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Train Traditional Birth Attendants, Don’t Ban Them

Traditional birth attendants (TBAs) remain the main providers of delivery services, especially in rural and remote areas. Rather than banning them, governments should support them to reduce maternal and child mortality, and ensure that they get adequate training.

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Throughout African history, traditional birth attendants (TBAs) have provided maternity care for women despite having no formal training.

Poverty, cultural practices, and a shortage of primary healthcare services are forcing women to seek the help of untrained traditional birth attendants, despite the serious risks involved.

Last year Kenya recorded a maternal death rate of about 362 per 100,000 live births and an under-five death rate of 52 per 1,000 live births, while in Tanzania, one in every 126 women die due to maternity complications. The story is the same in Uganda and Ghana as well. According to the World Health Organisation (WHO)’s figures for 2016 on maternal mortality, 560 women die per 100,000 births in Nigeria.

Despite these shocking figures, women, even learned ones, are still flocking to unskilled birth attendants’ homes to give birth, putting their lives at risk. Why is this so? Is it is because governments are failing them?

For some women, traditions prevent them from attending hospital. For others, long distances to medical facilities prevent them from reaching a health facility in time to give birth. Some are put off by health workers’ attitudes.

TBAs can provide them with all the care they need, both during and after pregnancy and childbirth, and there is no doubt they are a much-needed resource.

In 2013, the Kenyan government introduced free maternal healthcare. The goal was to encourage more women to give birth in health facilities. However, according to data from the Kenya National Bureau of Statistics (KNBS) released this year, more women are still flocking to TBAs.

It is evident that pregnant women are not satisfied with the quality of care they are given at the hospitals. With the high number of women taking advantage of the free services, combined with the few health care workers to attend to them, some women are giving birth on their own even when they are in hospitals.

In 2013, Kenya had one of the highest maternal mortality rates in the world: 488 maternal deaths per 100,000 live births, according to the Ministry of Health.

In 2013, the Kenyan government introduced free maternal healthcare. The goal was to encourage more women to give birth in health facilities. However, according to data from the Kenya National Bureau of Statistics (KNBS) released this year, more women are still flocking to TBAs.

According to KNBS data for 2015/2016, the findings reveal that three out of ten children were delivered at home in 2018 in Kenya; this is an estimated 31.3 per cent improvement from 53.9 per cent recorded in 2005/06.

The survey showed that in rural areas the proportion of children born at home was 40.7 per cent compared to 13.3 per cent in urban areas.

Childbirth statistics in Kenya
“The county with the lowest proportion of children born at home was Kirinyaga, at 3.8 per cent, while Wajir, Mandera, Samburu and Marsabit had over 70 per cent of children born at home. Kirinyaga, Nyeri and Kisii counties recorded over 90 per cent of children born in a health facility,” KNBS stated.

The proportion of children delivered with the assistance of a traditional birth attendant in rural areas was 25.6 per cent compared to 7.8 per cent in urban areas. Wajir, Mandera and Samburu had over 60 per cent of the births assisted by a traditional birth attendant. Turkana County had the highest proportion of self-assisted births, at 34.5 per cent.

The low hospital births among pastoral communities may be partly linked to inadequate health facilities and personnel in the regions they live in. Families in pastoral counties also tend to be polygamous, which puts a strain on resources such as healthcare.

Nairobi, Kisii, Kiambu, Kirinyaga and Nyeri counties top in childbirths in hospitals, an indication of the success of the safety campaigns. These five counties are the only counties that recorded over 74 per cent of children born in hospitals.

Statistics further show that more deliveries are now handled by trained medical personnel, which is a plus in attaining safer childbirths. However, women in rural areas still prefer to be attended by TBAs, friends, and relatives during delivery.

According to WHO, with the exception of sub-Saharan Africa, where most births in rural areas are conducted by TBAs, rates of births assisted by a medically trained attendant have shown impressive increases over the past 15 to 20 years, Current data indicate that 59 per cent of births in the developing world are assisted by a medically trained professional.

Nairobi, Kisii, Kiambu, Kirinyaga and Nyeri counties top in childbirths in hospitals, an indication of the success of the safety campaigns. These five counties are the only counties that recorded over 74 per cent of children born in hospitals.

Uganda banned TBAs) in 2010 but they have continued to practise. Eighty per cent of rural women prefer TBAs to skilled attendants, according to officials at the Ministry of Health; 10 per cent of them delivered with the assistance of TBAs.

With TBAs playing such an important role in maternal and newborn healthcare, especially in rural areas, should governments abolish them completely or look for ways of incorporating them into the system as referral agents to hospitals?

