KAMPALA – I recently saw a news article published on 17th April on BBC that first got me angry. This article later made me realise that if each of us does not take time to get a real understanding of this pandemic, we may end up making the wrong decisions or living with a lot of fear and anxiety from what we read or see mostly in the media.
I have, therefore, decided to do a four-part series on the COVID-19 pandemic that I will be sharing over the next couple of days. These will be slightly longer than my usual newsletters but please take a moment and read them.
The title of the article I read on the BBC was Coronavirus: Africa could be the next epicentre, WHO (World Health Organization) warns.
Now, this made me angry for three reasons. First is that for so long, Africa has been portrayed as the dark continent by the west. Even when things aren’t as bad as they are in the west, Melinda Gates (wife to Billionaire Bill Gates) recently said that it would only take a matter of time before dead bodies from COVID-19 casualties line the streets of Africa if something drastic is not done to curb the spread of the virus. Second, is that many of the decisions being made that affect us all can be influenced by media stories, wealthy or “philanthropic” people and by organisations such as WHO that believe that disaster is our inevitable destination (even without any evidence). But thirdly and more importantly, such stories generate fear and anxiety in many of us, which is making many of us less objective and more irrational in our response.
So, if WHO thinks the next epicentre is in Africa, and if influential organisatoins like the Gates Foundation say we need drastic action in Africa, then, of course, people are going to be afraid. Who wouldn’t be? And these massive lockdowns that prevent the risk of spread and death seem the most logical and practical responses. Remember that people who make decisions are also human and can also be afraid. But is this what Africa really needs? Do we need drastic action with massive lockdowns? I will live it to you to decide, however, I would like to share some things that I hope you and our leaders can think about as we plan and decide what the best thing to do next is.
1. While it is clear that COVID-19 is a highly infectious virus that has the potential to spread and kill, the fact is the impact of COVID-19 has been different in every geographical region. And this means that every area should independently evaluate its situation and take its own measured responses while putting into serious consideration the consequences of decisions that are made both in the long and short term.
2. When it comes to COVID-19, I would like to mention that the most important thing we should focus on is not the number of infections but how many severe cases, hospitalisations and deaths arise. Let us not merely panic about the number of infected people or the potential projected infections. Of course, it is essential to know how many people are infected, but the most important thing is whether these infections make people critically ill or cause death. In Europe and the west, there have been very many deaths from COVID-19, but the same level of death has not been replicated everywhere and especially not in most parts of Africa.
Now many analysts and experts have argued that we in Africa are just at the beginning of the “curve” and like in many other places such as Italy, Spain or UK, they also began with few cases, only to see an exponential spike later on. They also argue that because many people who are infected remain asymptomatic while still being able to spread the virus, the virus can spread at a much higher rate than can be detected. Many also go further to argue that in Africa, we don’t have the capacity to test and so probably are not able to know the real extent of the disease.
These experts have also said the low number of cases of COVID-19 in African countries compared to other parts of the world is to a large extent because of the limited testing capability. Even before Uganda and other African countries recorded their first case, experts were already saying, we probably already had infections but were limited in knowing for sure because of limitations in testing. And given that many people in Africa live in crowded communities and slums, the narrative from the west is that we are sitting on a time bomb and things are likely to get much worse. And they say that when it gets worse many will die in Africa primarily because of our weak and fragile health systems.
“It’s going to be horrible in the developing world,” said Melinda Gates. “Part of the reasons you are seeing the case numbers still do not look very bad is because they don’t have access to many tests.” That is the narrative from the west.
This narrative makes people in Africa afraid. And who wouldn’t be? If there is a highly infectious virus moving around that can be transmitted even from people without symptoms and that has the potential to kill millions until dead bodies line the streets, there is reason to be afraid and to take drastic action. So, what is the best thing to do? Shut down everything and let everyone stay at home so that we don’t have millions of people dead on the streets? But is this narrative or expectation true of Africa? Read on.
One of the reasons we are being told of these worst-case scenarios is because the virus is expected to spread rapidly and yet we are not able to test as much as we would like to. But, I want to argue that neither the inability to do extensive testing nor the predictions of widespread infection (which by the way are purely based on models and speculation) are justification for drastic actions like massive long term lockdowns in Africa. Here is why.
