‘Anticipatory anxiety’: Africa on the cusp of pandemic

How will African health facilities cope with a flood of people with COVID-19? How can those living close together practise social distancing? Does Ebola offer any lessons?

Kerry mugshot.jpg
Kerry Cullinan
25 March 2020, 10.33am
NHS staff getting ready for Ebola in 2014
Simon Davis/DFID. CC BY 3.0. Some rights reserved.

There is a sense that Africans are on the shore watching the sea draw back before the tsunami of COVID-19 infections hits, overwhelming the continent’s health facilities and killing thousands of people.

In late February, a handful of African countries had recorded a few COVID-19 cases. Egypt, Algeria and South Africa, with their high volume of air traffic from affected regions beyond the continent, were hit first.

But this week, the virus was in 43 of the 54 African countries, according to the World Health Organization (WHO). Tedros Adhanom Ghebreyesus, the body’s director general, has warned the continent to “prepare for the worst”.

Tedros Adhanom Ghebreyesus, Director-General, World Health Organisation (WHO) speaks at a press conference at the UN Office in Geneva, Palais des Nations. 18 May 2018
Stark warning from Tedros Adhanom Ghebreyesus
Elma Okic/ UN Photos. CC BY-NC-ND 2.0. Some rights reserved.

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Most of those countries did not impose travel bans from high risk regions when the threat of COVID-19 became evident, mistakenly believing that screening travellers for fever and asking those from high-risk countries to self-quarantine would be enough.

Uganda alone took a hardline approach early on, insisting on a fourteen-day quarantine for international travellers from high-risk areas. That didn’t spare the country: this week it recorded its first cases, and they originated from a flight from Dubai – not on Uganda’s high-risk list. Containing the virus by policing travellers is not easy.

As elsewhere, African countries have been struggling to reconcile measures to arrest the virus, such as travel bans, social distancing and restricting public gatherings, with the need to protect their economies. In Africa, the weakness of those economies creates extra difficulty.

In spite of this, South Africa, which has the most cases on the continent, this week announced a 21-day total lockdown. Its number of cases have jumped from one to 709 in just twenty four days.

"Those countries that have acted swiftly and dramatically have been far more effective in controlling the spread of the disease," said the country’s president, Cyril Ramaphosa.

“While this measure will have a considerable impact on people’s livelihoods, on the life of our society and on our economy, the human cost of delaying this action would be far, far greater.”

Ramaphosa’s announcement comes amid growing consensus that China’s policy of lockdown and has proved the most effective way to reverse the pandemic.

The South African National Defence Force is on standby to enforce the lockdown from midnight on 26 March. With few safety nets for the millions of people who depend on the informal economy, there is no way of knowing whether citizens will abide by the lockdown rules.

What the continent needs

Meanwhile, epidemics experts are urging governments to do whatever they can to protect the continent’s thin line of health workers. They urgently need personal protective equipment such as masks, gloves and hand sanitiser.

“But other measures are very important, such as ventilation, spacing, early triage and separation of potential cases and increased access to water and supplies,” says Amanda McClelland, senior vice-president of the public health body Prevent Epidemics, who has fought a range of epidemics while working in the emergency health unit of the International Federation of Red Cross and Red Crescent Societies.

Amanda McClelland of Prevent Epidemics
A lot of unknowns, says Amanda McClelland
Prevent Epidemics. All rights reserved.

Gilles Van Cutsem, an infectious disease doctor and epidemiologist with Médicins sans Frontières (MSF), stresses that “there needs to be planning and preparation for screening and triage at health facilities to avoid overcrowding and saturation of hospitals, and ensure that hospitals do not become foci of transmission.

“In Italy and China triage tents were set up outside hospitals to receive and separate patients,” adds Van Cutsem.

HIV clinician Francois Venter adds that those who are “mildly symptomatic” need to stay away from health facilities to make sure that there is space for the very sick.

Speaking on his first day out after fourteen days in quarantine, Venter says he has “anticipatory anxiety” as he waits for the deluge of patients.

“I was almost disappointed that my [COVID-19] test was negative. For the first time in my life, I understand emotionally the relief that some of my gay clients expressed when they finally tested positive for HIV,” says Venter, the deputy executive director of the Wits Reproductive Health and HIV Initiative in Johannesburg.

Least prepared

Ebola, Lassa fever, yellow fever: a range of infectious disease outbreaks constantly besieges African countries. Yet the continent is the least prepared for epidemics, scoring an average of 39 out of 100 in comparison to the global average of 54 on a scale devised by Prevent Epidemics.

