A Doctor’s Thoughts on COVID-19

A Doctor’s Thoughts on COVID-19

Standard Coronavirus guidelines are difficult to implement in developing nations. Innovative solutions that can be applied locally are required for the world to end this pandemic

Dr Joyce Samoutou-Wong

I am a missionary doctor from Hong Kong and Britain serving in the Republic of Congo (‘Congo’). I grieve with the world as I watch the devastation caused by COVID-19. Our country now has 45 confirmed cases and who knows how many untested ones. My heart is heavy for Africa as I hear the time bomb ticking. While I wholeheartedly believe that God hears our prayers, math and science advise me that the transmission and mortality rates in Africa are bound to be much higher; and that the poorest of the poor will be hit the hardest by the economy free-fall. If developed countries are not coping, what will it be like for communities like ours? It is as if we are watching developed nations all around us struggle in their advanced four-wheel drives, knowing that we are following them in the same track heading towards the same terrifying exponential curve, and wondering how our old rusty cars that failed annual tests can miraculously make a swerve to avoid unrecoverable loss and death. Last month, Monseigneur Yves Monot, the Archbishop of the department of La Sangha, asked me, ‘As a doctor, what do you see for our community in the coming months and year?’ No longer able to hold back the tears, I replied,
‘Suffering … I see unimaginable suffering.’

I hesitated to write this article for two reasons. Firstly, for the past several weeks, our team has been working non-stop to help our community prepare. Secondly, right now, everyone in the world has problems and so it does not seem appropriate for charities like ours to speak up. This morning, however, I sat myself down to write this in the desperate hope that this will help us raise awareness and connect with others who can brainstorm and share creative solutions to tackle the additional challenges that communities like ours all over the world are facing. These problems normally require decades of development work, but time is not on our side. If the world ignores the problems in developing nations, no matter how much gain developed nations make in their own corners, we will never win the war against COVID-19. This is a pandemic and it can only end when every single nation in this world succeeds in controlling this virus.

Preventive / Containment Challenges for Communities in Developing Countries

Working with the local authorities, we are trying to advocate known preventive measures. However, we are sometimes embarrassed to ask people to adopt these practises because it is like asking them to do the impossible. When people are taught what they need to do but they cannot do them, they become even more anxious.

• ‘Wash your hands frequently with soap’: For many in our community, access to running water and basic sanitation is difficult. Worldwide, according to UNICEF, nearly three quarters of the people in least developed countries lack basic handwashing facilities at home.¹ When households need more water, the crowds at the water pump will grow. The pump handle is a hot spot for transmission of the virus. Many do not have money to buy extra buckets to store water or buy soap. Paper towels may not be available at all.

• ‘Social distancing / work from home / try stay home as much as possible’: More than 80 per cent of adult Africans work in the informal sector (‘petty traders, self-employed artisans or tillers of the soil’).² Not going out to work, even if just for a day, can mean no food for the family. Families must at least go out to fetch water and they now need more water than before. It is a case of risking infection versus starvation.

• ‘Self-isolation / quarantine to protect your family and community’: Crowded housing, shared beds or floors, as well as shared towels and dining utensils make this very difficult. They cannot bulk buy and store up on supplies because they can only just about afford what is needed for the day. There are no food or grocery deliveries. The borders are shut. Food and supplies are getting more limited and they are already going up in prices, making them even more unaffordable.

• ‘Call this phone number if you fall ill’: You cannot call if you do not have money to buy phone credit, if you cannot charge your phone because electricity is cut, or if the phone network is down again.

• ‘Disinfect surfaces and try keep as clean as possible’: What if you cannot afford disinfecting supplies and you only have one set of clothes?

• ‘Boost your immunity’: Difficult to do when you suffer from underlying malnutrition. According to the charity Action Against Hunger, sub-Saharan Africa has 239.1 million people who are undernourished in 2018,³ and now country-wide lockdowns have stopped them from going to work.

• ‘Use education packs at home / online schooling / home-schooling’: No photocopiers / no internet / no computers / no books / no stationery.

• ‘Try do as much as you can online, get educated and keep up to date with information, especially when fake news and false beliefs are rampant’: Our community relies on word of mouth. Schools and churches, our principal platform for communication, are already shut. Many do not have access to TV, radio, or internet.

In a nutshell, without supplementary measures, we are in essence asking our community to give up their livelihood to stay in crowded housing and to do without water, food, soap and necessities of daily living. While it goes without saying that it is very hard for the world to adapt to a ‘new normal’, it is far worse for communities like ours. Without any creative solutions, the only kind of ‘new normal’ that is an option for our community is unsustainable.

