Fighting Covid-19 Alone: Letter and Photos from Kairouan

Families of Covid-19 patients waiting outside the Ibn Jazzar hospital in Kairouan, June 29, 2021. Photo by Ghaya Ben Mbarek.

Late last month, when it was the region hardest hit by Covid-19, Meshkal/Nawaat went to Kairouan. The tragic situation there foreshadowed what the rest of the nation has since been living through: a sharp spike in cases made much worse by a lack of basic State services, personnel, and supplies. Without enough doctors, ambulances, vaccines or vaccination teams, protective gear or nurses, many in Kairouan faced their spike by relying on family for care, exacerbating the spread of the virus. Meanwhile, medical personnel themselves were unable to get vaccines and many worked without receiving salaries promised in their contracts.

A Covid-19 patient in a hospital room in the Ibn Jazzar hospital of Kairouan, June 29, 2021. Photo by Ghaya Ben Mbarek.

Here are some of the testimonies we gathered to offer a snapshot of Kairouan during its darkest days of the pandemic so far.

Virus Spreads Due to Lack of Basic Health Resources

Kairouan is a largely rural governorate dependent on agriculture. Many people living in the countryside are entirely cut off from healthcare services, health insurance, transportation and online systems that have been key in the State’s Covid-19 response. Instead of getting physicians or ambulances to take care of their sick, they have often had to rely on family.

Meshkal/Nawaat met two women wearing cloth masks who had been sitting for hours on a bench outside the Ibn Jazzar hospital in downtown Kairouan. They were waiting for news about their 40-year-old sister-in-law.

“We called for an ambulance but there was none…so we brought her in the back of a truck,” one of them told Meshkal/Nawaat.

The women, seasonal agricultural workers from the rural area of Nabch about 10 kilometers away, declined to give their names.

They offered some explanation for why the infection spread so quickly: “We have sympathy for each other, so we rush to help out, without even considering protecting ourselves,” they said, explaining whole families get sick this way.

But apart from sympathy, they may be turning to family first because there are no physicians where they live. The World Bank puts the number of physicians in Tunisia at 1.3 per 1000 residents, according to 2017 numbers. But most of these are concentrated in the capital Tunis, and Kairouan governorate only has 358 practicing physicians according to the National Council of the Order of Physicians, meaning 0.63 physicians per 1000 residents. Italy, which saw its hospitals overwhelmed in late March 2020, in contrast has 4 physicians per 1000 residents.

Staff at a field hospital set up for overflow of Covid-19 patients from Kairouan’s Ibn Jazzar hospital, June 29, 2021. Photo by Ghaya Ben Mbarek.

But even when they can access a doctor for treatment, the women said their income of 10 dinars a day—when they have work—isn’t enough.

“If you have money, you can treat yourself. If you do not, you just die there. Poor people just die there,” one of the women told Meshkal/Nawaat, explaining that they did not have the state-issued insurance card that is theoretically available to people unable to afford healthcare. “If someone gets sick with this disease, we don’t even have the means to save them…I have nothing, neither to save myself nor my children.”

Like many others living in the rural areas of Kairouan, neither woman was educated or knew their date of birth, let alone how to register using an online system like eVax, the Ministry of Health’s online vaccine registration platform which requires information like birth date and a phone.

While vaccinations have been provided for free in Tunisia, the vaccine campaign has not reached many rural areas.

“They did not come to us…They never ask about our region. It is as if we do not exist,” one of the two women said of the vaccinations.

Neither was skeptical of the vaccine and insisted they would like to be vaccinated.

“How come we do not want to save ourselves? Of course we want [the vaccine],” one said.

Family of Covid-19 patients help with nursing duties at a field hospital in Kairouan, June 29, 2021. Photo by Ghaya Ben Mbarek.

Family Members Become Nurses

In both Ibn Jazzar hospital and an emergency field hospital set up in April to reduce the overcrowding in Ibn Jazzar, patients receive basic nursing care from family members because there are not enough nurses.

“The risk of contamination is high because each patient has” a family member with them said local volunteer Radhi Najjar of the local Sanad association, which mostly volunteers to help older people. Most patients at Ibn Jazzar were older and were being looked after by their children or other younger relatives.

At the emergency field hospital set up a little outside Kairouan, the problem of inadequate staffing is a bit better than in Ibn Jazzar. But even there, most nursing responsibilities fall to family members of patients.

“They allow the patient to have their families with them because in Tunisia we do not have something called “nursing.” The nurse cannot be in charge of giving medication, measuring temperature, taking the patient to the bathroom and changing their diapers. For that there are specialized nurses, which we do not have in Tunisia,” Adel Manaa, the supervisor in charge at the field hospital told Meshkal/Nawaat.

Manaa explained that the field hospital has 18 nurses divided on two shifts, taking care of 71 patients on some days.

“The precautions we take is to make visitors wear their masks, and, if necessary, we make them wear the protective suit if they are going to feed them [the patients]. We also make sure that they don’t exceed five minutes visiting the patients,” Manaa said.