McClelland recently returned from Ethiopia, Africa’s second most populous African country, and has few illusions about the massive tasks that lie ahead: “There is still much more to do in Ethiopia to test and detect cases. The extent of transmission in this country with 105 million people is not really known.”

The Ethiopian government has acted fast in response to the threat. Within a week of recording its first case, the country closed schools, banned large public events and made buses available to transport civil servants to work. Currently, people returning to the country have to undergo a fourteen-day quarantine in a hotel at their own expense.

But there are two major challenges: preparing and training health workers – Ethiopia has only 19,000 – and engaging communities to change their personal behaviour to limit the spread.

Sobering new global data from Imperial College London predicts that 250 critical care beds will be needed per 100,000 people if non-pharmaceutical interventions such as social distancing and restricting gatherings fail.

Even US experts have revised their figures and believe their country will need ten times more ICU beds and ventilators than it currently has.

Ebola lessons

While trying to contain Ebola, Guinea introduced a form of community quarantine called ‘micro-cerclage’ (micro-encirclement) to limit the movement of people in Ebola-affected areas.

Those showing symptoms of Ebola were placed in isolation while those close to them were asked to limit their movements. Limited essential movement – such as attending to crops – was allowed, often implemented by teams monitoring people’s mobile phones with their consent.

Community leaders’ support for the policy was key, and local response teams enforced the monitoring. Affected households also received with food and basic toiletries.

“Microcerclage is one approach that will potentially add real value to addressing COVID-19 but this will depend on the scale of community transmission,” says McClelland. “If clusters can be detected early and isolated then this approach could help communities to not be negatively impacted and to continue to have access to key services and resources including food and water.”

A huge challenge is how to quarantine city dwellers. Over 20 million people live in crowded conditions in Lagos, 5 million live in Johannesburg and 3 million in Addis Ababa.

The experience of Ebola may help here, too. “Early and clear communication of what services are being limited, monitoring the negative impact, and implementing community-wide interventions such as handwashing and social distancing – non-pharmaceutical interventions – are lessons from Ebola that will serve this response well,” said McClelland.

“But we may see self-isolation and restriction of population movement on a much larger scale in some cities,” she says. “This would stretch the resources to be able to provide food, water and services on a citywide scale.”

Jean-Jacques Muyembe, general director of the National Institute of Biomedical Research (INRB) in the Democratic Republic of the Congo (DRC), says Ebola taught his country to “put in place systems to screen travellers and promote handwashing, and these measures are the same needed to fight against coronavirus”.

Many Ebola-affected countries have also increased their medical laboratory capacity, and Nigeria in particular has made substantial improvements in combating epidemics in the past few years. But Van Cutsem warns that the laboratory capacity of most African countries aside from South Africa is “extremely poor”.

“Countries have to find ways to improve the capacity of their laboratories to process tests, and we need the introduction of rapid tests,” he says.

Senegal is partnering with a British biotech firm to develop and produce rapid tests but production is only expected to start in June.

Ebola had some less positive lessons, too. During the crisis, not only patients but health workers too were stigmatised. MSF recorded more than 300 attacks on Ebola health workers in 2019 in the DRC alone, during which six people were killed and seventy wounded. In Ethiopia, foreigners assumed to be infected with COVID-19 are already at risk from a similar response. On 18 March, the US embassy in the country issued a security alert warning of “a rise in anti-foreigner sentiment revolving around the announcement of COVID-19.

“Incidents of harassment and assault directly related to COVID-19 have been reported by other foreigners living within Addis Ababa and other cities throughout the country,” the embassy reported. “Reports indicate that foreigners have been attacked with stones, denied transportation services, being spat on, chased on foot, and been accused of being infected with COVID-19.”

“Without community engagement and trust, the outcomes can be devastating,” warns McClelland. “In the Ebola response, this tragically included violence against first responders [trained personnel who assist during emergencies such as paramedics]. We must do everything we can to avoid this in the response to COVID-19.”

How long will it last?

While some African leaders have speculated that the virus may not survive in high temperatures, McClelland simply says: “The short answer is we do not know yet. The science is still not clear. There is some evidence that, in a laboratory, the virus may be affected by warmer temperatures. But we also have transmission occurring in warm climates like Australia, the Middle East and South-East Asia.

“Influenza transmits all year round in much of Africa and can actually be worse in dusty conditions. It is too early to assume Africa is protected due to heat and they must prepare with the same sense of urgency as other countries.”

Hopes that the pandemic may be short-lived are not shared by experts who quietly talk about the current conditions continuing for a year or more.

“Settle down to this. Social isolation might be the new normal for the rest of the year. Look after your mental health, check in with people and be kind,” advises Venter.

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