On January 3rd 2018, an article which I co-wrote with April Zhu was published on this platform. Its central premise: many years of political reform in Kenya have failed to muzzle dissent within the political establishment. Exactly three years later, Kandara Member of Parliament, Alice Wahome, seems to have sounded the alarm bells.
Rehearsing the message of her speech during the burial of Charles Rubia, a key figure in Kenya’s struggle for democracy, she castigated Uhuru Kenyatta and Raila Odinga (she described Raila as Uhuru’s new political mercenary for hire) as the “biggest existential threat to Kenya’s declining economy and democracy”. In short, Wahome was referring to the re-emergence in Kenya of a political culture of intolerance directed by the President himself. In fact, Wahome’s statement, coming as it does at the beginning of the year, may set the tone for opposition politics in the run-up to the 2022 general-elections.
But it has also rekindled memories of a sermon by a young Dr Timothy Njoya at St. Andrews Church in Nairobi thirty years ago, which garnered publicity and uproar in equal measure. During that New Year’s sermon, the young reverend remarked on the collapse of authoritarian regimes in Eastern Europe, and speculated about the return of multi-party politics in Kenya, a bold statement at the time. While his speculations would become a reality only two years later, he was immediately rebuked by politicians, all of whom were members of the ruling party, KANU—at the time the only political party in Kenya.
Njoya’s sermon is on my mind as I watch the condemnations that Wahome is receiving for criticising the political establishment. In a political climate akin to the one in which Njoya voiced his remarks, I see the re-setting of a dangerous trend in Kenya, a re-setting whose origins can be traced back to the aftermath of the 2007-08 post-election violence, but which was re-energised by the March 2018 handshake between Uhuru and Raila.
Indeed, since the March 2018 settlement, Kenyans have become accustomed to an increasingly irritable and angry president. He demands, but is not able to command, unfettered loyalty. More often than not, he unleashes in public bitter diatribes in his mother tongue targeted at people who disagree, or poke holes in his leadership. He continues to be on the defensive regarding his under-performing and expensive mega-infrastructure projects.
The climate of intolerance that the president is creating is the public face of a deeper and much more insidious plan. It is part of a wider attempt at remarshalling the forces that have preserved the political status-quo in Kenya since independence, and which the Building Bridges Initiative (BBI) process seems to be in the service of. The shouting down of Kipchumba Murkomen, the Senate Majority leader, during the launch of the BBI report at the Bomas of Kenya last November, and the recent jibes that have been thrown at Alice Wahome for criticising Uhuru, are quite revealing and instructive.
I see a dangerous trend that seems to have been re-set in Kenya, a re-setting whose origins can be traced back to the aftermath of the 2007-08 post-election violence
In an insightful piece also published on this platform, Akoko Aketch contends that the BBI exercise is a crisis of how the long-standing beneficiaries of the political establishment—a distinctly Gikuyu elite—can reproduce their domination “after Uhuru Kenyatta’s disastrous economic record, and of how to avert the possibility of having a president who is hostile to this elite’s interests.” He submits that the “BBI is a revisionist project and a mock test of a political formula that has sabotaged Kenya’s democracy since independence.”
The recent extension of the term of the BBI task-force is, for instance, being perceived as a way of creating more time to introduce radical proposals, such as the creation of the position of an Executive Prime-Minister, a position that, as many have argued, Uhuru will be qualified to assume come the next general elections in 2022. This thinking is not entirely pedestrian. While Uhuru has himself stated that he is not interested in another term as president, the push to change the constitution, his public attitudes regarding opposition politics, and the ongoing re-centralisation of power by the central government (despite devolution), leave a lot of room for speculation.
One way in which the elite in Kenya has reproduced its power is by putting the blame for the country’s woes squarely on the Kenyan public. In this script, underdevelopment and political violence is the work of Kenyans of poor judgement, political dissidents and their often-unemployed youthful followers, not the result of years of unaddressed injustices and skewed redistribution of power and resources. In fact, this line of thinking is one of the primary messages of the BBI report. Dr Wandia Njoya, in a recent article published on this platform, summarised the report as a “declaration of war by the political class against the people of Kenya”. In a painfully convoluted manner, the report, in its attempt to locate, or explain the lack of a national ethos, adopted a language that is not only recriminatory and accusatory, but is also regrettably informal.
