Coronavirus: A Unique Dilemma for Ethiopia

 

Ethiopia is facing a potential unprecedented crisis from coronavirus and how she responds is complicated by factors in her culture, traditions, geography, economics, and history.

In 1963, I was an elementary school child living in the Rio Grande Valley of South Texas when I first learned about hurricanes. My father, a neurologist-psychiatrist, told us that a bad storm was coming. We had to take precautions and ride it out. This was perhaps the first time in my life I had to deal with uncertainty. Although my father looked confident I could sense that we could not know exactly what the future could bring. Hurricane Beulah hit with high winds and much rain destroying much of our town. I thought the howling winds would never end.

Now more than 50 years later I am in Ethiopia facing another type of storm. We have seen the storm form in China, attack Europe, and now with a few cases in Ethiopia it is knocking at our door. Ethiopia where I have lived since 2012 has had her share of calamity. She is an ancient civilization extending perhaps more than 10,000 years before the birth of Christ. Over the past century she has seen multiple attempts at foreign invasion, famine, and civil war. Yet her traditions and strong sense of spirituality tied to organized religion have always seen her through adversity.

As an academic physician and member of the medical faculty of Mekelle University I am very concerned and once again feeling that same sense of uncertainty I did so long ago.  How will she face this new dilemma?

The Risk of Epidemic in Ethiopia
Moritz Kraemer, epidemiologist from Oxford University, has identified Ethiopia as one of the countries in Africa most at risk based upon an exhaustive analysis of asset the country possesses or not. Now that Ethiopia has several cases documented in Addis Ababa, what are the risk for spread? Adam Kucharski and his group from the London School of Tropical Health and Hygiene predict from a pre-printed study that when a country like Ethiopia has at least 3 confirmed cases there is 50% chance for the infection to become endemic and spread.

The Effect of Culture,Economics, and Geography
Africa accounts for 16% of the world population but only 1% of health care expenditures. With a 100 million population Ethiopia is the most rural country on the globe with 88% living in the countryside. Many families have incomes less than the equivalent of $20 per month. It may take hours to a day or so to seek medical treatment in a poorly equipped countryside clinic. There is little public health education with 75% of the women and 45% of the men being illiterate. There are few hospital beds (0.3/1000) population, few doctors, and limited diagnostic facilities.

Most Ethiopians do not travel outside the country but Addis Ababa, the capital, is one of the busiest airports and hub of Ethiopian Airlines which has daily flights from around the world including China and Europe. There is little doubt that this was the vector which introduced coronavirus to the country.

Ethiopians are a “touchy feely” culture like the Italians who are so troubled now. While there is little in the way of a government social safety net the people typically depend upon long standing bonds with extended family for emotional and financial support through hardship. Community interdependence is the rule. It is not unusual for people hospitalized to have many visitors and always also to have attendants (family or friend) stay the night helping to care for a patient. Trying to impose social isolation or even just social distancing will be difficult if not impossible.

The economic principle of scarcity, meaning that great value may be placed on resources which are scarce, is strong in Ethiopia. When going to the bank, airport, market, and clinic they frequently are a bit pushy because of a fear that what they are there for while run out before they get their chance. This is no doubt a left over from the Imperial and Derg times leading to distrust of authoritative promise.

When one sees the vastness of Ethiopia, about the size of Texas, and difficulty with transportation, an initial impression is that perhaps the virus will stay only in Addis Ababa. Unfortunately, that lesson was answered years ago when the HIV epidemic started with just a few truck drivers delivering goods throughout Ethiopia.

Typically when Ethiopians who are Orthodox are sick, they will often seek spiritual healing through church services, blessings, and consumption of Holy Water.  In fact, every month I have patients with curable brain tumors who presented late only after pursuing this spiritual method.

Many regions of the country have no reserve to deal with pandemics. For example the Tigray Regional Health Bureau only has a budget of 500,000 birr ($15,000 USD) to deal with a potential coronavirus epidemic. The cost of a single coronavirus is test is currently $ 500 USD. The government must try to seek payment from the patient as it cannot sustain doing testing without it. 

There are not more than 200 functioning ICU beds with ventilators in Ethiopia. The experience in China, Japan, South Korea, and Europe have shown that if 50% of the population becomes ill, out of that about 20% will require hospitalization, and maybe 10% will need ventilator support. Unfortunately there is no way they will be able to treat 5,000 patients on ventilators.

What Will Happen to Hospitals?
Coming out of the Imperial and Derg times when social institutions like hospitals were rare and for the upper castes they are now seen as pillars of society with an implied unobstructed access. The CDC and WHO call for restricted entry to hospitals as well as the segregation of coronavirus patients to alternate facilities could provoke misplaced fears in the population. There will have to be a clear and repeated message explaining the scientific reasoning and how such measure are really best for the population.

