As at 1:00 am yesterday, Accra, Kumasi, Tema and Obuasi are in lockdown. Ghana joins scores of countries around the world that are enforcing some form of restriction on movement in part or all of their territories in the hopes of slowing down the spread of COVID-19.
The disturbing scenes from hospitals in Lombardi, Italy’s best regional health system, are reason enough to give serious thought to imposing such restrictions.
The reports that almighty New York City – the jewel of American capitalism – will be out of medical supplies in a week merely reinforce the message. The restrictions on movement in Ghana are scheduled to last for two weeks as the Ghana Health Service and Ministry of Health race to catch up with the marauding virus.
But my DMs are brimming with questions from folks who are still unclear as to what the lockdown is actually supposed to accomplish, and many more so as to what it will not. Welcome to social distancing on steroids.
Why do we need a lockdown?
COVID-19 is not as lethal as most of the viral villains that preceded it over the last 40 years. It even discriminates in that respect by age and health status, a courtesy which its predecessors like SARS, Ebola and MERS generally did not extend. For young people, it can feel like a bad flu or even just a persistent cough. But 1 out of every 5 people over the age of 80 who contract it will die from respiratory failure or some other consequence of viral pneumonia. People with chronic conditions like diabetes and heart disease are also particularly at risk of developing life-threatening illness, as are all those whose immune systems have already been compromised by other infections like HIV.
But, altogether, the fatality rate generally ranges between 2 and 3%. At least so far. So why all the disruption and chaos for a virus that kills two out of every one hundred people? After all the original SARS virus killed ten out of every hundred, and MERS claimed the lives of about 34% of the afflicted.
The answer lies in two traits of the novel coronavirus: its infectiousness and its mode of transmission. The first estimates the probability that a healthy person who is exposed to the virus will go on to develop an infection. But the second is about how exactly it is passed on from the infected to the healthy.
This is where COVID-19 excels. It is caused by a respiratory virus, which means it can spread without direct contact. A cough or sneeze from an infected person close to you is quite enough. This is why “maintaining appropriate social distance” is now a part of our common vocabulary, or at least should be.
But the coronavirus is also incredibly opportunistic in its ability to spread indirectly by sticking to commonly used surfaces. And it exploits one of our most common subconscious actions to finish the job. We touch our faces an average of 20 times every hour, and each of those times provides the coronavirus with an opportunity for infection if we do so with “dirty” hands that have come into contact with it. I say “dirty” because visually clean hands are still suspect.
This is why “washing your hands with soap under running water for 20 seconds” is now part of our common vocabulary, or at least should be.
Therein lies the challenge. The ease with which COVID-19 jumps from person to person is staggering. Under normal social conditions, one infected person will infect about three others every three days. In epidemiology, the number of infections resulting from a single individual is known as the basic reproduction number(R? for the nerds in the crowd), and the three days it takes to generate those new infections is known as the serial interval.
The explosive spread of the virus is such that although its fatality rate is relatively moderate, the sheer number of people who may get infected is astronomical. And with a large enough pool of cases, the worldwide deaths could number in the millions. Germany, for example, expects that 70% of all of its citizens could be infected before this plague passes.
A 2% mortality rate there would amount to just over a million deaths. That level of trauma, replicated globally, is simply untenable. We do not as yet have the benefit of a vaccine or cure – both are probably at least a year away – so we are dependent on social and behavioural change to avert this disaster.
What does this mean in a practical sense? One way is to focus on individual behaviour change as a means of reducing the likelihood of getting or passing on the virus. This is where good hand hygiene and limited face touching come in. But people are people, and old habits die hard. I literally touched my own nose after I wrote that last sentence, and some of the conversations about handwashing in my WhatsApp groups make me scared of shaking hands ever again.
So the alternative is to reduce the rate of spread by disrupting normal social conditions in order to reduce the opportunities for transmission. To do this, we have to reduce the number of healthy people who come into contact with others infected with the virus. And one of the more drastic measures in this respect is an enforced lockdown, the quarantine of everyone in a given community from everyone else. No contacts mean no spread.
It is a numbers game
A lockdown is, in essence, a game of averages that goes back to the basic reproduction number. That statistic is a product of the raw infectiousness of the virus and the number of people an average person in a community comes into contact with on a daily basis. The first variable in that equation is fixed; the infectiousness of a virus is an immutable feature that is encoded in its biology and ours.
