What Covid-19 means for rural Ghana

What Covid-19 means for rural Ghana - a first report from Adaklu, Volta Region.

Karsten Gareis, HITA, 4/5/2020 (updated 4/14/2020) - Thanks for input to Jacob Ahiave / Grow Your Dream Foundation and Celestin Yao Etiam, Adaklu, Ghana.

1.) Introduction

The country of Ghana appears well-positioned to address the current threat of massive spread of Covid-19 based on its experience with previous epidemics, particularly the Ebola epidemic in West Africa (2013-2016). At the time, Ghana received much praise from the WHO and experts worldwide for having very successfully managed the threat of Ebola. This success was attributed to: "interministerial efforts to monitor ports, immigration and security services, and the Ghana Health Service, as well as national and regional technical coordination committees and public health awareness efforts. Three Ebola treatment centers have been established to manage cases. They were tasked with surveillance, situation monitoring and assessment, case management, health education, social mobilization and risk communication, logistics, security, provision of financial resources, and planning and coordination. Special insurance coverage has been introduced for frontline health workers working to prevent and control Ebola - another positive step. To keep Ebola out of Ghana, the government undertook wide-ranging education and training efforts, created awareness in the media, churches, schools, and public places, and promoted preventive measures such as hand washing, avoiding unnecessary physical contact with sick people, changing burial procedures, and increasing surveillance/searches at ports." [1] Of course, there are significant differences between Ebola and Corona. Ebola is about 30 times more deadly than Corona, but the latter spreads much more easily. Nevertheless, many of the procedures tested during the Ebola epidemic can also be applied to the current challenge. The first case of individuals infected with Corona in Ghana was reported on 12/3/2020. Until 12.4. the number of cases rose to 566, 8 of which were fatal. In the Volta region, the first 9 cases were reported on 12/4. reported.

The government responded quickly and decisively to the Corona outbreak. On 3/15/2020, 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. Elementary schools, secondary schools and universities, both public and private, were also closed. Since 22.3. until at least 19.4. all external borders are closed. On 30.3. an initial two-week curfew was put in place for three city regions where cases of infection had been reported: Accra, Tema, and Kumasi (including their suburbs). The curfew has since been extended for another two weeks. In these areas, only residents who provide vital services, such as health care workers, some key government officials, restaurants, and food vendors, are allowed to leave their homes. In addition, people are allowed to leave their dwellings to buy food. One focus is on identifying people with whom those proven to be infected have had recent contact and increasing the use of testing in all parts of the country. 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. In addition, the government and the Government Health Service (GHS) took a number of measures to inform the public about appropriate behavior to mitigate the threat of Corona; a Whatsapp-based notification service was introduced, and posters were displayed nationwide with instructions on proper behavior.

The crucial question now is to what extent the measures taken can help to prevent a major spread of the virus in the Ghanaian population. Scientists are not yet clear on whether, or to what extent, warm weather tends to inhibit the spread of the virus, which would save countries like Ghana - where the thermometer almost never dips below 20° C in much of the country - from the worst effects of the pandemic. On the other hand, there is a distinct possibility that the emergence of this new disease will have a devastating and lasting impact on the country's already fragile health care system. Ghana's health authorities are well aware "that hospitals could only care for a fraction of those in need if the virus spreads in crowded cities, remote villages, and among vulnerable populations such as refugees, the malnourished, or people suffering from HIV and other chronic diseases" [2] . Based on the recent experiences of other countries, Ghana would certainly be well advised to prepare for the worst.

As in other low- and lower-middle-income countries (LMICs), the context for managing a Corona infection wave in Ghana is extremely unfavorable. In many places in Ghana, even washing hands is a challenge because there is hardly any access to running water. Isolation of cases (i.e., physical separation of people who have already tested positive from other community and household members) and home quarantine (14-day total curfew for people who have been exposed and may be infected) will only be possible if there is a willingness in the population to follow public instructions. This can be a challenge, particularly due to fear of stigma and lack of understanding of the logic of the epidemic, i.e. the fact that people with no or mild symptoms can transmit them to others, putting them at serious risk. Outside the major agglomerations, moreover, it is likely to prove very difficult to completely seal off individual regions from others.

The danger situation is aggravated by the wide spread of diseases such as malaria and tuberculosis. Many people already suffer from chronic diseases and are therefore particularly vulnerable. Mortality among persons who develop pneumonia or other lower respiratory tract infections (typical of severe cases of covid-19) is significantly higher in Africa than in higher-income countries [3]. Looking at mortality across all age groups in Ghana, such infections account for more deaths than any other cause (about 20,000 annually). Approximately 5,000 children under 5 years of age die each year from pneumonia [4]. Under these conditions, coronavirus could easily lead to a large number of additional deaths.

Thus, while a rapid spread of Corona could have catastrophic consequences for Ghana, even if the virus itself does not directly lead to a significant increase in mortality rates, the pandemic will have a far-reaching impact on the health of the Ghanaian population. The reason is the indirect effects of the measures to combat Corona. These include unemployment and the resulting decline in household incomes, rising prices for consumer durables, and a spreading tendency among the sick, pregnant women, and others in need of care to stop seeking medical attention for fear of infection or quarantine (see next section).

