CORONAVIRUS (COVID-19): A call to action

I hope we are all complying with the following personal hygiene measures: washing our hands often with soap and running water for at least 20 seconds after we have been in a public place; in the absence of water and soap we are using sanitizer which contains at least 60% alcohol; avoiding touching your eyes, nose, and mouth with hands not washed; and social distancing in order to reduce infection by the Coronavirus, one of the most virulent epidemics/pandemics in modern history. Few days ago March 21, 2020, at 9pm, the President, His Excellency Nana Akufo-Addo informed the country about the passing away of one of the 19 COVID-19 patients recorded in the country, and further announced that the borders of Ghana: land, air and sea would be closed for 2 weeks beginning midnight Sunday, the next day. This is in addition to the earlier measures of closure of schools, churches, mosques, and other religious centres among others. However, these did not and still does not include clubs, restaurants and work places. No action has been announced as far as public and commercial transport is concerned even as individuals are bound to take public transport, a major means of transport for most of us and a very likely infection channel. Since the nationally televised address, Ghana is said to have recorded 3 more deaths and a total of 93 infections and still rising.

Ghanaians welcome  the news that additional 50,000 testing materials have been ordered but wish a concrete or estimated date of arrival was given rather than the open ended “very soon”. Again calling on retired medical personnel to assist is not the best since the epidemiology of the disease indicates the elderly are more at risk? For example data from Italy indicates the vulnerability of the elderly, people with underlying health conditions such as hypertension, diabetes, and heart disease. Ghana has a significant number of its population with these comorbid conditions.

In the President’s earlier address a week and half ago, Sunday March 15, 2020 in which he gave us the news we were all hoping never to record any infections, unfortunately that has not been the case.

Since his first address, Ghana has moved from “imported” cases (vertical transmission) to community infected cases (horizontal) hence we can say that we have reached the propagation stage or diffusion stage of the virus in the country. Like past plagues of earlier years which killed millions, nobody knows how this will play out.  The scientists cannot tell if there are reinfections or immunities are built after infection. With Coronavirus we are in uncharted waters.  We have also seen with trepidation how COVID-19 mortality has caused havoc and continues to do so in some Asian and European countries especially Italy and Spain even with advanced healthcare system.

Apart from high mortality the virus can collapse the health care system of a country. Luckily, we have seen how drastic public measures have worked in China where the pandemic started and these actions can be benchmarked. Rwanda, an African country has announced measures which are enforced  The United States of America delayed and even though measures of lockdown were taken later by most states the morbidity and mortality (54,453 and 737 as of 25^th March 2020) respectively are daunting. It had single digits from 20^th  January 2020 to 13 cases on 7^th  February and 165 cases on 1^st  March 2020. Are we waiting to experience what advanced countries are facing even with their superior clinical and public health infrastructure?

In Ghana we are, unfortunately, woefully unprepared and have inadequate means to deal with the sick. Using 2016 figures, our doctor to patient ratio (1:8481 as against WHO’s 1:5000), nurse patient ratio (1:542 compared WHO 1:1,000).  We continue to pray that the infections continue to be low. At present the country has less than 100 ventilators. We are urging people to wash their hands with running water but we have less than 50% of our population with running water. We are advising people not to congregate but our living conditions are already congregations. Depending on the location, some houses are communal and can have 40 to 50 people. How many intensive care unit (ICU) beds are available to deal with patients with respiratory failure? How many ventilators are available across the country? How many doctors have been trained and provided with personal protective equipment (PPEs)? It is also interesting to note that while President Akufo-Addo is calling on retired doctors to come back to join the workforce, we have numerous young domestic and foreign trained doctors in Ghana waiting for financial clearance from Ghana to work !!!!!!

