Infectious diseases have been around since time immemorial! Even some of the biblical plagues may have been due to infections. The deadliest was the Black Death in the 14th century killing over 200 million people.Others of note are smallpox in the 19th century and Spanish flu at the beginning of the 20th.
So killer infections are nothing new and Covid-19 won’t be the last. When infectious diseases become widespread in a country or affect many countries, they are called pandemics.Because pandemics pose such a serious threat to health and life, countries must be prepared to deal with them. It’s very unfortunate that countries especially in Africa choose to ignore this fact.In any health ministry there should be a department of public health. Within that department there should be a section of infectious diseases. This is what we are going to explore.The mandate of this small department is to protect the nation from infections within the country and from outside. In all large clinics and hospitals there is an infection control nurse whose job is to feed information about emerging infections to the central infectious diseases (CID) department in the ministry. The CID also takes pro-active steps to monitor infections via direct communication with health facilities and monitoring social media and the news.
If there is any evidence of a cluster of infections this information is passed to the Permanent Secretary (PS) who would engage a rapid response team to kill the infection. The CID will keep following up the PS to ensure all is being done. The whole of this exercise is to deal with national epidemics and pandemics.With regard to international and regional infections the CID is most important. These infections will tend to represent a much bigger threat to the Nation’s health. It is very important for the CID to keep an eye on international and regional infection trends. It does this by monitoring social media and mainstream media. Because of the amount of international travel all countries of earth are deemed a threat. Any outbreak anywhere on earth is a threat until its dead.When an outbreak takes place anyway in the world the CID does a risk assessment. To do this it looks at 3 factors:
1. Infectivity: the likelihood that an agent will infect a host 2. Virulence: the likelihood of causing severe disease among those with disease (in most susceptible ones).
3. Lack of preparedness of the medical facilities in the country to deal with severe cases
You then rank these 3 parameters from 0 to 10. Zero means no issues and 10 means very bad. A risk of 0-10 means you have nothing to worry about. Eleven to 20 you start being vigilant and preparing. Twenty-one to 30 you go to war!Now, let us apply this approach to Covid-19 on Botswana. The CID would have done this in January 2020 when the virus was still in Wuhan, China.
1. Infectivity. From information coming out of China it was clear that the virus is highly infectious. For this I give it a 9/10 2. Virulence. For the majority of the people, the effect is very mild. However, the older people and those with other disease the effect is very severe and leads to death in many. Since our goal is to protect those most likely to succumb, I give it an 8/10.
3. Medical Services. Looking at the medical needs of ill patients in China it is clear that in Botswana the facilities are very poor. Therefore, I give this 10/10. This pathetic state is due to the selfishness of African Politicians! They can easily go outside the country for healthcare when they are ill and choose to leave their constituents to their fate.
Therefore, the total risk for Botswana was 27/30 in January meaning the country needed to go on a war footing to prepare for the Virus.The CID would then inform the Director of Health Services (DHS) about this eminent threat. At this stage the DHS would decide to form a Medical Task Force (MTF) and inform the Minister and the Permanent Secretary (PS). The MTF would consist of the Chief Nursing Officer, The Chief Medical Officer, a Public Health Specialist (epidemiologist), an Intensivist (critical care specialist), a Family Medical Practitioner, an Internal Physician, a General surgeon and the DHS. The team is chosen at this level to avoid political interference. All members of this team are health practitioners. There is no place for non-medics in this team. Other medical practitioners can be called to give advice as necessary. The function of this team is to do all the medical planning for the impending pandemic.After being informed about the impending pandemic the Minister would inform the President. They would then plan to form a Presidential Task Force (PTF). This will protect the country against all negative impact of the virus: medical, social, financial, psychological, economic, security, food, educational etc. The PTF has different professionals in it and the medical team is represented by the DHS and the Public Health Specialist from the MTF.
The President will brief cabinet, leaders of opposition parties and the House of chiefs about the plan.The reasons why you need 2 two task forces is because if you have only the medical team they will only concentrate on a medical model. Legal, Social, psychological, economic effects etc will be ignored leading to social ills such as GBV and other negative problems.Remember all this is done long before the virus reaches our shores! Medical Task Force.The MTF is the operational unit in the fight against a pandemic. It should have highly trained and experienced health care workers in it.
THERE IS NOT PLACE FOR VETERINARIANS! It does not matter what their accomplishment is, in their field! Just because a person has a degree in Epizoology (animal epidemiology) or botanical epidemiology does not mean they are suitable. We are dealing with humans and not animals that can be easily locked up or even shot, with no consideration for their social or psychological welfare!Who leads the MTF does not really matter. It can be a nurse, a social worker or a physician. All that matters is that they should have good leadership and communication skills and be trained in human medicine. This team will carry out the following:
1. Preparation of the acute medical services to deal with the ill people. This is by far the most important function. You ignore this you have failed!
