Ugandapanda

It’s high time to deepen the discussion about Euthanasia. Cards on the table, I’m against it, but what I’m most concerned about is that we have a serious conversation rather than reducing the discussion to “People have the right to choose” on one side, or “Doctor’s shouldn’t kill people” on the other, which are both unhelpful oversimplifications. Whether we are currently for, or against euthanasia, there’s a good chance we haven’t thought about it hard enough. Euthanasia is a complex and multifaceted issue, there’s no easy way out of the rabbit hole. Here are 5 questions I think we should all ask ourselves before we decide if we are really in favour of Euthanasia.

1) Why are most professionals who work with the dying against euthanasia?
Most medical professional associations in New Zealand that work intimately with dying humans don’t support euthanasia. It’s important to consider the thoughts and opinions of people who give themselves every day for those who are suffering and dying.

• The Australian and New Zealand Society of Palliative medicine (Palliative Care Doctors)
• Palliative Care Nurses New Zealand
• NZMA – New Zealand’s largest Medical association
• Hospice NZ 

Why is there such a mismatch between the public, who are overwhelmingly in favour of euthanasia, and end-of-life professionals who are mostly against it?

2) Is one Mistake too many?
Mistakes are inevitable in any field, especially medicine. Although tragic, mistakes are acceptable while doctors attempt to save lives. Are mistakes OK while doctors end lives? Last year in New Zealand us medical professionals made many mistakes, including programming a pacemaker wrong which caused a cardiac arrest. One study suggested that 1 in every 25 people sentenced to death in America may be innocent. Is that OK? What if 1 in every 100 humans whose life ended through euthanasia didn’t really want to die? What if  perceived or real burden on their family drove them to euthanasia but they never revealed their true thoughts? Or worse received euthanasia after a mis-diagnosed terminal condition?

One 62 year old lawyer was ‘helped’ with assisted suicide in Switzerland after he was diagnosed with terminal bowel cancer. On autopsy he was found not to have cancer. He wasn’t going to die. Mistakes happen. Is there an acceptable mistake rate when it comes to euthanasia? Do you agree with famous British Surgeon Henry Marsh when he said “Even if a few grannies get bullied into it, isn’t that the price worth paying for all the people who could die with dignity?”

3) Would some people have changed their mind soon after dying?
Many people, after seemingly making the decision to end their life, change their mind and want to continue living. In Oregon, there is a different system from euthanasia where people get prescribed a lethal medication, which they then take themselves. It’s called “physician assisted suicide”. Since 1998, one in every three people didn’t take the lethal drug after being given a prescription. That’s 861 people who went through the whole process of paperwork and psychological evaluation, were given a prescription for the lethal drug then didn’t take it. Obviously it’s fantastic that they changed their mind and chose to keep living, but it disturbs me that so many people could change their mind after such a vigorous process. How many people might have changed their mind a week or a month later after they died of euthanasia?

4) Could euthanasia abuse the vulnerable?
Of all vulnerable populations, elderly are most likely to be abused, mostly by those close to them. A 2015 New Zealand report showed that 1 in 10 people over 65 are abused. Rates among Maori are even higher.  Will abusive family members pressure elderly to be euthanised? Even in loving families, could elderly people opt for euthanasia because they silently feel like a burden? Disability rights groups have expressed deep concerns about Euthanasia. In the USA, most disability advocacy groups are strongly against Euthanasia, because they can see the potential for people with disabilities to die prematurely due to abuse of the system.

5) Is this really a Progressive vs. Conservative, or Religious vs Non-religious issue?I think it’s helpful to set aside labels, and ideologies. Euthanasia isn’t automatically a “progressive” or “liberal” win, nor a “conservative” loss. Martin “Bomber” Bradbury, a prominent liberal left wing blogger is against euthanasia. On the other hand a minority of christian organisations support euthanasia, for example “Christians for Voluntary euthanasia” in Australia. One Ex Archbishop of Canterbury (Head of the Anglican Church in England) now supports Euthanansia. Should we draw lines and divide into camps on this issue, or instead think deeply and open up respectful discussions with our family and friends?

I encourage you to think through these questions (and more) deeply before coming to a decision. Euthenasia is a complex issue that I’m not sure any of us can fully understand – but we should try our best before we enter the ballot box

Yesterday South Africa suffered the 4^th highest number of confirmed coronavirus cases in the world, clocking over 12,000 cases. This meant that 2 out of every 3  cases in Africa came from only one country, South Africa.

South Africa has a similar population to Uganda, yet has suffered from 300,000 coronavirus cases while Uganda has only just clocked 1000. When it comes to coronavirus in Africa at the moment, we really should focus on South Africa.

It may seem strange that a country with 5% of Africa’s population, made up 70% of the continent’s confirmed cases, but there are a number of  reasons which might explain why coronavirus is spreading so rapidly down south.

Why is South Africa suffering?

South Africa is radically different from many other African countries. In fact South Africa has many features similar to European and American countries which have suffered terribly form coronavirus. I hope there’s no-one out there who still thinks Africa is one country, but I’m sure you won’t after reading this!

1) South Africa’s Older Population.  Older people are not only have more severe disease, but are more likely to get infected with coronavirus. This nature article estimated that those over 20 years old are twice as likely to catch coronavirus than people under 20. As well as catching it more easily, older people also more likely to spread corona as they are more symptomatic. In South Africa, 4 in 5 people are over 20, while  only 2 in 5 Ugandans are over 20 years old! South Africa’s older population facilitates easier spread of coronavirus than in other countries. This lack of spread in younger people a should also make countries like Uganda be less worried than they are about opening schools, but that’s another issue.

