It took a while for the Zimbabwean government to meaningfully respond to the Covid19 pandemic, better late than never.
Now that President Emmerson Mnangagwa has decreed that there shall be a 21-day lockdown for the ailing country, a lot needs to be done to ensure the efficacy of this intervention in achieving its main objective of flattening the curve.
Using a statistical analogy, the task at hand is akin to transforming a normal distribution into a t-distribution. The curve has to be flattened so that the health system is not overwhelmed with too many simultaneous demands. The flattening of the curve does not necessarily lower the aggregate number of infections but just slows the process down which in turn preserves the health system from collapse.
Now that the lockdown has been announced, it is necessary that we have a robust local response plan that decentralises responsibilities and equips first responders across the country with the necessary skills and equipment to contain this virus.
Government should take control of the coordination role whilst empowering the people on the ground to do the job.
Whilst pondering on the nature of the plan that the Mnangagwa government can come up with, I bumped into a document written by the esteemed Tariro Makadzange is a Tutu Fellow and seasoned infectious disease physician and immunologist. She is a Harvard Medical School qualified medical doctor and a Doctor of Philosophy (PHD) in Immunology holder from the University of Oxford.
I stopped in my tracks to note Makadzange’s inputs which I am using as the basis for this article. The recommendations are not in order of priority thus the article should be read in its entirety.
The greatest challenge in the Zimbabwean setting is overcrowding in the townships, from the hostels, to the homes where multiple individuals are sharing a room. This could potentially be fuel for a virus that rapidly spreads from person to person and is airborne. It’s airborne nature means that all Zimbabweans are equally at risk. The best approach to deal with this within a fragile health system is to rapidly and effectively implement sound public health measures. With local transmission now, it is important to implement appropriate measures.
Social distancing is critical for flattening the curve in western societies so as to not burden the health system. In the Zimbabwean setting this will be critical to prevent significant morbidity and mortality. The lockdown is appropriate, but Zimbabwe should be prepared for the need to expand it beyond 21 days.
No more than 10 people should attend a funeral and they should each be at least 2 metres apart. All gatherings should be restricted to no more than 10 individuals. 50 individuals is way to much. This applies to any other celebration including weddings and other ceremonies.
Funeral Parlours need to plan for a potential substantial increase in deaths which will require the use of funeral parlours and their facilities. They should ensure that they have adequately planned for mortuary capabilities, refrigerated trucks, and well as funeral management capabilities.
In as much as it is an incovenience but hospital visits should be banned totally. No more visitors to hospitals.
All churches and large social gatherings should close. This is difficult for church leaders and parishioners, however is critical for the survival of the church community. Messages of care and support, including outreach should be continued virtually as this time of social isolation will be very challenging for all.
Control crowds in shops, sticking to the principles of keeping people 2m apart, keeping store workers and well as customers safe.
Public health interventions
A complete lockdown should be implemented. Zimbabwe should turn the military into public health heroes, and/or rapidly train a team of public health warriors – modeling after the EHTs in the city health system would be reasonable. The role of the military will be as social implementers (they are not at war with the people, but at war against an invisible virus that threatens national security in a manner that nothing else has threatened national security in the country). The military will be responsible for ensuring no one travels outside of their home.
No inter/intra country travel should occur – it would be a disaster if disease is transmitted to rural communities where the lack of healthcare infrastructure is even more acute. Everyone should shelter in the place where they are now. University students should not return to their homes and villages, similarly school students who have not returned home should shelter in place in school. The military will also be responsible for building the infrastructure that may become necessary for this response.
Telecoms providers should work to set up a free public health line where individuals can send a text or Whatsapp if any member of the household is unwell with respiratory symptoms. These individuals are subsequently picked up and transported for testing and/or isolation as a person under investigation and/or persons with mild/moderate respiratory disease. Persons with symptoms that require acute hospital care should be directed to the appropriately designated acute care centers.
Determining the scope of the problem
Establish testing center for acute care – PCR based tests will be important for acute management. Would also encourage getting rapid antibody tests, this will be important not necessarily for patient diagnosis but for understanding the scope of the disease, and the developing immunity. This will be very important for surveillance and will assist with planning.
The government needs to establish 3 types of centers in each town (some will need more than 3 and places like Harare may need to have these in each city district e.g. Mbare, Kuwadzana, Mabvuku etc) urgently.
- Center for Persons under investigation. This can be a hotel/ 1. hostel where individuals can be housed in individual rooms. Some persons with symptoms may not be COVID19 e.g. fever due to malaria and so these should not be mixed while under investigation with people who may actually be positive.
- Center for persons with mild or moderate disease. Here it is important to follow the China model. If patients are confirmed positive you can have wide open wards, if testing is not sufficient here again these individuals should be housed in individual rooms, and isolated from their families to prevent transmission to close household contacts. As seen in many countries, those most at risk are close household contacts.
- Center for persons with severe disease. These should be acute care hospitals that are capable of providing the level of care needed for severe patients.
