COVID-19: Will history be repeating itself?

Professor Anthony Mawuli Sallar, PhD writes

According to David Patterson and David Killingray (The Influenza epidemic of 1918-19 in the Gold Coast, and The New Imperial Disease: The Influenza Pandemic of 1918-1919 and its impact on the British Empire”) the Gold Coast was totally unprepared for the influenza epidemic. On August 28, 1918, the Governor of Sierra Leone sent a wire message to his counterpart in Ghana, (then Gold Coast) that influenza was ravaging Freetown and advised that all ships from England and Sierra Leone to Ghana should be considered infected. The American vessel, S.S. Shonga, arrived in Cape Coast on August 31 and when it reached Accra September 3, all crew members were sick. Within two weeks after the ship landed in Accra, the disease was widespread as dock workers, hospital workers, students were infected and Accra was declared a no go area for troops. As the infection propagated with raging aggression, schools closed, no public meetings were held, and businesses came to a standstill.
It was termed the worst demographic disaster in the history of Gold Coast as close to 80-100,000 people died out of an estimated 2,213,000 people (3.6% to 4.5% mortality rate) in a short period with the northern and upper regions struck hardest. No village, clan, extended family system was spared by the virus and the infection seemed unresponsive to the prayers of Christians and Muslims or traditional religions.
The virus did not linger long but it left a lasting mark on its survivors with untold hardships.
As of today April 28, 2020, there have been 1,671 confirmed cases and 16 deaths attributable to COVID 19 cases. On Sunday April 19,,2020, the President of the Republic of Ghana, President Nana Akuffo Addo lifted the three weeks lockdown of Accra, Tema, Kasoa and Kumasi, the four hotbeds of the COVID- 19 epidemic in Ghana. There have been calls for government to increase the duration of the lockdown with some professionals and individuals saying the president prematurely ended the lockdown. Without timely and publicly available data, most healthcare professionals are unable to make sense of what prompted the lockdown to be lifted. Was it economic or political reasons or was the decision driven by scientific data? That debate will continue to play out in the public for a long time to come.
As a country we seem to be missing the boat every time in our reaction to the COVID-19 pandemic.
We delayed in closing our borders, entry points and unwittingly brought imported cases to the country and allowed horizontal transmission to take place.

When the government initiated partial lockdown (even though a country-wide lock down was
preferable), the implementation was wrongfully carried out. Prior to the lockdown the Chiefs of Avatime and Kwahu Traditional Areas appealed to their citizens living in Accra and Kumasi to stay put in their areas. Ideally, our government should have "locked down" the four cities with immediate effect rather, our government gave people 48 hours’ notice. Just as we expected, people travelled to their villages and now we have the virus throughout most of the regions. If fighting the virus in 2 or 3 major cities is daunting one can imagine fighting it in all corners of Ghana. Yes,
the horse left the barn and the government started trying to put a padlock on….too late.

Now the lockdown has been lifted and some are rejoicing, and the lorry stations and markets are packed. Social or physical distancing is now almost difficult to enforce. Are we drawing lessons from other countries as to what they did wrong and the devastating consequences? Much as we try, there is a massive shortcoming in our contact tracing. Let us assume Kwadzo is positive in Accra and travels to Aflao in a Toyota Hiace car with 14 other people. How is the contact tracing going to be done? Who has the contacts of the other passengers who also assuming they get infected also infect others? That is just our reality. The Ghana reality.

According to an interview published by JoyFM, on April 21, 2020 Dr. Anthony Nsiah -Asare, former Director General of Ghana Health Service, and currently Presidential advisor on
COVID-19 stated that 10% of the population is likely to test positive. That is 3 million in a population of 30 million with about 15,000 deaths out of 150,000 critically ill.

Another example of how one can be suspicious of the quality of data of our contact tracing relates to a recent incident of a friend who arrived in Ghana from USA few days before we closed our borders. They called him and was told he would be called back. They never called him back. As an academician he called back after many days. The number that was used to call him was a number you could not call. Talk about scientific contact tracing!!!!!
There may be asymptomatic cases, mild cases and moderate cases who may continue to infect others. Thus what we have as cases may be the tip of the iceberg. In the concept of the iceberg phenomenon of disease control, an infectious one like COVID-19, there are strategies to use for the above drivers of undercounting.
Some have argued that with the removal of the lockdown people would be infected and we could develop herd immunity. So far the science does not point to that. Evidence from China shows that people can be reinfected by COVID-19. The science of herd immunity indicates that its success in controlling the disease depends on the proportion of subjects with immunity. In a population, immunity can be from immunization or infection. Before herd immunity can be a success, one standard question is what is the proportion of people in Ghana with the immunity? Sure one develops immunity either through infection or vaccination at what is known as critical immunization threshold only then can that infectious disease be eliminated or not spread. For some diseases this can be 94% (measles for example) and 90% for mumps. Generally the more infectious the organism the higher the threshold.

