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There is much talk about Africa’s weak health systems, faced with Covid-19. It is true that Africa lacks the advanced facilities found in Europe and North America. But Covid-19 is an epidemic, and epidemics respond to old-fashioned public health measures.
Recent research established that there was a much more effective response by the local health system to early phases of the Ebola epidemic in Sierra Leone in 2014–15 once medical responders knew what they were dealing with and had basic protective equipment. In fact, Sierra Leone set standards for tasks such as contact tracing that countries like the UK have struggled to emulate during the current pandemic of Covid-19.
So, beware the pessimists! The idea that because the epidemic is bad in Europe or North America it must be far worse in Africa reflects a knee-jerk mentality of racial and technical superiority. There are as yet no technical solutions to Covid 19. Suppression will depend to a large extent on community responses. This is an opportunity for Africa to map out its own social pathways to epidemic control.
Recent experience with Ebola in West Africa and the Democratic Republic of Congo has useful lessons to offer. One instance where recent African experience may be relevant to Covid-19 concerns ways of reducing pressure on regular medical facilities through timely deployment of field isolation units.
In Ebola in Sierra Leone these were known as Community Care Centres (CCCs). CCCs were quickly erected temporary facilities staffed by medical and community volunteers. Some were in tents, while others were in repurposed school buildings. Wells and pumps, additional toilets, and generator houses were quickly added. They were located in communities where cases were just beginning to occur, and served as triage centres, testing and isolating patients and treating other sicknesses.
Because the centres and the staff were local, they were more readily trusted by patients and their families than distant and larger Ebola Treatment Centres, around which dark rumours swirled. As a result, cases were reported by family members and tested more promptly, resulting in reduction in community spread of the disease.
Something similar may now be needed for Covid-19. Experience shows that this new respiratory corona virus spreads very quickly, especially in regular hospitals, where patients admitted for other diseases can succumb in large numbers. In these conditions, having an advanced medical care system is not an advantage. Better community care arrangements are needed, and might make a crucial difference.
The turn to community-based treatment is in any case now a general trend. Field hospitals are springing up across the world in order to cope with numbers and keep Covid-19 cases and out of mainstream hospitals. Sierra Leoneans will have been surprised to see what is to all and intents and purposes an Ebola-style Community Care Centre spring up in Central Park in the heart of New York.
Covid-19 is different from Ebola, however, and these differences need to be carefully noted.
Without treatment, death rates with the Zaire species of Ebola Virus in the West African outbreak in 2014–15 were around 70 percent across all age groups. Covid-19 probably has a death rate of something less than one percent and is much less dangerous to the individual, particularly the young and healthy. This means that care-in-the-community is much less risky.
Its propensity to spread, however, is somewhat higher than Ebola (with an Ro (reproduction) rate of about 2.5, compared to 1.7 to 2.0 for Ebola). Shortage of approved, reliable infection and antibody tests means it is also more difficult to prevent spread in the community through contact tracing and isolation.
The biggest difference, however, is the total caseload generated by Covid-19. This means that infections might reach 50–60 per cent of the total population. So even with a death rate of only about one in a hundred eventual aggregate deaths in African countries are likely to be far higher than the total numbers of deaths resulting from recent episodes of Ebola. The high numbers of individuals living with HIV or TB are at risk and will fuel the spread. The dislocation when the epidemic peaks also results in many deaths from other diseases through health facilities having no spare capacity to treat them.
Given this scenario, and the urgent need to reduce nosocomial (hospital-based) infections, the return of CCCs to handle excess cases is almost unavoidable, both to provide care for patients, and protection for health workers dealing with other diseases, during the peak weeks of infection (a period likely to last from six weeks to three months).
It seems likely that the return of the CCC will unfold as almost a natural process, according to the following scenario.
Cases of Covid-19 start to arrive at a community health centre mainly dealing with maternity and malaria cases. The nurse in charge does not want these highly infective patients mingling with the pregnant mothers, so she asks community volunteers to build some simple sheds with sticks and thatch as quarantine booths for the sick.
Directed by the town chief, the youths of the town or village do this construction work on a nearby primary school playing field (the school is closed due to the epidemic but has toilets and a water supply).