However, Meshkal/Nawaat observed more than one family member taking care of a single patient and visitors leaving and entering the area multiple times without being checked by the security at the entrance who are supposed to organize visitation. Meshkal/Nawaat also observed many visitors far exceeding their allotted five minute visitation time. Meshkal/Nawaat also did not see any visitors using protective suits.

“These are the precautions we are taking, but this is not what should be taking place…The Ministry of Health should be providing the staff…the ones specialized in nursing. We do not even have the staff specialized in taking the blood to the testing lab,” Manaa said.

Graffiti reading “Hospital” on the side of a cemetery in Kairouan, June 29, 2021. Photo by Ghaya Ben Mbarek.

Physicians Unvaccinated, Unpaid

Meshkal/Nawaat was able to tour the Ibn Jazzar hospital. It appeared as if the entire emergency room had turned into a Covid ward, with no separation between Covid patients and other emergency cases. The small waiting area in front of the registration window is shared with the pediatric emergency room, something that supervising personnel said could explain the increasing contamination rate among infants.

“You could find one person with Covid standing to register to be hospitalized and in the same queue, you would find a mother with her baby waiting to register as well,” said Marwa Naffeti.

Naffeti is a nurse who has been working in Ibn Jazzar’s Covid ward under temporary contract for nine months. When Meshkal/Nawaat spoke to her, she had not been paid for any of her work and she was not offered a chance to get vaccinated, despite being a front line health worker.

“When you speak up about this, they tell you: ‘If you don’t like it, then work elsewhere. We can always substitute you,’” Naffeti said of the payment issue.

At least four medical personnel at the hospital told Meshkal/Nawaat that although they had signed up for vaccinations on eVax, they were never summoned to receive them. Front line health workers were supposed to be among the first in the priority list to be vaccinated.

“What vaccine? We did not receive any vaccines…Only two doctors in this whole ward received it,” another nurse inside the Covid ward who declined to give her name told Meshkal/Nawaat.

Meshkal/Nawaat waited outside the office of the regional health director–the top Health Ministry official in Kairouan governorate–to ask about the overall situation and to ask for official comment or explanation regarding some of the claims made by hospital staff. After Meshkal/Nawaat’s journalist waited for a meeting for an hour and a half, the director was distracted by visits from the governor and a delegation from the World Health Organization (WHO) and could not make time for an interview.

A representative from WHO did, however, make time to speak with Meshkal/Nawaat.

“Of course the [Kairouan] governorate needs more equipment for oxygenation, and also we need to accelerate the vaccination campaign. The governorate of Kairouan is less advanced than many other governorates in the country,”  Dr. Yves Souteyrand, the WHO representative in Tunisia, told Meshkal/Nawaat following their delegation’s meetings with regional officials.

Dr. Souteyrand said that Tunisia needs technology transfer to be able to produce vaccines in Tunisia to cover domestic needs.

“Of course Tunisia can be one country where vaccines can be produced. Tunisia is already a vaccine producer [of other vaccines]…It has the capacity; It has the expertise. And we try to support Tunisia,” Dr. Souteyrand said. “I think one of the key factors is to have a deal with other [vaccine] producers to ensure that technology transfer can be done from other countries to Tunisia…I think it’s very important that many countries are able to produce vaccines because we know that today there is a real supply issue and it will help to solve this challenge.”

Dr. Souteyrand gave these comments on June 29, before several countries significantly increased their vaccine and equipment donations to Tunisia during July, when the spike in infections hit also spread to other parts of the country.

A Covid-19 patient beside oxygen canisters at the Ibn Jazzar hospital in Kairouan, June 29, 2021. Photo by Ghaya Ben Mbarek.

Unbearable Working Conditions

Aside from going unpaid and unvaccinated, medical personnel at Ibn Jazzar hospital said that their working conditions were unbearable, with patients sometimes becoming violent towards hospital staff.

“Every day we receive no less than 20 patients, even though we only have nine oxygen sources… the 11 remaining [patients] are left without [oxygen],” Naffeti said.

“There are no beds for other emergency cases. The other day we had to resuscitate a patient with a cardiac arrest on the ER’s floor. We’re forced to work like that,” a third nurse told Meshkal/Nawaat.

These conditions foreshadowed what would become daily occurrences in many other hospitals and clinics around Tunisia in more recent days as infections have spread. With the Tunisian public health care system under severe strain, videos and testimonies of exhausted and helpless medical staff have swept social media networks.

“The situation is catastrophic! I can’t handle it anymore. The reserves of oxygen can only cover the next hour. As if we have a time bomb, and all the patients die, but we can’t tell them about it,” said Dr. Bounawara of the Moknine hospital in the Monastir governorate, in a video posted online.

Another video of the Mateur Hospital director, Habib Wachem, went viral as he sat and wept after running out of oxygen reserves. “How am I going to be able to save people? Why is this happening?” he said in the video, visibly distraught.

Naffeti, the Ibn Jazzar nurse, said that because of the lack of equipment and staff, they were the ones targeted with violence from angry family members of patients.

But some patients are understanding of the challenges staff are facing.

