The year was 1998, just after the second multiparty elections that, like the first, was marred by ethnicized political violence and allegations of massive fraud. The horizon was ominous. Moi would be coming to his two-term limit in the subsequent election, and there was already talk of a constitutional amendment to remove the term limit as was happening in Zambia and elsewhere at the time. The economy was in free fall. The big imponderable then was whether Moi would go when the time came, and whether the country could survive a conflagration if he sought to cling to power by hook or crook.
The departure point of Scenarios was that Kenya’s business model had reached the end of the road: “Kenya had reached the limits of its chosen political and economic models.” This prognosis was captured by an analogy of an umbrella. We inherited at independence a dualism of the colonial era which created a “modern” enclave sector occupied by Europeans and their Asian and African auxiliaries, and a “native sector” occupied by the excluded African masses. The modern enclave, which I prefer to call the privilege sector, comprised the State, a small corporatized economy with superior social amenities especially education facilities and urban residencies. Colonial Europeans had the exclusive Duke of York, Prince of Wales and other exclusive schools, Asians had their own — the Duke of Gloucester, Allidina Visram, Racecourse Secondary — and the lucky few Africans had Alliance, Maseno, Mang’u and a few others. Even though African schools and urban residencies were below those enjoyed by Europeans they were way above the life of the ordinary native. Once you got into one of these schools, you had made it.
The departure point of Scenarios was that Kenya’s business model had reached the end of the road: “Kenya had reached the limits of its chosen political and economic models.”
Now think of the enclave economy, the privilege sector if you like, as an umbrella. People under the umbrella are protected from the elements, but how well protected you are depends on your position inside the umbrella. People at the centre are completely protected and warm, while those at the periphery are less protected, but they are better than those outside. The trick is to get deeper into the umbrella until you are the guy actually holding it.
Before independence Europeans were at the centre, followed by Asians, and Africans at the periphery. After independence, many Europeans and some Asians left making more room for Africans to move deeper into the umbrella, and a few more to move into the shelter.
A fresh graduate was guaranteed a position previously occupied by a European, and a high school leaver, a position previously occupied by an Asian. Even though there was a whiff of tribalism, with Kikuyus getting the prime jobs, all Africans with university education got on the gravy train. Those with post-graduate degrees went straight to the top of the public service.
We inherited at independence a dualism of the colonial era which created a “modern” enclave sector occupied by Europeans and their Asian and African auxiliaries, and a “native sector” occupied by the excluded African masses.
By the mid-seventies the privilege sector was already feeling the strain of the numbers of people. Up until then anybody with an O-Level Div. 3 was assured a good clerical job in the private sector while A Levels who did not proceed to university or diploma courses joined as management trainees.
By the end of the `80s, the economy was struggling to absorb 2000 university graduates a year.
The problem was about to get a whole lot worse.
In 1990, the labour force was in the order of four million people, of which one million, a quarter that is, were in the “privilege sector” (i.e. public and private sector formal wage jobs). The other three quarters were in the informal non-agricultural and smallholder agriculture. Unemployment was relatively low, since smallholder agriculture and informal sector was absorbing those who did not get into the privilege sector.
Three decades on, the Kenya National Bureau of Statistics estimated the economically active population (15-64 year-olds) at 25 million, and the actual labour force (i..e excluding students and others inactive) at 19 million — a five-fold increase. Formal wage employment is estimated at 2.7 million and non-farm informal employment at 14 million, leaving one million unemployed, and implying that there are just about two million smallholder farmers and pastoralists. Out of the increase of 16 million, the privilege sector has absorbed 1.7 million, only 10 percent, and its contribution to employment is down to 8.5 percent from 25 percent three decades ago.
In the meantime, university enrolment has increased to 500,000 which works out to 125,000 graduates a year, or 63 times the rate three decades ago, while the privilege sector is absorbing just over 100,000 a year. Even if they took up all the jobs, the privilege sector simply cannot absorb the annual throughput of university graduates.
In 1990, the labour force was in the order of four million people, of which one million, a quarter that is, were in the “privilege sector”… Three decades on, the economically active population (15-64 year-olds) is at 25 million, and the actual labour forceS at 19 million — a five-fold increase.
This encapsulates what the scenarios team meant by the end of the road: “Radical changes to revive the economy, a comprehensive reorganization of Kenya’s primary institutions, models of governance and relationships between citizenry and the government are all required.” Would it happen?