It simply does not change unless its genetic coding does. But the second variable is a reflection of the dynamics of social life in a community. How communal is its culture? How densely populated is its area? How multigenerational are its households? How young is its population? How much freedom of movement does the society guarantee? How is commerce conducted in its economy?
The answers to those questions determine how often members of a community come into contact with each other, and each of those contacts is an opportunity to pass on or contract the disease. If they amount to a highly engaged, interactive and youthful society then the basic reproduction number will typically be higher than that of a more individualistic, isolated and older society for the exact same disease.
A lockdown does not change the biological infectiousness of the COVID-19 virus, but it can change how frequently it is passed on during the period if it is effective in reducing the average contacts per person over the course of its enforcement.
The question, then, is what the specific target level of interpersonal contact should be and how intensive the lockdown must be to attain it. Again, we return to the basic reproduction number. To kill off a pandemic, it must fall below 1. A basic reproduction number less than 1 means that each infected person cannot pass on the virus to a “full” person.
This happens when an infected person comes into contact with so few people over the lockdown period that passing on the virus to a healthy person becomes highly improbable by virtue of the physical distance between the two and the minimal overlap in their environments. This is extreme social distancing, and to achieve this in Ghana we would need to reduce our average daily contacts by about two-thirds.
To actually kill off the pandemic in the lockdown hotspots, however, there will have to be no more importation of cases, and it would have to last a lot longer than just two weeks. The latter is almost certain, and the former is highly unlikely. So, in reality, it is a question of slowing down the rate of spread by as much as the real-world conditions will allow.
There are, however, people whose work is considered essential to the functioning of the State, the maintenance of public order, and the sustenance of life and living standards. These individuals cannot be expected to abide by the lockdown regulations, and their exemptions will mean that not everyone will actually reduce their daily contacts in a meaningful way. But, again, this is a game of averages.
If all the rest of the “non-essential” folk do abide by the rules, they should balance out the continued activities of the excluded individuals the exemptions granted are not overly broad and systematically abused. The combined average activity of the two groups could still result in a meaningful net reduction in contacts, but the latitude of the exemptions must be based on technical objectives and not merely on convenience and political calculations.
It is not a magic trick
The lockdown of the hotspots is one of the sharper weapons in our fight against COVID-19, and it can flatten the pandemic curve if it lasts long enough (two weeks may be a little optimistic). But the lockdown is only a treatment for a pandemic, not a cure. While it will deal with what comes after it goes into effect, it will do absolutely nothing about all the cumulative transmissions of the virus that have occurred so far. All of those people infected before the lockdown will still be infected after it, many will feel unwell, some will still need to see a doctor, and a few will still need life-saving medical care. Those facts remain unchanged and their consequences are unavoidable by the mere declaration of the lockdown.
The lockdown will not reduce the total number of people who end up getting infected in the long run either if a vaccine or cure is not found before it is over. Fewer people will be infected and new cases will appear less frequently in the enforcement window, but there will still be some ongoing transmission. It will simply take a much longer time for everyone to get infected because movement is more limited and contacts less frequent. What a lockdown represents, in reality, is a stalling tactic. It will limit the rate of new infections, but its effects will not be felt for at least two more weeks.
The announcement of the lockdown will not rewind the clock on the cascade of events leading up to it. Such a decision is understandably complicated, especially in the Ghanaian context. A lockdown that does not consider our socioeconomic realities amounts to a starvation order for the millions of socially and economically vulnerable people who survive on the daily hustle. No president, no party, no politician, no policymaker – could get all the necessary planning perfectly correct. It would be pedantic and unreasonable to expect that.
We elect our leaders on the basis of their moral courage and competence (at least that’s what the instruction manual says). We are justified in expecting them to have foresight and to apply themselves to safeguarding our collective wellbeing. Surprise is no excuse, and especially not when every house in the neighborhood but ours was burning.
They should not have waited for the embers to lick the roof before they started looking for the buckets. It is fair to expect proactiveness in projecting, planning for and mitigating the impacts of the worst case scenario of this pandemic well ahead of time. The signs that a comprehensive worst-case scenario plan would be necessary in Ghana have been obvious for months now, and the lethargy in preparing for a possible lockdown ultimately paid off in the delays in implementing one.
