“Never dress a deep wound superficially.” – Somali proverb
A recent article by The Elephant’s senior writer Dauti Kahura suggests that one of the main reasons why a sizeable number of Kikuyus are going to vote for William Ruto in 2022 is that they are afraid that if they don’t – and especially if he loses or is forced out of the election race – Ruto will unleash terror on Kikuyus living in the Rift Valley, the kind of terror that Kikuyus in the region experienced when hundreds of them were killed and hundreds of thousands of them were displaced after the disputed 2007 election.
“It is the Kikuyu electorate that finds itself torn between the devil and the deep blue sea,” wrote Kahura. “Whatever option it takes, it will not be an easy choice because Ruto has presented the Kikuyus with the greatest dilemma. If they do not support Ruto, is there a risk that the violence of 2007/8 will be repeated?”
One Kikuyu lady told Kahura that she will definitely be voting for Ruto come 2022 because he was part of the deal that Uhuru Kenyatta made when the duo joined forces. In that sense, Kikuyus owe Ruto a political debt. “We entered into a pact with the Kalenjin people, that they would help our son capture power and protect our people in the Rift. In return, we would also lend our support to their son after Uhuru’s terms ended. It would now be disingenuous for the Kikuyu people to renege on that promise . . . it actually would be dangerous. I have relatives in the Rift and I can tell you they are not sitting pretty.”
For those who are neither Kikuyu nor Kalenjin, this rationale sounds like pure and simple blackmail: “If you vote for me, I won’t kill you.” The horror of this thinking cannot be overstated. If this blackmailing tool is what Kalenjins (read Ruto) are going to be using to win the next election, then we are in a very bad place indeed. It not only mocks our democratic right to live wherever we choose but also entrenches a mindset that views Kenya as belonging to only two tribes – the Kikuyu and the Kalenjin – whose agendas we have to accept regardless of whether they are against our own interests. And we must honour every deal they make with each other to stay in power.
If this blackmailing tool is what Kalenjins (read Ruto) are going to be using to win the next election, then we are in a very bad place indeed
It seems like a strange logic, but one that has become normalised in Kenya since 2013. Although many analysts insist that the UhuRuto victory was simply a mathematical probability, in that it united two of Kenya’s largest ethnic groups into one formidable voting bloc, thereby outnumbering the opposition, many also believe that the alliance was a pact based on the threat of violence. In addition, by declaring the election as a “referendum against the ICC [International Criminal Court]”, Uhuru and Ruto managed to galvanise two communities whose elites have held onto power since independence.
How did we get here?
It all started when Justice Philip Waki handed over the secret list of names of the suspected perpetrators of the 2007/8 post-election violence to the African Union’s envoy Kofi Annan in 2009. Kenya had the option to form a local tribunal within a year, but failed to do so. At that time, Raila Odinga, who was then the Prime Minister, had campaigned for the formation of such a tribunal, if for no other reason than that it would end speculation about the identity of the perpetrators.
When the ICC went ahead to charge the so-called Ocampo Six, including Uhuru Kenyatta and William Ruto, with crimes against humanity, Kalonzo Musyoka, who was then the Vice President, travelled to New York to try and convince the United Nations Security Council to defer the cases, ostensibly because “the ICC process has the potential to affect Kenya’s fragile stability”.
The whole episode was filled with intrigues and innuendos. Luis Moreno Ocampo’s threat that he would “make an example of Kenya” sounded childish, vindictive and selective. As I have commented before, why did the ICC not go after Mwai Kibaki, who was in charge of the security forces that unleashed much of the 2007/2008 terror and Raila Odinga, who was the leader of the party to which William Ruto belonged, and who did nothing to stop the violence?
