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Legalise It: The Absurd Ban on Marijuana as a Metaphor for Maendeleo-Development

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Why marijuana remains illegal (in most of Africa) and tobacco legal speaks volumes about the contradictions of capitalism. Why native enterprises remain ‘informal’ while foreign investment is favoured and sought after by African governments is an old, insidious trick of imperialism. DAVID NDII pens an anti-development manifesto.

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A few weeks ago I made what I thought was an innocuous comment on a Twitter news post in response to a news post reporting that police had intercepted a 17 kg marijuana haul, to which I commented “legalize marijuana”, thereby unleashing a tweetstorm that went on for days.

Why is marijuana illegal? Consumption of marijuana is a victimless crime. It has proven therapeutic value, while tobacco is a proven carcinogen that harms both the smoker and third parties through second hand smoke, yet cigarette smoking is legal but marijuana is criminalized? Is it perhaps because, as I opined in the Twitter debate, tobacco is a big global capitalist enterprise, but everyone can roll their own joint?

This article is not about marijuana. It is a critical reflection on the phenomenon we call development. I will be arguing that the phenomenon we call development shares the same historical DNA as the criminalization of marijuana. The case for decriminalization of marijuana is a metaphor for the deconstruction of this thing we call development. This DNA consists of three things: colonialism, Christianity and capitalism. I will reflect on each in turn.

Why is marijuana illegal? Consumption of marijuana is a victimless crime. It has proven therapeutic value, while tobacco is a proven carcinogen that harms both the smoker and third parties through second hand smoke, yet cigarette smoking is legal but marijuana is criminalized? Is it perhaps because, as I opined in the Twitter debate, tobacco is a big global capitalist enterprise, but everyone can roll their own joint?

In her irreverent and hilarious novel, Red Strangers, Espelth Huxley subjects European superiority complex to Kikuyu customary law. When Karue sends his insolent young son to collect a long overdue bride-price debt that was the subject of a running feud, a fight breaks out and the young man is killed. The family sets about collecting the “blood money”, a hundred and seventeen goats, to compensate the Karue clan for the loss of their son. But the white man has already arrived and Matu is arrested for the murder of the young man and taken to Tetu to face the white man’s justice.

Karue testifies against Matu (though he was not at the scene) but to his great consternation, he learns that his clan will not be paid blood money. Even though it is Matu’s brother Muthengi’s sword which killed the young man, they agree that Matu will confess to the crime since they are brothers – it does not matter; it could as well have been Matu – only to learn that Matu will belong to the white man for six seasons:

The phenomenon we call development shares the same historical DNA as the criminalization of marijuana. The case for decriminalization of marijuana is a metaphor for the deconstruction of this thing we call development. This DNA consists of three things: colonialism, Christianity and capitalism.

Matu said nothing, for the words did not seem to make sense. He supposed that the interpreter had made a mistake. Muthengi however asked: “But why is Matu to stay here in Tetu? The affair of the young man’s death is between Karue and my father Waseru. What has the stranger to do with it?”

“That is the stranger’s law. Matu killed the evil man. Therefore he stays with stranger.”

“Does the stranger give him to Karue?” Muthengi persisted.

“No, he stays here.”

“Who gives him food?”

“The stranger gives him food.”

“Then what does Karue receive in compensation for his son, who is dead?”

“He does not receive anything.”

“That I cannot understand!” Muthengi exclaimed. “If a man loses his son, or a child his father, must not his family be given compensation for their loss? How else can justice be done?”

“Stranger’s justice is different,” the interpreter said. “Matu must stay here.”

“Then the stranger gets something for Karue’s loss, and Karue’s clan gets nothing at all,” Muthengi said. “This seems to me to be a very peculiar law, and one with no justice in it at all. Now I understand how these strangers have become so exceedingly rich; when they sit in judgement they award nothing to the injured person, but everything to themselves.”

“That is the law nonetheless.” The interpreter said.

A law with no justice at all. Law without justice is the essence of colonialism.

The Agikuyu also concluded that Gūtirī mūthūngū na mūbīa (the white man and the priest are one and the same), by which they meant that the church was part of the colonizing mission. I can attest to this.

I spent a considerable part of my childhood and youth at my grandparents’ home in Kijabe, a Christian mission hamlet sad to be the third largest missionary centre in the world, run by the African Inland Mission, the parent of the African Inland Church (AIC). It is, to the best of my knowledge, the only alcohol-free community in Kenya. There is not a single bar in the town, and the shops do not stock alcohol and cigarettes either.

The town belongs to the church. With the exception of public schools, all other formal institutions in the town are part of the church establishment. There’s the Kijabe Mission Hospital, a bible school, a radio station, printing press and the Rift Valley Academy, an international school. Formal wage jobs and business opportunities are given on the basis of religiosity.

