We lost the COVID-19 plot, but we can still get it right

By Ndung’u Wainaina

Covid-19 has grave implications for the entire world. Kenya, as with many others, has been adversely impacted by a catastrophic ‘double burden’: a health and economic crisis.

Clinical, epidemiological, and laboratory knowledge for the control of the coronavirus indicate that humankind will have to “live with the virus”, and operational strategies rapidly need to recalibrate from containment to mitigation. Emerging evidence indicates that the pandemic has worsened existing health inequities, and public health measures need to make that concern central.

Although the global community is collaborating and sharing information on COVID-19, it is the sole responsibility of individual governments to formulate a comprehensive, effective, efficient, and sustainable strategy plan of action to control this pandemic. For starters, there should be open and transparent data sharing among scientists, public health professionals, and the public at large, something that has been conspicuously absent in Kenya to date. Information-sharing will strengthen pandemic control measures, build bottom-up consensus, and build an ecosystem of engagement and trust.

Kenya’s“lockdown” has been one of the most stringent and yet COVID-19 cases have continued to increase exponentially through this phase. The draconian lockdown was presumably in response to a modelling exercise from an influential institution with a ‘worst-case simulation’. The model came up with an estimated 2.2 million deaths globally. Subsequent events have proved that the predictions of this model were way off the mark.

It is evident that had the Kenya government held limited consultations with epidemiologists, who have a better grasp of disease’s transmission dynamics compared to modellers, we would have better contained the pandemic. From the limited information available in the public domain, it seems that the government was primarily advised by clinicians and academic epidemiologists with limited field training and skills. Policymakers relied overwhelmingly on general administrative and security bureaucrats. Engagement with experts in the areas of epidemiology, public health, preventive medicine, and social scientists was severely limited or almost nonexistent.  

Kenya is paying a heavy price both in terms of socio-economic fortunes and the virus’ spread. The incoherent and often rapidly shifting strategies and poorly communicated policies at the national level are a reflection of “afterthought” and “catching up” phenomenon on part of the policymakers; there didn’t seem to be a cogent strategy, well-thought out strategy with an epidemiologic basis. So far the country does not seem to have any well-planned effective monitoring and assessment of the virus spread in rural areas.

Most infected persons are asymptomatic. Even when symptoms show, they are usually mild and not life-threatening. The majority of the patients do not require hospitalization and can be treated at the domiciliary level with modified “enforced physical distancing” imposed on the household.

It is unrealistic to expect that the COVID-19 pandemic can be eliminated at this stage given that community transmission is already well-established across large sections or sub-populations in the country. No vaccine or effective treatment is currently available or seems to be available in near future, even with a few promising candidates. The expected benefit of this stringent nationwide lockdown was to spread out the disease over an extended period and effectively plan and manage so that the healthcare delivery system is not overwhelmed. This seems to have been achieved albeit with extraordinary inconvenience and disruption of the economy and life of the general public.

The case fatality rate in Kenya has been relatively on the lower side and is mostly limited to the high-risk groups (those with pre-existing co-morbidities and so on).

However, the lockdown cannot be enforced indefinitely as the mortality attributable to the lockdown itself (primarily because of the total shutdown of routine health services and livelihood disruption of nearly the entire bottom half of the Kenyan population) may overtake lives saved due to lockdown mediated slowing of Covid-19 progression.

The national government has made just about every possible mistake in tackling COVID-19. After mismanaging the COVID-19 response and to avoid blame and accountability, it has strategically shifted the problem of containment and management to the ill-prepared and underfunded county governments.

The National Government ignored the enormity of the COVID-19 threat despite having the advantage of prior information about the pandemic. It paid little attention to the level of preparedness and response required in situations for when the virus hit. Meanwhile, the Presidency preoccupied itself with political health.

Shift focus to the counties

The National Government failed to set up a joint coordination and response platform with County Governments (health being devolved), leave alone having a national COVID-19 preparedness and response strategy with clear set goals and objectives. It even threatened the counties by declaring that anything COVID-19 related would be coordinated and reported from Nairobi. It failed to set up and acquire the testing and tracing systems needed to control the virus. It failed to support the strengthening of hospitals and equipping of health workers to counter the pandemic. The failure was political. Our leadership has not been open or transparent. There were never attempts at citizen participation and public health education. County governments, which have the advantage of being closer to the people, were reduced into mere spectators.