Annan’s decision to hand over the secret list of names of the perpetrators to the ICC’s Chief Prosecutor was probably made in good faith but had the net effect of shrouding the ICC cases in ambiguity and secrecy. This ambiguity was exploited by Uhuru and Ruto, whose 2013 election campaign was pegged on the claim that they had been “fixed” and scapegoated by the likes of Raila and others who were using the ICC to get rid of their political rivals.
In the end, the ICC ended up delivering the presidency to Uhuru and Ruto. If the court had not relentlessly pursued the Kenyan cases (and bungled them), and if, as many believe, the election had not been rigged or manipulated by the likes of Cambridge Analytica, there would be no Jubilee government in place today. The ICC cases, therefore, had the unintended consequence of galvanising a nation against it.
Unfortunately, the social and economic cost of the UhuRuto political union has been unacceptably high. Kalenjin and Kikuyu politicians interpreted the truce between the two communities as a licence for theft and impunity. Members of the Jubilee government have been implicated in a looting spree of public coffers of a magnitude that has not been witnessed since the Moi years. Some would argue that the looting today is unprecedented, and has even surpassed that of the Moi era – a position that is supported by data coming out of the Auditor General’s office.
The lesson we might learn from this saga is that if political reconciliation between two groups results in the political and economic exclusion of other groups, there is no guarantee that electoral or other types of violence will not remain an option for the disenfranchised – with or without the ICC. The article by Kahura also suggests that the pact between the Kikuyu and the Kalenjin is built on a fragile foundation that can easily be destabilised by the threat of future violence.
The ICC cases against Uhuru and Ruto collapsed due to lack of sufficient evidence. It is entirely possible that key witnesses were intimidated, killed or silenced in other ways. However, Kenyans also know that the perpetrators of the violence are still walking freely in Nairobi, Naivasha, Nakuru, Eldoret, Kisumu and other places. Men who gang-raped grandmothers and chopped of their neighbours’ hands have not been arrested or charged with any crime, nor have they been ostracised by their communities.
Nor did Kenya establish Rwanda-style “Gacaca” courts to bring about reconciliation among aggrieved parties. The wounds of 2007/2008 have thus not yet healed. If true, the claim by William Ruto during a recent interview on NTV that the ICC case against him is being revived by his opponents to finish him will not heal these wounds either as many communities, not just the Kikuyu, also lost loved ones during that dark period. It would be naïve to believe that the ICC will deliver justice to the post-election violence victims because Ruto is now back in the dock.
The original sin
However, Kenyans’ wounds run deeper than the 2007/2008 trauma. These wounds can only heal if processes are put in place and serious efforts are made to address the structural and systemic causes of violence and greed in our society.
Structural and systemic violence has been part of Kenya’s DNA since before independence, and has often manifested itself in the forced eviction or displacement of people from their land. British colonialism in Kenya was in essence a violent land grab.
The first large-scale post-independence land grab began during the first few years of Jomo Kenyatta’s presidency when a resettlement scheme was implemented to “buy back” one million acres of land from white settlers in order to resettle displaced (mostly Kikuyu) Kenyans. Kenyatta had argued then that since the British colonialists and white settlers had taken land away from indigenous African communities, they were obliged to fund a large-scale settlement programme – using long-term loans with easy repayment conditions – to provide land to the landless.
It would be naïve to believe that the ICC will deliver justice to the post-election violence victims because Ruto is now back in the dock
However, a group led by Oginga Odinga, Bildad Kaggia and Paul Ngei opposed the buying of land for resettlement; they argued that Africans could not buy back land that was originally theirs, a contention that did not go down well with Kenyatta because “there were no free things and that land was not free, but must be purchased”. Kenyatta’s position mirrored that of the outgoing British colonial administration that made it clear that “African settlers could not get free land but were expected to either purchase it directly with their money or borrow the loan that was to be repaid to the British government”.
This first betrayal would be followed by many others. As the scheme operated on a “willing-seller-willing-buyer” basis, hundreds of thousands of people, particularly in the coast and Rift Valley regions, remained landless.
