Covid-19 in Zim: A critique

THE uncanny resemblance of the current Covid-19 to the Spanish flu of 1918 is striking. Both were caused by an avian flu virus. Whereas the Spanish flu originated in a military base in Arkansas (located in a swampy area with lots of waterfowl and pigs) in 1918, Covid-19 started in Wuhan, a city in China’s Hubei province (at a wet market where wild mammals, birds and reptiles are slaughtered and sold). For Covid-19, the natural hosts most certainly are bats, transmitted to humans via an intermediary small mammal, most likely the pangolin.

Antony Mutamba

New flu epidemics often arise when people have close contact with sick wild animals. The new disease arises when a pathogen from sick animals jumps species and begins infecting humans. The new virus strains are highly contagious and extremely deadly. The Spanish flu outbreak occurred during the First World War (only called the Spanish flu because it was well studied in Spain, a country which did not participate in the First World War, hence conditions were conducive to studying the virus), in 1918.

What the Spanish flu lacked in terms of rapid transmission, it simply made up for through massive troop movements during the First World War by boat or train.
With Covid-19, it has been through rapid air travel. The mortality of Spanish flu was 2%, but highly infectious; same as Covid-19, which has 2% mortality and is highly contagious.

The Spanish flu infected 500 million people, with 50 to 100 million deaths). To date, Covid-19 has infected more than 1,3 million, with more than 75 000 deaths (As of Tuesday). A slight difference, though, in that the Spanish flu predominantly killed those aged 15 to 45, whereas Covid-19 kills mostly those over 65.
As for the Spanish flu, the worst outbreak probably occurred in Philadelphia and it was made immeasurably worse through mismanagement by leaders who ignored warnings from public health doctors. The city was overwhelmed to the point of using garbage trucks to collect and dump bodies in mass graves.

With Covid-19, in New York City, morgues and funeral parlours have been overwhelmed, with bodies now being buried in temporary mass graves within the city’s parks.

In other jurisdictions afflicted with Covid-19, ice rinks are being converted to makeshift morgues. The only place that escaped the worst of the Spanish flu was San Francisco and historians credit that to aggressive response by the local government who listened to their public health officials.

The public health director, William Hasler, who knew it was only a matter of time, quarantined all naval stations before they had any reported cases, he ordered all public schools and gathering places closed, he divided the cities into separate districts with distinct support staff so as to segregate outbreaks. He laid out plans and organised the flu response before the flu ever hit the city so they would be ready when it did. The government, medical and civic organisations banded together to educate citizens on prevention such as hand washing, avoiding public places and wearing a facemask.

While Philadelphia’s local government was still denying there was a problem, San Francisco authorities were distributing face masks with police enforcing the face mask rule. The last region to be affected by the Spanish flu was sub-Saharan Africa. So terrifying was the disease, it could kill so swiftly. Many victims died within a day of showing their first symptoms.

According to a story recounted in the book The Great Influenza, a man in Cape Town boarded a streetcar just as the conductor died. During the three-mile (4,8 kilometres) ride to his house six more people died and, when the driver died, he got off the streetcar and walked home.

Perfectly healthy people would die within 12 hours of showing the first symptom. It seems this time round the last place to bear the brunt of Covid-19 is going to be sub-Saharan Africa. The Spanish flu came in three waves. So far, Covid-19 is having its second wave in China, albeit not as severe as the first wave, partly on account of herd immunity from the first wave.

To understand the significance of the Spanish flu, one would simply have started by asking whether something similar could happen again. The Spanish flu was devastating for a number of reasons unique to that time. However, the essential formula for a similar pandemic still exists.

Response to pandemics

Viruses sometimes jump species from wild animals to humans; this can happen anytime anywhere in the world. Seasonal flu viruses are constantly mutating and usually mutations are minor, but occasionally big mutations can occur. This has happened a few times in recent history, for instance the Russian flu of 1889 killed about one million people; the Asian flu of 1957 killed about two million and in the Hong Kong flu of 1968 about two million were killed.

Experts say when it comes to the probability of the pandemic flu happening again, it is not a question of if, but when. Quite unlike the predictions of Zimbabwe’s ubiquitous prophets, there is no prophecy worth talking about. Most countries saw the current pandemic coming their way but they were overtaken by events while trying to search for a solution. Most countries have however swiftly put emergency pandemic measures into action with promising results of containment from China, Italy and Spain.

