COVID-19 Response in Sub-Saharan Africa: A Hybrid Approach is Needed - OpEd

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The 2014 Ebola Virus outbreak in West Africa wreaked havoc on a number of already fragile states — Liberia, Sierra Leone, Guinea, and the Democratic Republic of Congo. At the peak, people were lying dead in the streets and in their homes. It felt like the end of the world. No country wants a repeat of that sort of horror. The justifiable haste to avert that sort of scenario has led many Sub-Saharan Africa states to copy the lockdown approach in responding to the COVID-19 pandemic.

There have been debates about the workability of the lockdown on the largely informal economies of Sub-Saharan Africa (SSA). The concern is that the majority of the population in these countries are informal sector workers who essentially live from hand-to-mouth. Furthermore, the absence of reliable databases of individual and family incomes, traceable home and business addresses make it nearly impossible to effectively deploy government palliatives to those who really need them. Added to the debates is the weak capacity of health systems in SSA countries.

It does appear that the virus is not as transmissible in Sub-Saharan Africa as it is in North America and Europe. Experts have sought to explain why this is so. However, it is not only because of inadequate testing. As of April 27, 2020, Ghana has conducted 100,622 tests, 1,550 of which are positive. Ghana has recorded 11 deaths so far. We would be seeing an upsurge in unexplained Ebola outbreak-style deaths in communities if the low numbers of cases and low case fatality ratio could be explained by low test numbers alone.

So, what should these countries do? Do they relax movement restrictions and risk unrestrained spread of the virus, or do they maintain lockdowns and risk civil unrest? I propose a different approach that combines containment (COVID-19 control measures with minimal disruption of economic activity) and suppression (a total lockdown, driven by local context at the state level and governed by appropriate authorities).

Image credit: twitter.com/MBuhari

Containment
A containment strategy requires public health authorities to institute a responsive surveillance system that can quickly identify, test and isolate positive cases and their contacts. Once a suspected case is reported by the public, the individual is quickly reached and tested. If they test positive, they will be required to isolate while their contacts are traced and tested.

Where should cases be isolated?
A few questions will need to be answered: can the individual and close household contacts remain at home without making any contact with other people? No going out to fetch water, buy fuel for the generator, buy phone recharge card, buy food? Can they be reached quickly with an appropriate ambulance to convey them to a treatment facility if their situation worsens? If the answer to any of these is no, then isolate in a designated isolation centre.

In the containment phase, the farmer and the cobbler can continue to work; the petty trader and the seamstress can open shop; the mason and the carpenter can continue to earn income. Most businesses should be able to stay open with modifications to keep people apart as much as possible. Schools may reopen with staggered classes and school days for different categories of students. 

What is required for this to work?
Governments, either at state or regional level, will need to embark on massive social and behavioral change communication activities to discourage practices that facilitate the spread of the virus. This will include discouraging social gatherings, avoidance of crowds, discouraging all non-essential travels, restricting non-essential contact with old people and those with underlying illnesses, avoidance of handshakes and hugs, and generally encouraging physical distancing measures. Practices like frequent hand washing, use of hand sanitizers, staying home when feeling unwell will have to be continually emphasised. Mandatory use of face masks -even cloth facemasks- when leaving home will need to be put in place.

Image credit: Nigeria Health Watch

Trust is imperative and citizens should be encouraged to quickly report any suspected case. Authorities would need to work with communities, traditional institutions, market unions and trade groups to promote physical distancing procedures and establish mechanisms to discourage the violation of public health measures put in place.

What if containment fails?
Each state or regional authority will need to set a threshold for moving from containment to suppression. That threshold should be based on number of new cases per day which in turn depends on estimates of case reproduction numbers. To determine the threshold, the following will need to be taken into account:

  • The proportion of cases that are likely to require hospitalisation
  • The proportion of hospitalised cases that are likely to require intensive care and mechanical ventilation
  • The number of ventilators available
  • The number of intensive care spaces available
  • The number of designated hospital beds available
  • The number of frontline health workers available
  • Other local considerations

Once that threshold is reached, the authorities will as a necessity scale up to suppression.

Suppression
Suppression is the disruptive lockdown phase that we have all become familiar with. Any state that reaches its containment threshold will reintroduce a lockdown phase and keep same in place until the case load drops below the threshold number.