Interestingly, the scheme also offered loans to Africans who were not landless. In this group fell a select group of people who had been loyal to the colonial administration – the so-called homeguards – who gobbled up prime land in Central Kenya and the Rift Valley. Among this group were provincial commissioners, ministers, permanent secretaries and others within Kenyatta’s inner circle who would go on to become Kenya’s new ruling elite.
According to the report of the Truth, Justice and Reconciliation Commission (TJRC), “rich businessmen and businesswomen, rich and powerful politicians who were loyal to the colonial administration, managed to acquire thousands of acres at the expense of the poor and the landless.” Hence, “instead of redressing land-related injustices perpetrated by the colonialists on Africans, the resettlement process created a privileged class of African elites, leaving those who had suffered land alienation either on tiny unproductive pieces of land or landless.”
These alienated “lesser Kikuyus”, particularly those residing in the Rift Valley, have remained vulnerable to violence perpetrated by other ethnic groups as well as by their own ethnic group. (Recall the politically-instigated “ethnic cleansing” in the Rift Valley in the 1990s during the Moi regime and the shoot-to-kill-Mungiki order given by the late John Michuki in 2007.)
When Kenyatta died in 1978, there was a fear that his successor, President Daniel arap Moi, would reverse the Kenyatta-era land-related and other injustices by targeting Kikuyu elites who had benefitted from Kenyatta’s patronage. This fear, however, was unfounded – not only did Moi follow in Kenyatta’s footsteps by grabbing land for himself, he also entrenched a patronage network that mostly benefitted members of his own ethnic group, the Kalenjin.
Structural and systemic violence has been part of Kenya’s DNA since before independence, and has often manifested itself in the forced eviction or displacement of people from their land
Having experienced violence during the Moi regime, and having suffered under Kikuyu leadership (not even Mwai Kibaki could protect the Kikuyus in the Rift during the post-election violence of 2007/8) why would these Kikuyus now trust Moi’s protégé William Ruto and a (former?) Uhuru ally to protect them?
And if indeed, as Kahura notes, the choice is between the “devil and the deep blue sea”, why choose someone whose reputation is tainted with corruption and other misdeeds, including Youth for Kanu 92 shenanigans, not to mention crimes against humanity? Ruto is known to be a scheming and vindictive politician, a man who has the capacity to crush anyone opposed to him. Do we need someone with such a Machiavellian temperament at the helm?
As for Raila, after the famous “handshake” between him and Uhuru, even some of his most ardent supporters are questioning whether he ran an opportunistic and cynical campaign as leader of the opposition and whether his main objective has always been to gain political power, not to fight for the rights of ordinary Kenyans. Many Kenyans are still recovering from his about-turn after being sworn in as the “People’s President” on 30 January 2018 at a rally attended by thousands, and after so many lives had been lost unnecessarily, including that of Baby Pendo.
Listening to the Building Bridges Initiative (BBI) rally in Mombasa on 25 January this year, one got the impression that none of the politicians present at the rally had any political ambitions, that Kenya was now one big happy family where everyone was expected to get along and think about the country first.
Politicians present at the rally, including Raila and his lieutenant James Orengo, urged wananchi not to think too much about the 2022 elections but to focus on nation-building. The rhetoric had an eerie resemblance to the “accept and move on” mantra of the Jubilee government when it took power in 2013. It was a hoodwinking exercise that made people believe that every single politician on the podium that day was not preparing a war chest with which to retain their seats in the next polls.
What was also omitted was the fact that the Independent Electoral and Boundaries Commission (IEBC) remains as inept and as corrupt as it was during the 2013 and 2017 elections, and that what worries Kenyans is whether they can trust this electoral body to conduct a free and fair election in 2022.
