Author: Humanitarian Health Ethics Research Network

By Gojjam Limenih

Gojjam Limenih, is a senior lecturer and researcher of Public Health, The University of Gondar and an Advisory Council Member, Ministry of Science and Higher Education of Ethiopia (MoSHE). 

Ethiopia may not yet have witnessed the worst of this pandemic. In times of health crisis, such as the COVID-19 pandemic, we need our health systems to be working at their very best. This means that we need to trust our health system; health workers must have the equipment they need to do their job while protecting themselves and others, and healthcare must be accessible for all. Ethiopia’s health system and infrastructure is weak. The latest readiness assessments from the WHO indicate that there is extremely limited intensive care capacity for the treatment of severe COVID-19 cases if the surge comes[4]. The ability to treat severe forms of COVID-19 will depend on the availability of ventilators, electricity, and oxygen, all of which are scarce in Ethiopia. As the Ministry of Health reports, currently, there are only 600 ventilators for over 100 million people [1,2]. Even securing a supply of personal protective equipment (PPE), the first line of defence at the individual level, remains a major challenge.

Strategies and innovation in the face of the unprecedented    

The challenges our country faces in mitigating the spread of COVID-19 are enormous – however, there have been a range of proactive and coordinated efforts to respond to the pandemic. The government has been mobilizing different stakeholders and devising strategies to contain the virus through aggressive health measures and law enforcement. In order to reverse the rising numbers of infections, broader suppression measures were put in place, including closing schools and universities, prohibiting gatherings and promoting “social distancing” to the entire population. The current focus is reducing transmission of COVID-19 through individual and population-level measures, including personal hygiene, physical distancing, testing, isolating and tracking contacts and travel restrictions.

Ministry of Health (MOH) and National Public Health Institute (EPHI), provide regular updates (i.e. held press conferences) to inform the public. The Ministry is also working with a network of experts to coordinate regional surveillance efforts, diagnostics, clinical care and treatment, and other ways to identify, manage the disease and limit transmission. But hospitals are struggling to cope with COVID-19 as they face bed shortages, ICU equipment and testing facilities. To ease this pressure, shelter hospitals are ready and taken as a crucial step to isolate, treat, and triage patients with mild to moderate COVID-19. Hence, large, temporary hospitals are prepared by converting public venues, such as exhibition centres, into health-care facilities to isolate patients with mild to moderate symptoms of an infectious disease from their families and communities, while providing medical care, disease monitoring, food, shelter, and social activities. In Addis Ababa, Millennium Hall and other large avenues are ready for this purpose, which will help to isolate and treat more people who are infected. Many investors are lending their hotels to be prepared as quarantine centres and hospitals which will be crucial to contain the virus. 

Social cohesion and social gatherings are of great importance for Ethiopian society. Churches and Mosques are now closed to limit the spread of the virus. Instead, the government and religious authorities have worked together to launch a television program for all major religions to broadcast their spiritual education so that their followers can continue to observe their faith while staying at home. Nevertheless, the battle is real to keep people at home when the one thing that is so meaningful to most—their spiritual engagement— has been taken away by the pandemic. 

The arrival of the virus in Ethiopia has also given rise to local innovation. There are promising efforts to promote home-grown production of PPE to manage the spread of the virus. Factories in Addis Ababa and other manufacturing hubs have started producing alcohol-based cleaning solutions and hand sanitizer for distribution to high-risk areas. Textile factories are now focused on producing more face masks. Most of the universities are producing hand sanitizers and distributing them to the nearby communities. Researchers and students at Addis Ababa Technology University and manufacturers are working to assemble ventilators from locally sourced components. Notably, all these fast-moving efforts help to stay ahead of the virus long enough to put into place testing, contact tracing, and isolation, as well as temporary intensive care facilities. However, there is a need to better coordinate these scattered innovations towards the goal of greater long-term effectiveness and efficiency in fighting against COVID-19.

Recognizing limitations and uneven impacts

The present efforts to limit the spread of the virus are very encouraging. However, physical distancing and hand washing, globally adopted interventions to combat the spread of COVID-19, remain a major challenge in the context of overcrowding, poverty, and weak health-care systems.