Either way, the country is highly likely to be set back years in its efforts to achieve the much-discussed Sustainable Development Goals (e.g., reducing maternal and newborn mortality rates).

2) General challenges for Ghana with reference to Covid-19.

The first cases of Covid-19 in the Volta region were not reported until April 12. Already in the weeks before, the government's actions, as well as media coverage and social media communication, have begun to affect daily life in even the most remote parts of the country.

Dissemination of misinformation

A major challenge is what has been termed the "corona infodemic" - that is, the enormous spread of rumors and misinformation surrounding the current epidemic. Some of these rumors cause harm by lulling people into a perceived sense of security, for example, by claiming that blacks are immune to the virus or that it dies off at temperatures above 26°C. Such a notion may sound plausible, given that most reported cases of infected individuals are among people who entered the country from outside Africa. However, due to the extremely low number of people being tested for the virus in Ghana, it is easily possible that large portions of the local population are already infected without it being detected. Other rumors cause direct harm by enticing people to engage in dangerous types of self-medication, such as taking bleach for a viral infection. Such types of misinformation tend to spread quickly from mouth to mouth, especially in parts of the country where few residents have access to television or cell phones and many cannot read English.

Declining use of health services

Some evidence suggests that even in regions far from Corona hotspots in Ghana, residents have begun to avoid visits to hospitals and health posts, assuming that they might come into contact with infected persons at these locations. During the 2013-2016 Ebola epidemic, declining rates of attended births were reported for most of West Africa. Transporting people who need professional help to a health care facility is also likely to become increasingly difficult, as service providers charge higher prices and stop transporting people who are thought to be infected.

The current practice of isolating people thought to be infected with Corona makes matters worse. From our contacts in the region, we received reports that in Adaklu and the town of Ho (which is close to Adaklu and whose university hospital also serves the district's population), people who see a doctor for symptoms that could be caused by Corona, or who are suspected for other reasons to be infected, are not allowed to return home but are quarantined for 14 days in a building on the hospital grounds. Given this practice, it is not surprising that many residents will avoid visits to a health facility - to avoid the risk of being quarantined, even if there is no evidence that they are actually infected with Corona.

Exploding prices for personal hygiene products

Market prices for soap and disinfectants, not to mention protective masks and clothing, have skyrocketed since the outbreak of the epidemic. This makes it much more difficult for people to wash their hands with sufficient frequency, at a time when this is crucial to containing the spread of corona.

Rising prices also for everyday goods

Prices for all kinds of everyday goods, not just soap and disinfectants, have risen significantly in recent weeks. As a result, it will be difficult or impossible for more and more households to provide all family members with sufficient nutrients. The government has responded by cutting household electricity bills by half (and by 100% for very low-income households) - a move that must be seen in the context of the parliamentary elections scheduled for the end of this year, and which is likely to lead to an accumulation of power outages in the medium term.

Unemployment and resulting loss of income

While prices are rising, many employees and workers in the informal economy are losing their jobs as a result of the lockdown, or are at least being put on unpaid leave. Families already living close to the poverty line are particularly affected - with foreseeable negative effects on their health.

Incompatibility with traditions of public life

The health authorities' call to avoid shaking hands and the ban on religious gatherings and funerals affect aspects of life that Ghanaians consider sacred. As Ghanaian journalist Elizabeth Ohene notes in a report for the BBC:

"Here in Ghana, there are some things that are sacred in our lives, and no one questions them - under any circumstances: religion, handshakes, and funerals. These are issues that are not up for discussion, and many people believe that they define our existence. [...] The ban on religious gatherings [...] has a great impact on people for whom communal prayer and the discipline of the religious calendar are at the center of their lives" [5]

But now the churches remained closed over Easter, the holiest festival in the calendar of Ghanaian Christians. If restrictions of this type are to be maintained over an extended period of time, strong communication efforts are needed to enforce them - and to avoid looking for scapegoats in the current situation. Also, there is a high likelihood that many families will try to hide symptoms that may be caused by infection with Corona rather than report them to health authorities; because no one wants to be known as the person who introduced the virus into a neighborhood!

Mental health and domestic violence

Experts working in the area have expressed concern that lockdowns, such as those currently in place in Accra, Tema and Kumasi, could trigger an increase in domestic violence, with women and children particularly at risk. The psychological stress of not being allowed to leave home in cramped living conditions, which are prevalent throughout Ghana, can also lead to more general psychological problems. Measures are needed to help families and communities cope, especially if the curfew is maintained for an extended period of time.

3) Initial conditions in Adaklu District, Volta Region, Ghana

Adaklu District is one of the 18 districts of the Volta Region of the Republic of Ghana with Adaklu-Waya as its capital. The district has a population of 36,391 according to the 2010 Population and Housing Census (Ghana Statistical Service estimates are 44,300 in 2019). The vast majority (~90%) of the district's labor force is engaged in agriculture.