The endorsement of BBI by Kipchumba Murkomen, a diehard Ruto supporter, also suggested that the BBI was a national project that had nothing to do with personal ambition. The cooption of Ruto’s allies into the BBI fold could be just a survival tactic (or perhaps a form of deception?) to ensure that they do not miss out on the “eating”. As development consultant Jerotich Seii so aptly put it on Twitter, “The slices of the 2022 Succession Pie just got a little thinner because Tanga Tanga has brought itself firmly into the mix.”
Kilifi governor Amason Kingi emphasised that historical land injustices in the coast region must be addressed by the BBI, but there was no mention of the post-election violence victims, many of whom are still displaced, nor of the fact that the government of Mwai Kibaki spent millions of shillings on the TJRC whose recommendations on historical and other injustices have yet to be implemented.
The BBI is being sold to us as a project that in one fell swoop will wipe out all the evils in our society, including tribalism. But as other commentators have noted, if the Ndung’u Land Commission’s report and the TJRC report could not bring about radical reforms in Kenya, what hope is there that the BBI will? There is simply no political will to bring about reforms, particularly on land, because too many rich and powerful people will be adversely affected.
Between the devil and the deep blue sea, the only option in this case would be to choose neither. For the sake of Kenya, both Raila and Ruto should step aside and let someone who has a clean governance record vie for the top leadership in 2022. This would make the Uhuru succession politics less toxic and less polarised.
This leader’s top priorities would be to steer the country out of the deep economic morass that the Jubilee administration headed by Uhuru Kenytatta has got us into and to slay the twin dragons of corruption and tribalism that have bedevilled this country since independence. Hopefully, he or she will also be committed to implementing the myriad recommendations that have come out of the umpteen reports and commissions that aimed to make Kenya a more just and inclusive country.
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.
Lockdown: Flying Blind in the Season of Coronavirus
The government’s contingency plan for tackling the coronavirus is not clear and so far appears to focus on surveillance and containing the spread of the coronavirus pandemic. It needs to invest in the clinical set-up beyond capacity but the supply of oxygen ventilators and other materials is likely to be complicated by the greatly increased demand in the global market.
A dozen military trucks roll out of the memorial cemetery in Bergamo, northern Italy, on the evening of March 19, 2020. Three more follow them. Each is carrying bodies that have been piling up for days inside the cemetery church because the city crematorium cannot cope with the deaths from the coronavirus pandemic.
One of the coffins being loaded onto the trucks by forklift holds the body of 74-year-old Italian software engineer Duilio Scaricamazza, recently returned from an East African business trip that took him to Uganda, Kenya and Djibouti in early February.
The closest the world has come to this scale of tragedy from a contagion in recent times are the Ebola outbreaks in West Africa, which the World Health Organisation classified as a public health emergency of international concern in July last year.
Videos of the military trucks are the only ritual of Duilio’s final journey through which his family and friends will reach closure. He had passed all the screening tests at the departure and arrival lounges in Kampala and Nairobi. Airport thermometers and thermal scanners, notorious for failing to detect Ebola, serious acute respiratory syndrome (SARS) and H1N1 influenza, are no match for the fever, cough and shortness of breath that are the symptoms of the coronavirus disease.
Those who contract the coronavirus can sometimes fail to show any of these symptoms and it is not clear if Duilio was infected before his return home to Italy but, in less than a month, he was dead from COVID-19, the disease caused by the coronavirus.
On December 31, 2019, Chinese authorities reported to the WHO country office that they had detected a pneumonia of unknown cause in Wuhan. WHO subsequently classified the outbreak as a Public Health Emergency of International Concern on January 30, 2020, giving it its name, COVID-19, on February 11, 2020, and declaring it a pandemic a month later.
“Once you have a system that warns you of an oncoming pandemic like this one, you will have the time to map out your immediate areas of focus. For example, had Kenya had an early warning system that could show us where the first case would potentially come from, we would have cancelled flights to and from those places as a national security priority”, says anthropologist and media columnist Gabriel Oguda.