The different measures in place are also urban-centric educational campaigns through media outlets that don’t consider the reality of rural society. It is only those with the privilege of access to radio and television that may hear about coronavirus risks, but not in great detail. Reaching out to the most vulnerable population in rural areas is vital. 75% percent of the Ethiopian people live in scattered rural villages. It requires special attention to prevent the spread before it gets to the villages. If it gets there, there may not be much room for intervention. Access to safe water and sanitation is low in Ethiopia, which inhibits people’s abilities to limit the infection. For now, the isolation of rural villages might shield them from the worst of COVID-19. But the absence of facilities and services makes the possibility of an outbreak in such areas particularly troubling. 

Another challenge for Ethiopia concerns the feasibility of the pandemic suppression strategies being applied. While Ethiopia didn’t decree a complete lockdown, forcing all but the most essential businesses to close down or operate online makes sense to control the spread. But such approaches will hit some people much harder than others. Self–isolation and staying at home mechanisms work very well to a certain extent if there is regular money coming in, but it doesn’t work as well when so many are living on the edge of poverty. Poverty maintains its deep grip. Many live on what they earn each day, and won’t eat if they can’t work. 

The pandemic has left many Ethiopians with the unenviable choice of either feeding their families or protecting them from COVID-19. The problem with approaches that do not take into account inequities is that these can end up limiting sustainable interventions. Evidently, more community engagement to develop culturally and contextually feasible health promotion activities is crucial in the fight against a disease such as COVID-19 and beyond. 

While infection control and mitigation strategies have uneven impacts across Ethiopian society, the COVID-19 pandemic is underlining the fragility of Ethiopia’s health system. Access to basic health services remains the exception rather than the norm. Access to health care is severely limited, especially in rural areas. The spread of COVID-19 in Ethiopia is as much the product of its fragile health system and social inequalities as it is about epidemic dynamics. 

The pandemic has created social panic, as contagious and dangerous as COVID-19 itself. As the sharp increase in infections is observed, worries ranging from the ability of strained healthcare systems to handle a severe outbreak, to the effect of the restrictions will have on those in the informal economy, play on people’s minds. Unless properly handled, the situation will create social unrest in the near future. COVID-19 is profoundly affecting people’s finances, with mental, physical and social health implications that will linger for years to come. As we anticipate the long-term social, economic and health effects of the pandemic, Ethiopia needs to address vulnerability and inequity to ensure communities rebound. 

The grand lesson? COVID-19 has presented the world with myriad opportunities for revising, rebuilding and renewing health systems. What we need now is a firm resolve and global action to rectify inequity. While it is hard to overhaul systems in the middle of a crisis, it is evident that health system strengthening in Ethiopia has to be a top priority. It is an unprecedented opportunity for the country to dig deeper into what really needs to be done, for the future health of Ethiopian society.

References

1. Ethiopian public health Institute COVID-19 daily update (EPHI), www.ephi.gov.et May 17 2020.
2. Ethiopian Ministry of Health COVID-19 daily update; www.moh.gov.et/ejcc/en, May 17 2020
3. Africa Joint Continental Strategy for COVID-19 outbreak: AU, Africa CDC, 2020 
4. WHO COVID-19, situational report, 1-3  www.who.int/emergencies/diseases/novel-coronavirus-may 8, 2020/situation-reports

By: Sekou Kouyaté

“As a member of the Humanitarian Health Ethics Research Group (HHERG), your presence is requested at a Dissemination and Workshop Event in Geneva, Switzerland hosted by CERAH (Centre d’enseignement et de recherche en action humanitaire de Genève – Geneva Centre for Teaching and Research in Humanitarian Action) from 23 September to 28 September 2018…”

When I received this letter on July 9th, 2018, I was overcome with joy and hope. First, joy: for the feeling that I will become known by several colleagues I had corresponded with for over a year, and never met, and have the opportunity for them to hear me share my thoughts first-hand. Hope:  to meet international researchers in a renowned city. I immediately agreed because, as an African research assistant, the opportunity to participate in a workshop in Europe that focuses on public health research which affects thousands of Africans is rare and therefore impossible to refuse.