One midwife’s experience

The Telegraph, through an informal survey in Kisumu’s Nyalenda Estate in Kenya, established that some mothers delivering in hospitals still relied on traditional birth companions during pregnancy and after giving birth.

Pictures of newborn babies adorn the walls of Margret Owino’s house. They are a treasured decor in the improvised maternity ward in her two-roomed corrugated iron-walled house. Hundreds of women have trekked the dusty and curvy road to Ms Owino’s Kisumu home, judging from the many pictures.

It is at 6 am when we got to her house. Dressed in a blue nylon apron, she is busy attending to a pregnant woman. In a busy month, she delivers over 60 children, according to her well-kept records.

Her small house acts as a labour and delivery room. She is among traditional midwives who assist women at childbirth, mostly in areas that lack infrastructure and trained health personnel.

Even though there are several health facilities in the area, some pregnant women prefer traditional birth attendants. They say they are more comfortable with them than obstetricians and trained midwives.

Ms Owino learned the midwife’s skills at a tender age. When she was 15 her late grandmother, who was a midwife, placed herbs in her right hand and some coins in the left — the traditional way of transferring the skills to her. This has since been her job. She is among Kenya’s 35 registered traditional birth attendants who work with hospitals to ensure safe deliveries.

She has had women who are bleeding profusely brought to her in the middle of the night. She does not attend to them but sends them immediately to the nearby hospital. Some clinics contact her to attend to mothers with breech births and at times they are brought to her “clinic”.

She also refers HIV-positive women to the hospital, but says she knows not all women disclose their status to her. She says it is a constant risk.

Her maternity services are similar to those in health facilities. She records clients’ details in a book and weighs infants on a weighing machine given to her as a token.

One of her clients said that harassment in public hospitals is one of the reasons they still troop to traditional birth attendants’ clinics.

Even though there are several health facilities in the area, some pregnant women prefer traditional birth attendants. They say they are more comfortable with them than obstetricians and trained midwives.

‘‘The midwives harass us, calling us names while we are often left in the hands of inexperienced trainees. The midwife can detect when a woman has the strength to push the baby or not, or if the baby is in the right position,” she says.

She says community midwives pamper and take care of women during and after delivery. She says this helps them give birth with dignity. That is why a lot of women come back to her when they are having another baby

Initially, the government was threatening the TBAs while others were being harassed and their tools were being confiscated. However, this has since changed; they are now being registered and undergo training to ensure safe deliveries.

The Ugandan government has also lifted the ban on TBAs and the focus now is training them. As a result, there has been a shift towards skilled birth attendants capable of averting and managing childbirth complications.

Ms Owino only attends to women who know their HIV status. She ensures that HIV positive clients have antiretroviral (ARVs) drugs given by a doctor, which she gives to the child immediately after tying the umbilical cord.

Benefits of supporting and training TBAs

Rather than educate against the use of TBAs, the United Nations Population Fund (UNFPA) believes that working with them is the best solution. It did a a study on the benefits of supporting and training TBAs across the world. The study was done in the Upper East Region in Ghana, and tracked antenatal visits and deliveries conducted by trained TBAs from 1990 to 1993.

“Antenatal visits increased from 20,000 to 180,000. Deliveries reported by TBAs increased from less than 10,000 to 50,000. Nationally, the percentage of TBA deliveries as a percentage of supervised deliveries increased from 16.4 percent to 22.2 percent between 1992 and 1993. Policymakers and program managers state that TBAs have contributed to: improve prenatal care, increase contraceptive acceptance rate, and decrease neonatal tetanus admissions”.

“The role of traditional birth attendants in the provision of healthcare in resource-poor countries is still important because of the current inadequacy of human resources for health. In developing countries for years to come, TBAs will remain the main providers of child deliveries in rural areas,” it states.

Dr Elizabeth Ogaja, a health analyst, says that midwives are an integral part of the healthcare system, adding that the reduction of maternal and newborn mortality in developing countries requires rigorous efforts that involve governments and non-governmental organisations in identifying TBAs who are known by the community to be experts.

“Recruitment and training of TBAs using adult learning techniques is important. The programmes should focus on basic primary healthcare, especially on symptoms of risky cases that need to be referred to formal health services and on hygiene to prevent mother and child from infections,” she says.

“Creation of dialogue, trustworthiness, patient, tolerance, willingness to collaborate, transparent and familiarity during training are key when working with TBAs as partners in health care and when sharing experiences,” says Dr Ogaja.

Training, she says, should be followed up by frequent meetings to share feedback and problems TBAs experience.

“We have realised that they are very important. Mothers trust them and we want to integrate them as much as we can. We advise that they bring pregnant mothers to hospitals so that we can take it from there,” she says.