A healthcare crisis such as COVID-19 cannot be dealt with through government propaganda. We need to adhere to the scientific knowledge out there and immediately take steps to halt the transmission of the virus and to adequately care for the sick.  I will advise government as a matter of urgency consider the following:

1. Government should enforce a mandatory three-week shutdown of the country or at minimum regions where current COVID-19 cases reside. In the meantime, this shut down of a sort is likely to slow down the propagation. Unless there is a mandatory shut down our trotro systems, intercity public transportation systems can be fertile grounds for transmission. The limited option we have to contain the pandemic is to prevent the horizontal infection by drastic measures or best practices from elsewhere. COVID 19 is a pulmonary disease basically and in its worst form, the individual cannot breathe and can only breathe with ventilators and with less than 100 ventilators in Ghana, we may be faced with a disaster. The shutdown will enable those who are infected and are unaware to either develop symptoms or recover. Only essential services ambulances, electricity and water and health personnel should be in the streets. In an era of technology transfer and exchange of knowledge Ghana does not need to reinvent the wheel. Let us adapt best practices in the face of our shortcomings and marshal our resources as a nation to address the scourge posed by the Coronavirus
2. Set up a task force of public health experts to make inputs as to how measures can be effected: short term; medium; and long term. For example, now that the disease is in the community how are the data managed for surveillance efforts, contact tracings, survival rates, and incident cases. Some contacts we cannot trace hence the task force should model a simulation using what we know now as to how many people are likely to be infected in the next 15 days, 30 days, and 45 days for effective planning. Without planning we are bound to fail (“If you don’t plan, you are planning to fail”, a friend always says).
3. Government should immediately engage the Ghana Medical Association and other healthcare groups to quickly provide financial clearance for all healthcare workers especially the medical doctors awaiting employment. In addition, the government can incentivize the medical schools to offer early graduation to final year medical students. One-tenth of the $100 million government plans to spend can employ 1,500 health workers on a salary of 3,000 GHS per month for a year. Government should also address long overdue conditions of service for our doctors to motivate them as they take the front line lead role on the task ahead.
4. Create and massively publicise through public service announcements a website as a repository of relevant and scientific based information which should be updated daily regarding infections, mortality, prevention etc. This will prevent dissemination of wrong information and hysteria emanating from incorrect information circulating on social media about unscientific claims of therapy which can cure COVID-19.
5. I also appeal to the government to use a minimal amount of its $100 million US commitment to spruce up 2 medical hospitals which have been completed since 2016 and 2017 and are not being used: the University of Ghana Medical Centre whose Phase 1 was completed in 2016. It is a fully 650 bed capacity and only OPD is functional and the Bank of Ghana Hospital which is located in Cantonments and was completed in 2017 and has never been used. Can’t these facilities be coopted as COVID-19 Emergency facilities where the healthcare workers are fully equipped? Posterity will not forgive us to let these facilities stand when the current facilities we have are already overstretched even without COVID 19 diffusion into the populace where increasing numbers are just matters of time.
6. I suggest the government to as a matter of urgency procure more ventilators and put them at strategic health facilities across the country.

Finally, this is the time for proactive actions, use of best practices and call to action. Fellow countrymen and women, let us take the preventive and precautionary measures of washing our hands frequently, using hand sanitisers, social distancing among others seriously by adhering to them because ultimately, it is personal hygiene, personal individual decision-making by complying with these measures that will save us from the virus. Public health actions are multi-faceted: no one action solves the problem 100%: 10% reduction by intervention 1; 5% reduction by intervention 2; 30% reduction by intervention 3;  and 45% by intervention 4 would yield 90% results. Coronavirus is not HIV where an individual can take preventive measures and protect him/herself.

Mr. President, please close Ghana down now. Most of us were at a loss when we heard that NIA was still operating in Eastern region and EC was interviewing candidates for electoral jobs even though the government had directed against public gathering. These actions are inadmissible as well as irreconcilable and would contribute to more exponential infections. What Ghana needs now is a strong and charismatic leadership to lead with courage, truth and take scientific advice. This is not the time for politics and propaganda. Ghana is blessed with seasoned epidemiologists, microbiologists, medical personnel, global health experts, other top notch public health professionals who can contribute. The question is, are the political leaders or government willing to listen? Long live Ghana and may we all continue to stay safe.

By Professor Anthony Mawuli Sallar, PhD

The writer, Anthony Mawuli Sallar, has a PhD in Epidemiology from University of British Columbia in Vancouver Canada. He is a Professor at GIMPA where he teaches Epidemiology, Global Health, Maternal and Child Health, and Ethics. He was a former Board Chairman of  Korle Bu Teaching Hospital, Accra Ghana. He can be reached on [email protected]