BEYOND THOSE COVID-19 NUMBERS

Like a scene from a sci-fi movie, COVID-19 has changed the way we live, the way we dress, the places we go, the way we think, the way we greet and how we move. Even a little child knows better than to go and shake hands with that uncle or aunt that just stopped by.

Weddings have taken place with as little as just ten or fewer in attendance.

School graduations have taken place virtually. Football matches have taken place in empty stadiums. Parents who thought they could never master the navigations of a computer have been forced to undergo a crash course in basic computer skills to help their primary school children with homework. All those board meetings that seemed like if one was not physically present, the world would collapse have now been replaced by virtual meetings. The quadrennial summer Olympic Games have not been spared. It has been postponed till 2021. The only other time the Olympics did not take place was in 1944 due to World War II. Even as the anti-coronavirus lockdown on airports are being eased around the world, many people are still weary of traveling by air. Apart from the historic pre check ins that will emerge at the airports, one is never going to be sure of which passenger or crew member is an asymptomatic carrier. Then when you think of the ventilation systems in the airplane, one has plenty of reasons to buckle at traveling. Even when offered a first-class international ticket some people will refuse to fly because this virus does not differentiate between the first class or other classes. You must really weigh the importance of your travel against the risks. This time, not the hovering risk of accidents and insurgents but that of an infection. What is it that is putting so much fear in the hearts and minds of people? As of 27th May, 35 states and the FCT had registered the presence of the disease. This brings us to the numbers we have been seeing on our television screens every day now for the past 13 weeks. These numbers have become a regular staple and a familiar sight. No one can miss the colors of the traffic lights that connote the number of confirmed, discharged and dead persons. The colors bearing yellow, green and red. The red signifies those who died while green, those who have been discharged and yellow the total number of confirmed cases. The public holidays in May did not put a kink in these numbers. The five -day public holiday was punctuated with the daily update and increase of these COVID-19 numbers. At first glance, these numbers can be intimidating and rightly so because from the first week till now they have continued to increase and even double. The president established the Presidential Task Force on the 9th of March, 2020.

The worrisome part is that the viewer is left to make sense of the increasing numbers like a spectator watching a magician doing a hat trick. How are viewers supposed to go to bed at night or go about their daily bread without worrying at what awaits him or her with this easing of the lockdown? There's nothing quite as fearful as the unknown.

When the mash-up of numbers keep increasing and viewers are given a daily view of these numbers in token, short and sometimes elongated briefings with little or inadequate explanations about them, it becomes one of the many foci of mistrust of the government and the conundrum of explanations by some people which ends up birthing several myths and conspiracies. With a mysterious phenomenon like we have in this unseen enemy that has invaded the lives of both the poor and the rich alike, myths are bound to develop. And Nigerians are not short on imaginations. These myths would only continue to grow unless, correct and comprehensive information is given to the public. It is not enough to display the numbers with token explanations but we should go several steps further by expanding on the daily display of numbers. Some people are going as far as saying these numbers are fictitious. These numbers are very real. They are not fictitious numbers conjured up by some mathematicians or wicked magicians. These numbers represent real people. These increasing COVID-19 numbers as I've chosen to call them are instilling fear because they seem to appear mysteriously and no one is wiser about the people behind the numbers. As a medical doctor, the privacy and confidentiality of patients is of paramount importance to me. It is a sacred duty. I applaud the presidential task force team for upholding that confidentiality. However, while still upholding that trust we can expand on the numbers without infringing on the confidentiality of the patients. If three tests are conducted on one person, i.e one test that confirms the disease and two negative tests that gives that same person the all clear from the disease, totaling three tests; Are these three tests counted separately or are they counted as one because the tests all belong to one person?