2) Most South Africans live in cities. In South Africa, 2 out of every 3 people live in urban areas. Around the world, coronavirus has thrived in busy, packed cities – think of the disasters in Milan, London and New York. Here in Uganda only 1 in 4 people live in urban areas, a minority of the population.

3) Colder Temperatures. We know that hot weather doesn’t stop coronavirus, but it does slow spread a little. Here’s the forecast for Johannesburg this week, perhaps not what you would expect – lows of 3 degrees!!!

4) Obesity Epidemic. South Africa has THE HIGHEST obesity rates in Sub-saharan Africa. More than 1 in 4 adults are obese, similar to Australia, Mexico and the UK. In  Uganda on the other hand only 1 in 20 adults are obese. Higher obesity rates increase virus spread as obese people are more likely to have symptomatic disease, and therefore more likely to spread it to others. Obese people are also more likely to catch influenza, and this may well be the same for coronavirus although there isn’t yet solid evidence to support this this theory. 

With all those factors driving the terrible outbreak, we hope South Africa’s public health measures and decent health system can control the spread soon. Unfortunately even if theyturn the corner in the next couple of weeks, it’s going to be many months before South Africa has coronavirus truly under control.

Our friend James has been at home from school for 3 months. His home situation is tough and while he’s been off school he got in with the wrong crowd, was taken to the police station and threatened with prison. He’s currently farming in the village learning nothing. Coronavirus has his life course is now teetering on the edge when  it was on the right track. All because schools are still closed.

Uganda’s decision to keep schools closed may be one of the worst decisions that the government has made in their recent history, yet few people are complaining. While the IMF and World Bank are lining the pockets of Uganda’s corrupt government, I haven’t heard of any call or any pressure from them or others in the international community pressuring Uganda to re-open their schools. There isn’t much complaint locally either, in the news or on the streets. It’s strange that barely anyone is protesting against a decision which will un-necessarily hurt Ugandans on a huge scale for years to come.

Before I start this thinly veiled rant well reasoned blog, I actually agreed with the decision to close all Ugandan educational institutions back in March. At the time, Covid was wreaking havoc around the globe and we didn’t know how it might affect Uganda. It was a bold, early decision that seemed prudent. But the outbreak here has not just been less severe than expected, it hasn’t even got off the ground. I’m not going to cover why exactly the outbreak might be so slow in Uganda. We really don’t know, but if you’re
interested I have mused about this elsewhere.

Coronavirus isn’t killing Ugandans’
Uganda has one of the slowest Co-vid outbreaks in the world – if you can even call it an outbreak. Only around 700 people have tested positive, and not one person has died!

Let me repeat that, not one person has died.

There is only one country in the world with a larger population than Uganda  (Vietnam) which also has no deaths. They have already re-opened their schools

To put this in context, in the 3 month period of Covid malaria may have infected around 3,000,000 Ugandans and killed 5000 people (estimated from global burden of disease). I tried to make a graph to compare the burden of the two conditions, but it didn’t work because the scale difference was so big. It’s kind of like those pictures where you compare the size of the Sun to the earth.

Yet out of fear of a disease which hasn’t killed one person we still have to wait one month to find out when schools are opening, or if they will open this year at all.

But why is closing schools such a big deal? If it can help prevent the spread of coronavirus why not be cautious? For a start we may have a year with no new doctors, nurses or teachers trained in Uganda, but the effects run far deeper. Here are just 3 of many reasons why closing schools for more than 6 months in Uganda is not just an inconvenience, but a disaster.

1) Children go BACKWARDS
Closing schools has a far more drastic effect than just lost education time. Children FORGET what they already know. This means they don’t start again where they left off, they instead have to RE-LEARN what they previously knew, but have now forgotten. This means that after 6 months off school, it might take another 2 or 3 months just to get back to their previous level. If Uganda closes their schools for 9 months, it may be equivalent to more than a year of lost education. This problem has been recognized even in countries like America, where unlikely Uganda most children are able to be home schooled.

2) INEQUALITY is exacerbated
Richer kids (especially in Kampala), can still learn when school is off. Their parents are empowered and able to teach them. They can learn on the internet. Their parents can buy them work books and reading books. They might even not go backwards, but can still progress while they are out of school.

The situation for poor kids in the village (75% of Ugandan children) is worlds apart. Kids have either sporadic access to educational radio, or no access to learning at all. They don’t have books to write in or read from. They dig every morning to provide food for the family, then play at home. They barely learn anything new, and will go backwards. Every month schools are closed, the inequality between kids in the village and kids in Kampala becomes worse. School closures causing exacerbated inequality has been well documented around the world, by developed and developing countries alike, and in Uganda will be as bad as anywhere in the world.

3) LIVES WILL BE SHORTENED.
There is a strong association between education level and reduced life expectancy. People with lower levels of education (primary school), live shorter lives on average than those with higher levels of education (secondary school or above). It’s impossible to prove that lower levels of education CAUSE lower life expectancy, but especially in developing countries like Uganda it makes sense that poor education means you are more likely to die younger.

Poor education leads to poverty, which means you are more likely to live in unsanitary living conditions, more likely to have poor access to healthcare, more likely to die in childbirth because you can’t reach a hospital. In Uganda even more so than richer countries where this link has been studied, less education may shorten your life. It’s entirely possible that the effect of lost education alone, may cause more lost years of life than coronavirus.