Kijabe, a Christian mission hamlet sad to be the third largest missionary centre in the world, run by the African Inland Mission…the town belongs to the church…[and] the community is divided into two: the “saved” and the “unsaved.” My grandfather who was a rebel of sorts designated the Holy Joes as either “hinga” (hypocrites) or “njuhiga” (opportunists). The combination of the two he reserved for the clergy.

The community is divided into two: the “saved” and the “unsaved.” My grandfather who was a rebel of sorts (he was a school teacher far away and only came home on occasional weekends and school holidays) designated the Holy Joes as either “hinga” (hypocrites) or “njuhiga” (opportunists). The combination of the two he reserved for the clergy. Four decades on, not much has changed. It is still a place where drunkards are upright, honorable people, and obsequious sanctimonious scoundrels are the pillars of society. Kijabe is a microcosm of the damage that the Church has wrought in Africa.

The Oxford English Dictionary defines capitalism as “an economic system in which a country’s trade and industry are controlled by private owners for profit, rather than the state”. The Marriam-Webster is more elaborate. It defines capitalism as “an economic system characterized by private or corporate ownership of capital goods, by investments that are determined by private decision and by prices, production and distribution of goods that are determined mainly by competition in a free market”.

According to these definitions we would be compelled to conclude that pre-colonial Africa was capitalist. Being largely stateless, trade was unregulated and the means of production privately owned by default. We would be wrong. These dictionary definitions are flawed. What they define are contemporary and mostly Western market economics. The juxtaposition of private and state ownership already points to the capitalism/socialism dichotomy, a 20th century phenomenon.

Capitalism as a distinct economic system was introduced in the political lexicon by Karl Marx. Marx refers to it variously as the “capitalist mode of production” or “capitalist system,” and it is thus defined in the Communist Manifesto co-authored by Marx and Friedrich Engels:

“The directing motive, the end and aim of capitalist production is to extract the greatest possible amount of surplus value, and consequently to exploit labour power to the greatest possible extent.”

Abraham Lincoln, in a speech to the US congress, weighed in on the presumption of capitalism as the default of market economy thus:

“It is not needed, nor fitting here that a general argument should be made in favor of popular institutions; but there is one point, with its connections, not so hackneyed as most others, to which I ask a brief attention. It is the effect to place capital on an equal footing with, if not above, labor, in the structure of government. It is assumed that labor is available only in connection with capital; that nobody labors unless somebody else, owning capital, somehow by the use of it induces him to labor. Now, there is no such relation between capital and labor as assumed, nor is there any such thing as a free man being fixed for life in the condition of a hired laborer. Both these assumptions are false, and all inferences from them are groundless. Labor is prior to, and independent of, capital. Capital is only the fruit of labor, and could never have existed if labor had not first existed. Labor is the superior of capital, and deserves much the higher consideration. Capital has its rights, which are as worthy of protection as any other rights. Nor is it denied that there is, and probably always will be, a relation between labor and capital, producing mutual benefits. The error is in assuming that the whole labor of community exists within that relation.”

Although Lincoln’s speech, given in 1861, predates his famed correspondence with Marx, Lincoln was very likely influenced by his ideas, since Marx was a prolific contributor to the US press in the 1850s.

The dictionary definition’s most dangerous flaw is that of conflating capitalism with a market economy. It gives the market economy a bad name. The defining feature of capitalism is one where capital employs wage labour. A market economy on the other hand, does not prescribe which factor of production employs the other. Capital can hire labour, or labour can hire capital. To illustrate, consider the boda boda industry. One will find riders (labour) who hire motorcycles (capital) at a fixed fee, owner-operators and even riders who have invested in motorcycles that they lease out.

The defining feature of capitalism is one where capital employs wage labour. A market economy on the other hand, does not prescribe which factor of production employs the other. Capital can hire labour, or labour can hire capital.

It is tempting to dismiss the boda boda industry as a jua kali anomaly, an exception rather than the rule. Here in Kenya we have cooperatives and other collective commercial enterprises operating in many sectors, including one of the largest and most successful financial cooperatives (SACCOs) sectors in the world. SACCOs operate in the market economy, for profit, but they really don’t compete with each other—the serve their members. The smallholder farmer-owned KTDA conglomerate is Kenya’s largest manufacturing concern, and the single largest exporter of black teas on the world. These enterprises operate in the market, they really do not compete with each other, they coexist and cooperate, as each seeks to serve their respective members.

Their objective is not to maximize profit but rather, to improve the welfare of their members. It is possible to conceive of a market economy consisting of a boda boda-style industrial organization, cooperatives and KTDA-type concerns. It is also readily apparent that such an economy would not have the malevolent character we associate with modern-day globalized capitalism.