Dr Lawrence Koteng’, the Homa Bay health executive, acknowledges the role played by traditional midwives but encourages expectant women to deliver in health facilities.

He says the county health department is training community health workers to discourage unsafe home deliveries.

“We do not support expectant women to deliver at home or anywhere except at health facilities where there are experts who can help whenever there is a complication,” says Dr Koteng’.

However, Allan Mayi, the deputy project director at Elizabeth Glaser Paediatric Aids Foundation, says the birth attendants should not attend to expectant mothers because they lack the skills needed to offer safe deliveries.

The organisation encourages women to deliver in hospitals and even offers incentives to birth attendants to take them to health facilities.

“Most mother-to-child HIV transmissions are recorded at midwives’ homes,” says Mr Mayi.

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Angela is a prolific and award-winning health writer who has written for the Daily Nation and is currently in a US-sponsored exchange program in Washington DC.

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Modelling the COVID-19 Pandemic in East Africa

Using mathematical modelling to track and predict the progress of the coronavirus outbreak.

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Modelling the COVID-19 Pandemic in East Africa
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Mathematical models allow us to extrapolate from information currently available about the state and progress of an outbreak, to predict future cases. In this article, we illustrate how, using mathematical models, the COVID-19 outbreak can be modelled mathematically to help prepare for the worst-case scenario and to develop a vaccination policy.

As can be seen from Figure 1, it is clear that the outbreak of COVID-19 in East Africa is taking a similar shape to that of China, USA and other European countries. The infections in China seem to have flattened by the last week of February 2020. East African countries seem to be at different phases of the disease outbreak. Kenya has the highest number of reported cases so far. This could be attributed to the relatively higher number of tests Kenya is carrying out compared to other East African countries. The United States has over 800,000 confirmed cases so far. The time it will take for the infections to significantly slowdown is of much interest to all the stakeholders.

Figure 1: COVID-19 Cumulative confirmed cases in East Africa, Europe, USA and China between 22/01/2020 and 21/04/2020. Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

Daily Confirmed Cases

The daily confirmed cases in East Africa, China, USA and some selected countries in Europe are given in Figure 2. It is clear that the confirmed cases in East Africa are still very low compared to Europe, the US and China. This could be attributed to the relatively fewer tests in East Africa. However, Tanzania has reported the highest daily confirmed cases (84) followed by Kenya (29). Daily confirmed cases in China, UK, Italy, France, and Germany are declining while they are increasing in Russia. The trend is quite unstable in USA.

Figure 2: COVID-19 Daily confirmed cases in East Africa, Europe, USA and China between 22/01/2020 and 21/04/2020. Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

Daily Confirmed Cases Curve in Europe, USA and China

As can be seen from Figure 3, the infections in China, Italy, France, Germany and Spain are in the decline. On the other hand, the daily infections in the US and Russia are yet to start declining.

Figure 3: Daily confirmed cases in China and some selected countries in Europe
Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

Considering that the follow-up in China started on 2 December 2019 while in all other countries in the world it started on 22 January 2020, Figure 4 shows the time it took China, Italy, France, Germany and Spain to experience a downward trend in daily infections.

Figure 4: Time taken to experience a downward trend in the Infections in Chinam Italy, France, Germany and Spain
Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

These countries took 67 days, on average, to experience a downward trend in daily infections. Considering the health facilities in these countries and the time they took to implement a total lockdown, 67 days seems to be the earliest time a country can take to experience a downward trend in COVID–19 infections taking into account the measures taken by these countries such as testing, lockdown, social distancing, surveillance and contact tracing. 140 days (about 5 months) is the minimum time any country will take to return to normalcy in terms of COVID-19.

Daily Confirmed and Recovered Cases

Figure 5 gives the daily confirmed and recovered cases in China and Kenya. It is clear that the number of recovered cases in Kenya is currently lower than the number of daily infections. The daily infections in Kenya seem to be increasing despite the country having experienced a decline around the second week of April 2020. This could be attributed to the increased number of daily tests. The recoveries in China had overshot the infections by the first week of March 2020.

Figure 5: Daily Confirmed and Recovered Cases in Kenya and China
Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

Daily Recovered and Dead Cases in East Africa

Figure 6 gives the percentage of recovered and dead cases in East Africa. Burundi has reported the highest percentage deaths (20 per cent). South Sudan has not recorded any recoveries or deaths so far despite reporting four confirmed cases so far. Uganda and Rwanda have not reported any deaths so far. The percentage of recoveries in the two countries (Uganda and Rwanda) are the highest so far in East Africa. The percentage recovered is a key parameter in modelling of infectious diseases. Every country in the world will have its own recovery rate based on such factors as status of health facilities and mean age at infection.

