Not since the 1918 flu pandemic, or the smallpox epidemic in pre-Gold Coast, Ghana (1864) before it, has our country been as focused on a global viral illness. There are a number of themes that emerge consistently across the world, as we grapple with how to wrestle this COVID-19 pandemic to the ground in different jurisdictions from big to small and rich to poor.
In Ghana, we have 21confirmed cases and 1 death by testing, which is by no means widely available to the population. We know that our initial cases have come in from Europe predominantly. Screening measures have been taken, arriving travellers have been asked to socially isolate themselves and quarantine measures have been instituted. Individual prevention interventions, such as hand-washing and social distancing have been strongly promoted.
We are often reassured by videos of people having their temperatures taken as they enter airports, land entry points and even as they get on State Transport Corporation buses. Herein lies the rub. Someone with a normal temperature may be an active carrier of COVID-19 who is asymptomatic. If such a person enters the country, as many have, and do not self-isolate as recommended, they are a risk to the general population because they may even only experience mild flu-like illness for a few days and recover. However, they would have been a vector, spreading the virus to many.
One person with illness, whether they are the beneficiary of a test or not, will on average spread it to 2.5 people. Ten cycles of such spread every 5-6 days will lead to roughly 3500 exposed individuals within a short period of time. So, if we consider that every undetected person has this ability to spread the condition within such a short space of time, at such great intensity, then we should have a more aggressive approach to preventing the spread to prevent a strong “surge” of cases.
Yesterday’s announcement, by President Akufo-Addo of border closures for two weeks is a step in the right direction but is of limited effectiveness if it is not combined with at least a partial lockdown of large urban areas, where we already have clusters. This would, of course, allow for limited movement of people, for shopping and medical services. As much as possible, government services must be leveraged by technology so that employees may work from computers or mobile platforms away from offices, limiting their exposure to the public. Unfortunately, many calls to Covid - 19 hotlines have gone unanswered per many reports.
Because community spread has taken hold, closing the borders is too little too late.
We have a stark choice. We can start locking down now or start locking down after the deaths begin to roll in. Ghanaians always want to see (fiili-fiili) before they act but this is an invisible enemy and we must view it as a war and approach it with the kinds of measures we would take if we were a society under a military siege.
Our current social distancing efforts are limited by the reality of people going about their daily lives, achieving their professional, social and economic goals. In a war, these are luxuries that cannot be afforded. We must, therefore, get on with it and lockdown to prevent the mass travel within our large urban areas and their environs, using tro-tros and other high-density vehicles for travelling for inter-city travel. High-density vehicles like the tro-tros, VIP buses and STC buses are now the major vectors for community spread of Covid-19 within Ghana. You cannot practice social distancing in a tro-tro. This is a major reason why at least a partial lockdown is necessary to curtail non-essential travel for two weeks to accompany the border closure.
The initial order suspending church services and large funerals was a good place to start but given the fact that community spread is already taking place, we need to bring that to a halt by locking down before exponential spread and mortality set in to overwhelm our fragile health care system. Many families have also postponed funerals indefinitely, gumming up the mortuaries, which will create a secondary health crisis if there is not an order for funerals to occur within a 4 week time frame after death, with attendance limited to 25 or less.
The government must be transparent about these issues, worry less about political outcomes and optics and be truthful about the risks that we are facing so that Ghanaians are able to trust the authorities and adapt to short-term suffering that will protect us all from preventable deaths from COVID-19 if we do not change our behaviours.
Taking temperatures and testing are necessary but they do not tell us the whole story about the risks that we face and the very limited time we have to implement significant changes that must be enforced, including relying on our military resources. This will assist the public in compliance across the whole country.
It is a well-known fact in healthcare that human behaviour, rooted in good health literacy, accounts for over 50% of the determinants of health status, ahead of genetics (20%), social status(20%) and access to healthcare providers(10%). In a pandemic like this, the imperative for helping any society go against its own cultural norms and behavioural patterns is greater than in any other situation. We saw this most recently in the Ebola epidemic of 2014-16 in our sub-region.
We must take advantage of the situation also to teach and reinforce basic hygiene behaviours which have been lacking in Ghana for a very long time. We must leap from this pandemic experience to resolve our perennial sanitation issues, which also have a role to play in perpetuating not only this pandemic but future epidemics and other endemic conditions within our country.
Finally, it appears that chloroquine and hydroxychloroquine, on the basis of small open studies, may have a role to play in the treatment and secondary prevention of COVID-19. These drugs are not currently available on the market in Ghana because of chloroquine-resistant malaria but it may be prudent to treat current cases with these medications, to help us understand if their use will benefit the population at large.
We don’t know if weekly prophylaxis, that was the case with malaria can prevent this condition.
This presents an opportunity for our public health and clinical researchers to study this closely and rapidly for the benefit of the population.
Our borders are of course quite porous and so the need to coordinate lockdowns and other interventions with our regional partners is also very important in stopping COVID-19 in its tracks in West Africa.
T. P. Manus Ulzen is Professor of Psychiatry and Behavioral Medicine at the University of Alabama, Annual Visiting Professor at the University of Cape Coast School of Medical Sciences and author of “Java Hill: An African Journey” – A historiography of Ghana