Walking a fine line
At every stage of the process, public health authorities will need to provide daily updates using means that are appropriate for each state/region. Residents of Sub-Saharan African countries will need to realize that the price to pay to avoid the pain of the suppression phase is compliance with the inconveniences of the containment phase. Until an effective vaccine or treatment becomes available, governments in SSA will need to walk a fine line between total societal breakdown from an out-of-control virus or an out-of-control hungry populace.
 
Have you heard of other measures that might fit the Sub-Sahara African context? Let us know on our social media platforms, at @nighealthwatch on Twitter and @nigeriahealthwatch on Facebook and Instagram.
 
Author’s Bio: Ikedichi Arnold Okpani, MB; BS, MSc, is a public health practitioner with interest in primary health care systems development, maternal and child health, and health systems research. He is a PhD student in the School of Population and Public Health, University of British Columbia, Vancouver, Canada. He received his medical degree from Ebonyi State University, Nigeria, and his masters’ degree in Public Health in Developing Countries from the London School of Hygiene and Tropical Medicine, United Kingdom. He is a fellow of the International Program in Public Health Leadership of the Evans School of Public Policy and Governance of the University of Washington, Seattle, USA. He tweets as @IA_Okpani

Discussion3 Comments

  1. PROF.O.A.Moronkola

    A well thought approach than looks like what will work to curb unrest and still make local economic initiatives thrive and health system to respond effectively within the limit of available resources.
    Nigeria should as a matter of urgency consider my submission below:
    Lesson from COVID 19 Pandemic: The Need for Compulsory Teaching of Health Education in Schools and Pride of Place in Primary Health Care
    Health may be perceived as freedom from disease; a necessity of life and as the ability and capacity to carry out daily activities efficiently and effectively and have sufficient energy left to meet emergencies and enjoy our leisure activities. In Nigeria, despite advances in health care there are lots of cases of communicable diseases [e.g meningitis, whooping cough, sexually transmitted infections, cholera, typhoid, skin diseases, whooping cough] , non -communicable diseases[ cancer, diabetes, cardiovascular diseases, dental caries etc] confronting both the poor and the rich .These diseases may be acute i. e sudden and with correct diagnosis and treatment, the person may get back to normal life within a short period of time or chronic which starts slowly and steadily progresses for a long time and are caused by several factors like genetic make-up, nutrition, inactivity, stress confronting the people. Health indicators of varying types of morbidity and mortality rates are terrifying in the country.
    The contemporary impact of COVID 19 pandemic have shown the state of our health facilities and supplies as well as the need to routine personal health practices especially the need for routine effective hand washing which shows the need for Health Education be given a pride of place at all levels of health care delivery and the need for compulsory teaching of Health Education of a school subject. School age children and adolescents constitute a significant proportion of the nation’s population and though they are characterised by buoyancy of energy to move all over the places, they are as group confronted and also at –risk of avoidable lifestyle that are inimical to their current and future health status which calls for the appropriate health education. National and world health statistics about adolescents are staggering as they engage more in health risk behaviours or affected by diseases due to peer pressure, ignorance, mass media, internet and cross-cultural events. The daily lifestyle choices they are making will have significant impact on their health now and later in life resulting in drug addiction, alcoholism, heart and lung diseases, cancer etc.as there is a link between lifestyle and health of the people and chronic diseases increasingly dominate epidemiological pattern more than ever before. The general outlook for the health of Nigerian children and adolescents makes imperative the need for contributions that school health education can make in the improvement in their physical, mental, social-emotional health and general well-being and their education outcomes. Health education as school subject therefore, is also important with respect to addressing the health problems of wider community. This is because what the child learns in schools can be diffused into the community especially among the immediate family members.
    The health of Nigerians across social demographics will be improved not only through increase in medical care but also through a renewed national and institutional commitment to efforts designed to prevent diseases and promote health through health education. At any setting where health education is to take place, the aims of health education should include too ; instill in the individual[s],the need for healthful life for quality living that will ensure high productivity, take care of their personal and community health, change negative attitudes towards health to positive ones, change negative health practices to good ones, use available health services, make people see the need for preventing diseases rather than spending money on treatment and to encourage people to continue with their local ways. This is why Health Education as a component of Primary Health Care must be seriously implemented across all the centres in the country. We need also to appreciate the fact that young people today are sandwiched between culturally approved health behaviour and the influence of globalization on their health related attitude and behaviour and the ill health or damaging behaviour situation of young people has been of great concern to parents, guardians, school authorities, civil societies and various levels of government. The Nigerian Government must