Outlook for the ill

If medical facilities are overwhelmed in countries with first-class health systems, how much worse will it be for developing countries? While Africa carries 23% of the world’s disease burden, it contains only 1% of its financial resources for healthcare and only 3% of its healthcare workforce.⁴ The global shortages in ventilators and intensive care unit (ICU) beds are even more severe in Africa.

Table 1. Number of Ventilators per Million Population ^{5, 6, 7}

Table 2. Number of ICU beds per Million Population ^{8, 9, 10}

While published data is limited, we know that for many countries as in Table 1, the average number of ventilators is 1 or less per million population. As for ICU capacity (Table 2), in Uganda, there is only 1 ICU bed per 1 million people.¹¹ To put this into perspective, the number of ICU beds per million population is 347 in USA and 292 in Germany.¹² As of 2015, the African Region had an average of 1.30 health workers per 1000 population, far below the 4.5 per 1000 required for the United Nations Sustainable Development Goals.¹³ That means we only have 1/3 of the health workers needed – and that is before the new workload that will come with COVID-19. Again, to put this into perspective, the countries from the Organization for Economic Co-operation and Development have almost twenty times the number of health workers at 24.8 per 1000 population.¹⁴ Nowhere is this deficit of human resources for healthcare more severe than in Sub-Saharan Africa.

In developed countries, 20-30% of those infected with COVID-19 become seriously ill. In developing countries, many of these cases will likely die. Moreover, as the health system collapses, the mortality rate for those suffering from other illnesses will also increase. Imagine a disease ferociously devouring a country, killing 2-3 out of every 10 infected persons! Actually – it is unimaginable.

Outlook for African communities

While the economy is hit globally, the World Bank’s President David Malpass made in a statement on 27 March 2020 that ‘poorer countries will take the hardest hit, especially ones that were already heavily indebted before the crisis’.¹⁵ Economic Commission for Africa estimated that Africa as a continent may lose half of its GDP while having to stomach around an additional USD10.6 billion in unanticipated increases in health spending to curtail the virus from spreading.¹⁶ On the job front, the United Nations Development Programme (UNDP) warned that nearly half of all jobs in Africa could be lost, with income losses expected to exceed USD220 billion. The UNDP went on to say that,’ without support from the international community, we risk a massive reversal of gains made over the last two decades, and an entire generation lost, if not in lives then in rights, opportunities and dignity.’^{17, 18}

Arguments for or against African governments to enact lockdowns are equally powerful because the financial and human costs could be too high to bear. Imperial College’s COVID-19 response team estimates that nearly 2.5 million Africans will die if nothing is done as mitigation, ‘But with enforced social distancing,’ i.e. lockdowns, ‘even with Africa’s limited medical resources – fatalities could be cut to 298,000.’¹⁹

Can anything be done?

During a lesson, I asked my nursing students what they could do to help with the situation. They told me that they did not have any financial means. This is an answer I hear a lot of whenever I ask the locals if we can try something – for example, if we want to call a meeting to discuss Coronavirus preparation, the chiefs of the ‘quartiers’ will ask for payment beyond travel expenses just to come. The students and I had a wonderful time discussing the exponential power of health promotion and how we can all play a part. Right then, they made up a song from what we learned, about what everyone can do to prevent the spread of Coronavirus: wave hello but don’t shake hands; wash your hands regularly; sneeze and cough in your elbow; and stay at home if you are unwell. They then mobilised other youth and recorded the song together. They have thoughtfully integrated different genres of music that will appeal to different demographics of our society. The song is being powerfully used on the radio and in the community. More importantly, these youths have been empowered. What we can do may be small, but it cannot stop us from doing what we can. We can all do something.

Indeed, despite the overwhelming challenges, we are thankful that before the national lockdown started, we were able to distribute over 12,000 printed leaflets and posters, held seminars, utilised social media for health promotion and recorded several interviews in local dialects that are being broadcasted in Congo and even other African countries. Africa is a society that thrives on stories and music. This is why in addition to our students’ original song, our children have written a radio play about COVID-19 to be recorded and broadcast, and about to be translated into different dialects. Our message has concentrated on dispelling myths and encouraging the community to focus on what they can do, rather than what they cannot do. While communities like ours wait for much-needed funding, resources and solutions, it is heartening to see portable handwashing systems being installed all over our town, to hear our students’ song being played and sung on the streets, and to see fear and worry giving way to knowledge through health education. We cannot follow all the standard guidelines right now, but we are trying our best to do what we can and to forge ways that can work locally. We cannot physically hold onto each other right now, but here in a corner of Africa, we are holding tightly onto hope as a community.