Figure 6: Percentage Recovered and Dead Cases in East Africa
Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

African Countries with the Highest Number of Confirmed Cases

As can be seen in Figure 7, Egypt, South Africa and Morocco have over 3,000 confirmed cases while Algeria has slightly over 2,500 cases. Ghana and Cameroon have slightly over 1,000 confirmed cases so far.

Figure 7: African Countries with the highest confirmed cases
Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

Recoveries and Deaths in African Countries with the highest number of Confirmed Cases

As can be seen in Figure 8, Algeria has the highest recovery and death rates amongst the six countries. Furthermore, among the six African countries, only Algeria has a death rate higher than 10%. Ghana has the lowest death rate of the six African countries while having the highest number of confirmed cases.

Figure 8: Cumulative Recovered and Dead cases in some selected countries in Africa
Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

Recoveries and Deaths in some selected countries outside Africa

Figure 9 gives the percentage of recoveries and deaths in China, the US and some selected countries in Europe. Surprisingly, recoveries in the UK are very low compared to other major economies in Europe. Also, the number of deaths in the UK are greater than the recoveries. This could be pointing to a strained National Health System (NHS). The recoveries are highest in China (92.6 per cent), an indication of the expected recovery rate in a well-developed country which took the necessary steps early enough. Similarly, a death rate of 5.5 per cent in China points to the expected long-term death rate in a well-developed country which took the necessary steps early enough.

Figure 9: Percentage recoveries and deaths in some selected countries outside Africa
Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

Prediction of Infection in Kenya

The transmissibility of COVID-19 was assessed through the estimation of the reproduction number R, defined as the number of expected secondary cases per infected case. In the early stages of an outbreak, and assuming no immunity in the population, this quantity is also the basic reproduction number R0, i.e. R in a fully susceptible population.

Figure 10 gives the estimated reproduction number of 1.241. This estimate is derived from the available daily COVID-19 incidences in Kenya so far. A serial interval distribution with a mean of 7.5 days and a standard deviation of 3.4 days was used, similar to the COVID-19 Wuhan characteristics.

Figure 10: Reproduction Number
Data Source: Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE)

Predicted Infections in Kenya for the next 5 days

Figure 11 gives the projected incidences in Kenya for the next five (5) days. For the country to experience a reduction in infections, measures must be taken to reduce the reproduction number by continuing to stress on social distancing, hand washing, etc. Infections can be minimised by implementing targeted total lockdown.

Figure 11: Predicted Infections in Kenya for the next 5 days
Source: Author

Table 1 shows the projected daily infections from 22/04/2020 to 26/04/2020. The upper limits can be taken as the worst-case scenario for the given transmission rate of 1.2 for about 600 daily tests for COVID-19 in Kenya. A similar analysis can be done for any other country whose daily incidences are available.

Table 1: Projected Infections in Kenya

 

       Date

 

Prediction

               95% Confidence Interval
Lower Limit Upper Limit
22/04/2020 12 5 20
23/04/2020 12 6 20
24/04/2020 13 6 21
25/04/2020 13 7 22
26/04/2020 14 7 23

 

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Why China? A Look at Viral Outbreaks That, Like COVID-19, Originate From the East

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China, officially the Peoples Republic of China (PRC), is a country in East Asia and is the most populous country in the world, with a population of around 1.4 billion people. It is also one of the world’s first civilizations.

With over 34,687 species of animals and plants, China is the third-most biodiverse country in the world after Brazil and Colombia. It is home to at least 551 species of mammals, 1221 species of birds and 424 species of reptiles and 333 species of amphibians; most of which are consumed as food.

On December 31 last year, Chinese authorities alerted the World Health Organization, WHO, of an outbreak of a novel strain of coronavirus causing severe illness. It was subsequently named SARS-CoV-2 and is now known as the causative agent of COVID-19. The origin of the virus was the city of Wuhan in China.

The disease, that has flu-like symptoms, has so far infected over 2 million people and caused over 140,000 deaths across 209 countries around the world. The effects it has left in its trail have caused different countries to take extreme measures in a bid to curb the spread of the virus.

This is, however, not the first time China has been the origin of a viral outbreak.

Infographic: AFP

Asian Flu

In February 1957, the Asian flu (H2N2) virus emerged in East Asia, triggering a pandemic. It was later traced back to China with a stop in Singapore. It then spread to Hong Kong and to coastal cities in the United States in the summer of 1957.

According to the Centers for Disease Control and Prevention, CDC, the number of deaths caused by the virus stands at 1.1 million people worldwide including 116,000 in the US. A vaccine was developed and the flu tapered off in 1958.