Let’s s look at what we know about this virus. The virus is very infectious and can even be transmitted from contaminated surfaces. With this in mind, as long as a few infectious people enter the community, the virus should begin to spread. We know that on average, one person infects two others. Given that a large number of people live in congested communities and slums, the virus should be able to spread at quite a fast rate. And, we know that some of the people who were infected with COVID-19 had the chance to get into contact with other people in the community. So, we expect that the number of people with COVID-19 should sooner or later begin to grow at about the same rate as has been seen in other parts of the world. Many experts will argue as I have already mentioned, that this is already what is happening in Africa, but that limited testing makes this hard to ascertain.
Ok, so let’s imagine this is true. We should, therefore, expect that just like in most of the western countries that eventually had hundreds of thousands of cases, the virus will spread slowly in the first few days and weeks giving the impression that the situation is not as bad. But then it will begin to spread rather exponentially and devastate our countries. In most places, after about four weeks there were about, on average 50 to 100 cases. From case 50 onwards, most countries have been having an increase of about 20% of infections per day until they have quickly grown to 10,000 to 100,000 cases in the next about four weeks. If we assume that this is also true for Uganda and Africa, then we should be beginning to see those effects considering that COVID-19 has been in Africa for over two months now. But let’s see what the current reality is (not what we have been told will happen). In Uganda, we had 50 confirmed cases from about 5th April (more than two weeks ago) and so by the expected projections seen elsewhere, at this point we should have in excess of at least 500 cases. Let’s assume that like the experts say this is actually true, but because of limited testing, we cannot actually tell. And if the trend continues within two more weeks, many African countries should likely have more than 10,000 cases. Is this or will this really be the case?
We know that the incubation period for the virus is between 2 to 14 days (sometimes much longer) but on average 5 to 7 days. We also know that about 80% of cases only have mild symptoms and about 1 in 5 go on to have more severe and critical disease. So, one month from the first recorded infection, as explained earlier, based on the expected rate of spread, in Uganda we should have about 500 cases (whether or not we can accurately test them). So about 100 of these people should begin to show some moderate to severe symptoms as is expected with COVID-19. At this point, based on the facts about COVID-19, even if we cannot test in large numbers, we should at least start to see people being admitted to hospital with severe or critical respiratory symptoms due to COVID-19. I don’t think anyone with severe symptoms will stay at home and I don’t think any health facility that receives a patient with a cough, fever and difficulty in breathing will fail to test them for COVID-19. So we would definitely detect any of the 20% of cases that have moderate to severe symptoms which should be at about 100 at this point. One month on we do not have one single person who has been admitted from the community because they have moderate to severe COVID-19 symptoms. Yet, some of the known 56 people who tested positive for COVID-19 had already interacted with the community before being taken for treatment and quarantine.
If our problem is a limitation in testing and we likely have more infections, where are the 20% of the potential 500 infections who get more severe disease? There are two likely answers. First, if they are actually there, they are not progressing to more severe and critical disease like in other parts of the world or second, they actually are not there. Whatever the case it doesn’t matter because like I said, the problem is not infections, the problem is severe disease that can overwhelm the health care system or cause death. So, even if there are many infections, our health system is not being affected at all. But what about deaths?
Uganda has not had any known COVID-19 death. Now while it is possible to miss many infections, it is hard to miss deaths. Anyone dying from COVID like illness, especially one that may need intensive care or ventilator support would not be missed. Surely not. So this statistic is likely accurate —zero deaths in 4 weeks of infection. Now the same experts who say, you likely have more infections will now turn around and say, but you only have 56 cases, so the numbers are too small to see the real impact. So, when we are not dying, now the numbers are too low to tell. When we have few reported cases, they say, no there are more, but you are not testing. Whatever the situation, we have zero deaths from the known 56 cases and by the way, none of these has been in critical condition. With our well documented weak health care system, shouldn’t we have higher mortality even with the few cases?
