Health professionals should take the lead in promoting the resumption of the regular health services by taking the standard precautionary measures at all instances
Is it the direct or the indirect damage of COVID-19 what Africa may not withstand?
Five solid months passed since COVID-19 has started shaking the world. The very complex and bizarre disease manifestation inside the human body and the fast spreading nature of this pandemic is what makes it difficult and exceptional from previous pandemics. In this short period of time, it is not debatable that it has resulted in an easily irretrievable economic, social and health crisis globally. In the author’s opinion, by any measurable standard, the indirect damage incurred COVID-19 outweigh the direct detrimental health consequences.
It is obvious that COVID-19 has disrupted the global health, but the indirect damage may be more pronounced in Africa, where the Sub Saharan region of the continent, in particular, embraces many deadlier outbreaks and endemic communicable diseases. Among others, the disrupted and suspended regular health services in many African countries over the last four to five months are likely to inflate the backlog of patients waiting for hospitalization, deteriorate a large bunch of curable diseases, and widen the foundation for communicable diseases in the vulnerable communities.
When one sees the direct damage caused by COVID-19 in Africa, he/she may question about the indirect health damage. Contrary to the previous predictions, Africa is not yet among the COVID-19 hard-hit regions; all the 55 countries have contributed to 2.5% of the total tested positive, 1.2% of the total deaths, with a recovery proportion of 44%, which is close to the world average (48%). The slow increment in many African countries has enabled them to have a comparative advantage of balancing new infections with recovery. As the slow increment is likely to stay longer, balancing our focus to COVID-19 and other health matters is in the interest of this article.
As learnt from accessible literature and media, a lot of coverage and due attention has been given to the impact of COVID-19 on national and global economy, agriculture, human resource, education, and social interaction. However, there is a paucity of data addressing the impact of COVID-19 on regular health services. I feel that this is the right time to investigate it and recommend workable strategies before the indirect damage reaches an irreversible stage.
Therefore, the focus of the current article is principally contextualizing the impact of COVID-19 on other health services (prevention, promotion and treatment programs), at least to bring the context into the attention of researchers, programmers and policy makers.
The world health organization (WHO) in a three-week period of survey in May 2020 by involving 155 countries has revealed that more than 53% of services for hypertension, 49% for diabetes, 42% for cancer and 31% for cardiovascular emergency treatment have been disrupted because of the COVID-19 pandemic. Furthermore, 94% of the ministry of health staff working in the area of non-communicable diseases was partially or fully reassigned to support COVID-19 activities. WHO has also disclosed that 68 countries have suspended the vaccination program, as advised by the same organization to limit the spread of the current pandemic. As a result, millions of children are at higher risk of morbidity and mortality due to vaccine preventable diseases.
There is also a large body of anecdotal reports stating that worldwide, many of the primary health care and curative services at different levels of the health system have been partially or completely discontinued. In India, as high as 50% of patients on chronic care keep on missing clinic attendances. In Ethiopia too, in some big hospitals, more than 80% of patients called for an elective operation failed to report. In places where telemedicine is not yet established (in low income countries, in particular), the disconnection between the health service providers and the beneficiary population is fueling the already jeopardized health services for the needy.
Unfortunately, and exceptionally, many of the non-communicable diseases could not allow individuals to buy more time, like the majority of the communicable diseases. For instance, cancer patients may advance from operable stage to nonoperable stage; remission with radiotherapy and chemotherapy becomes impossible as the days and weeks passed since the time of detection. The same is true for poorly controlled hypertensive diseases, diabetes mellitus, chronic kidney failure, and cardiac/ heart emergencies.
It was also well noted from previous epidemics, pandemics, civil wars, internal displacements and refugees, how much the basic health services had suffered until the outbreaks and unrests were under control and systems reestablished. Currently, caseby-case global deaths due to COVID-19 are under scrutiny.
However, nobody knows how much COVID-19 has indirectly resulted in more deaths from other illnesses in low income countries, where the registration of vital statistics is not yet in their health information management system. In such set up, similar impacts are usually statistically substantiated after the active epidemic/pandemic is over. Of note, governments usually overlook the other health issues when an outbreak engulfs their available human, material and financial resources.
