Yohannes Kinfu (PhD)
A personal perspective on managing COVID-19
Addis Abeba, April 22/2020 – Few events, in our shared humanity, have divided and united the world at the same time as COVID-19. In most, if not all parts of the world, flights are largely suspended, dis-connecting the web of nations. In some, sub-national units within nations, are functioning like islands or a country of their own because of stringent restrictions on movements. In fact, it is not just countries, or states within them that now appear apart, the ‘social distancing’ interventions promoted across nations also give the impression of a divided society but looks can be glaringly deceiving. And, sure they are. In all these seemingly ‘divided entities’, what is clear is a united human front focused on fighting a single enemy: COVID-19.
The goal is universal. It is about saving lives, livelihoods and upholding social cohesion. But fighting such a deadly and universal enemy and winning the war (not the battle) requires each country choosing its weapon or weapons carefully.
The first COVID-19 case in Ethiopia was reported on March 13, 2020. It took 16 days to reach the first 20 cases; only seven to add another 20 and required even fewer days (5 days to be exact), to get to the next 20 cases. If we go by the trend for the week ending April 13, the country would have doubled its total number of cases—which, as of April 13, 2020, were at 74 – every 9 days. Fortunately for now, the nine days since April 13 saw less numbers recorded as compared to the days preceding the week of April 13. As of today the number of cases has reached 116.
However, for students of population sciences and disease monitoring, like myself, such a trend is still worrying because it signifies a steady expansion of cases, known scientifically, as exponential growth.
So, what should be done in the days, and months to come. The best place to start this is to talk about what should not be done. In times like this, it is not wish nor panic or being aloof of reality that would save the country from an impending disaster. In fact, when each day matters a great deal in one’s life, it is exactly there and then that one must look beyond wish and panic and seek their right weapon.
The weapon of choice to fight COVID-19 for most has been to follow international practice. In the case of Ethiopia, the government has already ordered civil servants to work from home, had asked citizens to observe hand hygiene and social distancing practices, while religious institutions had instructed their followers to observe religious practices from the comfort of their home. To co-ordinate national action, the government has also imposed national emergency law recently. All these actions are within the global to do list, and, no doubt, will help in significantly reducing the number of people each person would meet physically in their daily life. This is central to arresting any infectious disease.
However, weapons also need to adapt to local context. Intervention policies that are fit for a country in a middle of a pandemic should be qualitatively different from those which are in the early or later stages. For Ethiopia, most, if not all, of the new cases are so far imported, and this is where its key weapon also lies. A strong central team with skills and experience in disease surveillance is required. Each passenger coming into the country needs to be fully registered, and systematically allocated to a designated isolation or quarantine center. The management of the isolation centers and the entire airport need to be under the control of the military and viewed and managed, for all practical reasons, as a war zone. This is a fight against an enemy for which there is no vaccine or effective treatment options.
In terms of operation, controlling cross-infections within isolation centers and during transfer from Airport is highly critical. The designated isolation areas need to be completely sealed and ‘campers’ (read passengers) should not be allowed to mingle with others. Ideally, they should be assigned their own accommodation and should not be allowed to leave their rooms before they complete their quarantine period. It is also ideal if ‘campers’ coming from various destinations and during the same period are accommodated in the same location, because this makes it easier to trace cases should infection happens within the centers. Soldiers working in the designated areas, once allocated, should not be allowed to leave, and should be required to stay until they complete the quarantine period. At the end of the day a system is as good as its weakest link, and any lapse in these chains of events will ultimately cost the nation. Hence, to put it differently, but blatantly, the quarantine centers should be administered as high security ‘prisons’ with a human face.
The talk of ‘high security prisons’ and the call for the participation of the military is a tricky one and may raise eyebrows, given the past role of the military and high security prisons in Ethiopia and Africa more broadly. Those who know me well as an advocate and believer to the core of individual right and a minimalist government would also be surprised to see these suggestions coming from me. However, at times, especially during hard times when negative externalities are greater for the individual being some form of hard decisions and corrections could be necessary because the alternative to a strong and quick intervention is loss of life and livelihoods, and this is not an alternative that I am happy to live with. This said, it is important to emphasize that the military should exercise high level of discipline while executing its assignment. It is also important to establish a civilian team composed of health professionals, legal practitioners, experts in data science and supply management to monitor and provide oversight on the day to day functioning of the isolation centers. For the military, especially if it manages this operation professionally and successfully, this is like a lifetime opportunity to create a new image for itself in the nation.
The country should also focus on active surveillance rather than the current practice which appear to rely on citizens to call and report, if they had been in contact with confirmed COVID-19 patients. This is what is called passive surveillance. Passive surveillance has the merit of being cost-effective because the burden is pushed to the reporter, rather than the state. It is known to work well for events that have less serious impact on society. However, for the kind of crisis the world is faced now, time is the essence. Moreover, in a couple of cases reported in the daily brief on COVID-19 by the MoH, the source of infection had been reported as an ‘unidentified’. It must be understood by those in charge of surveillance that, for better or worse, the life and fortune of the nation is now primarily on their hands; in their ability to detect cases. All efforts should be made by the state to take the history of each suspected case in greater detail. One extra day and one unreported case can be a huge threat to the nation and in the long-term a big gamble on the life and livelihood of people, and the social cohesion of the country.