Though the cause is still not known, some authors believe the virus originated from a mutation in wild bucks combining with a pre-existing human strain. The strain later evolved, causing a milder pandemic between 1968-69.

The Asian flu was characterized by symptoms similar to many other strains of influenza, including fever, body aches, chills, cough, weakness, and loss of appetite. It is a respiratory illness, so a dry cough, sore throat, and difficulty breathing are all widely reported among flu sufferers. Other complications include pneumonia, seizures and heart failure.

Hong Kong Flu

The Hong Kong flu (H3N2) outbreak occurred in Hong Kong, China, between 1968-1969, killing an estimated 1 million people globally. It is said to have evolved from the H2N2 strain of influenza that had caused the Asian Flu.

It occurred in two waves, and in most places, the second wave caused more deaths that the first. A vaccine was later developed against the virus but it became available only after the pandemic had peaked in many countries.

Infection caused upper respiratory symptoms typical of influenza and produced symptoms of chills, fever and muscle pain and weakness. These symptoms usually persisted for between four and six days.

The H3N2 virus is still in circulation today and is considered to be a strain of seasonal influenza. In the 1990s, a closely related virus was isolated from pigs.

Bird Flu

In 1997, human infections with Bird flu (H7N9) were first reported in China. It is a zoonotic disease (one that passes from an animal or insect to a human), which infects humans after exposure to infected poultry or contaminated environments. Rare instances of person-to-person spread were been identified in China.

Since then, annual sporadic infections have been reported outside of Mainland China, Hong Kong and Macao, but all the cases have occurred among people who had travelled to China before becoming ill.

The current risk to the general public’s health posed by the virus is low but exposure to infected poultry pauses the risk of it spreading to neighbouring countries. There have been 6 waves of the epidemic over the years with the last one being in 2017.

Early symptoms included fever, headache, coughing that produces sputum, muscle pain breathing problems and general malaise. In later stages, other symptoms include pneumonia, multi-organ dysfunction, septic shock and brain damage.

SARS

In 2002, a viral respiratory disease caused by a coronavirus called Severe Acute Respiratory Syndrome (SARS-CoV), was reported in Asia.  It is thought to be an animal virus from an as-yet-uncertain animal reservoir, perhaps bats, that spread to other animals (civet cats) and first infected humans in the Guangdong province of Southern China.

According to National Foundation for Infectious Diseases, NFID, coronaviruses are a large group of viruses that cause diseases in animals and humans. They often circulate among camels, cats, and bats, and can sometimes evolve and infect people. They are named for the crown-like spikes on their surface.

Human coronaviruses were first identified in the mid-1960s. The CDC states that there are 7 coronaviruses that can infect people.

The SARS epidemic from China affected 26 countries and resulted in over 8000 infections in 2003. Some of the affected areas included Toronto in Canada, Hong Kong Special Administrative Region of China, Chinese Taipei, Singapore and Hanoi in Vietnam.

SARS also had influenza-like symptoms including fever, malaise, muscle pain, headache, diarrhoea, shivering, coughing (initially dry) and shortness of breathe. Severe cases often evolve rapidly, progressing to respiratory distress and requiring intensive care.

So Is China Fertile Ground For Future Pandemics?

Given the history above and the current situation the world is experiencing with the COVID-19 pandemic, what does China hold in terms of future outbreaks?

Dr Eddy Okoth Odari, a senior lecturer and researcher of Medical Virology in the Department of Medical Microbiology at the Jomo Kenyatta University of Agriculture and Technology (JKUAT), points out several factors.

“Potential for a pandemic would depend on various socio-economic and geopolitical factors attributed to a country or region. Most pandemics that have emanated from China have been viral in nature and have occurred as a result of such viruses crossing species from animals to humans. Viruses’ crossing from animals to humans is not a strange phenomenon. However, we have to appreciate that most of these viruses, which eventually end up in pandemics, have been traced to the “Wildlife Markets” (wet markets) in Southern China. The activity of trading in wildlife is unique to that region. China being an economic hub where a lot of businesses take place, many people travel to and out of China and therefore I would imagine that any outbreak occurring in China would easily and quickly spread to other regions compared to if such an outbreak would occur for example in an African country.”

In late January, China imposed a ban on trade and consumption of wildlife meat acquired through illegal trading activities, as cases of COVID-19 surged in Wuhan. The city of Shenzen went a step further to extend the ban on cats and dogs. This new law will be enforced on 1st May.

There have been 81,802 cases, 3,333 deaths and 77,279 recoveries since the outbreak (see our tracker for the most up to date numbers), numbers whose veracity continues to be heavily criticized after Chinese authorities reportedly suppressed the news of the outbreak when it first began.