In the current pandemic, in particular, one can estimate the increased risk of severity and mortality due to other illnesses by taking into account the implemented barriers and anticipated fears across Africa: the impact of lockdown, transportation shutdown, repurposing health facilities and commodities for COVID-19, patient’s frustration to visit health facilities, provider’s concern about contracting the virus, and the preoccupied health system with COVID-19 containment and mitigation activities.
It is also worth making a comparison of the COVID-19 related mortality with other causes to have a better view of the impact of this pandemic in other public health problems as discussed below. The comparison is from a credible source. I hope it gives a very good insight to what is going on and what is going to happen if the disconnection is further extended.
How significantly COVID-19 contributes to the global mortality?
The magnitude of direct and indirect mortality COVID-19 impacted will be determined as the fiscal year ends. Till then, comparing the global deaths attributed to COVID-19 with the gross estimate of the near midyear deaths due to some other common causes is assumed as enabling data to better predict the future.
According to the United Nations 2020 estimate, the global annual births, deaths and net population growth are approximately 140 million, 60 million and 80 million, respectively. The UN annual estimate for the second most populous African country (Ethiopia) is 3.6 million births, 768k deaths (more than 2k per day) and 2.9 million net population growth; the yearly Ethiopian population change in percent is almost equivalent to the African Average (2.57% vs 2.54%).
By citing the Global Burden of Diseases (WHO and Institute for Health Metrics and Evaluation) as a data source, the Worldometer daily estimates the global deaths due to selected or lead causes.
Therefore, the current estimate is based on the global metadata; the causes of deaths in this physical year and previous years, and the mitigation interventions on the ground are taken into account.
Because of COVID-19, many of the disease prevention programs are disrupted or suspended in many African countries. As a result, here and there, there are small scale malaria, measles, yellow fever and Ebola outbreaks, which all are likely to be taken into consideration for the current estimation. In Africa, in the months to come, the most feared are large vaccine preventable, waterborne and vector borne infectious disease outbreaks.
To make it a proxy estimate of mortality between COVID-19 and other causes, the author is interested in making horizontal comparison of these deaths with the already passed COVID-19 pandemic period (January to May 2020). This period is selected as it aligns with the official timeline of COVID-19 outbreak.
As depicted in the Figure below (as of June 5, 2020), COVID-19 was the 8th top cause of mortality globally; several other causes have already killed in the millions, taking the lion’s share of the 25 million deaths in the stated period. Among single causes, this year’s HIV and malaria-related deaths are far ahead of COVID-19-related deaths in five months. This is probably due to increased malaria outbreaks in many malaria endemic countries. It is as well predicted that the malaria outbreak and deaths may even worsen unless acted as soon as possible. In the worst scenario (with no containment and mitigation actions), WHO has already estimated the malaria-related mortality in Sub-Saharan Africa alone to be around 769k at the end of the physical year, which will be again higher than the predicted total COVID-19 deaths (1 million vs 920k).
Specific to COVID-19, the global case fatality rate (CFR) out of the total tested positive remained around 6% (6 persons out of 100) throughout the last five months. At a regional level, the highest CFR was in Europe (8.7%), the lowest in Oceania (1.2) and the second lowest in Asia (2.7%) and in Africa (2.8%). At country level, the top five are France (19.1%), Belgium (16.2%), Italy (14.4%), UK (14.2%), and the Netherlands (12.8%). The top 20 and top 10 richest countries contribute to 87% and 71% of the total deaths globally, respectively.
The recovery rates in Asia (60%), Europe (51%), South America (47%), Africa (44%), North America (40%), and in the least affected Oceania region (93%) have not as such shown remarkable regional disparity. At individual country level, however, the difference is statistically significant. The observed significant difference among countries may narrow down as the new infection rate similarly declines. One more, whether the observed almost proportional death and recovery rates among developed and developing countries is due to the similar natural course of the disease across the globe or comparable optimal care in every nation is a big research question.