not be satisfied with the ‘crisis’ health education provided in many schools by non-governmental organisations. Their programmes typically focuses on current issue for a short period after launching the programmes with fun fare ,and later after a short period, fizzle out. Federal and states governments need to employ health education teachers to teach health education in schools in line with national policy on education .The nation has many health education well trained specialist teachers trained at NCE and degree levels but many are not employed .Apart from teaching health education on various health issues, they will be also be in best position to fast track and ensure sustainability of health education projects being facilitated by government and various NGOs in schools and communities. As stated earlier, health education takes place at different settings including the school which is known as school health education, but when we think of it in term of school offering or subject the it is Health Education.
    School based health education, is the cheapest and most effective approach to improve health of children and that of their parents as schools offer easy and systematic access to health information all over the world. Undoubtedly just like general education, there is impactful positive relationship between children’s health and their social health and educational outcomes and improvement in general family health status. Though medical advances do play great impact on health outcomes, school and community health education prevent and reduces incidence of diseases and other health problems and put less pressure on nations health systems and facilities. Specifically, there is need to teach health education in schools at any period of a nation due to the following reasons; empowers learners to have knowledge, skills, and positive attitudes towards physical, mental, spiritual, emotional and social health, motivates learners to health maintenance, promotion and enhancement of knowledge and skills, that ensures improvement in their health, prevention of disease, and make them avoid risky health related behaviours like tobacco and alcohol use, provides opportunities to learn skills useful in making healthy choices throughout their lifetime e.g communication, assertive and negotiation skills.
    It also promotes learning in other subjects in the sense that when learners are healthy they are at advantage to do better in schools that less healthier ones with the same attributes apart from health status. In many homes and communities in Nigeria, teachers are more current on health matters than parents and are in vantage positions to keep children in pace with current health issues. Also parents nowadays have less time for their children and think schools have all what it takes which make many to erroneously abdicate their roles and which the schools must take as a challenge in the interest of the learners. School children are from diverse backgrounds with either negative or positive health attitudes and behaviour and with sound health teaching in schools, there will be less peer group influence in adoption of negative health attitudes and behaviour as the schools has critical mass of children which needs sound health teaching to prepare them ahead of future life challenges. There are excellent well prepared health education teachers in Nigeria who are willing to meet new challenges and awaiting the clarion call to fill the gap in the deficit of health education teaching in Nigerian schools for the advantage of all. The Nigerian Educational Research and Development Council have Health Education as integrated subject at primary to junior secondary schools but as a separate senior secondary school subject, with appropriate curriculum having the following major thematic areas learners are exposed to; History and Development of Health Education, Human Anatomy and Physiology, Personal Health, Community Health, Environmental Health, Food and Nutrition, Safety Education and First Aid, Drug Alcohol and Tobacco Education, Consumer Health as well Communicable and Non-Communicable Diseases .All the themes are broken down to sub-themes ,units and lessons taught to learners with educational based theories and from preventive approach. The West Africa and Examinational Council and National Examinations Council also have Health Education as an examinable subject.
    Prof. Olawale A. Moronkola JP, Dept. of Health Education, Faculty of Education, University of Ibadan, is a Fellow and Former President of School Health Educators and Professionals Association in Nigeria [Formerly Nigeria School Health Association], Former Dean of Faculty of Education, University of Ibadan. Currently, he is a Member of Nigeria Academy of Education, The Editor In Chief of Nigerian School Health Journal , a Journal of School Health Educators and Professionals Association in Nigeria as well as The Editor In Chief of The Nigerian Journal of Public Health, A Journal of the Society for Public Health Professionals of Nigeria [SPHPN].His 2017 Inaugural Lecture Delivered at University of Ibadan was on ’’School Health Programme in Nigeria: A Jewel in Search of True Love’’.

  2. A very brilliant piece. Concise and pungent strategies distilled out. Good works Dr. Ikedi. More grease to your elbow.

    Please more emphasis should be added on the strategy of Social and Behavioural Change Communication. We at SSA seems to be too religious and superstitious and hard to behaviour change malleability. The Governments of SSA nations should increase energy towards enforcing behaviour change and attitudinal conformity to the globally accepted preventive measures and best practices.

  3. Somiari I. Alex

    This is actually a strategy that’s in between. The very challenging factor of the SSA is leadership and citizen’s wrong behavioral pattern. The procedure for containment and suppression as proposed can be implemented and consequentially effective if the region can over look it’s short comings. Enforcement is key to achieving this template. I hope this template is considered.
    Kudos to the writer.

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