Commentary: The trinity of ‘patient Ethiopia’
By Belete A. Desimmie (MD, PhD) @adbelete
Addis Abeba, June 02/2020 – Today’s Ethiopia is suffering from three major ailments that are challenging its immune system rendering it ever more vulnerable. The trilemma metaphor provides a perfect framing for strategic thinking and the need to take one ailment at a time. The impossible trinity or the policy trilemma is used to describe, in the world of international economics, the impossibility of achieving financial integration, exchange rate stability and monetary autonomy all at the same time. ‘COVID-19’, the imminent ‘elections’, and the ‘constitutional moment’ are the three conditions ‘Patient Ethiopia’ is diagnosed for and requiring urgent treatment. In this piece, an attempt is made to underscore the need for pacing and sequencing of the treatment regimen.
COVID-19 and ‘Patient Ethiopia’
As of June 02, 6.2 million confirmed COVID-19 patients were reported across the globe, of which only 1257 of them were from Ethiopia. Rich or poor, literate or illiterate, and hygienic or unhygienic among us, we are continuously in contact with both harmless and harmful novel microbes. A human body has more germs than human cells. Under physiological condition, most are inoffensive to our health and routine bodily function. Because of our behavior and misadventures, occasionally a novel virus spills over from the environment to us. The virus finds a home in our body and compels our cells to support its replication. By doing so, this novel virus causes health problems registered as a profound disruption in our bodily and societal functions. For instance, SARS-CoV-2 that came unannounced about six months ago is showing up in every household using close friends and family members as Trojan horses.
COVID-19 has now reached to all corners of our planet and continues to wreak havoc around the world. SARS-CoV-2 uses its proteins to enter and infect our cells to cause COVID-19. Analogously, a few COVID-19 patients were imported through various entry points to Ethiopia, infected Ethiopia, and now the virus is spreading in different parts of the country.
For a moment let’s consider Ethiopia as a human body with heart and mind, blood and bile streaming through tributaries, defense systems, and muscle and fat anchored on bones; all of which give it the shape, soul, power, and identity it has now. In other word, like human being, Ethiopia survived by the harmonious co-existence of these attributes and the accompanying strengths and weaknesses. The long evolutionary history of Ethiopia in combating enemies – external or internal forces, involuntary or self-inflicted damages, natural or man-made disasters – has continued to morph and optimize its survival by nourishing itself, harmonizing its diverse population, exercising its sovereignty wisely, and taking care of its physical and mental health. Currently, Ethiopia is ill from COVID-19, a national security threat and an invisible enemy. If we do not intervene in time and diligently, it is at high risk to develop severe COVID-19 that threaten its existence. Why I am obliged to categorize Ethiopia in such high-risk group? It is because of the existing ‘co-morbidities’ that it has. These include the locust plague, the fragile healthcare system, the GERD saga, the deferring of the upcoming election, and the political volatility that underpins the past two years’ transition.
Despite the political volatility and our differences, the Ethiopian people have coalesced remarkably in facing the threat paused by this unprecedented pandemic. The big question is what is the ‘next normal’? Before answering this, we need to agree on our expectation from the government and the responsibilities of the public and other stakeholders.
The SARS-CoV-2 transmission in Ethiopia isn’t contained. It is clearly here to stay unless we eradicate it with an effective vaccine that will be given to the great majority if not every human being. We have done that before with smallpox – unfortunately, that’s an N of 1. That has taken us many years. Before even we have any viable pharmaceutical interventions, lately I noticed that the public, justifiably, is eager to know about the timing of the virus disappearance. I wish I could provide a definitive timetable. This virus is knocking the door of each and everyone’s house uninvited, partly because of our recklessness and behavior. I don’t think anyone can predict when or if this disease will fizzle out. But the good news is that, currently, multiple renowned scientists are working around the clock to develop safe and effective treatments and/or vaccines. And the global solidarity towards controlling this pandemic is commendable.