These data have two major limitations. Though the rate of mortality did not show a significant change over the last five months at all levels, the status is known only for about half of the tested positive cases. As countries are at different stage of the disease’s curve, determining the CFR for the cases with known status is identified as significantly increasing the estimation error. The second and probably most important limitation of these data is; the denominator includes only those who were tested and turned out to be positive. What is not yet clearly known is, how many untested asymptomatic and symptomatic COVID-19 cases are missed and recovered in the community. Until a reliable antibody test survey is done, a mathematical model (with the inclusion of the untested positives) is very likely to estimate the CFR of COVID-19 much lower than what is currently known. Moreover, if terminally and chronically ill patients are excluded out of the total deaths attributed to COVID-19, the adjusted CFR can be much lower than the current estimate.
It should be underlined that although the proportion of COVID-19 mortality is much lower than SARS CoV-1 (9.6%, 774 out of 8098 cases) and MERS CoV (34.4%, 861 out of 2,502 cases), the actual figure of COVID-19 (so far 382k out of 6 million) indicates that it is the most fatal disease among other corona viruses, but extremely less than the old time pandemics and still by far lower than the currently highly fatal endemic diseases. When we project the current COVID-19 mortality rate for the coming 7 months, the maximum global mortality will be close to 1 million. The annual fatality rate of other communicable diseases (excluding malaria, HIV and influenza) is projected to be 13 million; cancer, substance use and under five illnesses each 8 million; HIV-related 1.7 million; and road traffic accident 1.4 million, which all are incomparably higher than COVID-19 worst scenario.
Of all communicable diseases, the relative uniqueness of COVID-19 is its ultrafast contagiousness. Otherwise, as we learnt from the hard-hit countries, a large number of cases remain asymptomatic from the time they get infected to the time they stop shedding the virus. Likewise, more than 90% of symptomatic patients recover with some medical support or while they stay at home, probably with physical exercise, sunlight exposure and traditional remedies.
The global estimate of those COVID-19 patients requiring intensive care is 1-2% (the current worldwide critical cases are 2%); they are also the ones who usually suffer from chronic comorbid illnesses.
According to Garg and colleagues’ study (by including 14 states of USA), the hospitalization rate was 4.6 per 100,000 population (more than 89% were with one or more comorbid illnesses). This finding may complement with several anecdotal evidences which have shown the extremely low severity of the COVID-19 unless otherwise the infected person is already compromised with one or more chronic illnesses. A large cohort study from China by including 44k hospitalized patients with COVID-19 has shown that 81%, 14% and 5% had mild, severe and critical illnesses, respectively. The data excluded several thousand cases who were asymptomatic. In the USA, the proportion of hospitalization and ICU admission was 19% and 6%, respectively.
Therefore, to be more pragmatic, it is good to look into the depth of the implication of the above data and the already incapacitated regular health service programs in Africa. The ones causing several deaths (communicable diseases, including Tb, HIV, malaria, cholera, shigellosis and others), under five mortality of multiple causes, cigarette smoking, and alcohol intake) are still major public health problems of Sub Saharan Africa. Low and middle income countries of Africa do also share the non-communicable diseases burden and deaths with high income countries (like cancer, diabetes, heart and hypertensive disease). The implication is that, if the currently predominantly COVID-19 focused health program and the health professionals’ reluctance to receive non-emergency patients stay longer in Africa, the cumulative negative indirect impact of COVID-19 may not be easily reversible.
It may even reverse the remarkable achievements in the last decade in vaccine preventable and vector-borne diseases, for which many African countries have been applauded. Therefore, before COVID-19 causes much indirect damage to the health sector (as it is doing in many other sectors), the disrupted and suspended preventive and curative services should be resumed sooner rather than later. Health professionals should take the lead in promoting the resumption of the regular health services by taking the standard precautionary measures at all instances. The people must also be encouraged to come to health facilities for regular health checkups or vaccination without breaking the COVID-19 preventive measures.