Put simply, the way a nation responds could mean the difference between life or death. So how have most countries responded? The strategy has consisted of a four-pronged attack: containment, delaying, mitigation and research.

Zim’s mitigation measures

Containment requires massive testing, contact tracing and isolation. And Zimbabwe has had such a massive head-start, being one of the countries that have not experienced the brunt of the pandemic yet. That would give Zimbabwe time to plan and execute. Without knowing the number of people involved, no meaningful response can be deduced, either to upscale or downscale measures. And above all, probity in reporting what is at hand is of paramount importance.

The world over, 10 million people have been tested, positive cases number 1,3 million and deaths 75 000. When compared to Zimbabwe, 400 tested, 10 positive and 1 death.

But a simple epidemiological observation renders Zimbabwe’s statistics absurd. For every death from coronavirus, there are 100 infected people. Conversely, by stopping one positive patient from spreading, one protects 99 out of 100 people from getting it. For Zimbabwe to claim there has been one death and 10 positive cases, after testing some 400 or so people, suggests that there is under-reporting of huge magnitude. There is still one testing laboratory in Harare.

Why not decentralise as speedily as possible? Testing kits were donated by Chinese billionaire Jack Ma. Where are those kits? Are they lying in some warehouse somewhere, unopened?

The Health minister, Obadiah Moyo, just a few days ago, announced massive door-to-door testing soon, a frightfully deceitful promise, considering this has not happened anywhere in the world, let alone in Zimbabwe which has one testing laboratory so far. One can only imagine what will happen when testing becomes widely available. The benefit of under-reporting is overpoweringly negative to say the least.

Then comes the issue of contact tracing. The health minister pronounced that 15 000 people who returned to Zimbabwe when South Arica locked its borders would be under surveillance and would be monitored (since the government had the returnees’ passport details); an unashamed falsehood, for there is not the manpower nor the resources for such an undertaking.

With isolation, some are quarantined, and some are not, defeating the purpose of the whole enterprise. Then comes the issue of face masks.

There are two types of masks: the surgical mask and the N95 mask. The surgical mask made of paper or cloth is so porous that it does not protect the wearer, but it protects those around them from their sneezing and coughing, which generates an infective aerosol. In fact, since it has been observed that most super-spreaders of the disease have no symptoms, most jurisdictions are now making it mandatory for everyone to wear masks, of any variety, including home-made, to prevent the wearer from spreading to others, with New York City being one such place.

In order to protect the wearer, one needs the purpose-made N95 mask, which prevents fine particles like viruses from reaching the wearer. The surgical mask comes in one size and has such a poor fit around the face and nose. The N95 mask comes in three sizes and has a tight-fitting contour covering the mouth and the nose (the nose is the most potent route of transmission of air borne viruses). It was cringeworthy observing the health minister tie a surgical mask around the face of the President with his nose exposed — quite inexplicable given that the health minister is purportedly a medical doctor possessing an encyclopaedic number of medical qualifications!

And here is the big deal: The Office of the President is extremely paramount during times of crisis. All must be done to ensure the safety of the incumbent (especially for Zimbabwe where there has been perennial jostling for the post). Could anything happen to him from the coronavirus, one needs to look no further than the United Kingdom, where prime minister Boris Johnson is battling the illness, in spite of the advanced medical infrastructure there.

Delaying and suppressing the epidemic is meant to present healthcare systems from being overrun by patients through social distancing, banning of gatherings, closure of schools, working from home etc. That buys time for systems to continually update and be better positioned to cope.

The health minister told us that food markets would be open with a health inspector and a security personnel to ensure such measures were adhered to, and a cursory observation shows that not to be the case. Hordes of desperate people continue to queue for mealie meal, at the banks, supermarkets etc.

A taskforce was announced to deal with Covid-19 pandemic. There have been many taskforces before comprising largely the same characters with nothing palpable in terms of outcomes, for example the roller meal taskforce. And above all, any taskforce of this current pandemic cannot be complete without a chief medical adviser to enlighten and interpret trends and interventions.