• Plan for a parallel health system. Just because there is a pandemic does not mean other medical conditions go on leave. To effectively fight the medical problems in the country it is important to mobilise all the health care personnel in the country. This will include those who are in retirement and those in private practice. There may be even a need to get them from other countries that are not severely affected by the pandemic. • Acquisition of equipment from consumables to ventilators (including test kids) • Improving the laboratory services • Acquisition of Personal Protective Equipment (PPE) • Identification of ICU hospital (s) • Identification of centres for those with diseases but not severely affected (isolation centres) • Training of staff (ICU Medicine especially, donning and docking of PPE) • Plan on quarantining of contacts and those who come from high risk areas
2. Protection of the VVIPs from the disease
• President • Vice President • Speaker of the House • Attorney General
3. Plan for National Isolation
• Public Education in all aspects of the disease (especially preventive measures at individual level). • Communication with the press, the community and within teams (it is very important for the message to be the same) • Formation of countrywide rapid response teams. These are going to be the foot soldiers on the ground. If a case is suspected they should be there within hours to secure the case, then trace the contacts such that within 6 hours most of the contacts are known. • Basic tests eg temperatures and questionnaires of all coming into the country (these are not very useful but they are cheap and are used in very low risk situations) • Quarantining of those from high risk countries (high risk is defined by the number of infections in that area or the rapidity of spread or the proximity to Botswana) • Quarantining and testing of those coming into our borders (in the context of Africa there is no place for self-quarantine if you can cope with the volumes of people)
4. Plan for dealing with local and community acquired infections
• Preparation of Hospitals or quarantine centres. People who have mild disease need not be admitted to hospitals but have to be monitored in safe quarantine centres. • Contact tracing (primary and secondary) and what to do with them • Dealing with those who succumb to the disease and the unsalvageable (you might have to deal with mass casualties. There are also a group of very ill people that will die whatever you do, you need to decide whether you are going to waste money and resources or led them die! This is probably going to be a decision for the Presidential Task Force.
The Presidential Task ForceThis is the strategic wing of the fight against a pandemic. It takes a wider view of the effect of a pandemic on the country. It is going to advise the President, Cabinet and Parliament. Whatever decision is taken, it is not up to this team. That honour lies with the President and his cabinet (and the Legislature)This is a very, very important team. It should have the cream of the country. As I said before the Director of Health Services and the Epidemiologist from the MTF are intrinsic members of this team. I would add a senior constitutional lawyer, a senior army officer (General Rank), a senior police officer (Deputy Commissioner Rank), an Economist, the Chairperson of Business Botswana, a Behavioural scientist, a specialist in Moral Ethics, a Farmer, a logistics expert and an Educationist. This team should be led by a trained project manager of high repute.The function of the team is the following:
1. Plan for Escalation and de-escalation
• Resources to fight the Pandemic and its effects (capital and human) • Closing of the borders • Lockdown: how this is going to be done, what parameters are going to determine the need and mitigation for those affected • State of Emergency: when and rules of engagement during SOE, what parameters are going to determine when and how long for. • Continuous evaluation of the effects of the pandemic (medical, social and economic) • De-escalation and return to normalcy • In an infection pandemic cases may go up and down at various times. It is important to have a predetermined plan of what to do in various scenarios so that plans can be modified as necessary.
2. Engagement with regional partners
• It’s very important to engage with surrounding countries • If they don’t control the virus, you will fail.
This is how I would have planned to deal with Covid-19 in the Botswana. Some may disagree with me and that’s fine. In my view we have achieved very little to deal with Covid-19. We wasted a lot time during lockdown and a lot of money has been lost for nothing. We could have achieved the same without a total lockdown. Some will talk about hindsight bias but I would disagree!There was no need to stop commerce completely. We could have switched to e-commerce with home deliveries. The permit system was appalling. Had we had a high volume of community cases it would have been disastrous. People were denied the right to go and see to their animals or their agricultural produce.Even when we knew how dangerous the virus was, we allowed people to go to high risk areas and told them to self-quarantine when they got back. That was a huge mistake.What worries me most is the lack of preparation for possible cases. The very fact that most politicians and those who can afford it, go outside the public health system in Botswana means we are aware of how poor our system is. Even if the expected high cases do not materialise, the health resources that we would have invested in, would still be there post Covid-19 to help poor citizens of this country.I was shocked at the lack of coordination in our team with mixed messages being send. I would have loved to have had the President addressing the nation at least once a week though the Minister and the Director of Health Services did a sterling job talking about the virus. A simple thing that has been known since other Corona viruses like wearing of masks in public came very late. Do not be fooled by the few cases we have had and the 1 death.
It’s a matter of time before 1 infected person from Zimbabwe, Zambia or South Africa crosses the border at an ungazetted point. Patient 31 in South Korea, a country that has a great public health system, infected over 5000 people in about a month. Yes, we have done well in keeping the virus at bay by closing the borders. I was impressed by the rapid identification of contacts of that driver in Gaborone. Our public education about the virus has been absolutely superb. Building the diagnostic capacity was very rapid and exemplary. Dividing the country into 9 zones is a good idea and I hope they can respond locally without a need to get permission centrally. We have been very lucky that the cases we have had were mild and in other countries are not hospitalised.What concerns me is the belief that we are out of the woods. Assuming we have 200000 people who are either over 65 years or have Covid-19 susceptible co-morbidities and a fatality rate of 5%, you could be talking about 10 000 people dead in a very short time!
*Dr Lesedinyana Odiseng is a medical practitioner