In Marx and Engels’ day, capital meant industrial capital—machinery and equipment. When he talks of mutual benefits, Lincoln is talking about industrial capital. The malevolence of capitalism is rooted in the nature of finance capital — what Costas Lapavistas has termed “profiting without producing”. Financial capitalism separates profits from production and seeks only a return on money. The malevolence of finance capitalism was postulated most forcefully by Lenin in his 1917 essay Imperialism, the Highest Stage of Capitalism. E.K Hunt’s textbook History of Economic Thought provides a cogent and most pertinent summary of the thesis:

“When productive capacity grew faster than consumer demand, there was very soon an excess of this capacity and hence there were very few profitable domestic investment outlets. Foreign investment was the only answer. But in so far as the same problem existed in every industrialized capitalist country, such foreign investment was only possible if [the] non-capitalized could be “civilized”, “Christianized” and “uplifted” — that is, if their traditional institutions could be forcefully destroyed, and the people coercively brought under the domain of the “invisible hand” of market capitalism.”

“Uplifted.” Is this not the thing we now call development?

As regards destruction of traditional institutions, it is instructive that when colonialism introduced wage labour, the Agikuyu devised a name for it, guthukuma (verb), as distinct from wiira (work). Gūthūkūma which is most likely a corruption of the swahili word sukuma (to push) conveys involuntary toil. Work was not sold. Even destitute people were not subjected to wage labour. They were adopted as tenants (ahoi), and given an opportunity to work for themselves. When extra hands were needed, such as walling a hut (gūthinga), one invited community members to help (gūtūmana wiira meaning “invitation to work”). The only obligation was to feed the people generously. Even today, if you serve someone a large helping, they might exclaim kari ithinga? (is it for walling work). But over time the distinction disappeared, and wage labour appropriated wiira. People conscripted into servitude and undignified chores resigned themselves to the pragramism of wiira ni wiira, (“work is work”, kazi ni kazi in Kiswahili), which you still hear today. But hidden in the pragmatism is a psychology of resistance that makes Africans problematic wage labour. Deep down, we resent it.

When productive capacity grew faster than consumer demand, there was very soon an excess of this capacity and hence there were very few profitable domestic investment outlets. Foreign investment was the only answer. But in so far as the same problem existed in every industrialized capitalist country, such foreign investment was only possible if [the] non-capitalized could be “civilized”, “Christianized” and “uplifted” — that is, if their traditional institutions could be forcefully destroyed, and the people coercively brought under the domain of the “invisible hand” of market capitalism.

We need not revisit European imperialism to validate the thesis. With its US$ 3.2 trillion trade surplus and excess production capacity at home, China’s unfolding debt imperialism is as textbook a case of Lenin’s capitalist imperative as it can get. It is instructive that China’s imperial ambitions are propelled by the State, rather than private capital — the China Roads and Bridges Corporation is the new Imperial British East Africa Company. This is further repudiation of the dictionary definition of capitalism.

Not to be outdone, the whats-her-name-again Brexit-befuddled British premier was out here hawking “upliftment” aid and investment. The Iron Chancellor, Angela Merkel, is touring West Africa. Last year, Germany published a report proposing a Marshall Plan for Africa. It is a sloppy, callous offensive document, down to dredging up slavery and the 1884 Berlin Conference, as if we need a reminder. That aside, the big idea of the Marshal plan is surprise, surprise, to leverage aid to increase German private investment in Africa.

With its US$ 3.2 trillion trade surplus and excess production capacity at home, China’s unfolding debt imperialism is as textbook a case of Lenin’s capitalist imperative as it can get. It is instructive that China’s imperial ambitions are propelled by the State, rather than private capital — the China Roads and Bridges Corporation is the new Imperial British East Africa Company.

Development is but another name for imperialism.

David Ndii
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David Ndii is a leading Kenyan economist and public intellectual.

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Tackling Corona: The Need for a People-Driven Response

African governments need to adopt a “whole-of-society approach” to successfully face the threat posed by COVID-19. They need to recognise that involving non-governmental actors in the formulation, as well as in the implementation, of policies to address the pandemic, need not be perceived as a threat to their own legitimacy.

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The scenes of police viciously assaulting citizens while enforcing a nighttime curfew, as well the death by suicide of a South African woman after being forced into a deplorable government quarantine facility, have exposed the brutal face of Kenya’s coercive response to the coronavirus pandemic. While many have condemned the incidents, some have also felt that coercion is necessary given the extreme threat posed by the virus, the need for urgent action and the failure of the citizens to comply with the government’s directives. There is no time to debate the response, goes the argument. There is only time to act to save lives.

Yet there is a grave flaw at the heart of this argument. These very factors are what make it necessary that there is more, not less, public involvement. The threat being to the whole of society, the response needs to involve the whole of society. Trying to move fast without having a cooperative public in tow is a recipe for failure, as the Kenyan government is learning. And the way to get a cooperative public as well as mobilise society is to engage with the people, not just order them about.

“Epidemics are tests of social and political systems,” writes the Zimbabwean academic and Associate Professor of African Politics at the University of Oxford, Simukai Chigudu, in a fascinating article for the online platform, Africa Is A Country. Citing his book, The Political Life of an Epidemic: Cholera, Crisis and Citizenship in Zimbabwe, which looked into the roots of the 2008 cholera outbreak in his country, he notes that it is the “political, economic and social processes that…shape the trajectory of [an] epidemic”, not just the biological properties of the virus or bacterium involved.