The emerging evidence has shown that the commonly manifested symptoms and signs (fever, the taste and smell loss or disturbance, dry/productive cough, shortness of breath, other non-specific infection symptoms, and characteristic imaging findings) may not be revealed for weeks, while the patient is still highly infectious. According to several case reports from Western countries, these kinds of cases (having extra-respiratory serious illnesses) were the ones who had exposed many health professionals to contract this virus. Initially, they were having an impression of non-COVID-19 disease state, which had probably opened room for reluctance to apply the maximum precautions.
Here in Ethiopia, of the reported COVID-19 associated deaths, the COVID-19positiveness of most deceased people were revealed by postmortem examination, though most of them were on treatment for some other serious illness.
There were also two atypical cases who stayed for a long time in two big public hospitals. These two patients were the sources for dozens of health professionals to get contracted the current coronavirus. As a result, here in Addis alone, 49 health professionals and 16 health support staff are officially reported as tested positive, but so far all are in good health.
Nevertheless, it is our oath and lifetime commitment to treat sick people. Thus, we should not buy any more additional time to recommence and revitalize our routine activities. There is no doubt that the longer the ‘standstill’, the higher the health catastrophe due to other diseases. By applying universal precaution/wearing personal protective equipment of the time while treating all patients, we should be courageous enough to help those emergency patients and those with advancing disease condition the sooner possible.
The most important take home message is; assume that all patients with or without suggestive symptoms are SARS CoV-2 carriers, even those who are repeatedly tested and negative. Accumulating case studies from different parts of the world have shown the late positivity after 2-3 times negative results, for which the sensitivity of the test partly contributes to.
The WHO editor has concluded that “noncommunicable diseases (NCD) kill 41 million people each year, equivalent to 71% of all deaths globally. Each year, 15 million people die from an NCD between the ages of 30 and 69 years; more than 85% of these “premature” deaths occur in low- and middleincome countries”.
Every minute and an hour delay in resuming the regular health services in Africa is probably inviting further escalation of this number of NCD-related mortality and about 16 million mortality of communicable diseases.
Stigmatizing and discriminating COVID-19 patients/survivors must be condemned in very strong terms!
Publicly and privately, we have heard that many suspected or confirmed COVID-19 patients have been stigmatized and/or discriminated. Sadly, it started around the middle of last January by running away from Asians and white people, and to the worst, by harassing, beating, and on many occasions by prohibiting them from getting a commonly offered service. Later, health professionals and health support staff became a target, by being evicted from rental house, and discriminating them from the usual social interactions. Now, what is growing is discriminating and stigmatizing COVID-19 survivors and their family. This is a dangerous move, for which the public will pay the cost.
The author is deeply concerned about that the HIV/AIDS history in the 1990s may be repeated. It is freshly recalled that Sub-Saharan Africa is the most severely affected region by the HIV pandemic. For that much degree of HIV prevalence and mortality, Africans may not be exceptionally promiscuous from the outset.
The high prevalence of other sexually transmitted infections, malaria, malnutrition, multiparty, and polygamy are thought to have an additive effect to the increased risk of HIV transmission exceptionally in Africa.
Far beyond that, the significant delay in HIV testing has substantially contributed to the fast spread and high mortality of HIV in the African region. The test uptake was severely compromised partly because of fear of stigma and discrimination. Equally, HIV used to be symbolized by COBRA, skeleton and the dragon. Publicly, it was death, which was loudly spoken out. That time, the assumption was that scared and terrified people can abstain from risky sexual practices and contracting HIV.
Later, it was realized that people who were afraid of being positive, were reluctant or defiant for HIV testing until the opt out HIV testing approach and antiretroviral treatment have revolutionized the test uptake. When some courageous HIV positive individuals disclosed their HIV status, they were unbearably stigmatized and discriminated. It is in our fresh memory how many of them were desperately expressing their grievances with the maltreatment of the people in their area of residence. Unfortunately, when they were psychologically traumatized by the hostile public reaction here in Ethiopia, some were retaliating by further disseminating the virus to others. Some even established the ‘Shamo’ club (let everybody gets the virus as we do!)
