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COVID-19: Eritrea’s Success and Challenges (Part I)

By: Dr. Fikrejesus Amahazion

Coronavirus disease (COVID-19) is an infectious disease that first erupted on the global scene in late December 2019. The pandemic has been one of the greatest global crises in decades; to date, tens of millions of cases have been confirmed in countries across the globe, more than one million people have died, and the livelihoods of billions have been greatly affected.

While COVID-19 has been a truly global problem, respecting no boundaries, the situation in Africa has positively surprised many experts and observers, with infection and death rates in many African countries much lower than initially feared. Earlier this year, many experts had worriedly predicted that COVID-19 would devastate and ravage a continent characterized by weak health systems, poverty, and populations disproportionately affected by HIV, tuberculosis, and other infectious diseases. This sentiment was described in an article by Howard French, who remarked, “From the moment the novel coronavirus burst out of China and began to spread around the world, many commentators quickly took for granted that Africa would become the pandemic’s biggest and deadliest target.”

Fortunately, however, many countries in Africa experienced a jump in cases much later than countries in other regions and have consistently confirmed fewer cases per capita. The case-fatality ratio (CFR) for COVID-19 in Africa is lower than the global CFR, suggesting disease outcomes have been less severe among African populations (Partnership for Evidence-Based Response to COVID-19). Of course, while Africa as a continent has broadly been successful since the first reported case in mid-February 2020, different countries within the region have reported COVID-19 epidemics of vastly different intensities and responded to the disease with varying levels of success. One country that has had a particularly successful COVID-19 response is Eritrea.

As of this week, Eritrea has reported less than 500 total positive cases and it remains one of a small group of countries in the world with no deaths yet due to COVID- 19. Notably, Eritrea has thus far demonstrated an impressive recovery rate, with the number of recovered cases much higher than active cases. Several weeks ago, Eritrea’s Ministry of Health released a synopsis providing an overview of the national response and important details about the disease in the country. The following article builds on that, identifying several of the important factors in Eritrea’s fight to contain COVID-19. In the next edition of Eritrea Profile, I will discuss challenges and issues to keep in mind moving forward.

To begin, as with some other countries in Africa that have had some success against COVID-19, Eritrea’s demographics and low volume of international air traffic have played a positive role in containing the pandemic. Eritrea has a relatively young population. This is important since, globally, children and adolescents are at a much lower risk of symptomatic COVID-19 than any other age group. To date, most of those who have died due to COVID- 19 have been adults and those from older population groups. While the virus can certainly infect and kill children and young people, they tend to suffer much milder symptoms from COVID-19 compared to older populations and there are very few severe cases and deaths from COVID-19 among children and adolescents.

Other important risk factors for serious illness and death from COVID-19, which are often associated with older populations, such as obesity, high blood pressure, heart disease, lung disease, cancer, and diabetes, are also generally less prevalent in Eritrea.

In terms of international air traffic, research suggests that international air traffic (e.g., number of flight routes and total passenger volume) was a major facilitator in the early international distribution of COVID- 19 and contributed to the importation of cases from highly infected countries. Eritrea’s volume of air traffic, while steadily increasing year-on-year, remains relatively low and thus likely played a positive role in helping to reduce the early risk of importation.

However, one should not assume that these are the sole or main factors behind Eritrea’s success against COVID-19. Other countries with these characteristics and variables have fared quite poorly. Considerable credit thus must be given to the people, government, and health officials in the country. As I have noted in other pieces, beyond the factors outlined above, success in the fight against COVID-19 has been rooted in decisive leadership, great organization and coordination, and pragmatic planning with effective implementation. At every step, decisions – about restrictions, lockdown, and other safety or prevention measures – were made based on science-driven, public health advice and evolving evidence, ultimately helping to ensure containment and recovery. Decisive leadership was also reflected in the fact that strong, aggressive action was taken very early on in Eritrea, based on a clear understanding of the threat posed to the country by COVID-19. We now know that even small and brief delays (such as just a few days) made a considerable difference in the spread of COVID- 19 in many other countries around the world.