Just like when I was a small boy, I cannot know exactly what will happen. I will stay in Ethiopia, the country and her people I have grown to love, and pray she finds her way through this test.

Interpersonal Violence and Head Injury in Tigray:Public Health Issue

The head injury problem especially that due to interpersonal violence in Tigray is a growing and significant problem which requires a public health approach.

3d CT scan of man suffering depressed fracture of skull from stone injury

Research published by Fasika et al showed that 24.8% of head injury admissions came from interpersonal violence from 2011 to 2014 which was before neurosurgery was permanently established at Ayder Comprehensive Specialized Hospital. Currently we are seeing about 10 patients a day and operating on 2 to 3 every day. Most of the surgeries we do are for depressed fractures caused by stone injury received in interpersonal violence. The age range of these injuries ranges from preschool to the eighth decade of life. We know there is a cultural proclivity to this type of injury but it is not well studied.

The hospital burden of head injury includes about 19% of adult ICU admissions and bedspace and 25% of pediatric ICU admissions and bed space. Our average daily census on the adult ward is 5 for head injury and on the pediatric ward also 5. The length of stay can vary from 24 hours to months with most of the surgical patients requiring a least a 5 days stay in the hospital.This burden acts to limit the care those suffering from other maladies can receive.

At the current time there is no public health or government plan to try to prevent these injuries.The World Health Organization has created a Violence Prevention Alliance which sees interpersonal violence as requiring a public health approach.

This public health approach to violence prevention seeks to improve the health and safety of all individuals by addressing underlying risk factors that increase the likelihood that an individual will become a victim or a perpetrator of violence.

The approach consists of four steps:

1 To define the problem through the systematic collection of information about the magnitude, scope, characteristics and consequences of violence.
2 To establish why violence occurs using research to determine the causes and correlates of violence, the factors that increase or decrease the risk for violence, and the factors that could be modified through interventions.
3 To find out what works to prevent violence by designing, implementing and evaluating interventions.
4 To implement effective and promising interventions in a wide range of settings. The effects of these interventions on risk factors and the target outcome should be monitored, and their impact and cost-effectiveness should be evaluated.

 

Diagram of WHO prevention plan

By definition, public health aims to provide the maximum benefit for the largest number of people. Programs for the primary prevention of violence based on the public health approach are designed to expose a broad segment of a population to prevention measures and to reduce and prevent violence at a population-level.

I propose that Mekelle University put together a multidisciplinary team consisting of not only physicians but also social scientists, public health professionals, police and prosecutors ( this was previously discussed with the head of the Tigray police who was interested), and government stakeholders. This type of investigation and policy development is exactly the type of activity which the University with all its resources and knowledge base should be tackling.

Research:Neural Tube Defects in Tigray Ethiopia

Recent research we have done at Mekelle University soon to be published has confirmed that there is a high rate of neural tube defects affecting the brain and spinal cord in Tigray. Experience suggests this is also the case in other parts of Ethiopia as well. At least 131 out of every 10,000 births is affected with some areas having almost twice that number. Defects result in death at birth for about 77% of the pregnancies affected, usually with anencephaly, while the 23% born alive usually have severe paralysis of the lower extremities and often need a operations to close the open spine, closure of myelomeningocoel,  and to control pressure in the brain, ventricular peritoneal shunt, for lumbar and thoracic myelomeningocoel associated with an Arnold Chiari II malformation causing hydrocephalus. Lesser numbers of encephalocoel often requiring closure were encountered as well.

Ethiopian mother hold her child with lumbar myelomeningocoel

The most likely significant cause is lack of diversity in the diet and especially failing to consume foods with the vitamin folic acid. This is usually found in green and leafy vegetables as well as fresh fruits. Cooking foods such as chick peas which may contain folic acid will destroy much of it.

Around the world these birth defects have been reduced about 75% by encouraging women to plan their pregnancy and take 4 milligrams of folic acid daily starting before conception. We are working with our research group at Mekelle University to help the Tigray Regional Health Bureau and the Ethiopian Ministry of Health come up with programs to reduce these defects but this will take time.

In the meantime we encourage all women in Ethiopia to plan their pregnancy, starting folic acid supplementation before they conceive, and practice dietary diversity. They should try to wait one year between pregnancies, and understand that breast feeding increases their need for folic acid. Very young and older women are more susceptible to having children with these defects. Other factors may be involved besides folic acid deficiency but the good news is that folic acid supplementation will likely still reduce these defects.