Figure from “Netherlands, health systems review: 2016” European Observatory on Health Systems and Policies

Other countries are reopening schools
The Co-vid situation in South Africa is ominous, with colder weather, large urban slums and an Obese population paving the way for a far worse outbreak than we will ever have here. South Africa yesterday suffered from 3174 cases with 74 deaths.  The way things are going in Uganda, we may not reach 74 deaths from Covid this year, let alone in one day. And what are South Africa doing despite the outbreak? They are opening their schools!  Their government knows how much more important education is than perhaps preventing a handful of coronavirus deaths. South Africa’s approach is mirrored by most countries around the world. Uganda is in a small minority of countries making the tragic decision to close schools for an extended period.

A solution?

I don’t usually like to write without proposing some kind of solution. Here it’s tricky, but there’s a few actions that just might push the government to open schools sooner than they would have otherwise.

1) The international community should pressure Uganda to re-open their schools.  Large organisations who grant loans and aid like the USA, the IMF and World Bank could use their leverage to force re-opening of schools.

2) The WHO should stress the importance of education and keeping schools open. At the moment they are only doubling down on contact tracing and lockdowns. They need to recognize the public health importance of education, and publically encourage countries to open as soon as possible when outbreaks are under control.

3) Most importantly, Ugandans need to demand that their government re-opens schools. Museveni is a populist. If enough Ugandans kicked up a fuss he might consider re-opening them, as it doesn’t hurt him at all. It might not even take that much fuss! At the moment motorcycle taxis are holding demonstrations around the country, but I haven’t heard a whisper about schools, and everyone has children. Everyone is affected.

Education is the key to Uganda’s future. The benefit of opening schools now would be enormous, while the consequences of keeping them closed are monumental. Let’s not let a virus which has killed zero people further cripple the future of the country.

This was the front page of Al-Jazeera yesterday, a Qatari news agency.

I’d hoped Al-Jazeera would be the one major news network not biased towards Europe and the US. Instead there are four geographical areas mentioned on their front page.

US
UK
Europe
The world….. Says it all really

News agencies are making 2 major errors that we need to wake up to, if we want to have a truly global perspective.

Error 1) Not shifting their focus to match the outbreak

As the focus of the outbreak shifts around the world, the focus of the news should shift with it. But it hasn’t. If you follow major news sites you would think that the biggest problems are still in Europe and the USA. But the virus has now gone global. It’s not all about Europe any more.

Yesterday, 12 out of the 15 countries with the highest number of cases were NOT European or the USA. This may surprise some people. Would you have guessed that India, Peru and Turkey are in the top 10?

Russia and Brazil daily cases have reached a staggering 10,000. This peak EXCEEDS the peak of any European country. Yes you heard correctly, Russia and Brazil right now suffer from more cases every day than Spain or Italy ever had. The front page of coronavirus news should be full of stories from Russia and Brazil. There is no shortage. In the last week 3 Russian doctors appear to have committed suicide by jumping out of windows perhaps due to stress and pressure from the government. You may wonder why you haven’t heard that story, but hopefully it’s becoming clear.

Error 2) Reporting like the coronavirus outbreak is improving 

Things are getting better right? Much of the focus of the media is about improving case numbers, flattening of curves. How countries are going to lift restrictions and  re-open their economies. How England is re-opening schools. How Spanish Children can now go outside, how German football is about to restart. Success stories are good and we should share them, but the media should not give the false image that the outbreak is getting better.

One headline on the Al Jazeera front page says it all “world gambles with looser lockdowns, risking coronavirus revival”. As if coronavirus has now improved, but could get worse if we aren’t careful. This is a gross misinterpretation of the global reality.

Because coronavirus on a global scale HAS NOT IMPROVED. For the last month, the daily number of cases has flatlined. Coronavirus globally as bad as it ever was.

Where are the reports on the escalating situation in South America? On the struggle to control the virus in India? On major outbreaks in Eastern Europe? The stories are there, but they aren’t on the front page of the news websites.

The media focus should shift with the virus. But it hasn’t. I guess that’s the world the media lives in. A EuroAmerican centric world. I had hoped for better from journalists around the globe.

But we don’t have to live in the false reality of the global media. We can seek out the stories that don’t get shoved in our faces. The stories are there if you dig just a little. One approach is to visit a tracking website like worldometer and see which countries have the most cases. After that you can google those countries “coronavirus in Russia” or “Coronavirus in Peru” and the stories are there. You’ll even find them on the major news networks, tucked in behind their Eurocentric front pages. Yes this is more effort than just typing in www.bbc.com but I think the world outside Europe and America deserves our attention too.

Let’s put in that little bit of extra effort to have a truly global perspective.

Uganda’s lockdown is killing people. That’s not a guess, or an opinion – It’s a fact. Every lockdown kills some people, whether in England, America or Uganda. People die through lack of access to medical services, through increased poverty. Through suicide and violence. In England, lockdown may have contributed do a doubling in deaths due to domestic violence. In Nigeria, security forces have killed more people enforcing the lockdown than the virus has killed to date.

Obviously lockdown SAVES many people as well through preventing virus spread. The best question to ask is not whether  lockdown is saving people OR killing people, because the answer is always both. A far better question is.

Will our lockdown save more people than it will kill?

