If there is any silver lining in the coronavirus pandemic, it is that it has helped people around the globe to finally understand that nature is the most powerful force on this fragile earth of ours and that our survival as a species depends on how well we protect it. The virus infection known as Covid-19 has helped us understand one more thing – that in the face of a pandemic, neither wealth nor armies nor “good” genes can protect you from the disease – coronavirus is an equal opportunity predator.
The coronavirus has done for the climate what climate activist Greta Thunberg can only dream of – it has shown the world that nature is the real Almighty and we better listen to it before it is too late. As an Indian woman (who was not named in the video clip that was sent to me) told an audience: “Nature discards the species that is not supporting the whole”. Her message was that the human species is not separate from other species; we are all part of the same system, and our fates are intertwined.
As Yuval Noah Harari points out in his bestselling book, Sapiens: A Brief History of Humankind, the human species as we know it only emerged around 70,000 years ago. Because Homo sapiens’ survival depended on being social (i.e. cooperating with each other and relying on each other to ward off danger), this was the only species that went on to create cultures that we now call history.
According to Harari, the Cognitive Revolution that gave birth to human beings lasted nearly 60,000 years until the advent of the Agricultural Revolution that transformed hunter-gatherers into farmers some 12,000 years ago. The sedentary lifestyle of farmers allowed humans (who had bigger brains than other creatures) to create civilisations. Cities grew around fertile lands and rivers and an urban culture was born. Goods were bartered or bought; this led to the beginning of commerce and trade.
Then, around 500 years ago, another revolution – the Scientific Revolution – took place. This revolution, which gave us the nuclear bomb, aeroplanes, vaccines and computers, says, Harari, “may well end history and start something completely different”. In other words, life as we know it may end because human beings might create conditions for their own demise. In fact, we may be entering a phase that will see the extermination of human beings from the planet known as Earth.
Anti-doomsday proponents may say that this is all hogwash – that the planet and humans will survive, and not become extinct like dinosaurs. Religious leaders may say that this is a sign of the Apocalypse, the end of the world as we know it, as predicted in many religious texts. But what Harari and others are emphasising is that we may be the brainiest species on the planet, but we are certainly not the cleverest. Now look where our arrogance and conceit have taken us.
For once Africans are not being blamed
The coronavirus has also turned the political, social and economic equation upside down. People living in rich countries are becoming most vulnerable to it. And for once Africa and Africans are not being blamed. Let us compare how this pandemic has been treated, as compared to the HIV/AIDS epidemic in the 1980s and ‘90s and the recent Ebola outbreak in West Africa.
When HIV was first discovered among the gay artistic community in the United States, it was quickly dismissed as a disease that afflicts homosexuals. Some Christian leaders even claimed that it was God’s way of punishing those who go against nature. When it became apparent that heterosexuals were also becoming infected, new theories and conspiracy theories emerged. Some claimed that the virus had been concocted in a military laboratory and was some kind of chemical warfare that had gone terribly wrong. Others said that it was brought to America by Africans, who do unnatural things to monkeys. Before long, HIV was being viewed as an African disease.
We may be the brainiest species on the planet, but we are certainly not the cleverest
Unfortunately, the numbers seemed to support this racist theory: not only was HIV prevalence the highest in Africa, but heterosexual women were getting infected by their (supposedly) heterosexual partners. Some said that Africans (both men and women) were naturally promiscuous, and so brought the disease upon themselves. However, that epidemic led to the biggest and most generous initiative that significantly reduced the number of AIDS-related fatalities – President George Bush’s Emergency Plan for AIDS Relief (PEPFAR) that helped save millions of lives on the continent. But the damage had been done – HIV ended up stigmatising entire groups of people: homosexuals, Africans and commercial sex workers.
The Ebola outbreak in West Africa had a similar impact: Africans were blamed for bringing the disease upon themselves by eating bush meat. Countries affected by civil war, like Sierra Leone and Liberia, were further blamed for broken health systems, which could not handle a disease of this nature.
The coronavirus pandemic has completely shifted the blame game. In fact, I would say that if there is another silver lining to this disaster, it is that it has reconfigured the racialisation of epidemics and pandemics, even though when the infection was first detected in China – the ground zero of the disease, where more than 3,000 people have died – there was an initial impulse to blame the Chinese for creating the new virus. China responded by blaming the US for creating the virus and unleashing it on China.