Every country in the world has a chief medical adviser, be it in South Africa, the United Kingdom, China, US, etc. By a chief medical adviser is not implied the minister of health. It is in this great hour of need that the leader of the nation’s presence is especially felt, to calm and reassure a jittery nation that the measures being undertaken are what the nation needs most.

The nation must not only be led but must be seen to be led. US President Donald Trump is holding daily briefings, so is

British premier Boris Johnson (from his hospital bed), prime ministers of Italy and Spain, Angela Merkel (German Chancellor), etc. People have concerns about potential criminality being perpetrated by the country’s security forces that go well beyond the enforcement of quarantine, and the leadership should come out, condemn and encourage people to continue heeding the advice given.

Mitigation involves recruitment of more healthcare personnel, protective kits, and testing of frontline staff, security personnel redeployed to focus on major incidents, helping with logistical support, more ICU beds.

Healthcare personnel on the ground report no availability of the new vacancies promised by the health minister. Frontline health personnel decry the unavailability of protective kits, let alone testing. At the outset of the outbreak, a few weeks ago, the health minister announced that Wilkins Hospital was ready to welcome suspected cases.

There were a few scares, and announcements would be made that the patients tested negative hence did not need the ready facilities of Wilkins Hospital. Until, of course, a real patient came along and died in appalling circumstances (no oxygen, no ventilators, not even electric wall sockets, with the health team’s uncaring attitude in tow, and the patient would not be allowed to leave the facility until he died at Wilkins Hospital). Would it not be dissimilar to selling car insurance on the assumption that no accident would happen, hence no need for the insurance facility to be functional in the first place?

As if mistakes had been learnt, an announcement was made about the conversion of Arundel Hospital and St Anne’s Hospital to receive Covid-19 patients, all actively supported by Ministry of Health officials who wrote letters to facilitate the registration papers. But are these government hospitals? No.

Why not expand on the existing infectious diseases facilities like Beatrice Road Infectious Diseases and Wilkins (which both come directly under the Ministry of Health, not the City of Harare, during epidemics). The answer was to be found within the Twitter handle of the Ministry of Information secretary Nick Mangwana who declared that the people who wanted to open the two new hospitals were in it to make a profit.

Quite morally distasteful, especially coming from someone, a UK-trained nurse by profession, who would readily accept how repugnant such a thought is. Other wealthy countries have injected massive amounts of money to stimulate their economies, a move unlikely to be seen in Zimbabwe, as there is no wherewithal for such means.

Research

Finally comes research into temporising remedies, treatments, and ultimately vaccination. This takes time. Right now, the world over, improvised treatments and remedies are being touted, for example anti-malarial treatments, some anti-virals and some anti-biotics, some plasma treatments etc.

Ultimately, the solution is likely to come by way of returning the virus to its natural habitat in the wild (the only way Ebola has been managed since time immemorial).

It is encouraging that China has permanently shut down wet markets where they sell tortoises, snakes, raccoons, pangolins in cages next to each other, something unheard of in the wild. The rearing and consumption of domestic pets like cats and dogs has been banned.

Exciting as it might be that the state-run Harare Institute of Technology has made a ventilator, it is simply untested. We must think about the sterility of such improvised devices, their fail-safe mechanisms, the back-up should there be malfunction, etc, are all unknown. The current pandemic is particularly severe for those over 65 years of age who are 20 times more likely to die, should they contract the disease.

Conclusion

But what would be the trend in our local population which is demographically different from Europe or America?

Zimbabwe has had a massive head-start, with ample time to prepare, and there is still time to put appropriate measures in place. The focus has to be in containing the pandemic, less so with actual treatments (there is simply not enough personnel, infrastructure and consumables for such). And here is the worst tragedy, as the rest of the world recovers, it is not inconceivable that the whole world shall quarantine Zimbabwe as a nation. If they have not come to Zimbabwe’s rescue in fair weather, it is most unlikely now as they concentrate on their own economic recovery.

Dr Mutamba is a UK-based ophthalmic and oculoplastics surgeon, with a passionate interest in Zimbabwe. He works as a consultant in the UK. His credentials are as follows: BSc Hons (UZ), MBChB Hons (UZ), MSc (Lon), DTM&H (Lon), MRCP (UK), FRCOphth (UK).