However, for the first time since January, Wuhan reported no new deaths on April 7, joining the rest of China, which has reportedly seen no deaths since March – even though questions have been raised about the veracity of China’s claims. This sharp decline has been attributed to aggressive testing, quarantines and social distancing. Authorities have begun to ease restrictions on lockdowns though still taking precautions to fully resume normalcy in the country.

As to what the future of pandemics holds, Dr Okoth says it is not that easy to tell.

“It may not be possible to predict where a future pandemic may come from, but it is worth assessing such socio-economic and geopolitical factors when trying to generate a model to predict future pandemics.”

He, however, has a warning for African countries.

“Although so far tropical Africa is not recording very high cases as compared to the temperate regions, seasonal variations may work against us. For example, the cold season starting in June through to the end of July (in the case of Kenya) and other southern African countries may make these regions become the epicentres of infections (if not controlled in time) in the coming months.”

This article was originally published by Africa Uncensored. Graphics by Clement Kumalija.

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COVID-19: Echoes of the 20th Century in a 21st Century Pandemic

In modern history, the most notable major pandemic was the Spanish Flu of 1918-1919. Over a century later, the world is grappling with the effects of the ongoing COVID-19 pandemic that has currently infected over 2 million people and killed over 140,000.

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Diseases have plagued mankind throughout history. The Neolithic Revolution, which was marked by a shift to agrarian societies, preceded by hunting and gathering communities, brought about increased trading activities. The shift created new opportunities for increased human and animal interactions, which in turn, introduced and sped up the spread of new diseases. The more civilized humans became, the more the occurrences of pandemics was witnessed.

This led to outbreaks that left an indelible mark in history due to their severity.  Three of the deadliest pandemics include the Plague of Justinian (541-542 BC) that killed about 30-50 million people, Black Death (1347-1351) that killed 200 million and Smallpox (1520 onwards) that killed 56 million.

Infographic courtesy: Visual Capitalist

In modern history, the most notable major pandemic was the Spanish Flu of 1918-1919. Over a century later, the world is grappling with the effects of the ongoing COVID-19 pandemic that has currently infected over 2 million people and killed over 140,000.

But how does the Spanish flu compare to the current COVID-19 pandemic?

The mother of all flu pandemics in modern history

The Spanish flu pandemic of 1918 is sometimes referred to as the mother of all pandemics. It affected one-third of the world’s population and killed up to 50 million people, including some 675,000 Americans. It was the first known pandemic to involve the H1N1 virus.

The outbreak occurred during the final months of World War I. It came in several waves but its origin, however, is still a matter of debate to-date. Its name doesn’t necessarily mean it came from Spain.

An emergency hospital during Spanish flu influenza pandemic, Camp Funston, Kansas, c. 1918 Image Courtesy: National Museum of Health and Medicine

Spain was one of the earliest countries where the epidemic was identified. Historians believe this was likely a result of wartime media censorship. The country was a neutral nation during the war and did not enforce strict censorship on its press. This freedom of the press allowed them to freely publish early accounts of the illness. As a result, people falsely believed the illness was specific to Spain and hence earning the name “Spanish flu”.

Symptoms

Influenza or flu is a virus that attacks the respiratory system and is highly contagious.

Initial symptoms of the Spanish flu included a sore head and tiredness, followed by a dry hacking cough, loss of appetite, stomach problems and excessive sweating. As it progressed, the illness could affect the respiratory organs, and pneumonia could develop. This stage was often the main cause of death. This also explains why it is difficult to determine exact numbers killed by the flu, as the listed cause of death was often something other than the flu.

These symptoms are very similar to those of the ongoing COVID-19 pandemic.

Origin

For decades, the Spanish flu virus was lost to history and scientists still do not know for sure where the virus originated. Several theories as to what may have caused it point to France, the United States or China.

Research published in 1999 by a British team, led by virologist John Oxford theorized a major United Kingdom staging and hospital camp in Étaples, France as being the centre of the flu. In late 1917, military pathologists reported the onset of a new disease with high mortality in the overcrowded camp that they later recognized as the flu. The camp was also home to a piggery, and poultry was regularly brought for food from neighbouring villages. Oxford and his team theorized that a significant precursor virus harboured in birds, mutated and then migrated to the pigs.

Other statements have been that the flu originated from the United States, in Kansas. In 2018, another study found evidence against the flu originating from Kansas, as the cases and deaths there were fewer than those in New York City in the same period. The study did, however, find evidence suggesting that the virus may have been of North American Origin, though it wasn’t conclusive.

Multiple studies have placed the origin of the flu in China. The country had lower rates of flu mortality, which may have been due to an already acquired immunity possessed by the population.  The argument was that the virus was imported to Europe via infected Chinese and Southeast Asian soldiers and workers headed across the Atlantic.