This is not to say that the actions of governments are not important. The trajectory and the evolution of the pandemic so far have been largely dictated by the actions of states. The thousands of lives it has so far claimed are not evenly distributed globally, but rather concentrated in countries that for a variety of reasons either didn’t take the pandemic seriously or were slow to react to it. In a very real sense, it is not just the virus that is killing people; people are also dying from state inaction, incompetence and malfeasance.

The legacy of colonialism

Similarly, as the virus menaces Africa, it has been the actions of African governments – past and present – that have so far determined how the pandemic is unfolding on the continent. When fighting the disease, a crucial constraint for many African societies is the near universal failure to address the legacy of colonialism. In fact, as Prof Chigudu explains in relation to 21st century Zimbabwe, “the long-term factors that led to the cholera outbreak can be traced as far back as the late 19th century when Salisbury [today known as Harare] was founded as the administrative and political capital of Southern Rhodesia [the predecessor state of what is now Zimbabwe].”

In a very real sense, it is not just the virus that is killing people; people are also dying from state inaction, incompetence and malfeasance.

He goes on to write that rather than undoing the discriminatory nature of provision of public facilities, “colonial era by-laws, plans, and statutes largely remained in place, indicating the apparent tension between overturning the racial and socio-economic segregation of Rhodesian city planning and maintaining an inherited sense of modernity and orderliness in urban space”.

This experience will be familiar to many across the continent where, in the words of one of Kenya’s politicians speaking in Parliament in 1966, “Today we have a black man’s Government, and the black man’s Government administers exactly the same regulations, rigorously, as the colonial administration used to do”.

The persistence of colonial states and their twin logics of authoritarian exploitation and classist exclusion means that African governments begin with a deficit of public trust, as well as diminished capacity to implement policies. Just three years ago, Kenya was jailing doctors’ representatives for going on strike to demand a pay rise and improvements to services in public hospitals.

Corruption – another gift of colonialism – has focused attention on vanity projects that provide opportunities for looting, rather than on investments in basic health services. The result is high-end, expensive machines lying idle in hospitals that lack even basic amenities. The entire country, for example, only has around 400 isolation beds, and 155 intensive care unit beds for a population of over 48 million people.

The authoritarian and exclusionist streaks are also evident in the manner in which African governments are currently responding. In Kenya, rather than implementing a holistic approach that would mobilise all communities and civil society, the government has opted for a China-style top-down, dictatorial approach, one that decades of hollowing out of the state has been difficult to impose. Prominent activist Jerotich Seii has noted the “‘elite gaze’ that deploys a language of enforcement”. David Ndii, one of the country’s top economists and public intellectuals, has similarly decried the consequences of what he describes as a “boneheaded securocratic approach to a complex emergency”.

A holistic approach

Yet this need not be the case. Kenya has a long history of indigenous not‐for‐profit organisations, self-help societies and community-based organisations that it could leverage to win consent and mobilise society. In fact, in many communities, NGOs have become surrogates for the government, offering services that the state was either unable or unwilling to provide. They have even managed to penetrate into policy- and decision-making levels.

In Kenya, rather than implementing a holistic approach that would mobilise all communities and civil society, the government has opted for a China-style top-down, dictatorial approach…

As Prof Jennifer Brass noted in her PhD thesis a decade ago, “Contrary to both normative arguments that government should ‘steer’ the ship of state (make policy) while private actors ‘row’ (implement policy), and the belief that government is eroding or becoming irrelevant to the governance process, this dissertation shows that NGOs are now joining public actors and agencies at many levels in decision and policy making regarding service provision.”

Sadly, however, there is little evidence that the Kenyan government is doing much to incorporate the expertise and experience of NGOs and other civil society actors into its planning for COVID-19. When President Uhuru Kenyatta established the 21-member National Emergency Response Committee on Coronavirus at the end of February, there was no one from outside of government included in it. In this, the President went against his own National Contingency Plan which recommended the establishment of a National Public Health Emergency Steering Committee to “provide policy, strategic directions” which would include heads of “responding NGOs”.

Sadly, however, there is little evidence that the Kenyan government is doing much to incorporate the expertise and experience of NGOs and other civil society actors into its planning for COVID-19.

Perhaps the Kenya government’s reluctance to engage with civil society organisations should not come as a surprise. After all, this is a government that for the best part of the last decade has made the demonization of civil society (which its mouthpieces on social media happily branded “evil society”) a cornerstone of its propaganda efforts. Still, it is clear that the state alone cannot address this crisis.

Non-governmental actors, including professional associations, churches and volunteer, community and civil society organisations, will need to be involved in the “whole-of-society approach” that the World Health Organisation (WHO) says is required to successfully face the threat posed by COVID-19. And not just as “rowers”. Across the continent, governments will need to urgently recognise that involving others in the formulation, as well as in the implementation, of policy need not be perceived as a threat to their own legitimacy. As Prof Brass writes, “Governance is not the removal of government, but the addition and acceptance of other actors, including NGOs, in the steering process.”