Ten billion shillings later—as rumour has it—and more than twelve months after the BBI taskforce was appointed, the report that came out of the process was peppered with an embarrassing number of typos and presented in cheap layout and low-quality typesetting. Seductive images of the nation’s (supposedly egalitarian) past are constantly reproduced and projected, as a way of distracting from the realities of the impunity that has repeatedly been unleashed on the Kenyan public by the political class since the country gained independence in 1963. In a tragic misreading of how morality and communal responsibility actually works in Kenya, the BBI report went ahead to castigate Kenyans for “running away” from their culture, and for demanding rights, as opposed to responsibilities.
One way in which the elite in Kenya has reproduced its power is by putting the blame for the country’s woes squarely on the Kenyan public
This mind-set was alive and well during and after the 2013 elections, the first after the post-election violence of 2007-08. During those elections, which were haunted by the fear of a repeat of political violence, calls for peace intensified, and they immediately became disciplinary and forbidding. People were urged not to protest or question the electoral process. Even the media joined the peace bandwagon and began self-censoring.
In the end, the state regained its dominant position in directing political debate, and the political establishment precluded a potential assault on its privileged position. In fact, the only other time when fundamental reforms would have seen the light of day was during the protracted electoral process of 2017.
But if recent revelations by Dr David Ndii regarding events in the run-up to the March 2018 handshake are anything to go by, the critical part of the drama in 2017 took place off-stage, and the elections became a mere subplot. Seen in this manner, the détente between Uhuru and Raila was, in actual sense, a way of subverting fundamental transformation in Kenya and restoring the status-quo. The BBI, as Wahome has now warned, might be the “special purpose vehicle” for this mission.
The triumph of the system
While many people, including the adversaries of the BBI exercise, had expected that the report would make drastic recommendations that would fundamentally alter Kenya’s political landscape, especially the pure presidential system, the ongoing proposals to create the position of a powerful (as opposed to a prefectural) Prime Minister do not offer much promise either. In fact, whether it is true or not that Uhuru plans to become Prime Minister in a post-2022 arrangement with Raila as President, any cursory analysis of how politics actually work in Kenya will reveal that power (even under a parliamentary system that is not undergirded by powerful decentralised units) will continue to be concentrated at the centre.
The only other time when fundamental reforms would have seen the light of day was during the protracted electoral process of 2017
All politics, power and influence will continue to revolve around the Executive branch, whose control will continue to be grounded in its ability to direct political and economic activity across the country. In fact, combined with the minimal proposals that the report has made to restructure elections, the political party from which the President and Prime Minister will come will continue to dominate all key positions in government, producing the same exclusionary effects of the winner-takes-all system that have ailed the country’s politics since the return to multi-partyism in the 1990s.
As the year progresses, the BBI will prove itself to be an exercise that is merely aimed at reproducing what David Throup and Charles Hornsby referred to as “the triumph of the system” in their seminal book, Multi-Party Politics in Kenya. The first triumph was witnessed in the 1960s. Kenya, like many ex-British colonies, was bequeathed a Westminster-style parliamentary system of government when it became independent in 1963. The independence constitution also made provisions that took away power and significant functions of government from the centralised government in Nairobi, that is, a system of eight regional governments of equal status that was known in Swahili as Majimbo.
However, the parliamentary system through which Kenya became independent was dead by 1964. Kenya became a Republic and Jomo Kenyatta, Uhuru’s father, became its (unelected) first President. The Majimbo regional system, the next target, was abolished together with a post-independence Senate, at the same time as the first opposition party, the Kenya African Democratic Union (KADU), was folding itself, citing frustration from the Executive. By abolishing the Senate, the regional governments and the parliamentary system, the first post-colonial elite-pact of domination, or the first triumph of the system, had completed its mission.
As a result, the “Imperial Presidency” was born. From 1964 to 1992, the year multi-party politics resumed, the constitution had been amended over twenty times. The amendments served to empower the Executive branch of the government at the expense of Parliament and the Judiciary. At the height of this madness (in 1990), the office of the president (OP) included a staff of 43, 230, representing a ratio of 1 in 6 civil servants. The OP became a parallel government, with considerably more executive power than actual ministries. The instability that such a structure of government can introduce in a political system—where inequality and regional imbalances are rife, and where ethnicity is inexorably intertwined with how political representation and redistribution actually works—became clearer with the reintroduction of multi-party politics in 1992. Trust among the political elite became fickle, leading to the instrumentalisation of violence and ethnic identity in the political marketplace.