Whichever way these tests are counted we are still testing much fewer than we need to. Nigeria has a population of approximately 200 million people and had carried out 60,825 tests as of 29th of May. It means we are testing ZERO per one thousand persons. In precise terms, we are testing 0.30 per 1000 people. Without increasing the number of tests, we are unable to grasp the extent and spread of this asymptomatic disease. Whether or not we have the disease, our lives are being affected by it so we need to arm ourselves with as much information as people all the while getting the correct information from the right communication channels. If the right channels are not forthcoming with information, people will create their own imagined information and then it becomes difficult to separate the truth from fallacies. The U.K and USA were testing 35.75 and 27.80 per 1000 people by the 18th of May. The UK is hoping to increase her tests to two hundred thousand per day by June.

We need to know the socio demographic pattern of these numbers especially of those who recovered and those who died. These demographics are not to satisfy our curiosity but to give us a better and clearer understanding of the situation at hand; the situation we are facing, the situation we are all going to face going forward, the situation that we don't know the end date. An expansion of these numbers will also put some sort of "face" to the numbers. Importantly, they will help us to know the weaknesses and strengths of the virus. What do I mean? If we know the gender distribution, the age range, the nationality, the residential area, the religion, presence or absence of co morbidities, occupation, the genotype, then we can know which group of persons are likely to be very sick and draw up a preventative strategy for such groups. Further, we should know the nationalities and history of travel. Hypothetically, if we notice that patients aged 15-20 years are among 90 percent of those who recovered, then it can inform our decision that only students within that age group should return to school. Plans can be put in place for the remaining age groups to have an alternative schooling at home or nearer to their homes.

The socio demographic data can also give us pointers on areas of research. If those who recovered are predominantly of a particular genotype, we can categorically know those who are likely to get better faster and expand our research on protective proteins in the blood of such persons. If an elderly age group succumbs to the disease, then we can inform those in that age bracket to remain at home even after the lock down is eased.

Also, if we notice that those from a particular residential area have tested positive like ten times more than surrounding areas, then we'll begin to look at particular communal activities in that area. The communal activities may be nightclubbing, marketing, entertainment or religious activities where large gatherings take place. Designated personnel can go there to investigate and institute preventive measures. There are so many clues that the socio demographic patterns can give us. Another number we need to know is the reproduction number or the infectivity number of the virus. This number is dimensionless. It is not a proportion. It is denoted by R. It is the potential number of people that one infected person can infect. The R value for measles is 10-12 meaning it is highly infectious. One person infected with measles can infect at least 10-12 people. The R value for Ebola virus disease is 1.5-2 because the disease is spread by direct, close and physical contact with body fluids of an infected person. Measles is spread by both physical contact and by airborne respiratory droplets. The transmission of the COVID-19 virus is by respiratory droplets when the person is 1-2 meters within someone who has the disease. The COVID- 19 virus can also be spread by direct and indirect contact with infected people and contaminated surfaces. For the COVID-19, the R value is between 3 and 7 if left unchecked. It can vary depending on the population density; how many people per square km and the control of the disease. In Nigeria, the population density is 215 per square km over a land mass of approximately one million square km. The R value can be less than 1, equal to 1 or greater than 1. It is computed using the number of suspected, exposed, infected and recovered cases. We want the R number to be less than 1. If the R number is less than 1, it means we are winning, the spread of infection is on the decline even though it’s still infecting people. If the R value is higher than 1, then the virus is winning. It means it is increasing and one infected person can infect more than one person. If the R value is equal to 1, the disease is not going away but has become endemic. It is under control of the health systems. They are not overwhelmed. In our best-case scenario, we want the R value to be zero. However, the next best scenario should be below 1 or equal to 1 when the disease is endemic but under control by our health systems. Presently, the R value is much higher than 1.

Transparency is key in a pandemic. China was not transparent about the onset of this disease. Taiwan informed the WHO about the occurrence of a respiratory disease in neigbouring China before China reported it but WHO did not act, perhaps because Taiwan is not officially recognized as a state but as a breakaway province from China. It is unknown if this delay in communication cost many lives but it is safe to assume that had the world been informed earlier preventive strategies would have been instituted earlier. Nearer home, we should be transparent in the use of Chloroquine.