This question should be asked by the public. It should be asked by analysts. Most importantly this question should be asked by policy makers – those implementing the lockdown. There’s no way to answer this question accurately, as we are forced to make many guesses with little data. Which extra deaths were really caused by the lockdown? What would the future have been like without the lockdown? How many cases of coronavirus would there have been? But we must try.

Will our lockdown save more people than it will kill?

In richer developed countries the answer is a resounding YES. Early comprehensive lockdowns have saved thousands of lives, while there is no indication that large numbers of lives have been lost through health service delays or increased poverty. Sweden did not lock down, and coronavirus has killed over 2000 people. The similar sized country New Zealand locked down hard and only 17 people have died. It’s inconceivable that the consequences New Zealand’s lockdown has led to the death of 2000 people, so New Zealand’s strategy of lockdown is to date a winner.

Will our lockdown save more people than it will kill?

In high income countries lockdown kills few people, because governments have enough resources to look after their citizens in a crisis. Health systems have the capacity to continue regular services while also dealing with a surge of coronavirus cases. Governments avoid severe poverty by handing out money or food to those who can’t work. The economic consequences of lockdown might be severe, but the immediate medical consequences are not devastating and few extra people die.

In Uganda on the other hand…

In Uganda, the situation is far more complicated. Lockdown kills people for many reasons, but these two are super important. Both affect people’s ability to access healthcare when they get sick. Lockdown reduces access to health services is by making transport to healthcare facilities difficult, and by squeezing the poor financially.

1) Reaching hospital is now VERY difficult. This is the biggest tragedy of Uganda’s lockdown. Usually when people get very sick in the village, most people will hop on a motorbike taxi to reach the hospital. Right now however in many areas the army and “local defence units” prevent any movement on motorbikes. Motorbikes refuse to carry people even if the situation is desperate, so if you get sick you are in big trouble. There is more and more flexibility compared to a few weeks ago, but this remains a major problem.

 2) Already poor people become destitute. When you have a dollar in your pocket, if your kid get’s a fever you might to your local clinic and pay for a malaria test. If you don’t have a dollar you might stay at home and just hope your kid improves. Sometimes they don’t.

But how many people is lockdown killing?

That question is the big problem. It’s relatively easy to quantify coronavirus deaths, but it’s extremely difficult to estimate how many people a lockdown is killing. Uganda doesn’t keep meaningful death statistics so it’s impossible to know for sure if more people are dying during this time.

So I’m going to do something a bit outrageous.

I’m going to guesstimate how many people the lockdown might kill every month. This is unscientific, flawed and I may even make mathematical errors, but I’m going to do it anyway to illustrate just how many people lockdown might be killing. How will I do it? I’ll use a baseline estimate of the number of deaths that would have happened anyway, and then add a small percentage which might be caused by the lockdown. I’ll include only 4 causes of death which are likely to have increased under lockdown. Infectious diseases, maternal and neonatal mortality, chronic disease and physical violence. 

I‘ll be super conservative and assume that mortality for each cause of death won’t increase by much. I’m going to assume that mortality will only increase by between 2% and 10% for each of these causes of death, with a best guess of 5%. For the baseline mortality figures, I use estimates for Uganda in 2017 generated in the peer reviewed Global Burden of Disease study.

Infectious diseases (Malaria, pneumonia and diarrhea)
Two weeks ago, I received a call from a nurse in a remote OneDay health center we operate. Our amazing nurse had identified that a 12 year old kid had severe malaria with anemia. He desperately needed blood. Motorbikes refused to carry him to hospital as they feared beatings, or the army confiscating their motorbike. After 8 hours an ambulance finally came, but it was too late. Rubanga-Kwo died soon after reaching hospital.

Besides deadly transport delays, mosquito net distribution has been cancelled this year due to coronavirus, and there is no insecticide spraying planned. It’s likely to be a horrible malaria season. Under a worst case scenario, WHO modeling has raised the possibility of a 100% increase in malaria deaths this year mainly due to lockdown consequences. 

But I’ll be conservative and not use the worst case scenario of a 100% increase. If the lockdown caused just a 5% increase in mortality rates of malaria, pneumonia and diarrhea, then in one month lockdown may have killed 203 people with these diseases.

Maternal and neonatal mortality
One of our nurses at a different remote OneDay health center delivered 4 babies last week. Before lockdown in the previous 12 months he didn’t deliver one baby. He isn’t properly trained or equipped to deliver babies, but was forced to as women couldn’t travel to the proper maternity centers and arrived to the facility late in the labour process. Fortunately the mothers and the babies are all OK, but the situation was high risk, and a recipe for disaster. We’ve now liaised with the district up a better system for referral, as well as equipping him for emergencies.

Besides the actual delivery process, getting antenatal visits to be checked up and receive iron, folate and malaria prevention has also become more difficult.

If the lockdown caused just a 5% increase in the maternal and neonatal mortality rate, then in one month the lockdown may have killed 118 people with these diseases.

Chronic diseases (Cardiovascular disease, diabetes and kidney disorders)
Last week, 7 people were supposed to come to my hypertension and diabetes clinic at St. Philip health center. Only 3 made it. The rest of course couldn’t get to the health center because they normally arrive on the back of motorbikes. Without their regular medications, those people  are at higher risk of heart attacks and strokes.

If the lockdown caused just a 5% increase in deaths due to these chronic diseases, then in one month the lockdown may have killed 123 people.

Physical violence
Under times of stress, domestic violence and suicide are likely to increase. In addition, in some countries army and police brutality to enforce lockdown is killing some people.