How effective are lockdowns?

The absence of non-governmental actors at the decision-making table may also be manifesting in the choices that African countries are making. For example, many have opted to go the way of China and other (though by no means all) European countries by imposing “lockdowns” – shuttering factories, businesses and markets; banning mass events from church services to political rallies; and forcing people to stay at home or imposing stringent restrictions on their movement – in an attempt to curtail the rate of spread of the disease and ensure their already fragile health systems are not overwhelmed. Beginning with Rwanda, the lockdowns have swept the continent, affecting economies large and small, from Nigeria to Uganda. In addition, by the end of March, nearly all countries had some form of travel restriction, with more than half imposing full border closures.

However, in an article for The Conversation, Prof Alex Broadbent and Prof Benjamin Smart argue that a one-size-fits-all approach may have lethal consequences for Africa. They note that the “the major components of the recommended public health measures – social distancing and hygiene – are extremely difficult to implement effectively in much of Africa” and that the net effect of lockdowns “may thus be to prevent people from working, without actually achieving the distancing that would slow the spread of the virus”. They also question the value of “flattening the curve” in a scenario where at the best of times public healthcare is inaccessible to a huge proportion of the population.

Similarly, in an interview with Africa Report, John Nkengasong, the director of the Africa Centre for Disease Control and Prevention, which is part of the African Union, also pointed out that lockdowns are not only difficult to sustain but would also “lead to other consequences, such as shortages of food, medicine and other basic supplies”. He also said that the shutdown of air travel and closing of borders across the continent was making it more difficult to coordinate the distribution of desperately needed medical supplies and equipment. Making much the same point on the Kenyan news programme Punchline, Dr Mary Stephens of WHO said that blanket travel bans and border closures would prevent African countries from accessing external medical experts needed to plug gaps in their health systems.

The resort to force by governments across the continent to counter the resistance of their populations to such measures speaks to the lack of a social consensus for the necessity of such measures. It is the poor, for the most part, who will bear the pain of the lockdowns, especially the many working in the informal sector who cannot afford to stay at home for a day, let alone for weeks. Yet they are almost completely excluded from the decision-making table.

Similarly, in an interview with Africa Report, John Nkengasong…pointed out that lockdowns are not only difficult to sustain but would also “lead to other consequences, such as shortages of food, medicine and other basic supplies”.

If they were allowed to have a say, perhaps they would point out that there are other options and examples that African countries could look to. In the Far East, for example, countries and cities like Japan, South Korea as well as Singapore, Hong Kong and Taiwan, while not yet out of the woods, have managed to tackle the pandemic within their borders while largely avoiding the crippling lockdowns.

Nobel laureate Amartya Sen famously declared that “no famine has ever taken place in the history of the world in a functioning democracy”. He noted that democratic governments, “facing elections and criticisms from opposition parties and independent newspapers”, would be compelled to take decisions to avert disaster.

Democracy may not be such a sure shield against epidemics, but it is clear that, at least on the African continent, its absence, and the prevalence of governments used to wielding clubs and guns against their citizens rather than listening to them, may be turning a looming disaster into a catastrophe.

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Slaying the Giant: An Epidemiologist’s Perspective on How Kenya Can Tackle COVID-19

There hasn’t been a pandemic control that has succeeded without social capital. How Kenya and Africa will deal with this pandemic will squarely depend on the strength, resilience and adaptability of our social capital to weather the storm.

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Slaying the Virus: An Epidemiologist’s Perspective on How Kenya Can Tackle COVID-19
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Epidemiologists measure how a disease spreads through populations using the basic reproduction number, otherwise known as R0 (pronounced “R naught”). Typical seasonal flu has a reproductive number of 1.2, while that of COVID-19 is reported to be approximately 2.5.

R = Reproductive number: How many people a given patient is likely to infect. If the reproductive number is greater than one (R>1), each case on average is transmitting it to at least one other person. The epidemic will therefore increase. Reproductive number is affected by factors including but not limited to population density, environment, age and immunity.

Typical seasonal flu has a reproductive number of 1.2; Spanish flu has a reproductive number of 2-3, while COVID-19 is reported to be approximately 2.5.

From a policy planning perspective, it offers a very clear objective: Reduce the reproductive number to less than one (R<1)

D= Duration: How long someone is infectious. If someone is infectious twice as long, then that’s twice as long as they can spread the infection. For COVID-19, people are infectious for up to 21 days. This can usually be reduced by treatment but there is currently no approved treatment for COVID-19.

O= Opportunity: The number of contacts of the infected person during the duration of the infection. If people are isolated (no contacts), then community spread does not occur or is minimised. This is achieved through social distancing.