These days, a few survivors of COVID-19 are also publicly and privately expressing their grievances with the discrimination and stigma. If the growing maltreatment of suspected or confirmed COVID-19 patients is not prematurely aborted, it may provoke anger and similar retaliatory actions, which for sure can worsen the spread of the virus and severity of the illness.
So far, what is observed as an immediate effect of the discrimination here in Ethiopia includes: avoiding testing, hiding the disease’s symptoms and keeping COVID-19 patients at home, which were noticed as an increasing risk factor for the disease severity.
The author of this manuscript knows two individuals who were tested positive for COVID-19 and afraid of disclosing their illness for days. Later, they were escorted by police and taken to the treatment center. In some localities, health professionals who went out to take samples at household level were harassed and people were largely defiant. The health professionals were tagged with a name of “666” by counting the letters in CORONA and COVID-19. We have also heard a lot of similar stories from other African countries.
There is no ambiguity about the reason why people are discriminating and stigmatizing HIV or COVID-19 patients and survivors; it is fear of contracting the virus. Sadly, the unhealthy fear has even resulted in committing suicide and homicide here in Ethiopia and some other African countries. This is probably as a result of the horrible image created in the public mind about this disease by health professionals and media.
Looks minor, but important, people are not able to freely sneeze or cough back in the village for simple airway irritation; they are warned about that somebody around may pick his/her phone and call to the notification center. The action is not as such bad, but it is creating a significant personal and social insecurity, fear and stress, which all have a potential to result in psychological trauma.
Notably, many other highly fatal outbreaks (including Ebola, Yellow fever, Rift valley hemorrhagic fever) have been experienced in the last decade, but people were not that much frightened as they do this time. It is not arguable that everybody has to take all the necessary preventive measures at all the time not to get infected by this virus, which is a healthy fear. Healthy fear (talking all necessary preventive measures not to contract the virus) is also appreciable and still encouraged. Fear to the extent of committing suicide, homicide, harassing others, jumping from the ambulance and disappearing from treatment centers is unhealthy and unacceptable. The unhealthy fear is also probably due to loss of hope of cure from this illness, as noted below. (For this article, unhealthy fear is assuming that all who contracted the coronavirus will die, while the reality is not).
What are the possible contributing factors for the unhealthy fear? Firstly, to the author’s perception, COVID-19 is highly promulgated by the international media by giving almost 24-hour coverage. This is probably because; while the pandemic was in its early stage, the most developed countries were disproportionately affected. The unprecedented case load with staggering speed of spread in the developed world has exacerbated the fear and uncertainty in the poor countries, probably as a spillover effect. Many experts in the field further escalated the frustration of the poor countries by putting their worst prediction for Africa. Besides, the international media and influential people put their expectations and worst prediction with heartbreaking words for Africa.
Secondly, the degree of multi-sectoral havoc COVID-19 has created in a short period of time globally, and the daily climbing deaths in Europe and North America, lets many people think about it as if this is the time of apocalypse/Armageddon. Thirdly, its indiscriminate infectivity to anyone on this planet, particularly reaching to unreachable house, including head of states and celebrities, has made the poor people to lose hope and get prepared for the worst to come. Fourthly, like the time of HIV peak, the local and international media have been overemphasizing how deadly this disease is, but little is said about the relatively high recovery rate. As a result, it is to everybody’s conscious memory how the African governments and the public at large frantically reacted when a few COVID-19 cases were reported from the African soil in the early times; without government enforcement, many service centers were closed, and there was almost no traffic jam for about a week.
With time, however, I am afraid that complacence may slowly grow as the people start to witness the high recovery rate. Here is the danger. In due course, people may become deaf for a few number of deaths, and start to build confidence to take risks. This is the time everybody needs to be guardian for him-/herself by letting others take all protective measures. African governments have to maintain the COVID-19 specific law enforcement to let people keep on physical distancing, universal mask use, handwashing, and disclosing suspected COVID-19 patients.