Sinophobia set in, with people avoiding eating at Chinese restaurants and avoiding Chinese people on the streets. Chinese eating habits were vilified; there was talk of wild animal meat, including rats and bats, being sold in Wuhan’s markets alongside steak and chicken. The United States, which has been having a trade war with China, saw it as an economic victory of sorts as flights and exports of goods from China stopped, and as manufacturing in China came to a standstill.
President Donald Trump initially downplayed the pandemic, but when it became obvious that Americans were also getting infected, he made a dramatic about-turn and declared the pandemic a national emergency. And then, before we knew it, Europe was being described as the “epicentre of the virus” and African presidents were making statements that were simply unthinkable before, such as, “We are not allowing passengers from Europe to enter our countries” and “Only Kenyan citizens will be permitted to disembark at Kenya’s international airports”. On the other hand, Kenyans are joking that Kenyan politicians can no longer go to Europe or America for medical treatment, as has previously been the case; for the first time they will get to experience the indignities and inefficiencies of the Kenyan healthcare system.
Overnight the narrative has changed: no one (except some fascist Eastern European countries) is blaming Syrian migrants or Somali refugees for spreading the disease – the carriers of the virus are wealthy Europeans and Americans. (Hollywood star Tom Hanks and his wife were among the first to go public.)
As of last week, Italy had the highest numbers of cases (24,747) in Europe, followed by Spain (7,844), Germany (5,813), and France (5,437). Switzerland, Denmark, UK, Norway, Sweden, Belgium, Austria and Greece have also been affected. (Another silver lining: The lockdown in Italy has sparked solidarity among neighbours, who are now entertaining each other by singing for each other on their balconies.) Meanwhile, the British Prime Minister, Boris Johnson, has already warned British citizens that things will get a lot worse before they get better and that they will lose loved ones. In fact, he has also suggested that the elderly will likely die in large numbers, a statement that created more, not less, panic. Europe, the dream destination of so many desperate Africans, is now a hot spot.
Of course, there are reasons for this, one being that there are far more people in Europe travelling by air and crossing borders than there are in Africa, so naturally the virus will travel. The virus also seems to thrive in cold wintry climates. Because of globalisation diseases travel faster and with more ferocity. Populations that have little or no immunity are often the first casualties. For example, smallpox and venereal diseases wiped out Native American populations when Europeans first set foot in the Americas.
In Kenya, there have so far been only seven known cases. The government has stepped up measures to prevent the disease from spreading, such as closing down schools, and postponing public gatherings, but there is fear that the numbers infected could be more than those detected, especially because Kenya has strong links with China, and Nairobi is an important international hub. The country’s health systems may not be able to cope if there is a major outbreak.
Europe, the dream destination of so many desperate Africans, is now a hot spot
Sadly, instead of dealing with the virus in a rational, scientific manner, the president declared a national day of prayer to combat the disease – which, ironically, reinforces the message that this disease, like HIV, is all part of God’s plan, and that if we are good Christians/Muslims/whatever, God will not inflict the disease upon us.
It is now becoming increasingly clear that not only is this a global health crisis, but it is also an economic disaster that may lead to a global recession as more people stay at home, as bars and restaurants close, as tourists cancel trips, as manufacturing plants stop producing, as exporters stop exporting essentials such as medicines, and as general panic sets in in the stock markets.
But maybe, just maybe, the madness that has recently been engulfing many parts of the world will stop. Rising racism and fascism, unbridled capitalism and militarisation, xenophobia, wanton destruction of the environment, and all the other things that are making the world more dangerous (and people more afraid and lonely) might be shown for what they are – foolish man-made ideas that nature has no time or respect for.
Nature is sending us a message. It is time to listen.
Tackling Corona: The Need for a People-Driven Response
African governments need to adopt a “whole-of-society approach” to successfully face the threat posed by COVID-19. They need to recognise that involving non-governmental actors in the formulation, as well as in the implementation, of policies to address the pandemic, need not be perceived as a threat to their own legitimacy.