If the lockdown caused just a 5% increase in deaths due to suicide and interpersonal violence, then in one month the lockdown may have killed 38 people.

How many lives will lockdown save in Uganda?

This is just as hard to predict, and is based on estimating how many coronavirus cases lockdown could prevent. Based on Uganda’s young population, I’ve estimated a mortality rate for coronavirus of 0.75%. It’s hard to predict how many coronavirus cases there might be per month under a less extreme lockdown scenario, but given the relatively slow progress of the virus in Sub-Saharan Africa so far, I’ve estimated that in a worst case scenario, Uganda may experience 50,000 cases a month (average of 1600 cases a day), and 375 deaths. To give some context, so far,the most cases reported in a single day Sub-Saharan African country was 318 yesterday in South Africa.

Under a less severe scenario, coronavirus cases may not exceed 10000 monthly even without a severe lockdown

If Uganda suffered from 20000 cases a month (a midrange estimate), coronavirus might kill 150 people a month, which is far less than my dodgy (but conservative) estimate of 482 deaths caused monthly by lockdown.

This graph indicates the number of coronavirus deaths under different scenarios. First assumes the current status quo of lockdown, while the second assumes a far less severe lockdown with spread of coronavirus. The blue bar indicates the “best guess” number of deaths, while the black lines indicate the range of possible numbers of deaths under each scenario.

As you can see from the graph, there are a range of possibilities, most of which estimate that Uganda’s lockdown will kill more people than it will save. This could be the case even if Uganda’s lockdown prevented 50,000 coronavirus cases a month, which might be a surprise to many. Given this situation, it’s worth considering a serious revision of how lockdown works here in Uganda. A couple of changes could make a huge difference in reducing lockdown related mortality.

1. Allow transport for all sick people, without needing written permission from officials. If sick people could move with only a written note from their medical professional on official facility headed paper, the transport issue could be mostly solved. Of course this would be widely abused, but the deaths safe through prompt treatment of sick people would outweigh the extra risk of coronavirus spread.
2. Widespread food or cash distribution. If a government closes their country down, they are under obligation to provide for their citizens during the lean time. This is EVEN MORE IMPORTANT in poorer countries like Uganda, where many are struggling to get by at the best of times. Supplying people with food or cash will help relieve stressful social situations, and free up money to access health services. Unfortunately the Ugandan government is prioritizing vehicles, allowances and giving millions of dollars to MPs rather than providing for their citizens.

I want to stress that these calculations are more about raising the issue of balancing lockdown killings vs coronavirus killings, rather than an accurate indication of the current situation. I’ve opened myself up to very reasonable criticism as to whether it’s fair to even try and make these guesstimates, but I think the only way to get people to take this issue seriously is to try and quantify the number of people lockdown might be killing.

I would love corrections and comments on my math and estimates, so together we can improve this hypothetical analysis. If you want to understand my working better, please make a comment, or contact me through the blog.

Stay safe Uganda!

Is it too much to hope for? Can the poorest region of the globe escape the worst?

What’s happening right now in Sub-Saharan Africa is nothing short of astounding. We have porous borders, poor healthcare systems and people packed together in chaotic cities and informal settlements. By conventional wisdom, it’s a recipe for infectious disease disaster and you’d expect coronavirus would slam the region.

But no

Sub-Saharan Africa is the least affected region of the planet. By a long way. About a billion people live here. On Saturday 11^th of April only 509 cases were reported across the entire region in 24 hours.

Not 509 deaths, but 509 confirmed cases. Only 5 deaths were reported.

Including Russia, there’s about a billion people in Europe as well. On the same day East Africa reported 5 deaths, Europe reported 3143 new deaths. Sub-Saharan Africa is doing very, very well. Or so it seems. There’s a couple of obvious rebuttals to this apparent success story, which I’ll deal with with before I move on.

Isn’t it still early in the outbreak?
Yes, but this doesn’t explain the low numbers. At the same stage of the outbreak in Europe, countries did not have huge case numbers, but most countries saw case growth rapidly increase. Over the last 10 days in Sub-Saharan Africa, not only have countries been spared exponential growth, we have not seen significant growth at all! The number of daily cases for most countries is a flat line. Below I’ve graphed cases per day for the four Sub-saharan African countries with the highest total number of coronavirus cases, plus Kenya from East Africa  to really prove the point. I haven’t even included countries the raft of countries where nothing much is happening, like Uganda which had only two positive cases in the last 7 days!

Looking back a month at South Africa, the country with the most cases and the most advanced outbreak, they appeared just on the cusp of exponential growth before….. flatlining. Incredible. Wonderful!

Are countries not testing enough?
Yes many African countries have far less testing capacity than more developed countries, but while their testing capacity is INCREASING, the number of positive cases remains stagnant. Here in Uganda, we have gone from testing around 200 a day two weeks ago to testing 600 in a day. South Africa, the Sub-saharan African country with the most cases has increased testing capacity from 1000 to 5000 a day in the last two weeks. If the virus was spreading fast you would expect increased testing to increase case numbers which isn’t happening. Poor testing capacity isn’t the reason for the low number of cases.

So why is Sub-Saharan Africa doing so well?

We really don’t know. Wow that’s an unsatisfying answer, I’m sorry.