T= Transmission Probability: The chance an infection is spread to a contact, hence the need to eliminate physical contact and hand washing.

S= Susceptibility: The chance a contact will develop the infection and become infectious themselves. We are all susceptible to COVID-19. Susceptibility is usually taken care of by vaccines, which we do not have for COVID-19.

Another important number for understanding diseases is the Case Fatality Rate (CFR): What percentage of people who have a disease die from it? On one extreme, we have rabies, which has a 99 percent fatality rate if untreated. On the other hand, is the common cold, which has a relatively high reproductive number but is almost never fatal. At the time of writing this, the crude case fatality rate for COVID-19 was 5.3 percent. I am calling it crude because thus far, testing has been selective. If testing protocols were to be expanded, this value will probably drop to 1 percent or less. But we will, however, work with the worst-case scenario for now.

In the case of the COVID-19, exponential growth will occur in the disease rate in humans as long as there is at least one infected person in the population pool, regular contact between infected and uninfected members of the population occurs, and there are large numbers of uninfected potential hosts among the population.

Which brings us to the term ‘doubling time’, which just means in this situation that cases/deaths will double in a given amount of time. Doubling rate in the United States of America has been reported to be three days, while China has managed to spread it out. And if the numbers from China are to be believed, they are now at six days. The longer the doubling time, the better.

One last terminology I will touch on is Herd Immunity, which simply means when a significant part of a population has become immune to a disease agent, its spread stops naturally because they are not enough susceptible people for efficient transmission. For COVID-19, immunity would come through getting the disease, assuming that it confers life-long immunity.

So what strategies do we have?

Do nothing

Based on the data we have from other countries, the reproductive number of COVID-19 is 2.5. That means, the population of people that will be infected to achieve herd Immunity is: 1-1/R0, equal to 60 percent. This translates to more than 28 million Kenyans getting it. Moreover, 80 percent (approximately 22 million people) of the population will have a mild disease or be asymptomatic. Another 14 percent (approximately 4 million people) will be in severe condition and may need hospitalisation, while 6 percent (approximately 1.7 million people) of Kenya’s population will be critical and may need intensive care facilities.

Going by case fatality rate of 5 percent, it means approximately 1.4 million Kenyans will die if we do nothing. I chose to stick with the global case fatality rate of 5 percent because even though we have a youthful population, we grapple significantly with both communicable – AIDS, Tuberculosis, malaria, pneumonia etc., and non-communicable illnesses. Furthermore, a majority of the population lives in squalid conditions and is prone to other competing illnesses. And to add salt to injury, as a country, we are still battling malnutrition and anaemia.

Doubling of new infections in the United States of America is happening every three days. This means the numbers will double ten times in a month. Though we have yet to reach the exponential phase, a quick back-of-the-envelope analysis places Kenya, with its current infection rate at 122, indicates the number of people with COVID-19 will double ten-times one month from today. The numbers will be compounded the longer we do nothing and the effects will be fatal to say the least.

Do something

Since there are no antiviral medications for COVID 19 and no vaccine, we must rely on non-pharmaceutical interventions like social distancing and eliminating physical contact.

The impact of early and widespread social distancing is flattening the curve. The flattening minimises overwhelming the healthcare facilities and their resources, which is good in the short run, but lengthens the duration of the epidemic in the long run. If the health system becomes overwhelmed, the majority of the extra deaths may not be due to coronavirus but to other common diseases and conditions such as heart attacks, strokes, trauma, bleeding, and other such diseases that are not adequately treated.

Too, if large numbers of Kenyans were to get very sick and start flooding into hospitals and health care facilities, our system will undergo a severe stress test. Our health system could be overrun in a very short period of time. Thus, figuring out how to plan for a massive influx of patients is one of the hardest parts of preparing for health emergencies, and it has yet to be adequately dealt with in Kenya.

If large numbers of Kenyans were to get very sick and start flooding into hospitals and health care facilities, our system will undergo a severe stress test. Our health system could be overrun in a very short period of time.

“Surge capacity” management is one of our biggest weaknesses, particularly at a time when we have shortages of health workers, and a weak supply chain management system. The national and county governments have spent very little on health care, choosing to focus on capital expenditure where there is something for them to ‘’eat’. Even in the course of this pandemic, health care workers are being appreciated by word of mouth but are not being protected, risking spreading this to patients, other workers, families as well as the public. The risk of COVID-19 being another nosocomial infection is very high. Indeed, the 3,000 unemployed doctors have yet to be absorbed into the healthcare system to mitigate this crisis, but I digress.

Mitigation

Here the focus is to slow the growth of the epidemic. Instead of having it double every three days, you put interventions in place to slow it down to double every seven days. This will ease the demand for health care services and give you breathing room. Interventions here include hospital isolation of confirmed cases, home isolation of suspect cases, home quarantine of those living in the same household as suspect /confirmed cases, and social distancing of the elderly and others at most risk of severe disease.