The scenes of police viciously assaulting citizens while enforcing a nighttime curfew, as well the death by suicide of a South African woman after being forced into a deplorable government quarantine facility, have exposed the brutal face of Kenya’s coercive response to the coronavirus pandemic. While many have condemned the incidents, some have also felt that coercion is necessary given the extreme threat posed by the virus, the need for urgent action and the failure of the citizens to comply with the government’s directives. There is no time to debate the response, goes the argument. There is only time to act to save lives.
Yet there is a grave flaw at the heart of this argument. These very factors are what make it necessary that there is more, not less, public involvement. The threat being to the whole of society, the response needs to involve the whole of society. Trying to move fast without having a cooperative public in tow is a recipe for failure, as the Kenyan government is learning. And the way to get a cooperative public as well as mobilise society is to engage with the people, not just order them about.
“Epidemics are tests of social and political systems,” writes the Zimbabwean academic and Associate Professor of African Politics at the University of Oxford, Simukai Chigudu, in a fascinating article for the online platform, Africa Is A Country. Citing his book, The Political Life of an Epidemic: Cholera, Crisis and Citizenship in Zimbabwe, which looked into the roots of the 2008 cholera outbreak in his country, he notes that it is the “political, economic and social processes that…shape the trajectory of [an] epidemic”, not just the biological properties of the virus or bacterium involved.
This is not to say that the actions of governments are not important. The trajectory and the evolution of the pandemic so far have been largely dictated by the actions of states. The thousands of lives it has so far claimed are not evenly distributed globally, but rather concentrated in countries that for a variety of reasons either didn’t take the pandemic seriously or were slow to react to it. In a very real sense, it is not just the virus that is killing people; people are also dying from state inaction, incompetence and malfeasance.
The legacy of colonialism
Similarly, as the virus menaces Africa, it has been the actions of African governments – past and present – that have so far determined how the pandemic is unfolding on the continent. When fighting the disease, a crucial constraint for many African societies is the near universal failure to address the legacy of colonialism. In fact, as Prof Chigudu explains in relation to 21st century Zimbabwe, “the long-term factors that led to the cholera outbreak can be traced as far back as the late 19th century when Salisbury [today known as Harare] was founded as the administrative and political capital of Southern Rhodesia [the predecessor state of what is now Zimbabwe].”
In a very real sense, it is not just the virus that is killing people; people are also dying from state inaction, incompetence and malfeasance.
He goes on to write that rather than undoing the discriminatory nature of provision of public facilities, “colonial era by-laws, plans, and statutes largely remained in place, indicating the apparent tension between overturning the racial and socio-economic segregation of Rhodesian city planning and maintaining an inherited sense of modernity and orderliness in urban space”.
This experience will be familiar to many across the continent where, in the words of one of Kenya’s politicians speaking in Parliament in 1966, “Today we have a black man’s Government, and the black man’s Government administers exactly the same regulations, rigorously, as the colonial administration used to do”.
The persistence of colonial states and their twin logics of authoritarian exploitation and classist exclusion means that African governments begin with a deficit of public trust, as well as diminished capacity to implement policies. Just three years ago, Kenya was jailing doctors’ representatives for going on strike to demand a pay rise and improvements to services in public hospitals.
Corruption – another gift of colonialism – has focused attention on vanity projects that provide opportunities for looting, rather than on investments in basic health services. The result is high-end, expensive machines lying idle in hospitals that lack even basic amenities. The entire country, for example, only has around 400 isolation beds, and 155 intensive care unit beds for a population of over 48 million people.
The authoritarian and exclusionist streaks are also evident in the manner in which African governments are currently responding. In Kenya, rather than implementing a holistic approach that would mobilise all communities and civil society, the government has opted for a China-style top-down, dictatorial approach, one that decades of hollowing out of the state has been difficult to impose. Prominent activist Jerotich Seii has noted the “‘elite gaze’ that deploys a language of enforcement”. David Ndii, one of the country’s top economists and public intellectuals, has similarly decried the consequences of what he describes as a “boneheaded securocratic approach to a complex emergency”.
A holistic approach
Yet this need not be the case. Kenya has a long history of indigenous not‐for‐profit organisations, self-help societies and community-based organisations that it could leverage to win consent and mobilise society. In fact, in many communities, NGOs have become surrogates for the government, offering services that the state was either unable or unwilling to provide. They have even managed to penetrate into policy- and decision-making levels.