Over a month ago on the 6^th of March I predicted that coronavirus “would not devastate Uganda” My three reasons were Uganda’s young population, a rural population, and a history of avoiding flu outbreaks. Of these three reasons the young population and rural population are currently irrelevant, because coronavirus hasn’t spread enough for us to know whether our young population will lead to low mortality (no-one has died yet in Uganda!) or whether coronavirus will spread less to rural areas.  My historical observation was the unexplained phenomenon that neither SARS nor H1N1 swine flu touched Uganda, which bodes well. None of these observations however even begin to explain the tiny number of cases reported across the region.

So what could it be? Why so few cases?

Is it the weather?
There is evidence that hot weather reduces spread , but this alone doesn’t explain the lack of cases. In other hot countries like Malaysia and Brazil, coronavirus is spreading far more quickly than any African country, although still not as rapidly as in Europe. Also there are regions such as Johannesburg in South Africa where the temperature isn’t exceeding the mid 20s, yet those areas aren’t seeing large numbers of cases. We can’t praise hot weather alone!

Genetics?
Significant genetic protection from the virus seems unlikely given the high infection and mortality rates among African Americans. That population hasn’t been in America long enough (a few hundred years) for their genetic code to be significantly different from (mostly) the population of West Africans where they originally came from.

Immunity?
Could it be that exposure to many pathogens, or malaria, or some other specific disease leads to increased coronavirus immunity? This has been suggested, but there is zero evidence to back it up. I hesitate to even suggest theories with zero evidence, especially this one which has been doing the fake news circuit but we know so little that I’m clutching at straws.

Harsh lockdowns?
Restrictions on movement and gatherings are not the secret to Sub-Saharan Africa’s success. Restrictions here just can’t bring about the same degree of social distancing possible in richer countries. Families are packed together in small houses. People can’t afford to stockpile food so have to interact with sellers every day. Corruption and laxity at borders is rife.

In Uganda 13 people with coronavirus passed through the airport without being stopped, and went back to their communities. Some of them went to the market and  used public transport before they were advised to self-quarantine. As far as we know so far, those 13 only infected three people, all family members! If this kind of breach happened in a European country, it would have lead to hundreds or even thousands of infections.

Social distancing becomes a farce, as Kenyans fight to receive food in Kibera settlement.

I’m sorry I’ve come with observations and not answers, but I don’t have any.

So not only do we not know why coronavirus isn’t bad, I haven’t heard any great theories. Hopefully soon someone will come up with better ideas, although there are obviously more pressing matters in other parts of the world at the moment.

Before finishing, I want to make clear that the virus is taking a heavy toll in a different way. The effects of Lockdowns in Sub-Saharan Africa have already killed thousands of people, and continue to kill many more every day. These lockdowns have caused crippling economic and healthcare system breakdown, with wage workers struggling for food and sick patients unable to reach hospital. In Uganda lockdowns are almost certainly going to kill far more people than the virus will, and tragically perhaps more people than the virus would have killed even if there had never been a lockdown. I plan to write about this in more detail soon.

Make no mistake, Some countries in Sub-Saharan Africa will probably have outbreaks that will kill a lot of people. We may well be far from seeing the worst of Coronavirus here. But that aside, right now the coronavirus situation is more positive than any epidemiologist, doctor or even layperson could have imagined.

May the Sub-Saharan miracle continue.

Yes things seem dire, but there are actually a lot of reasons to hope that we’re going to get through this. Humanity has come a long way over the millennia, and we’ve never been in a better position to fight a global pandemic. Here are four reasons to hope.

China’s miraculous efforts
China houses 1 in every 6 people on this planet. Just 6 weeks ago China had 4000 new cases in one day. Now, for 3 days they have reported no cases of internal transmission and they only have to worry about the rest of the world bringing it in. China  proved this thing is not only controllable, but it can be decimated quickly and completely. This is nothing short of a miracle, and should give us great hope.  The west should swallow their pride and look to China for advice and the way forward.

Summer is coming!
90% of the world’s population lives in the northern hemisphere. Europe, the biggest problem zone has moved into spring. For the next 3 months it’s getting hotter and hotter there which is ideal. There’s no question that hotter weather makes it harder for the virus to spread. Summer alone isn’t going to solve the problem, but it could be just what we need to turn the tide.

Promising Medication research
Initial medication trials have been more promising than for previous viral outbreaks. These medications won’t cure the virus, but could greatly reduce transmission and mortality rates. We have to be cautious, as randomized controlled trials haven’t been completed, but it’s possible that within a few weeks effective treatments could be disseminated around the world.

The vaccine will happen
A Vaccine isn’t going to help us int the near future, but even if we fail to control the virus this year, by early next year the vaccine should save us. Over 20 vaccines are in development, and early human testing has already started. Once we vaccinate the world, it’s likely we won’t have to worry so much any more.

Keep loving amidst both hope and fear (an encouragement)
Hope is important, but it’s even more important in this stressful time that we continue to love each other every day, through both kind words and kind actions. Remember that every time we wash our hands, we love our fellow human.

“And now these three remain: faith, hope and love. But the greatest of these is love.”

Ugandan President Museveni has just announced sweeping restrictions on social contact. This might seem normal to many of you around the world except…

Uganda hasn’t had one confirmed case yet!

For 1 month (and almost certainly longer)

– All schools closed!
– No religious gatherings
– No weddings/funerals/political gatherings/concerts
– No regular market days (This cuts off large scale trading between the village and town)
– No foreigners from 32 coronavirus rampant countries (Sad for people on holiday overseas)
– Only “essential” public transport (whatever that means, maybe more bribe opportunities…)

These are (I think) is THE MOST EXTREME MEASURES any country has taken before having a case

Do I agree? Probably not. Closing schools before the first confirmed case seems  premature if you believe in your Covid testing system. If you think you are missing cases than I would understand. Perhaps Uganda could wait for the first few cases at least before pulling the plug on the entire education system. Also we haven’t seen previous influenza pandemics or coronavirus go rampant in tropical countries, so we don’t know what course coronavirus will follow in Uganda – it’s not quite Europe in winter.