This has the potential to reduce infections and deaths by as much as 60 percent, and prevent the economy from collapsing completely the numbers will drop from 28 million infections with no mitigation, to approximately 11.2 million, and 560,000 deaths if we infer to the case fatality rate of 5 percent.

Suppression

With suppression, you want to reduce the reproductive number to below 1, hence stopping transmission. This is what we are doing now. Travel restrictions, social distancing, school closures, curfews, stopping mass gatherings. The only strategy that we haven’t adopted so far is sheltering in place, what people like to refer to as lockdown. The problem with this strategy is that it has enormous economic and social impacts. And as long as we live in a global village, there is a great risk of recrudescence especially when you open the borders. This means you have to maintain the strategies until a vaccine is discovered and you have vaccinated at least 60 percent of the population, or at least until a cure is found. We are probably 6-12 months away from a solution considering how clinical trials are being fast-tracked. There is the option of relaxing the strategies occasionally when the reproductive number is low, but this means you must have a meticulous method of disease surveillance to pick up recrudesce early.

How do we balance public health vs. economic consequences?

The bubonic plague of medieval Europe, the Spanish flu of 1918, SARS, H1N1 Swine flu and other infectious diseases have shaped the political economy of the world and so far, all evidence indicates that COVID-19 will do the same.

We must, now, grapple with philosophical issues such as how much economic value we are willing to lose to save a human life.

As a public health practitioner, I decree that saving life is more important than social and economic effects. I think there must also be a delicate political balance to be considered and policymakers should reflect whether they are doing more harm than good.

When making decisions, policymakers often use what’s called the Value of a Statistical Life (VSL) to set an upper bound on how much you can impose on people in order to save lives. But if policymakers assigned an infinite economic value to each life, they would spare no expense and be fearless in imposing any inconvenience.

Information

At a time when everyone needs better information, from disease modelers and governments, we lack reliable evidence on how many people have been infected with COVID-19. Better information is needed to guide decisions and actions of monumental significance to monitor their impact.

The data collected so far is unreliable. Given the limited testing to date, some deaths and probably the vast majority of infections due to COVID-19 are being missed. We can’t access if we are failing to capture infections by a factor of three or 300.

As a public health practitioner, I decree that saving life is more important than social and economic effects. I think there must also be a delicate political balance to be considered and policymakers should reflect whether they are doing more harm than good.

Too, we don’t know what factors are being modeled. Kenya, for instance, is a diverse country with densely populated counties like Nairobi, and less densely populated like Turkana. A one-size-fits-all model won’t work. The modeling models developed need to be county-specific, and interventions need to be more nuanced and contextual. Of course, the chain of command should remain at the ministry of health but with an aggressive inter-governmental coordination prescribing strategies for each county.

This is the time to fully implement the spirit of the 2010 constitution and bring in the devolved units, as health is a function of counties. It is here that strategies such as how will “sheltering in place” work for pastoralism communities be enforced? What strategies need to be considered for the rural areas where the majority of their populations are the elderly?

The overarching idea is to tailor-make a range of policy mixes suitable for the Kenyan context.

Is Kenya getting right?

Based on the numbers I have shared above; I would say it’s a mixed bag. Social distancing is yielding fruit, however, we need a scientifically determined threshold on when these can be relaxed or re-introduced. Indeed, there must be a robust health surveillance system in place, which has to be county-specific. The success of the ongoing strategies to mitigate community transmission will depend on how Kenyans collectively respond to the plea of physical distancing and hygiene.

Still, we have to do more. First, we are not testing enough. I posit that we should partner with certified private laboratories to scale-up testing. We must acquire testing kits that can be used on Genexpert platforms that were provided by PEPFAR and are available in all counties.

I can’t emphasise enough about testing.

You test, isolate and trace to minimise community spread. Without this, we are swimming blind. Secondly, we are not protecting our health care workers. They are the first-line workers and are at the greatest risk of acquiring COVID-19, transmitting it to other patients, as well as to the community.

Finally, there hasn’t been a pandemic control that has succeeded without social capital. How Kenya and Africa will deal with this pandemic will squarely depend on the strength, resilience and adaptability of our social capital to weather the storm.

Disclaimer: The opinions expressed here belong to the author, and do not purport to reflect the opinions or views of the MOH or other bodies involved in COVID-19 response.

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Controlling COVID-19: Lessons from East Asia

As authorities the world over restrict the movements of their populations, and governments benchmark their responses on the worst affected regions, there are lessons to be learnt from South Korea which has eschewed lockdowns in favour of early detection through mass testing, contact tracing and treatment.

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Controlling COVID-19: Lessons from East Asia
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By the third week of March 2020, the number of COVID-19 deaths in Italy had overtaken the number of deaths in China. Authorities all over the world are restricting the movements of their populations as part of efforts to control the spread of COVID-19.

For the time being, more and more governments are benchmarking their responses on the very worst outbreaks in Wuhan and northern Italy. But lockdowns inevitably have adverse economic impacts, especially for businesses, particularly small ones heavily reliant on continuous turnover. Are there other ways to bring the virus under control without lockdowns?