After news of the epidemic first broke in Wuhan, where 91 Kenyan students live and nine artistes were visiting, Ambassador Sarah Serem decreed that these 100 people would not be repatriated for fear of infecting one another, and bringing the disease home.
Less than a month after Serem’s statement, on February 27, 2020, Kenya Airways suspended airport security guard Ali Gure from his job for posting on his social media page a photograph of a Chinese airline landing at the Jomo Kenyatta International Airport with 239 passengers on board.
The Law Society of Kenya, two doctors and a lawyer obtained a High Court order the following day temporarily stopping flights from China and other coronavirus hotspots. Jolted by Justice James Makau’s order, which also required the government to take robust measures to prepare for the virus, President Uhuru Kenyatta established a coronavirus task force and ordered the completion of an isolation facility in seven days.
By then the horse had bolted and the country had begun a hopeless search for Patient Zero. No one seemed to know where to find him or her.
A fortnight after the court decision, Kenya announced it had found its first COVID-19 case—a 27-year-old arriving from the United States through London. Just two days later, on March 16, 2020, Kenyatta ordered a shutdown of schools, workplaces and a ban on large gatherings—and called a national day of prayer.
Erroneously described as a flu-like disease, COVID-19 is actually the collapse of the breathing system when the lungs swell and fill with fluid.
By then the horse had bolted and the country had begun a hopeless search for Patient Zero
Dr Warurua Mugo, a Nairobi-based chest specialist, explains that the virus enters the body through the nose or mouth and makes a home in the air sacs where it infects the protective epithelial cells, hooks itself onto membranes, and begins to multiply thus closing off the supply of oxygen and causing swelling in the lungs as they fill with fluid. The patient is overwhelmed by a sensation of drowning, and only a respirator and supplemental oxygen can hold death at bay because there is often the risk of multiple organ failure or septic shock.
“[When] WHO declared the first case of [COVID-19], that’s the day the president should have summoned the Health minister and asked him to constitute that corona team. We needed not to wait for the virus to start causing havoc before starting to run all over the place”, says Oguda.
What started as a droplet has turned into a steady trickle, with cases popping up in rural spots where people arriving from Europe and the United States have visited.
By March 15, 2020, Kenyatta felt compelled to order suspension of travel into the country except for national and permanent residents, self-quarantine for those who had arrived 14 days earlier, a shutdown of schools, and heightened hand hygiene and physical distancing.
With the count of COVID-19 cases reaching 25 in the country, some 96 people traced, tested and released, and the search on to trace 700 others believed to have come into contact with the infected, tighter restrictions are coming into force. Kenyatta’s new salesman, the former spin-master and one-time information communication technology minister Mutahi Kagwe, has been gently turning the screws since taking charge as Health Cabinet Secretary, with the country headed into a likely lockdown. Bars and restaurants have been closed, worship congregations banned, funeral attendance has been limited to only 15 family members and the number of passengers allowed in a public transport vehicle cut by half as exhortations to increase physical distance and wash hands regularly have doubled.
The patient is overwhelmed by a sensation of drowning, and only a respirator and supplemental oxygen can hold death at bay
Although Kenya was the first country on the continent to go into a 30-day slowdown, it has been swiftly followed by South Africa, which announced a 21-day lockdown and suspended all flights. Nigeria and Egypt, which identified COVID-19 patients ahead of Kenya, have similarly ordered lockdowns, as have Uganda and Rwanda, Angola, Burkina Faso and Namibia which were initially measured in their response. Tanzania and Sierra Leone, both of which were hesitant to take strong action, are following suit.
“It is overwhelming”, says Dr Ouma Oluga, the secretary-general of the Kenya Medical Practitioners and Dentists Union. “Doctors and health workers are a worried lot. Political directives that might be [well-intentioned] are being issued without adequate preparation on the ground, and therefore not congruent with reality”.
