COVID-19: No reason to give the all-clear - Update Volta Region
Karsten Gareis, HITA, 7/15/2020 - with input from Jacob Ahiave / Grow Your Dream Foundation.
1 The current situation
In a recent report. [1] Chatham House, a British think tank, summarizes the general perception of COVID-19's impact on the African continent as follows, "Despite public health constraints, widespread infectious diseases, and malnutrition, COVID-19 has so far caused less damage in Africa than originally feared." With the exception of South Africa, infection rates and COVID-19-related deaths have remained comparatively low in sub-Saharan Africa (SSA), especially compared with the number of deaths among nonwhite people in South America and other parts of the world. However, there is no reason for complacency yet, as "[...] the situation changes on a daily basis and considerable uncertainties remain. [...] Resilience should not lead to complacency, which would itself become a great risk" [2].
The Government of Ghana has paid a high level of attention to the COVID-19 issue from the beginning. In doing so, it drew on the country's successful experience in combating the West African Ebola epidemic (2013-2016). Ghana also benefits from $35 million in emergency assistance from the World Bank to "help the country provide improved response systems" [3].
On 15.3. this year, all public gatherings were banned, including conferences, workshops, funerals, festivals of all kinds, political rallies, church activities and other related events, in order to contain the spread of Corona. Since 22.3. all external borders are closed. From 29.3. until 20.4. a curfew was imposed over two city regions (Accra and Kumasi) where the first cases of infection had been reported. Other measures include the disinfection of markets, especially in the Accra region, special life insurance for health workers who come into direct contact with the pandemic, and the establishment of quarantine centers. Particular emphasis is being placed on expanding testing in all parts of the country and on tracking people with whom proven infected persons have had contact in the past two weeks. Also in April, all elementary schools, high schools and universities, both public and private, were closed. This is still the case today, with the exception of those cohorts for whom final exams are scheduled i this summer.
Wearing nose-to-mouth masks in public places and maintaining adequate distance has been mandatory nationwide since June. Penalties for non-compliance are severe: for refusal to wear a face mask in public, the new legislation provides for a prison sentence of 4 to 10 years or a fine of GHS 12,000-60,000 (about €2,000-10,000) or both (!!) [4]. The new law has been widely criticized as disproportionate given the fact that many poorer Ghanaians already struggle to afford the cost of a regular supply of face masks. The penalties actually imposed are therefore less draconian. For example, the Ho City Council has adopted an immediate penalty of GHS 20 against people caught in public without a face mask; this is also frequently imposed. [5]
Efforts made by the government and Ghana's national health system have certainly helped prevent rapid spread of the disease in the country. Looking at the total number of cases relative to the population, the rate in Ghana is currently about one-third that of Germany, one-fifth that of South Africa, and less than one-tenth that of the United States and Brazil [6]. Looking at the number of COVID-19-related deaths relative to the population, the number for Ghana is 25 times smaller than for Germany. At the beginning of July, the number of active cases exceeded the 5,000 mark for the first time, before declining slightly again. Officially, there have been 129 deaths so far causally linked to COVID-19 - a very low figure when compared, for example, to the number of annual tuberculosis deaths in Ghana (over 16,000). [7]
2 Is there cause for concern?
However, there are some reasons for not drawing hasty conclusions from the official statistics. Due to limited testing capacity in low- to middle-income countries, which includes Ghana, the number of COVID-19-related deaths is likely to be significantly underestimated compared with higher-income countries. Despite the government of Ghana's ambitious approach to scaling up testing and rigorous contact tracing, the actual number of people infected is likely to be many times higher than the official figure here as well. The number of tests (daily tests per 1 million people) in Ghana in early July was 99, compared with 843 in Germany and 752 in South Africa[8]. The number of tests per confirmed case in Ghana (5) is about the same as in South Africa (4.4), but significantly lower than in Germany (174).[9]
Compared to the low total number of reported COVID-19 infections and deaths in Ghana, it is striking how many politicians have been infected with the virus. The list includes:
- the acting Minister of Health (recovered);
- the head of the Sekondi-Takoradi Metropolitan Assembly (deceased);
- the head of the National Health Insurance Administration (NHIA) (recovered);
- the head of the Forestry Commission and former secretary general of the ruling New Patriotic Party, NPP (deceased);
- the Deputy Minister of Trade and Industry (recovered);
- the Regional Minister for the Volta Region (recovered);
- the "Senior Minister of the Republic of Ghana" (in isolation);
- the acting Minister of Education (recovered).
In early July, the Ministry of Education announced that 90% (!) of its employees had tested positive for the coronavirus [10]. As of this writing, Ghana's President Nana Akufo-Addo is still in self-imposed isolation on the advice of doctors: one person in his inner circle of advisors had tested positive for the coronavirus; however, the president himself reportedly tested negative [11].
Many of these cases are more recent, suggesting that it is not valid to claim that Ghana "peaked its COVID-19 infections as early as early May," as publicly stated by the Ghana Health Service (GHS) public health director and the government a few weeks ago [12]. Unfortunately, there are signs that electoral political considerations are having a not inconsiderable impact on the way the government is dealing with the pandemic: Ghana will hold presidential and parliamentary elections in December 2020, in which the ruling NPP and the opposition National Democratic Congress party figure they have about an equal chance of winning. Against this background, any official government statement on the evolution of the pandemic in Ghana should be taken with great caution.
Aside from the uncertainty about the actual extent of the spread of COVID-19, the country faces several challenges that need to be urgently addressed. Ghana's health minister listed some of these in a recent report to WHO on Ghana's experience with the pandemic: [13]
Dissemination of misinformation
As discussed in our first report on COVID-19 and the current situation in Adaklu, the spread of misinformation and rumors about the origin of the virus, its transmissibility, and methods of prevention and treatment is a significant problem in the current situation. Furthermore, there is an urgent need to take effective measures to improve public awareness.