On the other hand many countries that haven’t acted so early have suffered terribly, so I understand the sentiment. It’s impossible to be even close to sure what the best decision is yet, as we are still so early in the pandemic process.

More than anything, this is going to be a test of the power of the government in the everyday lives of Ugandans. Previous orders have failed both due to poor implementation and public resistance, like forcing people to register sim cards and enforcing a plastic bag ban. Will market days in remote places really stop? Will public transport slow down or will the police just cash in on extra bribe opportunities? Fear however is a powerful motivator, and will help enforcement

There’s also going to be huge grey areas. At the moment we are in the middle of launching 20 remote health centers through our social enterprise OneDay health. Are we allowed to keep doing that?

Also if you are Ugandan and keen for Uganda-specific advice and updates, St. Philip Health center just started sharing twice daily Coronavirus news and advice to help keep yourself safe. Sign up and stay informed!

First switch on your brain, then read carefully, then decide what’s right, what’s wrong, and what needs checking.

If there was ever a time for fake news to go viral, it’s now. You can publish anything with “coronavirus” in the title and people will clickity clickit. Even better if it instills fear. Who cares if a few of the facts are you know, not quite correct…

This matters because masses of us (me included) mindlessly scroll our facebook feeds, clicking on every coronavirus blog post, graphic and article. What we read affects how we feel, how we react and what we do. Every error-ridden article that instills fear can push our mental health down a notch. Or fuel a run on toilet paper. Or encourage us to stockpile masks…

I present 3 cases of fake news I’ve observed over the last few weeks, both from viral blog posts and the mainstream media.

Fake news no.1
“In Italy, doctors are having to decide who is worth saving”

When the clickbait article is entitled “I need you to read this…”, your bullsh!% radar should already be going ding ding ding. She propagated the  myth that Italian doctors are forced to decide who should survive and who dies. Currently Italian doctors  are stretched to the limit, but The Lombardy health chiefhas stated they aren’t turning critically ill away. “Gallera denied that ICU capacity was so limited that doctors had changed the criteria for ICU admissions.”

The Italian health system (and others) might well reach that point, but they haven’t yet.

Fake news no.2
“Coronavirus deaths and cases spike”

The BBC had the nerve to lead with this, after the number of new cases in China had been reducing for over a week! China had changed their case definition, which made the reported number of cases artificially increase, while the real number continued to drop. China had been doing an amazing job, and if I had to pick the headline, I might have gone for the opposite. “Coronavirus cases plummet” or “China defies the odds to control the virus”.

In this light, it’s a bit rich that the the BBC thinks that they are above major errors. “Over the past month, 12 February to 11 March, there have been over 575m page views globally to stories about coronavirus. People want trusted information and – unlike Megyn Kelly – know where to turn”. The BBC has proved more than once they are far from immune from using fake news to go viral. Another shocker was “There is no specific cure or vaccine. A number of people, however, have recovered after treatment.” By “a number of people” I take it you mean 98% percent of people? Nice one BBC… To their credit though, they did  remove this statement eventually.

Fake news no.3
“One of many tidbits of misinformation the president has broadcast during the coronavirus outbreak is his belief that warm weather will halt the spread of COVID-19. “The heat, generally speaking, kills this kind of virus,”

This New York magazine article popped up at the top of my feed when I googled “Weather and coronavirus”. Trump spouts so many lies about coronavirus and everything else, why did they bash on a rare statement that is largely true? Heat, generally speaking does kill this virus. What’s more bizarre is that the second half of this ‘publication’ contradicts the title and first paragraph, quoting a scientific article which states that hot weather will in fact, slow the spread of the virus. Absolute trash journalism!

A not yet peer reviewed Chinese study  showed that Coronavirus appeared to spread best in chilly temperatures of around 9 degrees celsius, and in a much better AlJazeera article one virologist stated that coronavirus is “not very heat-resistant, which means that the virus quickly breaks down when temperatures rise”.

This is just the tip of the fake news iceberg, and there’s plenty more coming soon so…

First switch on your brain, then read carefully, then decide what’s right, what’s wrong, and what needs checking.

This may seem like a bold statement with the probable pandemic peeking over the horizon but even based only on reason 1  (spoiler alert), I’m happy to make it. Uganda has multiple factors in its favour when it comes to Coronavirus.

Here are 3 reasons coronavirus is unlikely to be as bad in Uganda as in other countries, 3 reasons why Uganda might struggle with the virus, and 3 actions Uganda should take to mitigate the risk.

The BIGGEST REASON why coronavirus will not devastate Uganda

Ugandans are SUPER young

 It’s hard to fathom how young Uganda  is. Half  the population is under 15. Only 2% of Ugandans are over 65 years old and 9 out of 10 are under 50.

To compare this with other affected countries, China and Italy have over 10% of their population over 65.

Coronavirus mainly kills older people. The contrast between the mortality rates of the old and the young is staggering. If you are over 70, coronavirus is very dangerous – you have more than a 1 in 10 chance of dying from the disease, if you are under 50, it’s only 1 in 500.