In Kenya, rather than implementing a holistic approach that would mobilise all communities and civil society, the government has opted for a China-style top-down, dictatorial approach…
As Prof Jennifer Brass noted in her PhD thesis a decade ago, “Contrary to both normative arguments that government should ‘steer’ the ship of state (make policy) while private actors ‘row’ (implement policy), and the belief that government is eroding or becoming irrelevant to the governance process, this dissertation shows that NGOs are now joining public actors and agencies at many levels in decision and policy making regarding service provision.”
Sadly, however, there is little evidence that the Kenyan government is doing much to incorporate the expertise and experience of NGOs and other civil society actors into its planning for COVID-19. When President Uhuru Kenyatta established the 21-member National Emergency Response Committee on Coronavirus at the end of February, there was no one from outside of government included in it. In this, the President went against his own National Contingency Plan which recommended the establishment of a National Public Health Emergency Steering Committee to “provide policy, strategic directions” which would include heads of “responding NGOs”.
Sadly, however, there is little evidence that the Kenyan government is doing much to incorporate the expertise and experience of NGOs and other civil society actors into its planning for COVID-19.
Perhaps the Kenya government’s reluctance to engage with civil society organisations should not come as a surprise. After all, this is a government that for the best part of the last decade has made the demonization of civil society (which its mouthpieces on social media happily branded “evil society”) a cornerstone of its propaganda efforts. Still, it is clear that the state alone cannot address this crisis.
Non-governmental actors, including professional associations, churches and volunteer, community and civil society organisations, will need to be involved in the “whole-of-society approach” that the World Health Organisation (WHO) says is required to successfully face the threat posed by COVID-19. And not just as “rowers”. Across the continent, governments will need to urgently recognise that involving others in the formulation, as well as in the implementation, of policy need not be perceived as a threat to their own legitimacy. As Prof Brass writes, “Governance is not the removal of government, but the addition and acceptance of other actors, including NGOs, in the steering process.”
How effective are lockdowns?
The absence of non-governmental actors at the decision-making table may also be manifesting in the choices that African countries are making. For example, many have opted to go the way of China and other (though by no means all) European countries by imposing “lockdowns” – shuttering factories, businesses and markets; banning mass events from church services to political rallies; and forcing people to stay at home or imposing stringent restrictions on their movement – in an attempt to curtail the rate of spread of the disease and ensure their already fragile health systems are not overwhelmed. Beginning with Rwanda, the lockdowns have swept the continent, affecting economies large and small, from Nigeria to Uganda. In addition, by the end of March, nearly all countries had some form of travel restriction, with more than half imposing full border closures.
However, in an article for The Conversation, Prof Alex Broadbent and Prof Benjamin Smart argue that a one-size-fits-all approach may have lethal consequences for Africa. They note that the “the major components of the recommended public health measures – social distancing and hygiene – are extremely difficult to implement effectively in much of Africa” and that the net effect of lockdowns “may thus be to prevent people from working, without actually achieving the distancing that would slow the spread of the virus”. They also question the value of “flattening the curve” in a scenario where at the best of times public healthcare is inaccessible to a huge proportion of the population.
Similarly, in an interview with Africa Report, John Nkengasong, the director of the Africa Centre for Disease Control and Prevention, which is part of the African Union, also pointed out that lockdowns are not only difficult to sustain but would also “lead to other consequences, such as shortages of food, medicine and other basic supplies”. He also said that the shutdown of air travel and closing of borders across the continent was making it more difficult to coordinate the distribution of desperately needed medical supplies and equipment. Making much the same point on the Kenyan news programme Punchline, Dr Mary Stephens of WHO said that blanket travel bans and border closures would prevent African countries from accessing external medical experts needed to plug gaps in their health systems.
The resort to force by governments across the continent to counter the resistance of their populations to such measures speaks to the lack of a social consensus for the necessity of such measures. It is the poor, for the most part, who will bear the pain of the lockdowns, especially the many working in the informal sector who cannot afford to stay at home for a day, let alone for weeks. Yet they are almost completely excluded from the decision-making table.
Similarly, in an interview with Africa Report, John Nkengasong…pointed out that lockdowns are not only difficult to sustain but would also “lead to other consequences, such as shortages of food, medicine and other basic supplies”.