I am not a supporter of the lockdown intervention in Africa and elsewhere for all people. It sounds good if aged persons and those with comorbid illnesses limit their contact with non-family members, by staying at home and having good physical exercise and daily exposure to sunlight at least 20 to 30 minutes. The workforce should not be restricted from work; rather, applying the protective measures must be stringent.
The way forward
The successful control of COVID-19 in China and many more countries, 98% of the 3 million currently active cases having mild illnesses, the achievement in curbing the curve back to the base in many European countries, and the slow increment and promising recovery in the African region are green lights to aspire similar curbing even here in Africa.
This is possible provided that the African people keep on practicing the coronavirus transmission preventive measures all the time; eliminate unhealthy fears; encourage testing and early reporting of symptoms; sympathize and express solidarity with COVID-19 patients and survivors. To further build the public confidence on the health services to COVID-19 patients, the following available treatments mainly for secondary complications of COVID-19 should be publicized.
Antibiotics: Prophylactic/preventive and therapeutic antibiotics are given for secondary bacterial infections. Bacterial infections are among the immediate common causes of mortality.
2. Anticoagulants: Prophylactic and therapeutic anticoagulants/blood diluting agents are given to severely ill patients as atypical pulmonary (lungs) and disseminated intravascular blood clotting are the leading causes of mortality.
3. Antipyretics: are given as high-grade fever is common among severely ill patients, which often speed up the deterioration unless timely controlled. WHO recommends either Ibuprofen or Acetaminophen.
4. Anti-inflammatory medicine: may be initiated as it is practiced in many countries and WHO is not against with the use of it.
5. Intravenous fluids: (commonly known as ‘glucose’) are given to severely ill patients.
6. Blood transfusion: is provided, as its requirement is not uncommon among severely ill COVID-19 patients.
7. Convalescent plasma transfusion: is becoming a worldwide practice as China and European countries experience has shown good outcome. FDA approved for emergency use. COVID-19 survivors are the donors.
8. Oxygen: is a basic life support for patients with mild to severe respiratory failure.
9. Mechanical ventilation: for patients with severe respiratory or heart failure is a lifesaving intervention.
10. Kidney dialysis: is another lifesaving essential supportive treatment for COVID-19 patients who developed acute kidney failure, which is still not uncommon.
11. Remdesivir: is an antiviral medicine used to treat SARS CoV and Ebola. It is also a new hope for COVID-19 treatment, as the recent clinical trial in 1,000 patients has demonstrated quick recovery. It is already approved by FDA for emergency use, and is expected soon to be routinely prescribed.
Therefore, although currently there is no medicine available in the market that kills the virus, usually after two to four weeks, the clinical symptoms of COVID-19 subside, which is like many other serious viral infections. The peak or critical time since the onset of symptoms is between 8 and 14 days. This is the period that critically ill COVID-19 patients need one or more of the above listed interventions.
The media should not overemphasize the statement “no treatment for COVID-19” as it is becoming one of the push factors from health facilities. Rather, much has to be said on the preventive modalities and people have to be encouraged to be tested, to come to treatment centers, or else remain isolated (if they are eligible to do so). It is a universal principle that evidence based and informed decision has a long lasting effect.
Specific to the health system, the already initiated programs to build a resilient health system in the African setting should not be jeopardized by this pandemic. As the current pandemic may take several months to 1-2 years, we have to start providing all the regular preventive and curative services (at least for illnesses that can worsen with buying more time) soon. The immunization, malaria outbreak prevention and elimination, and many more preventive and promotive health programs can soon be reinstituted with no barrier.
The bottom line is; it is today, not tomorrow, that we have to learn and practice how to live with this virus. We should be able to critically appraise the trade-offs between COVID-19 risks and the benefits of other health services. If the suspension of health services is further extended, it will definitely have an inequitable and devastating impact in those African countries with fragile economy and health system. Africa cannot withstand the indirect health damage of COVID-19 unless a coping strategy is soon implemented.
The Ethiopian herald June 12,2020
BY PROF. YIFRU BERHAN