However, the Chinese Medical Association Journal published a report in 2016 with evidence that the 1918 virus had been circulating in the European armies for months and possibly years before the Spanish flu pandemic.

COVID-19, on the other hand, was first discovered in the Wuhan province of China late last year. There has been no argument against this so far. Research is still ongoing as to whether it was passed on from bats or the newly found connection to pangolins.

Spread

Much like COVID-19, the Spanish flu was spread from through air droplets, when an infected person sneezed or coughed, releasing more than half a million-virus particles that came into contact with uninfected people.

The close quarters and massive troop movements during the war hastened the spread of the flu. There are speculations that the soldiers’ already weakened immune systems were increasingly made vulnerable due to malnourishment and the stresses of combat and chemical attacks. More U.S soldiers in WW1 died from the flu than from the war.

A unique characteristic of the virus was the high death rate it caused among healthy adults 15-34 years of age. It lowered the average life expectancy in the U.S by more than 12 years.

COVID-19, on the other hand, does not discriminate in terms of age, but older people and those with other underlying medical conditions are being considered more vulnerable.

Measures

The measures being taken today to curb the spread of COVID-19 are very similar to those taken in 1918. Back then, physicians advised people to avoid crowded places and shaking hands with other people. Others suggested remedies included eating cinnamon, drinking wine and drinking Oxo’s beef broth. They also told people to keep their mouths and noses covered with masks in public.

Image courtesy: National Museum of Health and Medicine

In other areas quarantines were imposed and public places such as schools, theatres and churches were closed. Libraries stopped lending books and strict sanitary measures were passed to make spitting in the streets illegal.

Due to World War I, there was a shortage of doctors in some areas. Many of the physicians who were left became ill themselves. Schools and other buildings were turned into makeshift hospitals, where medical students had to step up to help the overwhelmed physicians.

Effects

Though the severity of COVID-19 has not gotten to the level of the Spanish flu, most of the effects the world is experiencing now are very relatable.

The Spanish flu killed with reckless abandon, leaving bodies piled up to such an extent that funeral parlours and cemeteries were overwhelmed. Family members were left to dig graves for their deceased loved ones. Strained state and local health centres also closed, hampering efforts to chronicle the spread of the flu and provide much-needed information to the public. Similar scenes are being witnessed in Italy today, which has so far recorded the highest number of deaths due to COVID-19.

The Spanish flu also adversely affected the economy as the deaths created a shortage of farmworkers, which in turn affected the summer harvest. A lack of staff and resources put other basic services such as waste collection and mail delivery under pressure. COVID-19 has seen some companies send their employees home on unpaid leave and others have imposed pay cuts. If the situation worsens, a majority is likely to lose their jobs.

Fake news during this time was also a problem. Even as people were dying, there were attempts to make money by advertising fake cures to desperate victims. On June 28, 1918, a public notice appeared in the British papers advising people of the symptoms of the flu. It however turned out this was actually an advertisement for Formamints, a tablet made and sold by a vitamin company. The advert stated that the mints were the “best means of preventing the infective processes” and that everyone, including children, should suck four or five of these tablets a day until they felt better.

Image courtesy: ICDS

Fake news has been a concern since the outbreak of COVID-19, with the Internet making it even easier to spread it. See some of our fact checks on the subject here.

The deadliness of WW1 coupled with censorship of the press and poor record-keeping made tracking and reporting on the virus very tedious. This explains why the flu remains of interest to date as some questions are yet to be answered. In contrast, Media coverage on COVID-19 has been commendable and very useful to the public in providing much-needed answers.

Treatment/Vaccine

When the Spanish flu hit, medical technology and countermeasures were limited or non-existent at the time. No diagnostic tests or influenza vaccines existed. The federal government also lacked a centralized role in helping to plan and initiate interventions during the pandemic.

Many doctors prescribed medication that they felt would be effective in alleviating symptoms, including aspirin. Patients were advised to take up to 30 grams per day, a dose now known to be toxic. It is now believed that some of the deaths were actually caused or hastened by aspirin poisoning.

The first licensed flu vaccine appeared in America in the 1940s and from there on, manufacturers could routinely produce vaccines that would help control and prevent future pandemics.

Fast forward to 2020; clinical trials of COVID-19 treatments/vaccines are either ongoing or recruiting patients. The drugs being tested range from repurposed flu treatments to failed Ebola drugs, blood pressure drug (Losartan), an immunosuppressant (Actemra- an arthritis drug) and malaria treatments developed decades ago.

An antiviral drug called Favipiravir or Avigan, developed by Fujifilm Toyama Chemical in Japan is showing promising outcomes in treating at least mild to moderate cases of COVID-19.