“The situation is catastrophic,” one man told Meshkal/Nawaat sitting as he waited outside a crowded room where his 87 year-old mother was hospitalized. “We know that the doctors and nurses no longer have power and just work with what they have.”

Two volunteers from an association helping with the Covid-19 response in Kairouan June 29, 2021. Photo by Ghaya Ben Mbarek.

Dying at Home

On June 20, Amina’s grandfather, who was attached to an oxygen concentrator to help him breathe due to Covid-19, passed away at home after a sudden 30 minute blackout took place across the city of Kairouan. (Amina, not her real name, spoke to Meshkal/Nawaat on condition of anonymity so that she could discuss the case while maintaining some privacy for her family.)

There was no space at the hospital, which was full, so the family kept him with an oxygen concentrator at home.

“What we heard is that because of the high number of people using oxygen [machines], either at the hospital or at home, electricity was cut…Unfortunately, because my grandfather already had weak lungs, he could not make it and passed away within 10 minutes [of the power outage],” Amina told Meshkal/Nawaat.

While Amina’s grandfather was over 100 years old, Amina said that she saw many other people from Kairouan share on social media that they had also lost family during those 30 minutes of power outage.

“We were told that a bird caused this…It’s stupid,” Amina told Meshkal/Nawaat in a phone interview. Amina said she was skeptical of the official explanation for the power outage and believed some officials were trying to “run from responsibility.” 

A small military field hospital set up to handle overflow of Covid-19 patients in Kairouan, June 29, 2021. Photo by Ghaya Ben Mbarek.

Military Steps in

The emergency field hospital which was set up to ease the burden on Ibn Jazzar hospital also had limited capacity to treat patients suffering from other issues.

“They bring them here, but with the condition that their situation is not bad—those suffering from cardiac or kidney failure for instance,” said Adel Manaa, the supervisor in charge at the field hospital.

To supplement the field hospital, the military added an extension to the field hospital and began treating patients there on June 21.

“The military now is in charge of taking those whose situation becomes critical. We no longer send them back to the hospital,” explained Manaa.

For Dr. Mohamed Ben Salah, the supervisor in charge of the military annex, the goal was to “consolidate the efforts of the Ministry of Health and counter the massive influx of patients and the increase in the number of cases.”

The military extension has some equipment—12 oxygen beds and 6 Intensive Care Unit (ICU) beds, according to Ben Salah.

“We have definitely decreased the workload. Whether in Ibn Jazzar hospital or the field hospital, there is a net impact since we are taking in patients…six ICU beds can definitely reduce the burden off the hospital,” he said.

According to him, lack of staffing was a bigger issue than lack of equipment.

“For sure it would be always beneficial to increase the number of ICU beds, but it is not a question of one bed. Who would be taking care of them?” he said. “There is a lack of staff.”

Patients and medical staff at Ibn Jazzar hospital in Kairouan, June 29, 2021. Photo by Ghaya Ben Mbarek.

Factories Stay Open, Despite “Lockdown”

The Prime Minister’s office had announced a total lockdown in Kairouan and three other governorates for 10 days starting on June 19, but locals said this was not enforced for everyone.

“Yesterday, they allowed the cable factory to resume its work, this is even before the end of the 10 days of general lockdown,” Hatem Chaaybi, a 28 year-old father of two told Meshkal/Nawaat on June 29 while selling fruit in the middle of the day in 44 degree heat. 

Chaaybi was referring to a cable factory in Kairouan linked to the South Korean Yura Corporation.

Mahdi, 28, told Meshkal/Nawaat that a decision had been taken to resume industrial activities in some foreign factories in the city despite the lockdown. As a result, public buses saw overcrowding with what he estimated was about 150 people using the bus at a time.

“You just open that factory to satisfy a foreign country and because you’re an agent to that foreign country,” Mahdi said.

Meshkal/Nawaat was unable to check on the status of factories operating in Kairouan.

“All louages are working. All sectors too. Why are you pretending that you closed down everything?” Chaaybi said.

For those still working, the price of healthcare has been a heavy burden. Chaaybi believes that health services during such a crisis should be public and that private clinics should be used to serve the needs of anyone who is sick.

“Clinics should become public in the cases of war and this is war…My friend spent five days at the Okba Clinic and he had to pay 15,000 dinars,” Chaaybi said.

Seeing private clinics working for profit is particularly upsetting for people who have lost jobs or been forced to close their businesses due to the health restrictions set out since June 2.

“If you go to see popular neighborhoods, you’ll find people with nothing to eat, and then you allow private clinics to stay open. Make it public!” Mahdi said. “Give us health! We did not ask you to give us a house or a car or nothing. This governor should be in prison for the crimes he has committed. If there was law in this country, he should be in prison.”

On July 17, following the meeting of the health ministry’s crisis cell, Tunisian Prime Minister Hichem Mechichi gave permission to the governors of nine hard hit governorates—including Kairouan—to use private health care facilities to host patients from overfull public hospitals.

This article was produced as part of a reporting partnership between Meshkal and Nawaat.