If they were allowed to have a say, perhaps they would point out that there are other options and examples that African countries could look to. In the Far East, for example, countries and cities like Japan, South Korea as well as Singapore, Hong Kong and Taiwan, while not yet out of the woods, have managed to tackle the pandemic within their borders while largely avoiding the crippling lockdowns.
Nobel laureate Amartya Sen famously declared that “no famine has ever taken place in the history of the world in a functioning democracy”. He noted that democratic governments, “facing elections and criticisms from opposition parties and independent newspapers”, would be compelled to take decisions to avert disaster.
Democracy may not be such a sure shield against epidemics, but it is clear that, at least on the African continent, its absence, and the prevalence of governments used to wielding clubs and guns against their citizens rather than listening to them, may be turning a looming disaster into a catastrophe.
Slaying the Giant: An Epidemiologist’s Perspective on How Kenya Can Tackle COVID-19
There hasn’t been a pandemic control that has succeeded without social capital. How Kenya and Africa will deal with this pandemic will squarely depend on the strength, resilience and adaptability of our social capital to weather the storm.
Epidemiologists measure how a disease spreads through populations using the basic reproduction number, otherwise known as R0 (pronounced “R naught”). Typical seasonal flu has a reproductive number of 1.2, while that of COVID-19 is reported to be approximately 2.5.
R = Reproductive number: How many people a given patient is likely to infect. If the reproductive number is greater than one (R>1), each case on average is transmitting it to at least one other person. The epidemic will therefore increase. Reproductive number is affected by factors including but not limited to population density, environment, age and immunity.
Typical seasonal flu has a reproductive number of 1.2; Spanish flu has a reproductive number of 2-3, while COVID-19 is reported to be approximately 2.5.
From a policy planning perspective, it offers a very clear objective: Reduce the reproductive number to less than one (R<1)
D= Duration: How long someone is infectious. If someone is infectious twice as long, then that’s twice as long as they can spread the infection. For COVID-19, people are infectious for up to 21 days. This can usually be reduced by treatment but there is currently no approved treatment for COVID-19.
O= Opportunity: The number of contacts of the infected person during the duration of the infection. If people are isolated (no contacts), then community spread does not occur or is minimised. This is achieved through social distancing.
T= Transmission Probability: The chance an infection is spread to a contact, hence the need to eliminate physical contact and hand washing.
S= Susceptibility: The chance a contact will develop the infection and become infectious themselves. We are all susceptible to COVID-19. Susceptibility is usually taken care of by vaccines, which we do not have for COVID-19.
Another important number for understanding diseases is the Case Fatality Rate (CFR): What percentage of people who have a disease die from it? On one extreme, we have rabies, which has a 99 percent fatality rate if untreated. On the other hand, is the common cold, which has a relatively high reproductive number but is almost never fatal. At the time of writing this, the crude case fatality rate for COVID-19 was 5.3 percent. I am calling it crude because thus far, testing has been selective. If testing protocols were to be expanded, this value will probably drop to 1 percent or less. But we will, however, work with the worst-case scenario for now.
In the case of the COVID-19, exponential growth will occur in the disease rate in humans as long as there is at least one infected person in the population pool, regular contact between infected and uninfected members of the population occurs, and there are large numbers of uninfected potential hosts among the population.
Which brings us to the term ‘doubling time’, which just means in this situation that cases/deaths will double in a given amount of time. Doubling rate in the United States of America has been reported to be three days, while China has managed to spread it out. And if the numbers from China are to be believed, they are now at six days. The longer the doubling time, the better.
One last terminology I will touch on is Herd Immunity, which simply means when a significant part of a population has become immune to a disease agent, its spread stops naturally because they are not enough susceptible people for efficient transmission. For COVID-19, immunity would come through getting the disease, assuming that it confers life-long immunity.
So what strategies do we have?
Based on the data we have from other countries, the reproductive number of COVID-19 is 2.5. That means, the population of people that will be infected to achieve herd Immunity is: 1-1/R0, equal to 60 percent. This translates to more than 28 million Kenyans getting it. Moreover, 80 percent (approximately 22 million people) of the population will have a mild disease or be asymptomatic. Another 14 percent (approximately 4 million people) will be in severe condition and may need hospitalisation, while 6 percent (approximately 1.7 million people) of Kenya’s population will be critical and may need intensive care facilities.