Countries have been cautioned against fighting the pandemic blindfolded, and as the WHO Director-General, Tedros Ghebreyesus, said on March 16, 2020, the way to fight back is through “testing, testing and testing”.
“Our numbers are likely to be underestimated because of low testing capacity”, Oluga adds. “Stringent criteria on who to test, because not everybody needed to be tested, meant waiting for people to be ill before testing”.
Danni Askini, an American healthcare professional, was billed $34,927 (Sh3.7 million) for the treatment she received after contracting Covid-19. Testing alone cost her $907 (Sh96,142). India’s government announced a 4,500 Rupees (Sh6,255) cap on what private laboratories can charge for two polymerase chain reaction tests for coronavirus.
The coronavirus epidemic is also showing up Kenya’s low investment in research. The National Influenza Laboratory in Nairobi, the Kenya Medical Research Institute (Kemri) in Nairobi, Kisumu and Kilifi as well as the University of Nairobi have the capacity to test for the coronavirus, and could be supported by private laboratories at Aga Khan University Teaching Hospital and Lancet Kenya. The shortage of testing kits has meant that results, which would typically come in after six to eight hours, are instead available in 24 hours. Chinese billionaire Jack Ma and his Alibaba Foundation donated 1.1 million test kits to Africa this week, with Kenya slated to receive 20,000 test kits, 100,000 masks and 1,000 medical suits and face shields.
What started as a droplet has turned into a steady trickle, with cases popping up in rural spots where people arriving from Europe and the United States had visited
There are two ways to become immune: one is to experience the infection to create antibodies, or receive a vaccine to stimulate antibodies without experiencing the disease. Britain had initially opted to tough it out and wait for those who would die of COVID-19 to do so before the pandemic stabilised, thereby creating what scientists refer to as herd immunity. It changed tack after WHO admonished the strategy: “Not testing alone. Not contact tracing alone. Not quarantine alone. Not social distancing alone. Do it all”, said Ghebreyesus.
“Herd immunity eventually develops but over a long period time of continuous exposure. I disagree with epidemiologists who expose everyone who expect immediate herd immunity because it can develop after 50 to 60 years . . . you lose it with time . . . the casualties would be too high, and vulnerable people will die”, Oluga says.
Shutdowns are an attempt to break transmission in order to enable health services to regroup and deal with the cases that show up. But the messaging has not been without its light moments. Justifying the ban on bars, Uganda’s Yoweri Museveni said, “Drunkards sit close to one another. They speak with saliva coming out of their mouth. They are a danger to themselves. All these [merrymaking activities] are suspended for a month”.
The irony of asking Kenya to go into lockdown when much of its population is already cooped up in congested and unsanitary residential areas, has been completely lost on the government. According to the Economic Survey 2019, there were 14,865,900 people working jobs in the informal sector. “The informal sector is characterized by small scale activities, easy entry and exit, skills majorly gained from vocational schools, less capital investment, no or limited job security and self-employment”.
“This sector excludes illegal activities,” the Survey adds. These statistics belie the precarious nature of the jobs in the informal sector: they are day-wage occupations that finance hand-to-mouth survival. Only 2,765,100 people are in formal wage employment and just 152,200 are in self-employment.
The Kenyan Section of the International Commission of Jurists (ICJ-Kenya) has appealed to the government to issue directives on food prices and other basic commodities as well as medicines and items that will be important in preventing and treating COVID-19.
The coronavirus epidemic is also showing up Kenya’s low investment in research
Additionally, ICJ-Kenya has urged the government to develop and implement socio-economic responses for Kenyans in informal employment who are not able to “work from home” and who would need assistance in meeting their basic needs.
Big economic players like tourism and travel, as well as horticulture, are in shutdown in an economy that had been projected to grow at 6.2 per cent. Central Bank of Kenya governor Patrick Njoroge announced that Kenya would be seeking $350 million emergency assistance from the World Bank.