Non-compliance with spacing rules
Despite the harsh penalties for violations of the COVID-19 rules adopted by the government, including the obligation to keep a distance, there is good reason to assume that the requirements are often not complied with in practice. There are many structural reasons for this, but also some that could have been avoided - at least according to many experts.
A key example is the current nationwide voter registration process for the December elections. The public process of registration, which takes place at central locations in all parts of the country, results in many people gathering in groups, often resulting in hours of queuing. Despite calls to postpone the creation of a new voter registry, the Electoral Commission of Ghana insisted on the need to create an entirely new registry instead of updating the existing one [14]. The Election Commission has promised to ensure that all COVID-19 rules are followed at registration posts, but many observers express doubt that this will be possible. A group of experts* from the health sector filed a formal complaint with the Election Commission stating that "conducting mass voter registration at a time when the country is battling the Covid-19 pandemic will lead to an increase in COVID-19 related deaths [...] as the process will encourage people to come together in a way that unintentionally undermines stand-off rules, thus facilitating the spread of the disease in the community." [15]
Observations in the city of Ho indeed indicate that voter registration endangers the safety of the population, as maintaining sufficient distance proves impossible due to the large number of voters seeking to register - see the photos below, taken on July 10.
Another government decision also risks violating standoff rules. In June, junior high and senior high school students, as well as university students, were asked to return to their classes insofar as they have final exams to take this semester. While President Akufo-Addo urged teachers to "conduct their classes in strict compliance with the spacing rules," the actual situation in schools and universities often makes this nearly impossible. According to reports from our partner schools in Ho, it is currently impossible to avoid dozens of students having to share a single dormitory - there is simply not enough space to maintain a minimum distance throughout. The situation is exacerbated by the fact that the rainy season began in April; the frequent, heavy rain inevitably means that students spend most of their time indoors, where the risk of transmission of the Corona virus is significantly higher. In fact, on July 13, the first COVID-19 cases were reported at both Mawuli and Mawuko Girls' Senior High Schools in Ho. [16]
Denial of asymptomatic COVID-19 cases.
Unlike other communicable diseases, infections with COVID-19 are often asymptomatic, i.e. a large proportion of those infected do not show any symptoms themselves. Many Ghanaians do not seem to accept the possibility that a person can be a carrier of the infection without experiencing any symptoms themselves - increasing the likelihood that the virus will be passed on through careless behavior such as inadequate spacing.
Stigmatization of recovered COVID-19 patients.
Stigmatization of patients who have experienced COVID-19 infection poses a significant risk to the mental health of those affected. In addition, fear of stigmatization (and of being isolated in central facilities) may lead individuals with symptoms potentially related to COVID-19 (such as coughing or sneezing) to try to hide their condition rather than seek medical attention.
Failure or delays in public health activities and underutilization of health services.
Experience in recent months has shown that many developing countries are suspending or postponing public health activities, such as vaccination campaigns, because dealing with the pandemic is taking up most of their resources. In addition, it has become more difficult to persuade the target groups of vaccinations and other health campaigns to participate because of fears that it could increase the risk of infection - because usually vaccinations take place at centralized locations such as a health post (in Ghana, for example, a CHPS compound).
According to estimates by Prof. Fred Binka of the University of Health and Allied Sciences in Hohoe, a leading epidemiologist in Ghana, maternal and infant screening utilization has declined by 50% nationwide since the COVID-19 outbreak. [17]
As part of Ghana's long-standing malaria prevention strategy, plans were in place to distribute insecticide-treated bed nets again in 2020. Such an action takes place every three years as part of a mass global campaign coordinated by WHO to distribute mosquito nets to the most affected segments of the population. However, in light of COVID-19, distribution in Ghana has been suspended for the time being. Any delay of this type is likely to lead directly to an increase in malaria-related deaths. [18]
The current practice of isolating individuals thought to be infected with coronavirus exacerbates the situation. We received reports that in Adaklu and the neighboring town of Ho, people who see a doctor for symptoms that could be caused by COVID-19, or who are otherwise believed to be infected, are not allowed to return home but are isolated for 14 days in a building on the grounds of the Kpetoe Health Center. The HITA team visited the facility in spring 2019 to hand over several hospital beds as well as IT equipment donated by our supporters*. The accompanying photo, taken during our visit, shows the building currently serving as an isolation ward. Under such circumstances, it seems more than understandable if many people avoid visiting a health facility because of the risk of being quarantined on the mere suspicion of being infected with Corona.
3 What we do
We are currently discussing with our friends in the Volta region how HITA can best help in the current situation. Our key partners in this effort are two University for Health and Allied Sciences (UHAS) schools, namely the School of Nursing and Midwifery (SONAM) in Ho and the School of Public Health (SPH) in Hohoe. In addition, we are in constant contact with Togbe Lablulu in Adaklu-Waya and with the Grow Your Life Foundation team. We worked with them to develop an intervention plan to explore rural people's opinions, perceptions, and behaviors related to COVID-19, focusing on the practical challenges people face in complying with COVID-19 regulations (e.g., spacing, protective clothing, hygiene, self-isolation) and accessing health services in the current situation. Based on the results, we will develop training interventions to further educate community health nurses in particular. Given their close contact with the village community, such nurses seem ideally suited to educate and directly support people in peripheral parts of the country on how best to cope with the risks and hardships caused by the pandemic.
As is HITA's conviction, we are particularly interested in measures that make use of information and communication technology. The plan is to fully exploit the potential of mobile telephony and the growing penetration of smartphones in rural regions of Ghana as well, in order to develop and deploy cost-effective solutions tailored to the needs of the rural population.