Two transformational imperatives were self evident, political and economic, making for four possible scenarios. The first is the No Reform scenario, that is, the continuation of the trajectory that the country was on at the time. We called this the El Nino scenario. The second is the economic reform-only scenario. We called this scenario Maendeleo. The third is political reform-only scenario. We called this the Katiba scenario. Initially, these were the only scenarios developed. But when presented to the project trustees, they argued that the presented scenarios were all too pessimistic and insisted that the team develop a fourth scenario with both political and economic reform. The team obliged, even as it felt this was not a viable prospect. We called this the Flying Geese scenario (See ‘Kenya Scenarios Project’ box).
Kenya’s politics for the better part of the last two decades can be characterized as a struggle between the Maendeleo and Katiba scenarios.
University enrolment has increased to 500,000 which works out to 125,000 graduates a year, or 63 times the rate three decades ago.
In 2003, the National Rainbow Coalition (NARC) rode to power on a Katiba platform. For a short while, the cross-ethnic unity of purpose displayed by erstwhile bitter political rivals, reminiscent of the Flying Geese scenario, made Kenyans the most optimistic people in the world. It did not last. On assuming office the old order coalesced around Kibaki, sabotaged the constitution-making process, and proclaimed a Maendeleo agenda. Instead of a constitution, we got Vision 2030. Katiba-Maendeleo was not just a battle between politics and economics but it played out in the economic arena, between NARC’s bottom-up-inclusive growth and the trickle-down economics of the privilege economy. A good number of the experts I mobilized to work on NARC’s Economic Recovery Strategy (ERS), Betty Maina, Sam Mwale, Gem Kodhek, Wachira Maina, Richard Ayah, John Kashangaki, Joslyn Ogai among others, were members of the scenarios team, as was Prof. Anyang’ Nyong’o, the minister in charge of the ERS. After the 2005 referendum, the transformative political and economic agenda was abandoned. Instead of a new constitution and the economic empowerment agenda that NARC had promised, we got the trickle-down infrastructure-led Vision 2030.
Kenya’s politics for the better part of the last two decades can be characterized as a struggle between the Maendeleo and Katiba
It took the 2007/8 post-election violence to jolt maendeleoism back to reality, and create the impetus for the 2010 Constitution. It is our great misfortune that we put the constitution in abeyance for two years instead of going to election immediately after promulgation as is the norm. This gave time for the old order to regroup behind the anti-ICC narrative. The rest, as they say, is history.
For the 2017 general election, we once again united the opposition around the Katiba platform. NASA was crafted straight out of the 2003 NARC playbook. Those who paid attention to the manifestos may have noted that the NASA manifesto led with the political reform agenda, followed by social and economic priorities in that order, while the Jubilee one led with an economic agenda; social and political reforms were treated almost as an afterthought.
It is our great misfortune that we put the constitution in abeyance for two years instead of going to election immediately after promulgation as is the norm.
The Jubilee government’s plunder and incompetence has no doubt contributed to the economic implosion that is now unfolding. Perhaps distracted by the melodrama of the plunder and blunders, the clawback of the privilege sector has gone, if not unnoticed, then unremarked. Recently, a Principal Secretary gloated on social media that they have secured US$26 billion in pledges from investors for the housing pillar of the so called Big Four Agenda, whose claim to bigness no one seems to know. Twenty-six billion dollars is a lot of money. It is equivalent to the GDP of Uganda. The idea that a government of a country that cannot feed itself can contemplate investing that kind of money in urban middle class housing, let alone shout about it, is astounding. The question I posed to him: what will the houses produce?
According to the National Housing Survey conducted by the KNBS five years ago, 60 percent of Kenyans live in their own houses (88 percent of rural. No surprises there — Kenya is still a predominantly agrarian society — 60 percent of Kenyans are rural and 88 percent live on land they own. Urban home ownership stood at 30 percent but this understates actual home ownership, as many urban residents also own rural homes, and actually see their sojourns into cities and towns as temporary.
Recently, a Principal Secretary gloated on social media that the government has secured US$26 billion in pledges from investors for the housing pillar of the so called Big Four Agenda. Twenty-six billion dollars is the equivalent to the GDP of Uganda. That a government of a country that cannot feed itself can contemplate investing that kind of money in urban middle class housing…is astounding.
More significant perhaps is that over 70 percent paid monthly rents under Sh. 6,000, and 90 percent under Sh.10,000. Realistically, only about 10 percent of urban residents, less than three percent of Kenyans, are in the potential home ownership bracket. It’s hard to see what kind of logic would lead the government to the conclusion that urban middle class home ownership is one of the country’s top four development priorities. But this is the logic of the privilege society.