For every day between the outbreak of COVID-19 in Ghana and the enforcement of the lockdown, more and more people in the hotspots were infected. The reservoir of the virus grew larger and larger, which constantly increased the likelihood that healthy people would come into contact with the infected and subsequently contract the virus themselves.
More and more infected persons will soon transition out of the incubation period and into the clinical phase where they will actually feel unwell. The resulting pressure on the healthcare system will balloon. Critical care intake at the hospitals will continue to increase by the day while the corresponding discharges remain at a trickle, so a backlog will begin to build because there are still limitations on the energy of the healthcare workers, still only a fixed number of ventilators, and still only 24 hours in a day.
And as the number of critically ill patients funneling into the health system increases, more and more of them will not receive the critical care they need or will not receive it in time if they do. So the later into the lockdown they present at hospitals – the later into the pandemic really – the less able the healthcare workers will be to provide them with adequate care. Many, sadly, will perish for lack of that.
The more of these patients that troop into hospitals in need of urgent care, the greater the risk to the healthcare workers by virtue of their increased exposure. This will be especially calamitous if they remain poorly supplied and continue to lack the necessary protective equipment to keep themselves safe. The lockdown will not avert this.
How large a wave could this possibly be? Big. Should we measure it by the current count of positive cases from laboratory testing? No. Testing is a lagging indicator, and the results can be entirely unrepresentative of the situation in the general population. Until now, Ghana’s testing strategy has been worryingly limited in its scale and myopic in its scope.
We have tested on the basis of travel history, contacts with other confirmed positive cases, or the presentation of symptoms. But, in doing so, we have ignored the realities of local transmission, the limitations of human memory, and the proliferation of asymptomatic carriers. That is a testing strategy grounded in the false security of wishful thinking and on a tenuous grasp on reality.
To understand the potential magnitude of the problem before us – and the need for proactive planning for a lockdown prior to the detection of any cases in Ghana – we must look to the maths underpinning the situation. A single case of community transmission of COVID-19 generates 3 more in 3 days. We know that from the basic reproduction number and serial interval of the virus, and we have known that since January. At the end of the first week, there would be a total of 7.
These would snowball into 80 at the end of the second week, and about 2700 at the end of the third. In 30 days, as many as 28,000 infections could follow from that single incidence of local transmission. This is not speculation. It is science.
All of the testing that has been completed in Ghana at the time of writing would not suffice to detect the true scale of the problem that even a single chain of transmission starting on March 12 would create in 3 weeks. It is for just that reason that centering a policy plan around the number of confirmed positive cases is particularly ill-advised when testing is slow, contact tracing is inefficient, and there are multiple known chains of transmission.
The real policy question in a pandemic is not what policymakers decide to do but when and how.
That determination should be based on the epidemiology of the disease and its projections, not the languid testing and its positives. Prescience and proactiveness must be the order of the day, not reactionism and rhetoric. Otherwise we will continue to chase this racehorse with a three-legged donkey.
The how of this lockdown itself follows from its truncated planning period. The 48-hour lead time built into it saw massive congestion at fuel stations, markets, malls and other key retail locations. From the technical standpoint of COVID-19 transmission, those scenes across Accra and Kumasi made for a sharp increase in the average daily contacts in the two-day window concurrent with a sharp decrease in the average interval between those contacts. Both dynamics present optimal transmission conditions. Top this off with the mass evacuation of residents from the hotspots, among who may be infected persons including asymptomatic carriers, and you have before you COVID-19’s day of glory. And it will reap that harvest in two to three weeks.
For now, however, all we can do is abide by the rules and we should. It is in our collective best interest for this lockdown to be successful in slowing down the rate of new transmission because that will indeed help to flatten the pandemic curve in the long run. But we must be honest with ourselves about all the things it will not do, and about all the things its modalities will. We cannot relent in firming up our health system and safeguarding the health of the frontline workers who will stand in the breach for all of us in the weeks ahead.
The lockdown will not do that for us. And we must recognize the errors in the implementation of the current lockdown, learn from the errors of Italy and Greece, and act expeditiously to contain the predictable risk of outward spread to previously unaffected areas.
The lockdown will not do that for us either. The problem at hand increasingly outpaces our capacity to react, and with every additional day of delay we fall further behind in this race against time.
The lockdown may slow down the pandemic, but it is up to us to hasten our steps to catch up with it. Sophocles was on to something: “I have no desire to suffer twice, in reality and then in retrospect.”
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