These centres should be well managed and PROVIDE CARE. There should not be a disincentive to make the state aware that you are ill either because of very poor conditions in the centres, or concern for the cost. Currently people dont seek care for pretty severe disease until it is advanced and often too late because they cannot afford care. In this public health emergency this should be different. All COVID related care as this is a public health situation (much like how we approach TB) should be paid for by the state.
Zimbabwe needs to prepare to convert large centers – dormitories etc that can be used to take care of COVID patients. They could use the military for this, military engineers, they should have the skills, capability and manpower to enable rapid conversion of buildings into these medical centers.
Remember that routine clinical cases will still occur. Your underlying burden of disease requiring acute care e.g. severe malaria, complications of HIV, TB, heart failure, hypertension, delivery etc will continue to occur. The tragic collateral damage would be if these individuals do not get the care that they need as hospital resources are diverted to COVID19. Or if they should pick up SARS-CoV2 while in a hospital for something else.
It is absolutely critical that baseline care continue to be available. It is uncertain if hospital air systems in most of our hospital are modern enough to allow for designating certain floors for COVID patients and other floors for other patients so as a consequence would recommend separating hospitals and care providers.
For example keep Harare and PARIRENYATWA as acute care hospitals, use BRIDH and Wilkins as Covid centers; as the disease burden amplifies additional COVID centers will need to be activated. At this time the government should be developing a strategic plan for which medical facilities will be converted to COVID facilities.
It is absolutely critical for hospitals to realize that this is an enveloped virus and like all enveloped viruses appropriate cleaning and disinfection will be sufficient to turn the hospital room around for another patient, and after this crisis to turn the hospital back into the acute care facility that it previously was. In many countries Covid patients are being cared for in the same facility as non COVID patients where appropriate air systems and isolation and cleaning procedures are in place. This will likely change as the scale of the problem amplifies and they too will move to what I recommend – seperate Covid hospitals.
All COVID related care should be free and paid for by the government. This government has lost a lot of trust from people and businesses. This is a time to ensure that trust is restored, cut all non-essential spending, and focus on this, make prepayments to private sector businesses that will need to be co-opted into the response and ensure that you make timely payments to them, as you do not want them to no longer exist because of government bills post this crisis. Provide tax relief and other incentives to ensure that you are able to get them to scale.
Rapidly get local production in place. Although chloroquine and hydroxychloroquine remain unproven, plan for the possibility that they have efficacy these are cheap, generic drugs. Procure as a government API for chloroquine, ensure that local industry e.g. CAPS, Varichem etc is able to produce thousands of supply. Procure and manufacture antimicrobials, paracetamol, etc.
The healthcare workers are the most important people at this time and its not just doctors and nurses but lab scientist and the vast array of allied workers who make healthcare possible. THESE ARE OUR TRUE NATIONAL HEROES.
At all times so many of them are heroes working in challenging conditions (taking care of TB patients daily without N95 respirators) and making personal sacrifices for all of us. The government must at this time pay them what they need, and the healthcare workers should exercise some reason and get back to doing what they love – taking care of patients.
Zimbabwe needs all healthcare workers to be back at work urgently. We always need healthcare workers to be at work and appropriately respected and compensated. The urgent need is to protect these healthcare workers. Stockpile and provide PPE urgently. All centers should be able to provide basic PPE – surgical mask, gloves, full length gown, goggles or face shield. The appropriate precautions when dealing with most patients with Covid-19 are:
- Standard precautions
- Droplet precautions
- Contact precautions
- Eye protection
Protecting healthcare workers also protects patients and the population at large. THIS IS A KEY PRIORITY AND CANNOT BE OVERSTATED.
Medical Registration and Licensing
The country has to make sure that medical registration and licensing process is efficient as we must be prepared for an onslaught on the health care system and the need for additional staff. Look at what is happening in New York. Given our density in the townships, although no one can predict the future, we should plan for an even worse situation.
The government ought to reach out to physicians, nurses, laboratory scientists, allied health worker and others who may be able to assist. We must rapidly develop a list of those individuals, retired or foreign-trained. Put in the legal requirements to enable those who are retired, or not working or in the diaspora who are in good standing to be able to assist (diasporans, but virtual telemedicine) and serve in this time of need. These immediate and rapid registration may be temporary to fulfill the immediate needs.
Rapidly register physicians, nurses and individuals with the necessary technical expertise so that they may provide care locally if they are able to be present or through telemedicine support to be able to assist physicians and doctors on the ground and provide much needed technical expertise that may not be readily available or whose numbers are limited and critical e.g. infectious disease, critical care, anaesthesia, pulmonologist, etc. These individuals must be in good standing at the time of retirement with the Zimbabwe board, or be registered and in good standing wherever they are practicing e.g. in Western Europe, North America, UK etc. Rapid registration should not compromise quality, but slow bottlenecks will compromise access to care. Registration may be temporary to meet this acute need.