To counteract viruses, our body mounts a defense by sending out semi-specific first-line armed guards (innate immunity) to pose roadblocks and stop them by depriving it precious nutrients to death. In addition, to make our body as inhospitable as possible for the virus, the temperature regulatory center in our brain orders the body to muster excessive energy to boil the blood and generate fearsome fever. Just like the human body, any nation can deploy first-line defenses from wanting the enemy to die and render it lifeless. Unfortunately, there is always a collateral damage on the healthy bystanders who suffer the most from the injuries and devastations that follow. Such is the nature of a battle – be it at an individual or national level – with a virus, our most formidable and invisible foe. Often times, the first-line defense systems work well to control any foreign invaders, but sometimes they don’t. And in those cases, we need help, particularly from the highly specialized and adapted defense forces. These specific defense systems are: a network of cells orchestrating a learned immunity called adaptive immunity. This extraordinarily specialized and yet rapidly developed adaptive immunity can recognize foreign pathogens and carry out the shoot-to-kill order; the army of killers (memory immune cells) will stay in stand by for any possible future re-invasion.
Likewise, at a national level, the executive branch can establish an evidence-driven multi-sectoral COVID-19 emergency preparedness and response task force. Our government did exactly that and then took swift actions to decrease the importation of COVID-19 infectors, procured essential items, trained healthcare workers, and strengthened the public health infrastructure. These actions greatly slowed the anticipated acceleration of COVID-19 spread. It should also be noted that the people of Ethiopia have sacrificed and continued to suffer with great unity to reduce the SARS-CoV-2 spread and save lives. Kudos to the people of Ethiopia!
We often hear the phrase, “Good policy is good politics” and its inference is clear. In a democracy, there exists a clear link between power, public service, and accountability. In my opinion, the actions taken and the willingness to engage the public by the reigning government to tackle COVID-19 while not losing its focus on any of the national issues and the continuity of ‘normalcy’ is a good politics. We know that inaction is not in our biology nor should it be in the nation that we inhabit.
The latest WHO projection model for the next one year on the potential effects of community spread of SARS-CoV-2 provides a rough guidance on how to gauge and fine-tune our policy. Accordingly, we need to continue to bolster our non-pharmaceutical interventions: physical distancing, isolation, and universal utilization of personal protective equipment to minimize the damage until we have a preventive vaccine. To this end, for the first time in human history, scientists are on track to make available an effective and a first-in-class SARS-CoV-2 vaccine as early as beginning of next year. We hope it will also be available to countries in the global south.
The Imminent Election
Ethiopia is in a unique situation, as are many other countries when it comes to deferred elections. While fighting COVID-19 spread and protecting its people, it is expected to conduct national and regional elections. From the time the virus was first reported in Ethiopia, our public health officials urged us to aggressively practice the #StayAtHome and #SocialDistancing measures to limit the virus spread and save lives. In other words, with lives on the line, our current (or, to be elected) leaders should not ignore these plans. However, if ignored, the potential risk and consequences on our health will be extraordinary.
The body that has exclusive monopoly on the planning and administration of elections, counting the votes caste, declaring winners, and handing over certificates to the victors has come out at the early stage of the pandemic and made public announcement. The rationale for the announcement was the impossibility of conducting a fair and transparent election and the perverse effect of organizing the election in an attempt to meet the constitutional deadline. It clarified the effects of the inevitable public gathering on the non-pharmaceutical interventions recommended by our Minister of Health and other international organizations, including the WHO to curtail the COVID-19 spread. This election, a regular health maintenance checkup intervention, is critical to the good health of the nation. It is required by the constitution, and was scheduled to be held at this unfortunate time when the republic is nursing this fatal ailment, COVID-19.