The nurse, well-supplied in advance by a vigilant Ministry of Health, distributes camp beds and a few other necessities for these makeshift isolation bays. She asks the families accompanying the patients each to designate one person as the carer and gives that person some basic items of personal protective equipment.
The other members of the family then busy themselves preparing food and bringing water for the patient and carer, leaving everything at a marked boundary over which only the carer passes to attend to the patient. From a safe distance the nurse herself advises on palliative care and medication.
In time, as case numbers rise, a small makeshift settlement of quarantine huts arises, with roofing reinforced by tarpaulins for the advancing rainy season, and now attended not only by family carers but also by paid medical ‘volunteers’ of the kind previously recruited in Sierra Leone for Ebola CCCs.
These medically trained auxiliaries assist some of the most severe cases with palliative medication and with ‘field’ breathing equipment. The US army has access to some suitable equipment, and other devices that will work in ‘field’ conditions are currently being developed (e.g. by a group of engineers and medical researchers at University College London working with the Mercedes Formula One racing engineering team).
Covid-19 CCCs will require infection control – including hand washing and disinfection of surfaces. Seemingly, covering the mouth is a really important way of reducing spread of infection, not least from those not yet aware they are ill, so face masks or improvised mouth covering with head ties and scarves will be necessary. In fact, this should be encouraged right across the community.
If possible, volunteers should also have professional-level personal protective equipment. But the consequences of slip-ups are not so severe as with Ebola, since most cases will result only in a mild sickness. This means that security details, and the strict delimitation into red and green zones of the Ebola CCC can probably be dropped.
The extent to which these emergent nursing camps might offer medical treatment is as yet unclear. This probably depends on the extent to which there is a pool of medically-trained volunteers. In Sierra Leone faced with Ebola this pool was much larger than anticipated. Trained but not yet employed nurses jumped at a chance to showcase their skills. It will also depend on the rapid availability of large quantities of ‘field’ equipment for assisted breathing – contingent (as noted) on international funding and supplies.
If we assume that 10 per cent of the population of a country might be sick at any one time during peak weeks of the epidemic, and that severe infections account for about 5–10 per cent of all cases, this implies having up to 5,000–10,000 temporary beds, in sheds on fields, per million of the population, if these cases are to be kept out of hospitals and health centres.
National governments and local authorities should start to plan the logistics for these ‘mushroom’ Covid-19 CCCs right away, including acquiring tents to replace the thatch shelters against the arrival of the rains. Suitable sites should be identified and an intensive community engagement programme launched to explain the need for these isolation annexes, and what communities can contribute. International aid agencies should locate the funding for this kind of activity.
The epidemic will be no less intense in Africa than elsewhere, and initial steps will do no more than reduce the eventual peak. United States President Trump thought that Covid-19 would end by a miracle, and his country is in now facing a major crisis as a result of poor policy choices and lack of strategic planning. Africa generally looks to the developed world for technical knowledge and advice. But there are, as yet, no technical solutions for Covid-19. The only viable current options lie in social and behavioural realms. Africa has rich reserves of social knowledge and behavioural inventiveness and should now plan to deploy these resources. Thinking through the challenge of protecting health facilities with improvised community care is one of the areas in which this knowledge and ingenuity will be vitally important.
 Ebola Gbalo Research Group, 2019, ‘Responding to the Ebola virus disease outbreak in DR Congo: when will we learn from Sierra Leone?’, The Lancet, 29 May. Available at: http://dx.doi.org/10.1016/S0140-6736(19)31211-5.
 Mokuwa, E.Y., Maat, H., 2020, ‘Rural populations exposed to Ebola Virus Disease respond positively to localised case handling: evidence from Sierra Leone’, PLoS Negl. Trop. Dis. 14 (1): e0007666. https://doi.org/10.1371/journal.pntd.0007666.
 Christensen, D., Dube, O., Haushofer, J., Siddiqi, B. and Voors, M., forthcoming, ‘Community-based crisis response: evidence from Sierra Leone’s Ebola outbreak’,AEA Papers and Proceedings, https://escholarship.org/uc/
 Nacoti,M., Ciocca,A., Giupponi,A., Brambillasca,P., Lussana,F., Pisano,M., Goisis,G., Bonacina,D., Fazzi,F., Naspro,R., Longhi,L., 2020, ‘At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation’, NEJM Catalyst Innovations in Care Delivery 1 (2).