Rapid registration of diagnostic tests
Zimbabwe should establish a framework that will allow for the rapid registration of diagnostic tests. Rigorously but rapidly review approval data from agencies with a proven and rigorous track record, e.g. FDA or European agencies. If you do not have the expertise, or have limited personnel who are busy on the current response or have limited capability to do this rapidly this is the time to plan for that, reach out to regional and international bodies such as the Africa CDC or African Academy of Sciences and other bodies that may enable you to find the appropriate support to facilitate this, as well as the technical expertise within your diaspora. Many people want to assist, just reach out and ask.
Approval Process of Clinical Trials
Establish a rapid process to approve clinical trials for repurposing drugs that may be registered locally or in other countries, as well as for new drugs. Develop the framework now, as a scenario may unfold where access to clinical trials for investigational medicines or new indications for new medications may be the only hope for severely ill patients. (Think back to the early days of HIV infection). If the regulatory processes are slow this will be a disadvantage. Again establish the framework now, and if there is no capability for a rapid and thorough technical and ethical review with a very short turn around time, establish the appropriate networks to help facilitate that now. Put the framework in place for rapid registration of any investigational drugs that show efficacy so that the people can access mediation rapidly. Enable local research and participation in international networks to evaluate novel therapies such as vaccines and biological therapies such as antibodies.
Zimbabwe is unable to have a $2 trillion bailout, but like every government we need to ensure the survival of our people. The government needs to ensure food security as this lockdown may last more than 21 days remember we are entering into our winter months when respiratory diseases are typically at their worst.
The government needs to work to ensure that it is providing a basic ration to all vulnerable people particularly the unemployed and those who live hand to mouth. They will be unable to stick to the quarantine measures if the government does not provide food security.
Food security will be a threat to national security if not handled correctly. This cannot be overemphasized. This will be a major area of vulnerability. Ensure that resources are adequately distributed to ensure that people will survive this and work with the private sector and NGOs to ensure this. Don’t rely on foreign agencies, this is the government’s responsibility first. Tap into local and diaspora expertise to support the logistics of doing this, as this is very complex and will need good orderly planning.
Taxes and Tariffs
Zimbabwe may not have the resources to support everybody so must be seen as using resources appropriately. Many people will need to rely on help from good neighbours and family in the diaspora.
The government has to implement measures that will assist the poor. Remove tariffs on money transfers both from domestic and international sources. This may also be temporary to ensure that people have the resources that they need to survive.
Extend ZIMRA deadlines and give businesses a tax break so that they will be able to open their doors when businesses restart, and the few that can may be able to continue to pay workers through this period.
Rapidly enable industry to upscale to support this national effort. As mentioned get CAPS, Varichem back up and running to provide supportive care needs from paracetamol, to chloroquine. Procure or enable them to procure API for manufacturing – the global bidding and competition is high. Ensure that BOC is able to provide adequate oxygen for inpatient needs.
Turn some of the cloth/cotton manufacturers into mask, disposable gowns manufacturers. Turn alcohol distillers into alcohol sanitizer industries. Provide incentives for soap and cleaning detergent manufacturers. Provide your young tech enterpreneurs who are keen on developing local solutions to health problems the opportunities to do so e.g. those who are developing apps to self screen for potential symptoms, apps to guide people to their local COVID center, GPS mapping and modeling techniques to identify disease hotspots, biotech entrepreneurs who want to develop rapid tests, mental health apps to support people during this period of isolation etc. Let the changes that you put in sustain beyond corona and also enable innovation .
Provide accurate information to the population. Work with professionals and talented media people to provide the appropriate messages to the population. There is much disinformation on the internet and social media. Become a credible source of information. Educate and be transparent. Pharmacy and Medications. Work with pharmacies to ensure that people are able to get the critical medications that they need during quarantine. We have many people on chronic medications for conditions such as HIV, HTN, etc it is critical that there not be a run on limited supplies while ensuring that people have sufficient medications to last them the next month.
What Does Success Look Like?
Have a clear vision of where you want us to be as a country 3 months from now, or 6 months from now and work towards that. The decisions made today will shape how the country will survive this period. Success will not look dramatic, success will be that nothing happened because you effectively implemented all the above.
Failure on the other hand will be dramatic, with the typical case of Africa being the worse case scenario. Rise to the occasion and stop this virus in its tracks. This is basic biology, a non living organism made of protein and nucleic acids that like HIV can destroy global societies and economies (at the beginning of December who would have imagined we would be here globally). You can prevent it with sound public health and effective execution. The consequences of poor planning and execution are evident in countries who saw it coming but did nothing.
This requires resource and one could say we are a third world country we cant do this. I would say on any day we find resources for vehicles, large cabinets, MP perks etc, we now need to be IN THIS TOGETHER to solve what could be a historically significant problem. If we do not get a handle of this we could potentially loose our loved ones, as some sadly already have, or have a severe seasonal problem as we enter our winter season, or develop into an endemic problem that will challenge our health care system in much the same way that HIV did and continues to do. Let us act decisively and appropriately.
PLAN FOR THE WORST, HOPE FOR THE BEST.