It is one of those situations where an ailment is left to self-contain, just to be watched without any aggressive treatment. In these circumstances, what a physician needs to do is to monitor the patient and minimize the risks of worsening of the relatively less severe condition and/or contracting a related or unrelated new disease. Similarly, suspending or postponing an election in such dire circumstances should not be equated to failure of democracy or the body politic.
We all are aware of the inherent requirements of public gathering during the election season. More importantly, the National Electoral Board will have to handle the logistics nightmare of assigning its officers to over 45,000 electoral districts, distributing materials (in some remote places this had to be done on the back of horses in earlier elections), and ensuring that voter trainings are sufficiently provided. That is why our patient will have to first deal with COVID-19 that has hand-cuffed the electoral body from doing what it would have done if the circumstances were different. Pushing this in any way will only lead to an undesirable public health crisis with all its repercussions to the future health of the patient – ‘Patient Ethiopia’.
Constitutional Moment
‘Patient Ethiopia’, through its representative i.e. the government, sought advice from its ‘specialist’, in this case the Council of Constitutional Inquiry (CCI), on how to deal with the predicament the country has found itself in. This could legitimately be called a ‘constitutional moment.’ This is a time when the mother of all laws in the country falls short of giving an answer. A ‘purposive interpretation’ of the constitution, as most of the scholars argued during the CCI hearings, will help the country navigate through these extraordinary moments when a government will have to survive beyond its full term. Unlike the human birth in which the parents safe guard and nurture the new comer, a parliament will have to ‘kill itself’ so that a new and independent one is born. The death could be brought by other means (using Article 60 as a weapon). However, the conveyance of power to the newly elected one is rendered impossible because of the mighty COVID-19, which claimed the elections as one of its casualties. What is, therefore, required of the ‘specialist’ is a unique proposal that may not necessarily be a curative treatment of the patient, instead, in the words of McConnell seek ‘intergenerational synthesis.’ This means that it may lead to an act to ‘subtly modify…provisions even if those…provisions were not explicitly amended.’ For a patient on a life support, it is imperative that the entire structure is viewed as a subject requiring life-saving treatment.
The indisputable reality is that Ethiopia is now a COVID-19 patient; we are having a conversation about the effect of COVID-19 on the upcoming election. The Ethiopian government is doing what is expected from it, i.e., to do no harm to Ethiopia. The proactive engagement, discussion, consultation, and teaching and learning process with the public about these critical, tough, goal-oriented, and forward-planning issues is admirable. That is exactly how a physician would approach to treat ‘Patient Ethiopia’, if it were her/his patient. The toughest conversations of all are often infrequent and ensue when the patient is so sick that there is no hope of recovery.
But that is not the case for Ethiopia. We have recently watched the Ethiopian Constitution Interpretation discussion convened by CCI. It was not only unprecedented, but will for sure restore the public’s trust and confidence on the system which is critical to maintain the good health of the country. In fact, Dr. Tadesse Lencho, one of the invited scholars during the CCI hearing nicely and metaphorically described Article 93 of the constitution as the intensive care unit (ICU) of the FDRE constitution. An interesting analogy, and as a physician-scientist it resonated and absolutely made sense to me.
I have to say it was a reassuring and faithful hearing. Without a doubt, it demonstrated that the civil conversation we are now having about ‘Patient Ethiopia’ is a challenging one. A multitude of internal and external exasperating factors put Ethiopia at high risk to the devastation of the smoldering COVID-19 spread and the collateral damages. H.E. PM Dr. Abiy Ahmed recently stated a much-needed message in these trying times when almost all the other nations are fighting their own fight and focusing their lens only inward. Yes, I am fairly confident that not only we can restore Ethiopia’s good health but we may even put our nation in a stronger position than before by unleashing indigenous innovation, investment, culture of solidarity, and preparation for a better solution to deal with such disasters in the future.