Even if you argue that it is too early to tell, what about countries like South Africa who had their first case on 5th March (over six weeks ago) and that does many more tests than in Uganda? As of 21st April, there are about 3300 cases and about 58 deaths. That is still way below the 30,000 cases Italy had six weeks after their first case. Ok, if we argue South Africa has more untested cases, they still only have 58 deaths (which is a death rate of less than 2% death rate) while Italy had about 2,500 deaths at the same point in time where South Africa is now.
Remember I said, it is not infections that matter but deaths and critical disease. So even if South Africa has 30,000 infections that are undetected, they only have 58 deaths (which makes the death rate even lower). So, it is clear that at the same point we are right now in our COVID-19 journey, we have a very different impact from what Europe went through. We must accept this and understand we are not Europe. We have fewer admissions, less severe disease and much fewer deaths. For some reason, people in Africa and Uganda don’t get as severe a disease and will have less death. Let us document this, accept this and use this as our baseline, not look for excuses why we are not like Europe and why we have to have an impact like theirs. It is ok to have a favourable impact. Perhaps our immune systems that regularly get exposed to infectious diseases respond better. Whatever the case, more research should be done by our own scientists to understand our unique situation. Bottom line, we are not going to have streets lined with dead bodies, and we are doing quite well right now.
People, wake up and stop being afraid of the unknown. There is no reason to live in fear because someone says we shall have massive deaths. If some researchers in western countries have openly said that they would like to test vaccines on Africans and if influential people like Melinda Gates say they see many deaths and dead bodies in Africa, when we are currently doing much better than they are, one can’t help but wonder whether the western world has any real interest in our wellbeing.
3. It is also clear that the biggest risk factor for severity and fatality due to COVID19 is age and pre-existing health problems. The fatality rate is highest in people 70 years and above and for those below 40 years is about 0.4% It is almost zero for those less than 30 years old. In fact, even in South Africa that has 56 deaths, over 70 percent of those are above 70 years with pre-existing health conditions. In Uganda, about 48% of the population is below 15 years (the age group that has literally no deaths), about 49.5 % are between 15 and 65 and only 2.5% above 65 (the age group at most risk for death). What is the biggest problem for the largest part of our population? COVID-19?
In most African countries, most people do not live until 70. The strategies being employed primarily in the western part of the world are targeting their demographics and situation. We need to think clearly about what are our real problems. We need to think about what is likely to kill most people at this time.
4. Is coronavirus the most pressing problem?
COVID-19 is dominating the world agenda to a large extent because it is killing many people in the “first world” or “great” countries. But mainly because it kills at a rapid rate and after requiring a lot of care that can overwhelm their health systems. As of 21st April 2020, when we are told that we have probably passed the peak of the virus globally, we have about 170,000 global COVID-19 deaths this year. But did you know as at the same date there were also 150,000 deaths due to seasonal flu-like illness? Flu-like illnesses kill about 500,000 people each year. So COVID-19 isn’t very much different from other flu-like diseases in terms of death. What is different is the way it is killing. COVID-19 is currently the most urgent public health problem in developed nations. But, is COVID-19 the most critical or pressing issue we have in Africa?
In Africa and developing nations, we have health problems that cause more death and suffering than COVID19. Every day in the world, 25,000 people die of pneumonia, diarrhoea, malaria and TB, about the same number that has died of COVID-19 since it began in Africa. Are we not responding to a problem in a way that is being shaped by what we see in other countries or continents?
5. Lockdown or not?
We must then ask ourselves if we are doing the right thing to keep everyone in lockdown for long periods. Is it the right thing to take such drastic measures that could affect millions negatively long term based on what the west is projecting on us? Or, is it because for once COVID-19 can kill the more affluent? Are we doing what is best for everyone?
What are the benefits vs the risks of a lockdown? Are some of our actions based on the massive death projections from the western world? A total lockdown affects everyone, and yet the majority of those being locked down have a very low risk for death or severe disease from COVID-19. Extreme lockdowns affect both the health and wellbeing of everyone. Restrictions in movement have already had real negative impacts on people’s health and lives due to delays and challenges is seeking timely medical care. The anticipated health benefits from a massive lockdown do not seem to outweigh the immediate ramification for the majority of the population that live on their daily earnings. Are we likely to have much more long-term risk for death from hunger and poverty-related illnesses like malaria, diarrhoea and pneumonia? These are questions our leaders should think through. But what is clear, as I hope I demonstrated earlier, is that the impact of COVID-19 is not one to generate fear.