Adaklu is one of the most disadvantaged districts in the country. The 2015 Ghana Poverty Mapping Project, published by the Ghana Statistical Service, found that poverty incidence, or the percentage of the district's population living below the national poverty line, is by far the highest in the Volta region at 89.7% (average: 33.3%) and the second highest in the country as a whole. Poverty in Adaklu is not only widespread, but also severe: according to the Depth of Poverty indicator, which measures how far below the poverty line the standard of living of the poor is on average, Adaklu has the third worst score of Ghana's 216 districts. Unlike some of the other poor parts of Ghana, however, inequality in Adaklu District is very low - lower than in any other district in the Volta Region.

Widespread economic hardship means that many residents rely on agricultural production for self-sufficiency to make ends meet (subsistence farming). To supplement their meager incomes, the majority of women in Adaklu are engaged in food processing and petty trade as well as handicraft production for their livelihood.

Specific challenges related to the fight against Corona in Adaklu include the following:

• Poor supply of drinking water in many parts of Adaklu district;
• Low disposable income available to purchase daily necessities (including soap and disinfectants), which have become much more expensive since the outbreak of the current epidemic;
• Living conditions in settlements in most parts of Adaklu District do not allow family members to be isolated from other members of the community;
• High percentage of residents who cannot read or understand English and therefore rely on information shared by other members of the community.

4.) What to do?

From the above, it can be concluded that in the current situation, much depends on how the measures taken against the spread of Corona are put into practice. In this context, Shannon Smith of the African Center for Strategic Studies in Washington, DC, emphasizes that:

"maintaining public confidence during this pandemic will be essential. Governments need to really communicate instead of just putting measures in place. Strategic communication is a critical element for public health. The Ebola epidemic in West Africa ultimately ended because of behavioral changes that took place under very difficult circumstances. This required community involvement at the local level, local interlocutors, and communication". [6]

Other experts agree with her that the village community and family level are central to successfully overcoming the current crisis: "Like Ebola, Covid-19 is a family disease in the sense that many infections occur at home. Travel restrictions can slow the spread of the disease, but it's also helpful if individuals and families understand the routes of infection and take home precautions." [7]

What is the most effective way to engage communities and families in their living environments in the fight against Corona, beyond simply disseminating codes of conduct? Is it possible to use co-creation and co-development approaches to establish a sense of ownership among the population for action against the disease? And what role could modern information and communication technology (ICT) play in this? In the fight against Covid-19, can we benefit from the fact that Ghana has tremendous smartphone penetration and a very dense mobile network, even in the most remote parts of the country?

What is needed is an approach that could help share best practices in dealing with the Corona threat as effectively as possible, but also develop and establish new approaches to stop the spread of the virus in a way that is adapted to local conditions and needs - in close cooperation with village communities and key local stakeholders such as health workers* and Ghana Health Services (GHS) representatives.

First activities at local level in Adaklu

Since mid-March 2020, the Grow Your Dream Foundation (GYDF) team has been communicating information about Corona as part of their community outreach activities in Adaklu. At the community-level meetings, which bring together many members of each village, the GYDF emphasizes the need to take the threat of Corona seriously. Special emphasis is placed on educating about misinformation and rumors spread through social media and word of mouth, such as the proven false claim that black Africans are immune to the virus.

Practical advice includes the need to wash hands frequently enough with soap and under running water. Unfortunately, only a small part of Adaklu District is connected to the piped water network, making hand washing a challenge. Commercial suppliers offer so-called Veronica Buckets, which consists of a wooden stand on which bucket, towel and soap dispenser are placed, a faucet and a one for the dirty water. Veronica Buckets were originally invented in Ghana as a simple way to allow everyone to wash their hands properly.

The price of buying a Veronica bucket is low, but may still be too high to make it affordable for the country's poorest communities, such as in Adaklu. The team at GYDF has found a solution that is even less expensive: By attaching a tap to a used canister and placing it on a fence or branch fork (see photo below, left), a handwashing facility can be implemented for very little money. Since such canisters are usually readily available in any community (as they are used to transport fresh water from nearby rivers), setup can be done in a matter of minutes.

Other communities already have convenient hand-washing facilities, called "tip taps," that have been installed outside a toilet or livestock shed (see photo below, right). They are based on an earlier initiative of an American development aid organization and consist of materials available on site. The "Tip Tap" uses a foot lever to get the water running, minimizing the risk of contracting a pathogen by touching a traditional faucet.

Outlook

Initial efforts are therefore already taking place at the local level as well, in cooperation with the rural communities in Adaklu, to prevent the spread of Corona or to mitigate the consequences of the epidemic should a wave of infection also occur in this part of the country. While it is comparatively easy to convince the rural population of the need to wash their hands, implementing some of the other instructions from health authorities is much more difficult. Many Ghanaians find it difficult to do without the obligatory handshake. The same applies to maintaining a distance of at least one meter between yourself and other people. In addition, fear of stigmatization (and of being affected by quarantine in a central location) may cause individuals with symptoms potentially related to corona, such as coughing or sneezing, to hide their condition rather than seek medical attention.

Article as PDF: Report - Covid 19 and Adaklu ________________________________________________