After many years of struggle for reforms, the structure of the “bureaucratic-executive” government, at the head of which was the President, survived with minimal alterations. The only significant structural change, many have argued, was the introduction of forty-seven devolved units. However, the mandate of county governments was significantly reduced compared to that which was allocated regional governments in the 1960s. Responsibility over land administration, education, mega-infrastructure and parastatals remained in the hands of the central government, and as such, under the direction of the presidency.
Raila Odinga, who had become the political champion of constitutional reform, especially the proposal to introduce a parliamentary system and strong devolution by 2007, gave up on these demands after the outcome of that year’s elections. At the Great Rift Valley Lodge in Naivasha, where the Parliamentary Select Committee made up of 14 Party of National Unity (PNU) members and 13 Orange Democratic Movement (ODM) members that had been selected to respond to the first harmonised draft that would become the 2010 constitution had met, people feared that the politicians would not find common ground, risking a return to conflict. Indeed, disagreement reigned but some deals were struck, of which the most important—which removed the blockage that threatened a deadlock in the discussions—was made by Raila and Uhuru (reportedly in a room at the lodge). The deal saw ODM let go of the parliamentary system altogether, in favour of the presidential system. In addition, Raila (who at the time was Prime Minister in a coalition arrangement with former President Mwai Kibaki) relaxed his demands for strong devolution, that is, a three-tier decentralised system of government in favour of the two-tier system that was favoured by PNU. As a result, the 2010 constitutional draft provided for a pure presidential system. Pure in the sense that, not only would cabinet ministers be appointed from outside of parliament, but losers of presidential elections, no matter how many votes they had garnered, would not be accorded any public office. The draft also scrapped the regional tier of government, and fixed the number of parliamentary constituencies at 290. Nothing much changed after that.
County governments were quickly reduced by central government bureaucrats to units of administration and development, as opposed to political representation
During the parliamentary debate over the draft that took place in mid-2010, ODM MPs—notably James Orengo—continued to push for the regional governments. Raila had already hit the streets, campaigning for the draft. Orengo was left alone. The draft was eventually promulgated in August 2010, after winning the popular vote at a referendum. The powerful presidency—with slight alterations—triumphed.
Tunakula nyama: politics since 2013
County governments came into place after the 2013 general elections, but they were quickly reduced by central government bureaucrats to units of administration and development, as opposed to political representation. Feelings of exclusion and marginalisation, underpinned by unaddressed historical injustices, continued to exist, despite constitutional change. The pure presidential system that the 2010 constitution provided had worked to the disadvantage of Raila Odinga—who lost both the 2013 and 2017 elections to Uhuru.
Between the two elections, Raila held no public office, yet he continued to exercise personal influence over vast swathes of the country, where ODM, his party, had won considerable numbers of constituency and county seats. To the chagrin of many who felt unrepresented at the centre, Uhuru stated, rather arrogantly, that they—the government in power—were eating the nyama choma [roast meat] and that those who were in the political cold should be content only with the smell. A number of times, Raila would instigate programmes—most notably, the Okoa Kenya initiative—which, incidentally, were part of his attempts to change the 2010 constitution, but which, one could also argue, were part of his struggle to remain politically relevant.
Raila’s strategy did not yield the expected results, but it had its uses. It proved that Raila was adept at combining his political fate with that of his supporters. In this way, the anger of Raila supporters that followed the announcement that he had lost the elections in 2013, and then again in 2017, could not be separated from the perception that they, also, had been excluded from the political process for many years. Following this logic, the feelings of exclusion felt by many of Raila’s supporters after the 2017 elections could only be addressed if Raila himself were to become part of the Executive—very similar to the situation in 2007-08.
While it had become apparent, after the 2017 elections were concluded, that Raila was the biggest victim of a constitution that he had done much to support, his move to “shake hands” with Uhuru was more the result of defeat at challenging the political establishment over the years than it was an effort to usher in fundamental political reforms. What is more important to consider is that Raila’s support of the current Presidential system in 2010 was also the result of an elite-pact with none other than Uhuru Kenyatta, his current partner in the BBI settlement nine years later.
These developments, where the political establishment that has been at the helm since the 1960s is seeking to maintain its hold on power and control, should concern Kenyans. Despite arguments to the contrary, much talk about the BBI will be about political positions, and as the current climate of political intolerance continues, fundamental questions regarding exclusion, injustice, and accountability will be glossed over, as has happened before.
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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