Going by case fatality rate of 5 percent, it means approximately 1.4 million Kenyans will die if we do nothing. I chose to stick with the global case fatality rate of 5 percent because even though we have a youthful population, we grapple significantly with both communicable – AIDS, Tuberculosis, malaria, pneumonia etc., and non-communicable illnesses. Furthermore, a majority of the population lives in squalid conditions and is prone to other competing illnesses. And to add salt to injury, as a country, we are still battling malnutrition and anaemia.
Doubling of new infections in the United States of America is happening every three days. This means the numbers will double ten times in a month. Though we have yet to reach the exponential phase, a quick back-of-the-envelope analysis places Kenya, with its current infection rate at 122, indicates the number of people with COVID-19 will double ten-times one month from today. The numbers will be compounded the longer we do nothing and the effects will be fatal to say the least.
Since there are no antiviral medications for COVID 19 and no vaccine, we must rely on non-pharmaceutical interventions like social distancing and eliminating physical contact.
The impact of early and widespread social distancing is flattening the curve. The flattening minimises overwhelming the healthcare facilities and their resources, which is good in the short run, but lengthens the duration of the epidemic in the long run. If the health system becomes overwhelmed, the majority of the extra deaths may not be due to coronavirus but to other common diseases and conditions such as heart attacks, strokes, trauma, bleeding, and other such diseases that are not adequately treated.
Too, if large numbers of Kenyans were to get very sick and start flooding into hospitals and health care facilities, our system will undergo a severe stress test. Our health system could be overrun in a very short period of time. Thus, figuring out how to plan for a massive influx of patients is one of the hardest parts of preparing for health emergencies, and it has yet to be adequately dealt with in Kenya.
If large numbers of Kenyans were to get very sick and start flooding into hospitals and health care facilities, our system will undergo a severe stress test. Our health system could be overrun in a very short period of time.
“Surge capacity” management is one of our biggest weaknesses, particularly at a time when we have shortages of health workers, and a weak supply chain management system. The national and county governments have spent very little on health care, choosing to focus on capital expenditure where there is something for them to ‘’eat’. Even in the course of this pandemic, health care workers are being appreciated by word of mouth but are not being protected, risking spreading this to patients, other workers, families as well as the public. The risk of COVID-19 being another nosocomial infection is very high. Indeed, the 3,000 unemployed doctors have yet to be absorbed into the healthcare system to mitigate this crisis, but I digress.
Here the focus is to slow the growth of the epidemic. Instead of having it double every three days, you put interventions in place to slow it down to double every seven days. This will ease the demand for health care services and give you breathing room. Interventions here include hospital isolation of confirmed cases, home isolation of suspect cases, home quarantine of those living in the same household as suspect /confirmed cases, and social distancing of the elderly and others at most risk of severe disease.
This has the potential to reduce infections and deaths by as much as 60 percent, and prevent the economy from collapsing completely the numbers will drop from 28 million infections with no mitigation, to approximately 11.2 million, and 560,000 deaths if we infer to the case fatality rate of 5 percent.
With suppression, you want to reduce the reproductive number to below 1, hence stopping transmission. This is what we are doing now. Travel restrictions, social distancing, school closures, curfews, stopping mass gatherings. The only strategy that we haven’t adopted so far is sheltering in place, what people like to refer to as lockdown. The problem with this strategy is that it has enormous economic and social impacts. And as long as we live in a global village, there is a great risk of recrudescence especially when you open the borders. This means you have to maintain the strategies until a vaccine is discovered and you have vaccinated at least 60 percent of the population, or at least until a cure is found. We are probably 6-12 months away from a solution considering how clinical trials are being fast-tracked. There is the option of relaxing the strategies occasionally when the reproductive number is low, but this means you must have a meticulous method of disease surveillance to pick up recrudesce early.
How do we balance public health vs. economic consequences?
The bubonic plague of medieval Europe, the Spanish flu of 1918, SARS, H1N1 Swine flu and other infectious diseases have shaped the political economy of the world and so far, all evidence indicates that COVID-19 will do the same.
We must, now, grapple with philosophical issues such as how much economic value we are willing to lose to save a human life.