Currently Ghana’s COVID-19 seems to be present in almost all the regions of the country. The most recent mortality is around 16 deaths. Our current data may not be reliable because we are yet to revamp testing efforts. Until we are able to increase our testing capacity, we may not know the true prevalence of the virus in our communities.
The COVID-19 pandemic should be a wakeup call for the authorities in Ghana to take a second look at our healthcare system as a whole. It is possible that COVID-19 may follow this current trajectory with manageable cases and deaths. However, there is also the possibility of increase in the number of cases as seen elsewhere and that can easily overwhelm our already inadequate healthcare system. The question is are we ready?

Suggestions to Government
Government should equip our current hospitals/health centers/CHIPS compounds with adequate PPEs. My checks on the ground reveal inadequate numbers of N95 masks, face masks, face shields, protective gowns in the towns and villages across the country. Every patient with a respiratory symptom that requires medical care should be treated as COVID-19 until this infection is ruled out with a negative test. We should aim at protecting the lives of our healthcare staff at this time.

Testing of COVID-19 should be decentralized within the shortest possible time. Noguchi in Accra, KATH in Kumasi and most recently UHAS in Ho are not enough to test the whole country. Keeping patients as possible COVID-19 cases for 3-4 days and as long as two weeks depending on distance before test results are released, is totally unacceptable during a pandemic. The delays in getting results can be very frustrating and lots of anxious moments and periods for those tested.

Instead of planning to build 88 new hospitals by December 2020, Government should rather pay all NHIS arrears to hospitals in the country so that they can purchase drugs, equipment and items needed to fully operate. Some hospitals have not been reimbursed for services rendered in August 2019 !! Building hospitals without efficiently managing our current system will not solve our healthcare crisis. Our problem is not from inadequate hospital beds alone but rather as a result of systemic failures in healthcare system management.

To those who are arguing that we should not copy from the advanced countries, what have we not copied from them? Their system of government? Don’t we drive cars? Don’t we fly in planes? Are these modes of transportation African made? What about their religion and franchising churches as business entities as is done in USA? How many Ghanaians will prefer holding Euros, Dollars, or Pound Sterling to the Cedi and all of a sudden we don’t want to copy from outside?

Why is the Minister of Information the spokesperson on COVID- 19? Is this not a health issue? Don’t we have bureaucrats at the Ministry of Health or Ghana Health Service who are well versed in Health Communication which is relevant in this case? For starters the way health matters are communicated is totally different from other communication sectors. Why can’t we have the same health.

communicators at the regional and district levels constantly giving out information at the local level? The citizens are more likely to receive these messages differently than when given by politicians. Our fellow citizens who are taking this virus as child’s play need to be informed by health communicators. For example, some of those who recover say “the virus is a monster, it feels like someone is drilling a screw into your joints and you have sleepless nights and incessant coughs with high fevers and chills”. Coming from a health professional is more likely to be accepted than from a NADMO Coordinator or a politician they have known in the community and has all of a sudden become a health expert!!!!!!

Scaling up of communication on how the virus is spread. There should be incessant preventive measures across all media, country, hourly, daily etc. This is critical as the message not sinking home. It is business as usual in some places in the nation.

Government use some of the millions of dollars of its funding to give free nose masks in vulnerable communities and of course PPEs to health facilities especially in areas of high prevalence.

Let the citizens know it is the responsibility of each person not to be infected and NOT to infect any other human being. That should be the core message to "not infect the other person". In Tamale a suspected case was in the market selling. She was invited because the health officials did not want to go there and create a scene. They had to eventually go and pick her. I believe this individual does not know the implications of her actions

In conclusion if this situation is not managed well, as I pointed out in the opening paragraphs we may live to regret what happened in Gold Coast in 1918-1919 when everybody, every household, every community was touched by the flu pandemic some 100 years ago. We still have time to reverse the course of history

Professor Anthony Mawuli Sallar, PhD
The writer has a PhD in Epidemiology from the University of British Columbia in Vancouver Canada. He is currently a Professor at GIMPA where he teaches Epidemiology, Global Health, Maternal and Child Health, Research Methods and Ethics. He can be reached on masallar@hotmail.com