but you come up with a way to answer it…
Containment is not at all suitable. In this type of situation, it would do more harm than good.
Economically and socially?
Containment works well if people are not at risk of hunger, if the economy has enough reserves to afford to stop working. The more we are in fragile economies, with people earning their living on a daily basis, the less tolerable this kind of action is.
So you have a long experience of fighting epidemics, especially cholera in Haiti and the DRC. How can the experience of epidemics, of cholera, of ebola, such as we have been able to face them, be used in the case of this pandemic in these countries as well as in those that share comparable living conditions with the DRC or Haiti?
What we can use and what makes sense is home visits, what we call mobile rapid response teams; it makes sense because if someone is reported to have a fairly severe form of VIDOC and problems accessing care, it is useful to go to the family to see if they do not need help and then organize their isolation in some way. For about 10 days, you have to make arrangements so that they don’t have to go to work, be in contact with others and so on. Programs like this should be done with home confinement of contagious people, but with real support from the community.
Public health in these countries also involves the fight against malaria, tuberculosis, AIDS, measles and cholera. What are the risks and how can the fight against Covid-19 be reconciled as far as possible without neglecting other diseases?
It’s complicated because the tendency, which we see even here in France, is that if a new disease arrives, it worries and mobilises a lot and so the rest is deserted. How do you do it? We can at least remind people that there are other diseases, that we must continue to take care of them. In addition, there are far fewer people available for these programs. Even without confinement, people are reluctant to go out, to expose themselves; health workers are in the same situation and there may be a shortage of staff to run the programs.
For the most vulnerable populations, in Sub-Saharan Africa, for the displaced, for refugees in the Middle East, in the Indian subcontinent, what can be the role of the communities of the populations concerned, in partnership with the relief teams, whether national or international? Is this an asset or a challenge?
There is a challenge, that of putting solidarity solutions back in place. It is a matter of preventing people from turning in on themselves and also avoiding the stigmatization, exclusion and all the deviances that often accompany epidemics, I am thinking of pogroms, the search for scapegoats and other such events.
We must therefore turn communities into allies, who develop collective protection by helping each other.
People must help each other. We have to advocate solidarity and not rejection, bigotry; it can be difficult.
And finally, to conclude this interview, do you want to add or clarify anything?
Simply, we discover in France that having experience with epidemics is useful, we draw inspiration from what we did in Haiti. Our public health forces in particular have deserted the field of epidemics in Third World countries. At Santé Publique France, some of the staff are under home confinement. Many in France have lost interest in the humanitarian problem. A gap has been created between humanitarian aid on the one hand and French institutional public health on the other. MSF has joined the coalition to fight against coronavirus in Paris, a coalition that has been supported by the Assistance Publique-Hôpitaux de Paris, local authorities, private companies, the Red Cross and Civil Security. I hope other NGOs will join us because they have know-how and that in the end, by fighting Ebola or cholera epidemics, we will acquire skills that have been lost elsewhere in France. This is good feedback.
You were just talking about what you are setting up in Paris with the mobile teams, you called on Jean-Sébastien Molitor, who is a humanitarian in the field. You can give us a few examples that could be useful to us, that would illustrate what you have just said.
The mobile teams were something that had not been considered in France and the government had no precise plan to get out of confinement without triggering a rebound in the epidemic. He was talking about mass screening, diagnosis, encouraging people who are in contact with the sick to get tested. In fact, there is a real need for people who will go to patients and help them protect their loved ones. This is what we do every day when we are in Haiti or the DRC and we no longer know how to do it in France. There is also the whole issue of migrant, Roma, homeless and excluded populations who are often more affected than others by the coronavirus and who, from an epidemiological point of view, can lead to a persistence of transmission. Finally, the fight against the epidemic requires taking into account the most vulnerable people. They must be allowed to get out of it. We must help them. For them, but also for us. Because if we don’t, we won’t be effective.
Interview by Alain Boinet.
Renaud Piarroux
Specialist in infectious diseases, particularly cholera and tropical medicine. Professor at the Faculty of Medicine of Sorbonne University. Member of the Pierre Louis Institute of Epidemiology and Public Health attached to INSERM and head of the parasitology department at the Pitié Salpêtrière.