The WHO recently stopped Chloroquine trials after a recent publication in the Lancet about an observational study on Chloroquine. A closer look at the study will indicate several biases and confounders that were not accounted for. There were observer and selection biases. In selection bias, the researcher might have selected an age group that with or without Chloroquine would have fared badly. There were also many confounders in the research. As an example, if I don’t eat meat and I conduct a research on meat eaters and association with lung cancer, I can wrongly conclude that meat eaters are likely to get lung cancer ignoring that meat eaters are likely to be cigarette smokers. Cigarette smoke is a cause of lung cancer and not necessarily the meat eating. However, the cigarette smoking is a confounder in my research which caused a misleading conclusion that eating meat causes lung cancer. Still hypothetically speaking, because I don’t eat meat, I might have unconsciously ignored the confounders in my study because I wanted to discourage people from eating meat. The observational study on Chloroquine that was published in the Lancet was deeply biased. The study published in Lancet was withdrawn prior to the publication of this article and WHO has resumed the Chloroquine trial. We need more transparency about what goes on in our isolation centers. People on the outside have heard about and watched different videos about patients in our isolation centers. Some of these videos are heartwarming while some are quite scary. Our presidential task force has been doing a lot of work considering the unique situation in Nigeria. There is room for improvement in the area of isolation centers. Transparency about what actually goes on in the isolation centers will quell some rumours, myths and anger about these places.

In the spirit of transparency, we can give a virtual tour of one of the isolation centers while protecting the privacy of the patients. And to reduce stigmatization, people who have been successfully discharged from there, should voluntarily talk about their experiences. Famous people who have been admitted and discharged can also champion their experiences on television, radio and other media platforms. They should let people know exactly what goes on in there so that they would not conjure up horror stories or feel that the isolation center is a prison or a death sentence. Their daily medications and activities should not be shrouded in mystery. It is this enigma of mystery that is fueling the generous imaginations of Nigerians.

Similarly, there should be transparency about what actually goes on in the treatment wards. What medications are they given? What activities do they do? Can they still communicate with their loved ones and what happens when the situation is irreversible? All these should be made transparent if we want our people to stop rumours and fears about the disease. If the presidential task force is concerned about people self-medicating on the drugs used in the treatment centers, massive, sustainable health education at the grass roots in every nook and cranny of Nigeria would go a very long way in preventing disastrous self-medication. Health Education is not a 100-meter sprint. It is a marathon. Health Education must be a sustainable, continuous process. Nigerians have always self-medicated and would continue to do so. Therefore, it is safe to give health education on use of the drugs they are likely to use when they self-medicate. It will reduce drug misuse. Many over the counter drugs we buy in Nigeria can only be bought by prescription in developed nations. Purchase of over the counter drugs is a panacea for us because more than eighty percent of the population do not have health insurance. The ability to buy over the counter drugs cuts away the direct and indirect cost of visiting a clinic or seeing a medical doctor.

The fight against the COVID-19 does not rest solely on the Government but also on the people. We need to be socially responsible. During this pandemic, we should take our temperatures at least once a day and if we have a fever, we should stay at home. We do not have to wait until we get to that bank or office and our temperature reading shows we have a fever before we know it. Once we are not feeling well, it will be good to check our temperatures. We must not become lackadaisical in the wearing of face masks, washing of hands, respiratory hygiene and social distancing. If we have been exposed to an infected person, we should self-isolate. Even as the lockdown is being eased in phases, we should stay away from crowds and not go out unless it is necessary.

In summary, our presidential task force should go beyond the daily display of numbers on the infected and discharged persons but should expand on the interpretation of those numbers by including the demographics and instituting preventive measures from their interpretations. We need to increase our testing from ZERO per 1000 persons to close to even 5-10 per 1000 persons. The recent observational study on Chloroquine published in the Lancet should also be interpreted with caution factoring the different biases and confounders in the research. Transparency in the isolation and treatment centers will quell fears, rumours and anger about these places. We need to increase the tempo of our health education and carry it to the grassroots. We also need to be socially responsible especially when we have a fever. We should not become user-fatigued in the wearing of face masks, washing of hands and in social distancing. Nigeria has a great potential and I know that together, we can win this battle.