Hand in hand, inter-regional movements need to be highly regulated and must be allowed only for life sustaining cases, such as to maintain supply chains. The movement between Djibouti and Somalia needs special focus, because these two countries are expected to be the hot bed of new infections in the days and months to come. Completely sealing the border between these countries and Ethiopia may not be feasible nor desirable, but drivers and those working on the supply chain may need to be asked to board at a designated site and made to undertake regular testing for timely intervention.
Community level screening should be strengthened. So far, the only one known to the public is those held in Addis Abeba and Adama. It is true that tests need to be used judiciously as test kits are likely to be in short supply, however they need to be efficiently targeted and follow standard statistical procedures to allow meaningful conclusions. The screening and tasting should also target high risk communities and areas. For example, some places to focus on include public transport users, traders in major marketplaces, banks and government offices.
Partial lock downs, as is the case in the country now, in the absence of effective surveillance and loose management of isolation centers and the main entry to the country, Bole Airport, will only drain life and livelihoods. The key issue, here, is to stop new infections from entering the community and when it is suspected or happens to deal with it in a timely manner, through isolation and clinical intervention. In a country, like Ethiopia where the health system is fragile and incapable of caring for a bigger case load, these are some of the cheapest and easiest weapons to fight back COVID-19. Once the infection jumps to the community, a complete lock down may be required to reduce the caseload to zero or to a level that will not be a trait to the country. Whether this is feasible or not will depend on resources, because this requires a huge war chest, probably a good share of the country’s GDP.
Finally, we need also to have the capacity to identify opportunities through our challenges. What history has shown is that, when humans are faced with the greatest threat that is also when they are known to rise and learn their greatest lesson. This is an opportune time for thinking soles in the country to be bold, and question old habits and learn new lessons that lasts. If there is any single important lesson from COVID-19 is that it only needs you to be human: your language, your ethnic origin or religious affiliation won’t matter. So, the politics of division must give way for one of co-operation. This is the other weapon that the country needs, perhaps up on which the success of those mentioned earlier greatly depend on. It requires each of us accepting the reality that if any part of the nation fails, it is a failure of the whole, the continent of Africa and the world. In the worst of circumstances, nations who are unable to deal with COVID-19 effectively, will eventually risk being completely cut of the global community, especially if that nation does not bring much to the world by way of global trade. Therefore, every Ethiopian and each part of the country, is in here together for better or worse. In here, it is also important not to lose sight of the place that Ethiopia and Ethiopian (i.e. Ethiopian Airlines) hold in the region and the African Continent more broadly. Given the country’s population and the fact that Ethiopian Airlines serves as a connection point for much of Africa, more specifically its role in bringing the world to Africa and taking Africans to the World, what happens in Addis Abeba and Ethiopia can have a seismic effect beyond our borders, which we cannot afford to ignore. This also means that a co-ordinated approach with other countries should be part of this important containment framework.
The government has recently adopted a State of Emergency to co-ordinate national efforts, which will be managed by members of the council of Ministers. However, given the federal structure in place and the fact that most COVID-19 related interventions need day to day follow up at local level, this is an opportune time to start practicing shared governance and get the regions involved effectively. Particularly for the purposes of COVID-19 it is preferable to establish a council of ‘governors’, which is independent of the party structure and its central committee. The council of ‘governors’ should involve each of the regional heads, the city administration of Addis Abeba and Dire Dawa, with the Prime Minister as its head. This body is more likely to be effective than the currently constituted group incorporating members of the council of ministers appointed to manage the emergency law, because members of the council of governors are intimately linked to local realities, and able to reflect on their challenges and share their success story. It can also cut the bureaucracy involved and bring on board all sections of the country on the same table. Parallel to this, to support the work of the Ministry of Health, it would also be prudent to establish a similar council for health, and other relevant ministries.
The idea of council of governors and the various sectoral councils could prove to be one of the most useful political innovations coming out of the COVID-19 crisis, because once the next election is held, chances are that the different regions of the country are likely to be led by diverse political parties and the old way of sorting our issues through a centralized party system may lead to further division and to a dysfunctional state. They can be permanent legacies of post COVID-19 Ethiopia, and a way to navigate the nation toward a more perfect union. AS
Editor’s Note: Yohannes Kinfu (PhD), is an economist and demographer by training, with research interests in the statistical and mathematical modelling of diseases, population processes, risk factors and the economics of health care in global context. He is currently an Associate Professor of Global Health at the Faculty of Health, University of Canberra; Associate Professor of Population Medicine at College of Medicine, Qatar University, and an Associate Professor (Affiliate) of Health Metrics at Department of Health Metrics Sciences, University of Washington. He also holds an Honorary Fellow position at Murdoch Children’s Research Institute at the Royal Children Hospital in Melbourne, Australia.
He can be reached at: firstname.lastname@example.org
Disclaimer: The views expressed in this opinion are that of the author and do not represent any of the institution he is affiliated with.