Stella Menyen struggles to go to sleep after midnight.

Her usual sleeping habits altered after her father died in May at the Bamenda Regional Hospital in Cameroon’s North-West region.  “I toss [on the] bed and look at his pictures and in my head recount my time with him, especially the last days,” says Menyen, the eldest of five other children.

The sudden loss of her father traumatized the entire family. Two days after his death, the hospital told them he had COVID-19.

Menyen disagrees and says he spent all his time in the village and never travelled anywhere. It rankles her that the hospital gave her a scan copy of the test results which, she says, is “not clear” and thinks is fake.

“If my father died of Covid-19, where is the original copy of his results?” the 31-year-old videographer asks with disbelief.

Menyen’s mounting skepticism mirrors a trend that has rocked Cameroon’s response to the coronavirus pandemic. Fiery disagreements between health workers and the families of the deceased patient or, in some instances, people refuting test results showing they tested positive to the virus, have grown steadily since late April.

Occasionally these disagreements have led to attacks on hospitals and healthcare workers. The Guardian Post Newspaper, Cameroon’s only private English-language daily said they have reported at least six 6 of such attacks between May and June.

The fear of stigma causes internal conflicts for families of patients who either have the virus or died from it. Their neighbours often try to avoid them and totally shun any invitations for funeral rites out of fear of being infected, some bereaved families say.

The general lack of trust and denial by patients stems from “limited knowledge” of the disease among the general population, Dr Che Soh Kingsley, NorthWest Regional Delegate for Public Health and Regional Incident Manager for the COVID-19 Response, says.

“Many just think it’s propaganda and that health personnel are actually faking the diagnosis,” Kingsley says, adding that “those who have either lost a loved one from COVID-19 or [got] infected themselves have understood it better and are helping health authorities in the sensitization process.”

Innocent Ali, an infectious disease genomics researcher, argues that the emergence of a new disease like the COVID-19 virus is “almost always associated with panic, fear of the unknown, lack of control, with a propensity to search for explanations and find antidotes.”

Ali says uncertainties and controversies about the origin of the virus, mode of transmission, how fast it can cause death and the effectiveness of treatment have combined to cause growing disbelief among the public.

People are being inundated with different versions of information, particularly on social media, about the disease and this could affect their trust, says Ali, a senior lecturer at the University of Dschang in Cameroon’s West region.

A field epidemiologist who recently worked with the government for five years says lack of proper communication has allowed rumors and misconceptions to flourish.

“People don’t have much information about it [the virus] and there are many unanswered questions about it,” he says.

“With COVID19, part of the treatment requires isolation and this scares people who think that once you test positive you will be taken to an isolation center where you will probably die.”

Limited financing for the public health sector coupled with insufficient molecular diagnostic capacity and disproportional distribution of facilities and personnel between rural and urban areas have heavily affected the government’s response to the pandemic.

Menyen says her family isolated themselves for two weeks to “clear our consciences and doubts” but said the hospital did not come to disinfect their house and do contact tracing like they had promised.

“We have done our part to isolate ourselves for longer than 14 days and no one in our family has shown any symptoms,” she remarks, insisting that she would return to the hospital to ask for the original copy of her late father’s test results.

Ali, the lecturer at the University of Dschang, says the public has grappled with “poor experiences” in government-owned hospitals which are more common in the country.

“Occurrences such as poor client treatment, out-of-pocket payment for free services, delayed case management, little access to specialist services, often poor equipment of hospitals (especially in rural settings) are not new,” he explains.

“These have contributed to shape the expectations of a large segment of the community. COVID-19 just projected that expectation characterized by mistrust.”

A contact tracing unit in the Regional Incident Management Team is supposed to collaborate with community health workers to conduct home visits but “we don’t yet have the means to engage these community health workers and therefore contact following is done by telephone,” Dr Kingsley Che Soh, the Regional Incident Manager for the COVID-19 response, says.

He blames a lack of funds to train at least 5,000 community health workers and mobilise them to conduct contact tracing rounds.

“The duration of follow up is 14 days and immediately a contact develops symptoms, s/he is immediately tested and, if positive, treated,” he says. “On the other hand, if the contact hasn’t reported symptoms after 14 days the contact follow up ends.”

Dr. Sangwe Clovis, founder and CEO of Rural Doctors, which promotes sustainable community disease prevention and response in rural areas, believes decentralizing testing will help to improve turnaround time and reduce conflicts.

Clovis urges health authorities to conduct basic research in local communities to “understand people’s perception of COVID-19 and prevention measures” and help communication experts to design suitable behavioural change messages.

“Behaviour change needs good communication,” says Clovis, “even fear of death has its limit when it comes to behaviour change.”

Ali says reassuring the public is integral to handling the crisis and calls on both the government and the public to find a common ground and understand each other.

“The powers that be need to demonstrate understanding of public outcry, acknowledge their deficiencies and tap into the resources of the community to build resilience,” he says.

“Communicators can work with scientists to demystify common myths about COVID-19.  Custodians of traditions of the people need to be involved beyond political rhetoric…hospital staff and scientists need to engage the community in meaningful ways.”

He calls for reforms in the healthcare system in terms of expanding capacity and infrastructure, increasing financial autonomy, and scaling universal health insurance.

“A more responsive health system will contribute in no small way to build trust,” he adds.

Experts say a multisectoral approach is needed to deal with the pandemic and tackle the ongoing communication crisis.

They say there should be more collaboration between government ministries, civil society and the media which they believe need to be actively engaged to drive nationwide awareness-raising campaigns.

“COVID is not just an issue for the Ministry of Public Health, it is supposed to be multisectoral,” says the field epidemiologist who does not want to be named.

“All sectors are supposed to come together and put efforts together. For example, wearing masks is essential to prevent COVID but its implementation is beyond the scope of the Ministry of Public Health so we need other administrators to carry out other high-impact measures to prevent COVID.”

Meanwhile, some families are angry that forcing them to bury their dead relatives – most of whom are treated as suspected cases due to delays with testing – often results

in bereaved families shunning time-honoured funeral traditions which are usually big and an important element of local customs.

In the agrarian village of Pinyin in Cameroon’s North West region, Menyen and her family had to perform another burial for her late father.

After he was buried hurriedly in a public cemetery in Bamenda, a two-hour drive away, the family’s elders took red earth from the graveside back to Pinyin to conduct symbolic funeral rites.

“Dead people have rights and a right to decent burial even if they die from COVID,” Ndong Christopher, a lawyer in Cameroon’s capital Yaoundé, said.

In order to douse tensions, Cameroon’s Public health ministry announced on June 16 that “corpses shall be buried with respect for human dignity and their cultural and religious traditions” without physical contact.

For Menyen and her family, the funeral in Pinyin gave them a better sense of closure.

“The second funeral to me was the real one done in accordance with our tradition,” she says.  “It gave us the chance to honour our father and bring him home.”

*Comfort Mussa popularly known as Commy is a multimedia journalist who has won a series of awards for he willigness to tackle the most difficult topics of the day, including corruption, development and religion. 

**Linus Unah is a journalist based in Lagos, Nigeria. He writes about global health, conflict, agriculture and development across West Africa.