There was no national testing and tracing strategy. We needed to carry out random testing or, to use an epidemiological term, sentinel surveillance — looking at all geographical areas and different population groups, and not just the so-called high-risk ones. Random (but systematic) testing is not mass testing. The government does not need to test all 50 million Kenyans, but we needed to have representative geographical distribution so we could have early detection and know the spread progression of the virus.

This moment to shift our focus to managing and suppressing COVID-19 to the counties as community transmission has come. Abundant scientific and evidence-based interventions are available to control the pandemic at County levels in Kenya. These measures should be implemented while at the same time ensuring optimal provisions for the livelihood of the poor and marginalized. Simultaneously, the provision of health care for all, especially children and women and those suffering from chronic conditions and emergencies requiring medical attention, is an urgent imperative.
Each county should constitute a special task force of interdisciplinary public health and preventive health experts and social scientists to address both public health and socio-economic crisis at the county level.

There has to be increased transparent collection, collation, and free sharing of data in the public domain. All data, including test results, should be made available in the public domain for the clinical, laboratory, public health (and social sciences) experts to access, analyze, and provide real-time context-specific solutions to control the pandemic in the county. The opaqueness maintained by the Government in the context of data so far has been a serious impediment to independent research and appropriate response to the pandemic.

We must move away from one size-fit-all blanket lockdowns and replace them with county-based cluster restrictions. So saying, the prevailing nationwide lockdown should have been long replaced with cluster specified restrictions based on epidemiological data assessment. What is more, reasonable criteria and milestones for control of the current phase of the pandemic in the country should be set, taking into account that successive waves of cases is possible. The raison d’etre of the lockdown is health system preparedness; the government needs to come out with clear monitorable benchmarks to this effect.

Further, we must resume all the routine health services. It is of utmost importance that all routine health services at all levels of (primary, secondary, and tertiary) care be immediately re-started with due measures to ensure the protection of health care workers. Ample evidence has emerged that the human cost of disruption of routine health services especially for terminally ill patients, those with life-threatening catastrophic health events and preventable measures like immunization have far outweighed the deaths due to COVID-19. The cost of the disruption of health services may even be higher in days to come.

Sentinel and active surveillance

We need source reduction measures through increased public awareness and practice of preventive measures. The most effective strategy for control of coronavirus spread during all stages of transmission is the source reduction strategy. The universal use of face masks is part of this strategy. Hand hygiene and cough etiquette are equally important and must be encouraged, with special focus to high-risk populations.

Along with physical distancing, we must collectively avoid social stigma. Physical distancing norms do slow down the spread of infection. At the same time, enhanced social bonding measures need to be promoted to address mental health concerns of anxiety and lockdown. Stigma can also occur after a person has been released from COVID-19 quarantine. The government, media, and civil society need to be proactive by making people aware and treating them with empathy and respect.

It is important to conduct extensive surveillance for COVID-19 and related influenza-like illnesses through accredited social health workers and nurses, and severe acute respiratory illness through clinical institutions, including private hospitals, as well as daily data reporting to identify geographic and temporal clustering of cases to trace transmission hot spots/cluster events. The use of already existing serological surveillance platforms like HIV could be a cost-effective way to do serological surveillance and also provide an estimate of the burden and trend and impact of other preventive strategies.

Kenya has had significantly low testing rates. Benchmarks based on population norms are essential to keep this key pandemic countermeasure on track. It is crucial to have accelerated capacity enhancement of the counties in this area. The government needs to support free testing in private laboratories as well. As the number of (potential) contacts and the movement of the population continue to increase rapidly across the country, we must work to support home quarantine, with active participation and support from frontline health workers and local communities.

Health workers must be provided with appropriate personal protection equipment (PPE), to instill confidence and alternate teams identified to take care of attrition due to fatigue, exposure, and quarantine. Commendably, the country has now enhanced capacity to produce quality PPEs and should continue to ramp up production.

The historic and systematic neglect of public health as a discipline and non-involvement of public health experts in policy making and strategy formulation has cost the nation enormously especially in the current pandemic. We must commit to conducting a rapid scaling up of public health including medical care – both services and research – and significantly increase health expenditure at the county level.

— Writer is the Executive Director International Centre for Policy and Conflict