As a public health practitioner, I decree that saving life is more important than social and economic effects. I think there must also be a delicate political balance to be considered and policymakers should reflect whether they are doing more harm than good.
When making decisions, policymakers often use what’s called the Value of a Statistical Life (VSL) to set an upper bound on how much you can impose on people in order to save lives. But if policymakers assigned an infinite economic value to each life, they would spare no expense and be fearless in imposing any inconvenience.
At a time when everyone needs better information, from disease modelers and governments, we lack reliable evidence on how many people have been infected with COVID-19. Better information is needed to guide decisions and actions of monumental significance to monitor their impact.
The data collected so far is unreliable. Given the limited testing to date, some deaths and probably the vast majority of infections due to COVID-19 are being missed. We can’t access if we are failing to capture infections by a factor of three or 300.
As a public health practitioner, I decree that saving life is more important than social and economic effects. I think there must also be a delicate political balance to be considered and policymakers should reflect whether they are doing more harm than good.
Too, we don’t know what factors are being modeled. Kenya, for instance, is a diverse country with densely populated counties like Nairobi, and less densely populated like Turkana. A one-size-fits-all model won’t work. The modeling models developed need to be county-specific, and interventions need to be more nuanced and contextual. Of course, the chain of command should remain at the ministry of health but with an aggressive inter-governmental coordination prescribing strategies for each county.
This is the time to fully implement the spirit of the 2010 constitution and bring in the devolved units, as health is a function of counties. It is here that strategies such as how will “sheltering in place” work for pastoralism communities be enforced? What strategies need to be considered for the rural areas where the majority of their populations are the elderly?
The overarching idea is to tailor-make a range of policy mixes suitable for the Kenyan context.
Is Kenya getting right?
Based on the numbers I have shared above; I would say it’s a mixed bag. Social distancing is yielding fruit, however, we need a scientifically determined threshold on when these can be relaxed or re-introduced. Indeed, there must be a robust health surveillance system in place, which has to be county-specific. The success of the ongoing strategies to mitigate community transmission will depend on how Kenyans collectively respond to the plea of physical distancing and hygiene.
Still, we have to do more. First, we are not testing enough. I posit that we should partner with certified private laboratories to scale-up testing. We must acquire testing kits that can be used on Genexpert platforms that were provided by PEPFAR and are available in all counties.
I can’t emphasise enough about testing.
You test, isolate and trace to minimise community spread. Without this, we are swimming blind. Secondly, we are not protecting our health care workers. They are the first-line workers and are at the greatest risk of acquiring COVID-19, transmitting it to other patients, as well as to the community.
Finally, there hasn’t been a pandemic control that has succeeded without social capital. How Kenya and Africa will deal with this pandemic will squarely depend on the strength, resilience and adaptability of our social capital to weather the storm.
Disclaimer: The opinions expressed here belong to the author, and do not purport to reflect the opinions or views of the MOH or other bodies involved in COVID-19 response.
Controlling COVID-19: Lessons from East Asia
As authorities the world over restrict the movements of their populations, and governments benchmark their responses on the worst affected regions, there are lessons to be learnt from South Korea which has eschewed lockdowns in favour of early detection through mass testing, contact tracing and treatment.
By the third week of March 2020, the number of COVID-19 deaths in Italy had overtaken the number of deaths in China. Authorities all over the world are restricting the movements of their populations as part of efforts to control the spread of COVID-19.
For the time being, more and more governments are benchmarking their responses on the very worst outbreaks in Wuhan and northern Italy. But lockdowns inevitably have adverse economic impacts, especially for businesses, particularly small ones heavily reliant on continuous turnover. Are there other ways to bring the virus under control without lockdowns?
South Korean lessons?
The Republic of Korea, or South Korea, is one of a handful of mainly East Asian economies that have dramatically reduced the number of COVID-19 cases as well as related deaths. On 29 February 2020, the country saw 909 newly confirmed cases.
By 25 March, the number of newly confirmed cases fell to 100. It has gone from having the second-highest rate of infection globally to eighth place, behind China, Italy, United States, Spain, Germany, Iran and France, all with varying rates of testing.
For now, South Korea has checked the spread of infections. It has managed to slow the spread of COVID-19 without imposing lockdowns, even in its most infected city, Daegu. How have they responded differently to the crisis?