The first step for this trip to Europe, I quickly learnt, posed an immediate challenge. I was to obtain a visa at the Swiss embassy located not in my home country (Guinea), as there was no such embassy in Guinea, but in Ivory Coast. Travelling there was costly. My economic limitations made me begin to lose hope, as travelling there overland would take days, and a plane ticket would cost 300 USD. The visa itself would cost 60 USD. Luckily, these financial concerns were short-lived. As soon as my Canadian supervisor and professor, Elysée Nouvet, heard that I needed to travel out of country for my application, she assured me all costs of this process would be covered by the project, and sent me the funds. I was off to Abidjan.

The submission of the application files, and the discussions that followed did not allow me to expect a departure to Europe. Neither my commitment to return to Africa after the workshop nor the invitation letters from CERAH and HHE, and the authenticity of my own files were sufficient or reassured the Swiss Embassy to grant me the visa. I was granted an interview at the embassy in Abidjan. During interview with more than one official, I was told that I seemed honest enough, but inevitably as a young African (I was 40 at the time), I essentially posed a risk of illegal migration. It seemed impossible, statistically and socially, to the officials, that I would return to Guinea if I made it to Europe. I was stunned, and frankly offended, that it was assumed no African would choose to stay in Africa if given access to Switzerland. I entreated my interlocutors with as many details of my commitments in Guinea. My father had been a diplomat, and I knew the situation was delicate and not in my favor. I learnt that my lack of PhD seemed to evoke distrust in and of itself: how could a socio-anthropologist without a PhD (from Africa) have enough to contribute to a workshop to merit his invitation to such an event? In the end, the interview lasted less than an hour. I felt devalued and judged. I felt I was being seen as a potential criminal and liar, which was like being called a criminal and liar. I am a deeply religious man, and my word was my honor, but this meant nothing. I showed them proof of dependents in Guinea and two small children, as well as research positions that were contingent on my ability to conduct interviews and analysis in Guinea: this was insufficient.  

From the Ivory Coast, grief, shame, and disappointment filled my heart and my head. These combined to create in me a feeling of profound rejection. I did not answer my phone for several days afterwards as I processed what had happened. This failure to obtain a visa was not only a notification of non-participation in the workshop. It was confirmation of the existence of unfair assumptions about the inherent appeal of moving to Europe for all Africans, and the bias of visitor visa granting based in colonial thinking and policy.  It was then that I lost all hope that the symbolic partnership would be transformed into an authentic partnership between researchers from the South and the North.

I write this short piece, because I think it is worthwhile to record. I aim to share my experience with all the decision-makers in health research, in humanities and policies, so that processes for visa applications and approvals for researchers from the south be rethought. Colleagues from the north come to Africa with ease, and with relatively limited worry over visa. Current policies strike me as unfair. They are also extremely costly, stressful, and even depressing. If we are serious about decolonizing research, there has to be more support for the mobility of African researchers to partake in international events where their contributions will be discussed. It is time to replace rhetoric. It is no longer acceptable for Africans to be on the receiving side of lessons from non-Africans. We are not just part of research to color the soup. 

During seminars and workshops in Europe, the consideration of the perception and experience of African researchers beyond Skype is an important element in the re-foundation of this cooperation. In the relationship between southern researchers and colleagues from the European and North American continents, it should be mentioned that the only initiative that can achieve sustainability is the one which facilitates the free movement of researchers.  

It is regrettable to consider that in the 21st century, the remnants of colonization are still visibly persistent in health research, while security, international trade and politics have been able to repaint the board. Nowadays, political advisers, diplomats, and security experts are no longer worried about their status (beginner, intern and senior) for obtaining visas to travel to Europe or America.

In the context of public health, Africa is considered a research site on diseases (infectious, non-infectious, neglected, experimental studies…). For a better understanding and consideration of the experts’ recommendations to policy makers and financial partners, it is necessary for Africans to participate in disseminations and to be given a voice in explaining the perceptions, reactions and representations of diseases. After all, the idea of the principle of justice is one of the pillars of health research ethics.