Other countries that lockdown have large numbers of vulnerable people and have economies that can weather the storm of a lockdown for a while. We have a much smaller number of vulnerable people. A total lockdown may have a much more massive potential devastation to our economy and to the livelihoods of the millions who live on daily income. We are even likely to worsen the already existing problem of hunger. And by the way, food insecurity leads to weaker immune systems that are less likely to work well under the attack of any infection. My view is that the move of an initial lockdown led by our president was timely, decisive and has bought us time to understand this problem better, but now we have a better picture and must re-think what is best.
6. How should we respond?
I don’t think I have the perfect answer. But, I honestly believe that the impact we see on our African people is not one to warrant a restrictive and long term lockdown although restrictions of some kind are definitely helpful. And in any case, most lockdowns aren’t really able to create the social distancing that they aim to achieve considering many people live in crowded communities often sharing facilities like toilets and bathrooms. If you live in an urban setting in Uganda, you only need to walk to the nearest trading centre to realise that many people are still getting together to chat in groups, are playing cards together, perhaps out of idleness, and sometimes you would never be able to tell that we are trying to maintain some kind of social distancing. And yet many, are more concerned about where their next meal will come from than about the risk of COVID19. I was hosted on a radio show just before the lockdown, and one listener called in and said, that most people out there were willing to take their chance with coronavirus rather than starve or fail to feed their families. We can force people not to drive and not to use public transport, but it will be a struggle to keep a hungry or disgruntled person at home. I, therefore, think we need to devise our own measured response to COVID-19 that will have the best long-term outlook for all.
In Uganda in particular, I think our leaders have done well, and I applaud and salute them for their decisive action. But, I think it is now time for us to consider a more measured approach. As our president said, the best approach is one where we all change our behaviour and follow guidelines to keep us safe. That is really the best way to stop or reduce the spread of the virus. I think it is time we consider easing the extensive lockdown while maintaining some restrictions in particular areas that gather many people together. I think we should find ways to allow people below a certain age (say 55 years) to carefully get back out there working while maintaining the various known protective measures to reduce risk of any potential spread. Older people could be advised to take more precaution and limit non-essential movement and more support given to vulnerable people who could be advised to stay at home. Other things that could be considered are:
• A more intense sensitisation program to alleviate fear, dispel myths and explain the benefits of following protective guidelines. When people understand they respond better.
• Scale-up testing, including antibody tests that can show a better picture of the COVID-19 impact. These tests could be paid for by the public to scale-up testing.
• Increase access to protective equipment for health workers and all people who need it
• Invest in improving the health infrastructure in the health facilities, not only in transportation, so that when required, we can handle any cases that need that service.
• Get our own scientists to lead a data-driven and scientifically sound response based on our unique situation. Is it time for us to have our own African Health Organisation that will do what is best for Africa? COVID-19 isn’t about to go away. There is likely a long, uncertain road ahead. We need to have our own scientists who have our best interests at heart come up with our own unique approach to COVID-19. We need scientists and leaders who have the courage to stand up to foreign nations and bodies where it is necessary. There is a lingering debate of a vaccine; I hope to discuss that in a later part of this four-part series, but if and when a time comes for a vaccine, it should be one that we can independently verify safety and efficacy.
I hope you can now understand that the impact of COVID-19 is different based on different factors. Any response taken should be one that is appropriate for that particular area and the people that live there.
In my next article of this 4 part series, I will be discussing what you can do to keep your immunity strong and to give your body the best chance against COVID-19 because this virus is likely going to be around for a while and some of us may eventually get exposed. If we do, we should be ready to defeat it.
The writer, Dr. Paul Kasenene, is a qualified medical doctor specialising in Nutritional, Functional and Lifestyle Medicine