Korean-style pandemic management
The key to South Korea’s response has been mass testing. South Korea has done the most COVID-19 tests by country, with over 300,000 tests as of 20 March 2020, or over 6,000 per million inhabitants. Germany, in second place, had done 167,000 by 15 March 2020, or 2,000 per million.
The infected who show no symptoms (i.e., the asymptomatic) or only have mild symptoms are more likely to transmit the virus to others. As such, undetected cases are more likely to spread infection, mass testing has checked the spread of the virus by identifying and breaking its chains of transmission.
The median incubation period, between infection and symptoms first appearing, is about five days, during which time asymptomatic individuals may unknowingly infect others. Mass testing detects infections early, so that individuals can self-isolate and get treatment instead of infecting others.
South Korea had built up its testing capabilities following the Middle East Respiratory Syndrome (MERS) outbreak in 2015. It was thus prepared with test kits and facilities for rapid development, approval and deployment in case of future outbreaks.
After South Korea confirmed its first case of Covid-19 on 20 January 2020, hundreds of testing facilities, ranging from drive-through kiosks to hospitals and local clinics, quickly became available across the country.
Trace, test, treat
The tests are mainly free for those whom medical professionals suspect need to be tested, e.g., if they recently returned from China. The tests are also free of charge for “secondary contacts” of a person known to be infected or to belong to an at-risk group.
Others who do not belong to these categories, but wish to be tested, are charged 160,000 Korean won (about US$130), but the amount is reimbursed if the result is positive, with any treatment needed paid for by the government.
Mass testing detects infections early, so that individuals can self-isolate and get treatment instead of infecting others
Another legacy of the MERS outbreak is that the government has the legal authority to collect mobile phone, credit card and other data from those who test positive for contact tracing efforts. China, too, has made use of artificial intelligence and big data to improve contact tracing and manage priority populations.
Although this has sparked debates over privacy concerns, South Korea’s proactive testing and contact tracing methods have also been praised by the World Health Organization (WHO), which is encouraging other countries to apply lessons learned in South Korea, China and elsewhere in East Asia.
Path not taken
Although South Koreans are banned from entry into more than 80 countries around the world, its authorities have only restricted incoming travellers from China’s Hubei province, whose capital city is Wuhan, and Japan, due to bilateral political tensions.
Special procedures require visitors from China and Iran to use smartphone applications to monitor for symptoms such as fever. As Europe has become the new epicentre of the pandemic, all visitors from Europe are now being tested for Covid-19, with those staying long-term quarantined first.
The Korean Centers for Disease Control and Prevention (KCDC) continue to urge people to practice social distancing and personal hygiene. Mass gatherings are discouraged, and employers encouraged to allow employees to work remotely. But no lockdown has been imposed, and South Korea has not imposed nationwide restrictions on movements of people within its borders.
Learning the right lessons
Besides South Korea, the WHO has also praised China for its Covid-19 response, which has rapidly reduced new cases, besides helping other countries with their efforts. More and more countries are restricting freedom of movement through lockdowns, citing China’s response in Wuhan.
However, Bruce Aylward, who led the WHO fact-finding mission to China, notes,
“The majority of the response in China, in 30 provinces, was about case finding, contact tracing, and suspension of public gatherings—all common measures used anywhere in the world to manage [infectious] diseases. The lockdowns people are referring to… [were] concentrated in Wuhan and two or three other cities . . . that got out of control in the beginning . . . [T]he key learning from China is . . . all about the speed. The faster you can find the cases, isolate the cases, and track their close contacts, the more successful you’re going to be”.
China and South Korea are now primed to detect and respond rapidly, which may make all the difference in preventing a new wave of infections. This is not to say that lockdowns are ineffective; we will soon know whether such measures in countries like Italy will succeed.
The faster you can find the cases, isolate the cases, and track their close contacts, the more successful you’re going to be
The South Korean and Chinese experiences suggest that resources should be concentrated on rapid and early detection, isolation and contact tracing, protecting the most vulnerable, and treating the infected, regardless of means, instead of mainly relying on strict lockdown measures.
This article was first published by inter press service news agency. The authors are both associated with Khazanah Research Institute but do not implicate KRI with the views expressed here.
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