Of course, Eritrea’s countless doctors, nurses, health workers, soldiers, security forces, police authorities, youth volunteers, and others serving on the “frontlines” have been truly amazing during the pandemic.

For many months now they have remained tirelessly dedicated to the cause, demonstrating utmost professionalism and inspirational selflessness.

Another key part of Eritrea’s response has been clear, consistent, and frequent communication. Clear and consistent communication can facilitate public health interventions and adherence of local groups, and a large body of work shows that people’s understanding of their personal risk affects how likely they are to support, engage in, and adhere to preventive behaviors. In addition to helping ensure that the population is able to understand the magnitude of the problem and the rationale behind various preventive measures, clear communication dispels rumors and false or misleading information, and reduces unnecessary public anxiety, fear, or panic.

From the outset, Eritrea’s Ministry of Health, Ministry of Education, and Ministry of Information have been providing clear and regular updates. Importantly, with Eritrea being an ethnically diverse, multilingual country, public service messages and information about COVID-19 were developed and translated into all nine local languages (as well as sign language) and have been regularly disseminated through various forms of media (national television and radio). Safety, prevention, and hygiene guidelines have also been delivered through short message services for cellular telephones, and three “24/7” toll-free hotlines were established to provide information on health, hygiene, and prevention, and to report symptoms. Additionally, informational posters and pamphlets have been put on display in pharmacies, health clinics, shopping areas, on billboards and notice boards, and within other public spaces. Safety messages and themes were also integrated into popular television and radio programs, while popular artists recorded songs and videos supporting the national campaign against COVID-19.
Local buy-in and adherence with guidelines have also been pillars of Eritrea’s success. A considerable amount of research shows the importance of community buy-in (which basically involves the trust, acceptance, and support of local residents) to the success, survival, and effectiveness of community projects and public health interventions. In Eritrea, buy-in has increased trust, reduced community resistance or reticence, and encouraged compliance with national policies and guidelines, despite considerable challenges. One strong reflection of buy-in is how the unfortunate dysfunction, chaos, violence, and coercion witnessed in some parts of the world during the pandemic have been nonexistent in Eritrea.

Importantly, community elders and religious leaders were engaged to strengthen buy-in and help facilitate the dissemination of updates and important information. These figures are key influencers, regarded as credible sources of information, and command high respect. They regularly made community announcements and delivered messages on different media. Just two days ago, for instance, during the Mawlid al-Nabi celebrations at Asmara’s Grand Mosque (taking place in a virtual format), Eritrea’s Acting Mufti, Sheikh Salim Ibrahim, urged “patience and resilience to maintain Eritrea’s commendable track record of controlling COVID- 19.”

Finally, COVID-19 success has required social cohesion and solidarity. In a May 2020 article titled, “COVID-19: Leveraging on Social Capital to ‘Flatten the Curve’ in Eritrea,” James Wakiaga, the United Nations Development Program Resident Representative in Eritrea, outlined the importance of social capital to Eritrea’s success. Specifically, he comments that Eritrea’s success in combatting COVID-19 “may be largely due to the country harnessing its social capital,” and goes on to explain that, “In the African context, social capital – also called ‘Ubuntu’, ‘Undugu’ or ‘Ujamaa’ – means the interpersonal relationships and network that give people a sense of identity, shared responsibility and collective accountability. What social capital teaches is that we need to place the responsibility of preparing and responding to the COVID-19 on the citizens and community at large.”

Since the emergence of COVID- 19, Eritreans from all socio-economic backgrounds and living here in the country or abroad have enthusiastically responded during the nation’s critical time of need, generously contributing money, precious resources, and other forms of assistance. Throughout the country, workplaces, neighborhoods, and communities have also been utilizing deeply-rooted traditional forms of mutual assistance and collective support to ensure that no one, particularly the elderly, single-headed households, disabled, unemployed, and other vulnerable populations, is forgotten or otherwise left behind during this difficult and uncertain period.

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