Lack of Covid-19 treatment and critical care could be catastrophic for Africa
The coronavirus pandemic could be disastrous as fragile and almost non-existent healthcare systems in African countries are overwhelmed. A lack of personal protective equipment, difficulties in establishing treatment centres and an absence of critical care facilities might lead to a devastating loss of life.
“Most of the countries have at least one treatment centre, but they range from some with less than 10 beds to some of them with 100 beds," said Michel Yao, emergency operations manager for Africa at the World Health Organisation (WHO).
The latest readiness assessments by 34 African countries collated by WHO paints a bleak picture of preparedness for the pandemic as the number of cases and deaths rise.
Only 50 per cent of African countries surveyed had undertaken any Covid-19 staff training for case management and just over half the countries had personal protection equipment (PPE) available and accessible to healthcare workers, according to WHO readiness response sheets.
Preparations on the African continent “need to be quickly scaled up” as patient capacity will soon be challenged, Yao told RFI in a telephone interview.
Treatment capacity is linked to the availability of PPE and equipment, yet these items are just not available in Africa and the international market is already saturated with demand from much richer countries. International transportation is also a challenge with cargo space reduced by airlines stopping their services to the African continent.
Medical humanitarian organisations like Médecins Sans Frontières (Doctors Without Borders) hope that transmission of the virus in Africa can be slowed by measures such as hand washing and perhaps mask-wearing, according to Natalie Roberts, who works for MSF in Nigeria.
The time to act is now, but such initiatives need considerable resources like soap distributions and hand washing stations, according to Roberts.
“It could potentially be catastrophic,” said the MSF doctor, discussing the increasing spread of cases. She said the only other hope is the fact that many African countries have a younger demographic and Covid-19 appears to cause more fatalities in the elderly.
Critical care difficult or impossible
Scaling up the response to the coronavirus pandemic as seen in Asia, Europe or North America would be “extremely difficult” on the African continent, according to Javed Ali, director of the emergency response unit for International Medical Corps.
A lack of resources complicates setting up isolation wards or treatment centres for coronavirus, according to Ali. And providing critical care to those suffering from the most severe cases of Covid-19 is just not going to be possible.
“Dealing with patients who require Level 3 ICU or critical care is going to be extremely difficult and in some countries it's going to be completely impossible," Ali told RFI. Level 3 care is defined as having to support two or more organs or providing mechanical ventilation to aid breathing.
Some African countries simply do not have the ventilators required for the severe respiratory problems Covid-19 can cause. Interational Medical Corps will instead focus on providing Level 1 care which includes providing basic oxygen or intravenous therapy.
It is a view echoed by MSF doctor Roberts, who also works on emergency management for health crises. "Intensive care is just not there and it’s just not accessible to people," said Roberts, explaining that some of those patients saved by critical care interventions in Europe and elsewhere will simply die in countries like Nigeria.
How many ICU beds does Africa have?
The responses by African health ministries to WHO’s Covid-19 readiness survey provides a sometimes confusing outlook of the actual ICU resources available as few repositories actually map the critical care facilities at various hospitals across the continent.
One such study in 2015 by three Canadian researchers entitled “Intensive Care Unit Capacity in Low-Income Countries: A Systematic Review” reveals the underfunded and under-resourced nature of African healthcare systems as seen through the number of ICU beds. Many African countries had less than two dozen ICU beds to cover their entire population.
Capacity has somewhat increased since 2015 with Kenya claiming more than 500 critical care beds, according to The Standard newspaper, and some 120 ICU beds in Nigeria, according to a 2017 report by the McKinsey management consultancy firm. Nevertheless, this pales in comparison with other regions across the world, especially in light of the care required for severe Covid-19 cases.
According to WHO’s readiness survey for Covid-19, countries such as Angola, Burkina Faso, Burundi, Central African Republic, Cote d’Ivoire, Congo Brazzaville, Guinea Bissau, Lesotho, Malawi, Mali, Mozambique, Niger, Sao Tome and Principe, Seychelles, South Sudan, and Zimbabwe have no ICU beds available to treat Covid-19.
It is not entirely clear whether the responses to WHO’s surveys by African governments include both public and private hospitals. The total ICU capacity is also not included as a survey question and neither is the number of ICU beds currently occupied.
Not enough specialised healthcare workers
The grim reality of critical care in African countries is not just about unavailable supplies or machines. It is also a question of human resources - the skills and experience of staff running the hospitals and ICUs, according to nurse Cliff Asher Aliga, who teaches at Aga Khan University Hospital in Kampala, Uganda.
“We are not well-prepared in term of ICU and that’s a very big concern for me,” Aliga told RFI. “If the situation requires five per cent of patients who are going to have Covid-19 to be admitted to ICU, we definitely do not have the capacity to do that, that’s a very big challenge.”
Uganda has 55 functioning ICU beds, according to a 2019 study by researchers from Makerere University. However, the required number of specialists has not kept pace with the number of beds, said Aliga. Healthcare facilities do not have enough anaesthesiologists for those 55 beds.
Staff training for dealing with Covid-19 case management in Uganda is “still in its infancy”, but is taking place, according to Aliga, who is president of the African Federation of Critical Care Nurses. Ugandan health authorities have a plan in place, designating certain hospitals for coronavirus patients and using a taskforce to transport cases to reduce the risk of infection.
Yet healthcare workers in Uganda are already starting to feel the pressure with an inadequate supply of PPE and “heightened tension in hospitals”, said Aliga, describing the potential for a large number of severe cases and an unpredictable situation.
“We’re now relying on hope that things don’t get like that, but in the event that things get like that, I don’t even have the words to describe what is likely to happen,” the specialist nurse added. Experts from medical humanitarian organisations are also pinning their hopes on the possibility that the spread of the pandemic could play out differently in Africa.
Severity of coronavirus in Africa
International Medical Corps is focusing its Covid-19 efforts in Cameroon, Chad, Democratic Republic of Congo, Ethiopia, Libya, Nigeria and South Sudan. Javed Ali said it is difficult to predict whether the intensity of the outbreak is going to be the same as seen elsewhere.
A more dispersed population in some countries, environmental factors, the level of poverty as well as extended family living together are all elements that could make the spread of Covid-19 in Africa either less potent or actually worsen it, according to Ali.
The rainy season in West Africa, coupled with increased food insecurity and malnutrition, and the prevalence of other diseases could “complicate the infection to severity ratio” compared to other regions, said the International Medical Corps emergency response director.
Dr Nathalie Roberts from MSF is sceptical that lockdowns in African countries will be respected and will not otherwise cause further harm, describing how stopping families from earning money will make it even harder for them to feed themselves.
She also believes that lockdowns in Africa are not sustainable and could lead to civil unrest, further complicating efforts to contain Covid-19. In places like Nigeria, testing is only available in big cities like Lagos and Abuja and isolating people who have been infected, yet do not exhibit symptoms or feel unwell is just not practical, the MSF doctor added.
Ensuring that people do not die from other conditions while dealing with the coronavirus is also likely to be a challenge, said Michel Yao from WHO: “when the system is overwhelmed you have some difficult choices to be made."
The resources for critical care are few and far between, but even the necessary supplies for providing oxygen therapy require considerable capacity, according to the WHO expert. Many African countries are going to have to rely on non-governmental organisations and donor countries to try and scale up their responses.
“If you don’t really have a health system then flattening the curve is just trying to avoid too many deaths at the same time,” said MSF’s Roberts, referring to how some Western governments have described measures to curb the spread of Covid-19. “Because it’s really unacceptable socially and politically to have people dying in the streets."
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