Similar to the doctor-patient interactions, here, we need to be willing participants by keeping up our respective end of the deal. Whether it is the body or the country, people want to heal and recover as quickly as possible. And, they both want to do it with minimally invasive interventions and with as little cost as possible. Doctors prefer this approach for their patients even if they knew that the most effective treatments could take prolonged time and conscientiousness. I found the participatory CCI hearing as an exemplary and evidence-based practice, a teaching moment for us and the generations to come. One thing that I have learned from the CCI hearings is that we Ethiopians are in good hands, and the civility, fact-based advice, and brilliance of the constitutional and public health scholars are testaments to this.
The systematic approach followed and undertaken here will hopefully bear the right and less invasive interventions. The treatment guideline being developed involves multiple specialties and experts. I am faithful that this will give birth to a safe and effective treatment to slowly but surely cure the chronically maligned nation – ‘Patient Ethiopia’. During the doctor-patient interactions, doctors must take time to explain the recommendation, why it should work, and the perils of taking or abandoning it. For example, I used to tell my HIV patients that stopping the antivirals for non-medical reasons is not allowed as it is worse than not taking one at all. This is because the risk of drug resistance is extremely high making my patients even worse off as the best and first-line treatment will be annulled for later use. No short cuts are used in treating patients, and so ought not be in treating ‘Patient Ethiopia’.
Right now, we all are worried about COVID-19 in Ethiopia. We are not even through the consequential therapy i.e. the strict non-pharmaceutical interventions and state of emergency. If we stop or relax it now, Ethiopia may not only lose ground on the current battle but could also dearly suffer from the unknowns of the ‘second wave’ of COVID-19 cyclone. In other word, we will do worse than now in all aspects of the wellbeing of the nation. The metaphorical novel resistant HIV strain may be unchecked.
Getting through this together means listening to the treatment recommendations, understanding and supporting the rationale, and not giving up hope through the process of healing and maintaining the good health of the nation – democratizing and achieving equitable livelihood in Ethiopia. These are tough times; the current pandemic isn’t the patient’s or the country’s fault. Just as those of us in the public health arena don’t know why our patients develop a myriad of crippling diseases; we don’t have definitive answer for why the world is suffering from COVID-19 at this time in our history. In my clinical experience, I always prefer not to blame my patients even if the problem was a self-inflicted injury as it will neither change how I treat the illness nor how the patient responds to the treatment. Placing blame in the current context towards anyone serves no purpose to the nation we all love and the people we serve. Let’s cast our eyes to the bright future and not be trapped in the foggy history of our past. To be fair to the current regimen and the CCI hearing process, the initiated treatment for ‘Patient Ethiopia’ is a timely, necessary, and participatory regimen. Patients want and deserve that. From my understanding there is a high likelihood that the treatment being proposed can work for the good health of the nation. Not surprisingly, most will tolerate and start responding positively to it. A few may not even bear it. The same is true in patients.
COVID-19 has exposed every nation’s inherent weaknesses and exacerbating risk factors; they all are learning from others that controlled the virus spread. At the moment every nation is developing its own roadmap on normalcy. Ethiopia is not there yet, but it is working hard and diligently to mitigate COVID-19 spread and define the ‘next normal’. The Ethiopian constitutional scholars and other discussants were asked during the CCI hearing if it is dangerous to have the constitutional interpretation; they all seem to agree on the restoration of the good health of the republic. This is a once in a lifetime opportunity to heal the body and mind of ‘Patient Ethiopia’. If we stay on track and together, we can make it happen now.
Ethiopia and the world are facing a serious threat. Of interest, Ethiopia is a high-risk COVID-19 patient with major existing and emerging ‘co-morbidities’. But if we faithfully take part in the process and contribute to the solutions together, they all are treatable and fixable. AS
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Author’s Note: I would like to thank my friends who shared with me their pearls of wisdom and expertise on the subject matters addressed in this article as the ‘Trinity’. Their criticisms and comments have greatly assisted in improving the metaphorical approach used here to dissect the intersection of the trilemma.