South Korean lessons?

The Republic of Korea, or South Korea, is one of a handful of mainly East Asian economies that have dramatically reduced the number of COVID-19 cases as well as related deaths. On 29 February 2020, the country saw 909 newly confirmed cases.

By 25 March, the number of newly confirmed cases fell to 100. It has gone from having the second-highest rate of infection globally to eighth place, behind China, Italy, United States, Spain, Germany, Iran and France, all with varying rates of testing.

For now, South Korea has checked the spread of infections. It has managed to slow the spread of COVID-19 without imposing lockdowns, even in its most infected city, Daegu. How have they responded differently to the crisis?

Korean-style pandemic management

The key to South Korea’s response has been mass testing. South Korea has done the most COVID-19 tests by country, with over 300,000 tests as of 20 March 2020, or over 6,000 per million inhabitants. Germany, in second place, had done 167,000 by 15 March 2020, or 2,000 per million.

The infected who show no symptoms (i.e., the asymptomatic) or only have mild symptoms are more likely to transmit the virus to others. As such, undetected cases are more likely to spread infection, mass testing has checked the spread of the virus by identifying and breaking its chains of transmission.

The median incubation period, between infection and symptoms first appearing, is about five days, during which time asymptomatic individuals may unknowingly infect others. Mass testing detects infections early, so that individuals can self-isolate and get treatment instead of infecting others.

South Korea had built up its testing capabilities following the Middle East Respiratory Syndrome (MERS) outbreak in 2015. It was thus prepared with test kits and facilities for rapid development, approval and deployment in case of future outbreaks.

After South Korea confirmed its first case of Covid-19 on 20 January 2020, hundreds of testing facilities, ranging from drive-through kiosks to hospitals and local clinics, quickly became available across the country.

Trace, test, treat

The tests are mainly free for those whom medical professionals suspect need to be tested, e.g., if they recently returned from China. The tests are also free of charge for “secondary contacts” of a person known to be infected or to belong to an at-risk group.

Others who do not belong to these categories, but wish to be tested, are charged 160,000 Korean won (about US$130), but the amount is reimbursed if the result is positive, with any treatment needed paid for by the government.

Mass testing detects infections early, so that individuals can self-isolate and get treatment instead of infecting others

Another legacy of the MERS outbreak is that the government has the legal authority to collect mobile phone, credit card and other data from those who test positive for contact tracing efforts. China, too, has made use of artificial intelligence and big data to improve contact tracing and manage priority populations.

Although this has sparked debates over privacy concerns, South Korea’s proactive testing and contact tracing methods have also been praised by the World Health Organization (WHO), which is encouraging other countries to apply lessons learned in South Korea, China and elsewhere in East Asia.

Path not taken

Although South Koreans are banned from entry into more than 80 countries around the world, its authorities have only restricted incoming travellers from China’s Hubei province, whose capital city is Wuhan, and Japan, due to bilateral political tensions.

Special procedures require visitors from China and Iran to use smartphone applications to monitor for symptoms such as fever. As Europe has become the new epicentre of the pandemic, all visitors from Europe are now being tested for Covid-19, with those staying long-term quarantined first.

The Korean Centers for Disease Control and Prevention (KCDC) continue to urge people to practice social distancing and personal hygiene. Mass gatherings are discouraged, and employers encouraged to allow employees to work remotely. But no lockdown has been imposed, and South Korea has not imposed nationwide restrictions on movements of people within its borders.

Learning the right lessons

Besides South Korea, the WHO has also praised China for its Covid-19 response, which has rapidly reduced new cases, besides helping other countries with their efforts. More and more countries are restricting freedom of movement through lockdowns, citing China’s response in Wuhan.

However, Bruce Aylward, who led the WHO fact-finding mission to China, notes,

“The majority of the response in China, in 30 provinces, was about case finding, contact tracing, and suspension of public gatherings—all common measures used anywhere in the world to manage [infectious] diseases. The lockdowns people are referring to… [were] concentrated in Wuhan and two or three other cities . . . that got out of control in the beginning . . . [T]he key learning from China is . . . all about the speed. The faster you can find the cases, isolate the cases, and track their close contacts, the more successful you’re going to be”.

China and South Korea are now primed to detect and respond rapidly, which may make all the difference in preventing a new wave of infections. This is not to say that lockdowns are ineffective; we will soon know whether such measures in countries like Italy will succeed.

The faster you can find the cases, isolate the cases, and track their close contacts, the more successful you’re going to be

The South Korean and Chinese experiences suggest that resources should be concentrated on rapid and early detection, isolation and contact tracing, protecting the most vulnerable, and treating the infected, regardless of means, instead of mainly relying on strict lockdown measures.

This article was first published by inter press service news agency. The authors are both associated with Khazanah Research Institute but do not implicate KRI with the views expressed here.

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