1. UNICEF. Handwashing with soap, critical in the fight against coronavirus, is ‘out of reach’ for billions. Fact Sheet; 2020 Mar 13 (cited Mar 30). Available from: https://www.unicef.org/press-releases/fact-sheet-handwashing-soap-critical-fight-against-coronavirus-out-reach-billions
2. Blomfield, Adrian and Peta Thornycroft. From denial to brutal lockdown: How Africa’s response to ‘rich man’s’ disease has evolved. The Telegraph; 2020 Apr 6 (cited 2020 Apr 9). Available from: https://www.telegraph.co.uk/global-health/science-and-disease/denial-brutal-lockdown-africas-response-rich-mans-disease-has/
3. Food and Agriculture Organization of the United Nations. State of Food Security and Nutrition in the World 2018. 2018 (cited 2020 Apr 9). Available from: http://www.fao.org/state-of-food-security-nutrition/2018/en. Cited in Action Against Hunger. Hunger Relief in Africa. https://www.actionagainsthunger.org/africa-hunger-relief-facts-charity-aid
4. Anyangwe, Stella C. E., and Chipayeni Mtonga. Inequities in the Global Health Workforce: The Greatest Impediment to Health in Sub-Saharan Africa. International Journal of Environmental Research and Public Health 4 (2): 93–100; 2007.
5. Petesch, Carley. Africa, Latin America Fragile Targets for Coronavirus Spread. Associated Press; 2020 Mar 20 (cited 2020 Mar 30). Available from: https://apnews.com/ced207f8898aff3044fa6f69672db959
6. Financial Times. African health officials warn of chronic medical shortages. 2020 Apr 8 (cited 2020 Apr 9). Available from: https://www.ft.com/content/72ed316a-32fb-4ae2-aa91-8885e8bbc1d0
7. International Rescue Committee. 5 Crisis Zones Threatened by Coronavirus Double Emergency. 2020 Apr 9 (cited 2020 Apr 9). Available from: https://www.rescue.org/article/5-crisis-zones-threatened-coronavirus-double-emergency
8. Ibid.
9. Murthy, Srinivas, Aleksandra Leligdowicz, and Neill K. J. Adhikari. Intensive Care Unit Capacity in Low-Income Countries: A Systematic Review. PLoS One. 2015; 10(1): e0116949; 2020 (cited 2020 Mar 30) . Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4305307/
10. McCarthy, Niall. The Countries With The Most Critical Care Beds Per Capita. Statista.com; 2020 Mar 12 (cited 2020 Mar 30). Available from: https://www.statista.com/chart/21105/number-of-critical-care-beds-per-100000-inhabitants/ (PDF version)
11. Murthy et al. Ibid.
12. McCarthy. Ibid.
13. WHO Africa. What needs to be done to solve the shortage of health workers in the African Region. 2017 Aug 24. Available from: https://www.afro.who.int/news/what-needs-be-done-solve-shortage-health-workers-african-region
14. Naicker S, Plange-Rhule J, Tutt RC, Eastwood JB. Shortage of healthcare workers in developing countries–Africa. Ethnicity & disease. 2009;19(1 Suppl 1):S1-60-4 (cited 2020 Mar 30). Downloaded from: https://ukdiss.com/examples/health-worker-shortage-sub-saharan-africa.php (Naicker Eastwood – Shortage of Healthcare Workers in Developing Countries-Africa)
15. World Bank. World Bank Group President David Malpass: Remarks to the International Monetary and Financial Committee. 2020 March 27 (cited 2020 Apr 2). Available from: https://www.worldbank.org/en/news/statement/2020/03/27/world-bank-group-president-david-malpass-remarks-to-the-international-monetary-and-financial-committee
16. Economic Commission for Africa. 13 March 2020. ECA estimates billions worth of losses in Africa due to COVID-19 impact. 2020 Mar 13 (cited 2020 Apr 2). Available from: https://www.uneca.org/stories/eca-estimates-billions-worth-losses-africa-due-covid-19-impact
17. United Nations Development Programme. COVID-19: Looming crisis in developing countries threatens to devastate economies and ramp up inequality. 2020 Mar 30 (cited 2020 Apr 2). Available from: https://www.undp.org/content/undp/en/home/news-centre/news/2020/COVID19_Crisis_in_developing_countries_threatens_devastate_economies.html
18. Suleymanova, Radmilla. Al Jazeera. Developing countries face economic collapse in COVID-19 fight: UN. 2020 March 30 (cited 2020 Apr 2). Available from: https://www.aljazeera.com/ajimpact/developing-countries-face-economic-collapse-covid-19-fight-200330003332689.html
19. Blomfield. Ibid.