Relief offered so far by the government in the form of free hand sanitisers, Loon balloons from which 4G internet will increase mobile phone coverage, and waiver of mobile money transaction fees charged by banks, does little to address the lived realities of people. Digital contact tracking is emerging as one of the tools—albeit controversial—for tackling the pandemic. Correspondence to Safaricom seeking confirmation that the firm would be assisting in tracking passengers who arrived in the country early this year—especially given that two Chinese telecommunication companies were able to track the movement of people out of Wuhan in the early days of the epidemic—did not receive a response.
Salome Bukachi, professor of medical anthropology at the University of Nairobi, says dialogue with the community can contribute to creating protocols for quarantine, lockdown and isolation in a manner that balances respect for social backgrounds and public health needs.
Alessandro Scarci, an Italian lawyer based in Kenya for the past 20 years who has been following developments in his home country, says no health system can withstand the pressure from the pandemic. Milan, which is one of the wealthiest parts of Europe, has seen one of the best health systems collapse. “Even if you think you can improve the health system, without 1,000 per cent containment, you cannot manage this pandemic if you do not contain people”, says Scarci. “Unless there are plans to distribute food and water for free in poor residential areas, and the armed services patrol the streets, there is going to be a riot,” he adds ominously.
Oluga agrees that a lockdown is probably the best option, but for developing countries with insufficient cash reserves and chronic underfunding of social protection, this path is fraught with difficulty. Some 2.5 million people live in slums in Kenya, where houses can be as small as 12 feet by 12 feet, without reliable water or sanitation services.
Acts of austerity belie the crisis waiting to explode in Kenya and on the continent. Treatment requires isolation beds, respirators and oxygen. And it requires people. So far, Kenya has announced that it has trained 1,100 health workers. Those numbers will prove woefully inadequate if more infections show up.
Milan, which is one of the wealthiest parts of Europe, has seen one of the best health systems collapse
Shortages of testing materials and capacity, as well as the low numbers of healthcare workers has meant that where one patient is diagnosed with the disease, seven doctors are in isolation, he adds. The effect on an already strained health workforce is likely to be devastating.
In Nairobi, nurses at Mbagathi Hospital—the institution designated as the isolation centre for COVID-19—went on strike to protest against uneven training and unavailability protective gear. Moreover, there is a limit to the number of patients healthcare workers can handle.
Already, the number of people currently being traced is quickly outstripping the 120-bed capacity at Mbagathi, the additional 60 beds at the Kenyatta National Hospital and the 300 reserve places at the Kenyatta University Teaching and Referral Hospital. Around the country, Moi Teaching and Referral Hospital (25), Kakamega Hospital (25), Meru County’s Level 5 Hospital (20), Coast General Hospital (19) and King Fahd Hospital in Lamu (8) bring the national total to just under 600 beds.
Still, questions linger about what will happen on April 16 when the 30-day measures announced by the government are supposed to be reviewed. What is the end-game in managing the COVID-19 epidemic in Kenya? After the lapse of the first 30-day measures, what would be the next steps? What are the best and worst-case scenarios for managing COVID-19 in Kenya after April 16? These questions were sent to CS Kagwe and to the Principal Secretary at the Ministry of Health, Susan Mochache, with no responses forthcoming.
On Tuesday, March 24, 2020, Law Society of Kenya lawyer Ochiel Dudley said the government had not filed its contingency plan for tackling the coronavirus as required by the High Court—but the judge was hesitant to ‘recall a general from the battlefront’.
So far, official scenario mapping has appeared to focus on surveillance and containing the spread of the pandemic. “We need to invest in the clinical set-up beyond capacity and think about what are we doing when people come to hospital”, says Oluga. “If treating, what we are doing needs to be endorsed and published in the form of second, practical guidelines”. Besides the headaches of infrastructure in terms of availability of beds in intensive care, the supply of oxygen ventilators and other materials will likely be complicated by the greatly increased demand in the global market.
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