As of now, doctors are using available drugs and health support systems such us ventilators to alleviate symptoms. There have been over 500,000 recoveries so far.

Doctors in China, South Korea, France and the U.S. have been using Chloroquine and hydroxychloroquine on some patients with promising results. The FDA is organizing a formal clinical trial of the drug, which has already been approved for the treatment of malaria, lupus and rheumatoid arthritis.

Mistakes

The mistakes and delays in taking quick action we are experiencing today with COVID-19 are not new. In the summer of 1918, a second wave of the Spanish flu returned to the American shores as infected soldiers came back home. With no vaccine available, it was the responsibility of the local authorities to come up with plans to protect the public, at a time when they were under pressure to appear patriotic and with a censored media downplaying the disease’s spread.

Some bad decisions were made in the process. In Philadelphia for instance, the response came in too little too late. The then director of Public Health and Charities for the city, Dr Wilmer Krusen, insisted that the increasing fatalities were not the Spanish flu but the normal flu. This left 15,000 dead and another 200,000 sick. Only then did the city close down public places.

The End Of the Pandemic

The pandemic came to an end by the end of the summer of 1919. Those who were infected either died or developed immunity. The world has experienced other flu outbreaks since then but none as deadly as the Spanish flu.

The Asian flu (H2N2), first Identified in China from 1957-1958, killed around 2 million people worldwide. The Hong Kong (H3N2), first detected in Hong Kong, from 1968-1969, killed about 1 million people. Between 1997-2003, Bird flu (H5N1), first detected in Hong Kong, killed over 300 people. More recently in 2009-2010, the Swine flu (H1N1), which originated from Mexico, killed over 18,000 people.

The world’s population has increased from 1.8 billion to 7.7 billion since 1918. Animals alike, which are used for food, have also increased significantly, giving room for more hosts for novel flu viruses to infect people. Transport systems have gotten better making global movement of people and goods much easier and faster, further widening the spread of viruses to other geographical regions.

Even though considerable medical, technological and societal advancements have been made since 1918, the best defence against the current pandemic continues to be the development of vaccine or herd immunity. The biggest challenge, however, is the time required to manufacture a new vaccine. According to the Centers for Disease Control and Prevention, CDC, it generally takes about 20 weeks to select and manufacture a new vaccine.

Dr Eddy Okoth Odari, a senior lecturer and researcher of Medical Virology in the Department of Medical Microbiology at the Jomo Kenyatta University of Agriculture and Technology breaks it down as follows:

“It is anticipated that “herd immunity” would protect the vulnerable groups. We must, however, appreciate that natural “herd immunity” may only occur when a sizeable number of the population gets infected. I note with concern that we may not know and should not gamble with the immunity or health of our populations. This would then call for an “induced herd immunity” through vaccination. Therefore as at now, we must increase our efforts in developing an effective vaccine.”

The World Health Organization (WHO) published instructions for countries to use in developing their own national pandemic plans, as well as a checklist for pandemic influenza risk and impact management. But even with all these plans, there are still loopholes that could still be devastating in the face of a pandemic, as we are currently witnessing.

Healthcare systems are getting overwhelmed and some hospitals and doctors are struggling to meet the demand from the number of patients requiring care. The manufacture and distribution of medications, products and life-saving medical equipment such as ventilators, masks and gloves have also significantly increased, seeing as there is already a shortage being experienced. Dr Okoth has a good explanation for this:

“Translation of research findings into proper policies has been slow since policy formulators have insisted on evidence. For example, as early as March 2019, publications had hinted into a possibility of a virus crossing over from bats to human populations in China, but unfortunately, there was no proper preparedness and if any, perhaps the magnitude of this potential infection was underestimated. Finally, the geopolitical wars and political inclinations among the superpowers are not helping much in the war against infectious diseases. When the pandemic started it was viewed as a Chinese problem, in fact, other nations insisted in it being called a “Chinese virus” or “Wuhan virus”. Even with clear evidence that the virus would spread outside China, the WHO (perhaps to appear neutral) insisted that China was containing the virus and delayed in declaring this a pandemic – the net result of this was that other countries became reluctant in upscaling their public health measures, yet other countries seem to have been keen not to be on the bad books of China.”

There is no telling how long the ongoing COVID-19 pandemic will go on for or when and how it will end, but global preparation for pandemics clearly still warrant improvement as Dr Okoth advises.

“Perhaps the lessons that we learn here is that diseases will not need permission to cross borders and since the world has become a global village, there should be proper investments in global health and scientific research.”

This article was originally published by Africa Uncensored. Graphics by Clement Kumalija.

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