In the old days, entitlement was rationalized with the graduates being the creme de la creme of society, a merited reward for scaling the heights to reach the pinnacle of academic achievement. Many students did the minimum necessary to graduate. Those who seemed to be “overworking” were often frowned upon. The former were right in a sense. Education replaced Race as a ticket to the top of the social ladder. Not what you do, but who you are, a graduate. Graduates were the new whites. Times and circumstances have changed, but culture dies hard. It is in the rubric of this culture that prioritizing residential housing over enterprises in a country with a monumental unemployment crisis can look perfectly normal.
With Maendeleo imploding, and Katiba proving too potent a threat to privilege, what we see now is a political class in self-preservation mode, laying the groundwork for what I’ve called an eat-and-let-eat grand ethnic coalition—KANU 3.0. In the meantime, the demographic clock ticks, at the rate of 150,000 university graduates a year. Frustrations rise.
Education replaced Race as a ticket to the top of the social ladder…Graduates were the new whites.
Where does the political class think it is going with this? No political reforms, no economic reforms. That would be El Nino:
“The state is captured by a small elite that employs it as an agent of its own private enterprise. On the other hand, the economy is characterized by low productivity which makes it impossible for the population to realize upward economic mobility. Thus, the construction of both the economic and political spaces generates tension and conflict. The result is an implosion.”
The Kenya at the Crossroads Scenarios proved prescient 20 years ago. It may well be yet again.
El Nino: “The state is captured by a small elite that employs it as an agent of its own private enterprise. On the other hand, the economy is characterized by low productivity which makes it impossible for the population to realize upward economic mobility. Thus, the construction of both the economic and political spaces generates tension and conflict. The result is an implosion.”
The Kenya at the Crossroads Scenarios
No Political Reforms, No Economic Reforms: El Nino
In the El Niño scenario, neither the reform of the state nor the restructuring of the economy takes place. It is a story in which the state remains predominantly patron-client based and therefore partisan, subjective and ineffective in the manner in which it performs its functions. The state is captured by a small elite that employs it as an agent of its own private enterprise. On the other hand, the economy is characterized by low productivity which makes it impossible for the population to realize upward economic mobility. Thus, the construction of both the economic and political spaces generates tension and conflict. The result is an implosion.
Economic Reforms with Minimal Political Reforms: Maendeleo
This scenario explores a technocratic attempt to reform the economy with a view to using economic gains as a means of pre-empting or forestalling demands for political reform. The major assumption in this scenarios is that if the economy is growing steadily, there will be little or reduced demand for political reform. Whilst this model is initially successful, as the limits of the system are reached and economic growth slows down, the demands for political reform pick up once again and the system is faced with two basic choices: to be repressive (and perpetuate the economic decline) or negotiate political reforms (and kick-start the economy again). Though this strategy leads to short-term gains, it breeds a lot of inequality. Without addressing the deeper political and structural questions with regard to Kenya’s problems, this success cannot be maintained for a long period. Sooner or later, one has to address these structural questions.
Political Reforms with Minimum Economic Reforms: Katiba
The Katiba scenario presupposes a successful political negotiation that sees the country adopt a new constitution which recognizes the diversity of the peoples of Kenya and puts in place a mechanism of checks and balances which ensure that the centre is not in a position to dominate over any of the regions of the country.nsuccessful, the outcome for the country can only be bleak. The Katiba story is a story of an inclusive long-drawn out but successful political negotiation process which leads to the reform of and creation of key national institutions. This process takes place in an environment in which there is little or no economic growth. It is the story of a stormy, painful, but decidedly successful attempt by Kenyans to resolve the inconsistencies in their political processes and key institutions of public life that have led to domination, marginalization and fostered corruption. The new institutions reflect the diversity of the country, increase the accountability of leadership at all levels and allow a greater role for the citizen in shaping and managing those activities that affect their day-to-day lives.
Simultaneous Economic and Political Reforms: Flying Geese
This is a scenario of inclusive growth and fundamental institutional reorganization. The team is persuaded that with decisive action and a keen interest in redressing the past and capturing the future, sufficient resolve could be brought to bear and this scenario launched. The Flying Geese story explores the renaissance of Kenya through a determined effort to reform the social, cultural, economic and political models in force. This effort is spearheaded by a new leadership which is armed with a vision and the conviction that Kenya deserves better and can be more than it presently is. For simultaneous reforms on both the economic and political fronts to succeed, a huge reservoir of goodwill is required. There is also a need to for there to be a body (or bodies) that can act as guarantors to the process.
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.
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.
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.
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?
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.
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.
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.
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.
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.
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.
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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