So even if the virus becomes widespread here, few people would get severe disease, and far, far fewer people would die compared with current countries ravaged by the virus. Based on Uganda’s demographics, 0.5%, less than 1 in every 200 infected people would die from the virus.

Reason 2: Previous pandemics have spared Sub-Saharan Africa

Africa was the least affected continent (besides Antarctica) in the two most recent viral pandemics, SARS and H1N1 swine flu. We don’t know why exactly, but one factor is that diseases spread by droplets don’t do well in hot, dry conditions. Perhaps the relative lack of international travel here also means less virus is imported. Although coronavirus a different disease, it has a similar mode of transmission to SARS and H1N1 so worldwide spread may to some extent follow past trends.

Ref: Swine flu and the current (H1N1) pandemic in humans: A review. Pwaiya et al.

Black indicates countries with confirmed death, red countries with confirmed cases.        Created by Maximillian Dorrbecker, using WHO data.

Don’t get me wrong, coronavirus will reach Uganda and will most likely cause a major public health problem, but if this virus follows past trends we may get off lightly compared to countries from other parts of the world

No. 3 Most people still live in the village

 Uganda is 70% rural. Many people are still in remote villages, and only have sporadic contact with people from town. Yes people move around and there is connections  through market days and visitors from town, but most people in Uganda aren’t packed into busy cities where the virus can easily spread. This means that the virus may spread more slowly, and may be easier control. This factor is weaker than the previous two, and is based on logic and intuition rather than evidence.

Reasons why Uganda might not manage the virus well

1. Lack of government ability to implement plans

It’s ironic that although Uganda has suffered under 35 years of a one-man dictatorship, the Ugandan government struggles to implement their most basic plans. This impotence is caused by understaffed government departments, disorganized bureaucracy and (obviously) corruption. Last year the government threatened to cut phone lines off if people didn’t register their sim-cards. People didn’t take the order seriously for a long time. The deadline for registration was extended 3 times, before the government finally started cutting of some lines.

In China, when the government ordered people to stay at home because of the virus, people stayed at home. If Museveni tells Ugandans to stay at home, it might take weeks for it to actually happen. If roads are blocked to prevent virus spread, “important” people will bribe their way through. If medical supplies are needed in remote regions, corruption and poor supply chain systems will cause huge delays. Government orders and the law aren’t taken seriously, which doesn’t bode well when managing an epidemic

2. The health system (obviously), especially the lack of oxygen

It goes without saying that the Ugandan health system is poorly equipped to cope with current health problems, let alone a new viral epidemic.

One major problem could be the lack of beds with oxygen. Coronavirus kills through respiratory infection. To grossly oversimplify, the virus damages the lungs until they can’t supply enough oxygen to the body. Supplying extra oxygen to the lungs is a crucial part of supportive care in severe coronavirus cases, buying time while the body fights off the disease. Towns of 200,000 people like Lira currently have under 20 hospital beds which can supply Oxygen, nowhere near enough.

3. Co-infection with malaria

Unfortunately if coronavirus does hit Uganda hard it may well be between May and August, the heart of malaria season. We don’t’ know how malaria interacts with coronavirus, but we do know that when pneumonia and malaria combine it can be a deadly combination. Coronavirus both causes a pneumonia like syndrome, and leaves the lungs vulnerable to secondary bacterial pneumonia infections. With over 50% of the population contracting malaria up North here in a bad year, there will be a ton of Covid Co-infection and it could turn ugly.

Actions Uganda should take

 1. Don’t waste Money and human resources testing for the virus

There will be the temptation to try and roll out expensive Coronavirus testing facilities across the country. Testing may have some value in the early “containment” phase to track where the virus initially spreads, but after the virus starts to move around the country it will be an exercise in futility to test everyone with a runny nose. Uganda doesn’t have the money, expertise, or infrastructure to track the virus real-time around the country in the same way as countries like England or China.

This global pandemic isn’t like an Ebola outbreak, where experts from around the world and tens of millions of dollars descend on the affected country to track and manage the virus. As the whole planet is affected at the same time, Uganda will have to manage this largely alone, and they should focus their efforts on fundamental public health measures and treating sick patients rather than virus testing. Unfortunately I doubt this will happen, and a lot of money and human resource is likely to be wasted on futile efforts to test for the virus and track the spread.

2. Supply More Oxygen to hospitals

Oxygen is a key resource to support patients who are critically ill with the virus and Uganda doesn’t have enough for their current illness burden, let alone for coronavirus patients as well. If the virus does take hold, Uganda is going to need more beds with oxygen. There may only be a few weeks to prepare now, so we should start buying now. Every empty cylinder in Uganda should be filled, and other oxygen production devices like concentrators should also be purchased. Uganda needs to stock up in a big way, and start transporting the extra oxygen to rural hospitals as well. Ugandan hospitals need more oxygen anyway so even if the virus doesn’t hit in a big way, it’s not like the money will have been wasted.

3. Break connections between “town” and the “village”

70% of Ugandans live rurally, in clusters of households on subsistence farms. Many of these people could be protected by minimizing the movement of people between towns and villages. Simple measures could be taken. Only allowing food and commodity supply vehicles to travel on main roads, while cutting off public transport would be one simple way to slow virus spread. Uganda has a huge advantage in that most people are largely self-sufficient and produce their own food, so cutting off the town from the village for a month or two wouldn’t be dangerous.

All things considered, coronavirus may not devastate Uganda to the same degree it will other countries. Feel free to share you own views and questions!