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OPINION 

Dr Misaki Wayengera

On March 1, 2020, following a three-week period of anxiety caused by active tracing and quarantine of contacts of travelers who entered the country after a ban on entry of international travellers was declared; Uganda registered its first case of COVID-19.

These events began what would turn out to be Uganda’s more than two-year nationwide response. And yet, up to now, many do not understand or comprehend why the country responded in the manner it did, why the authorities did what they did, or even why the disease behaved so unpredictably.

The emergence of the global COVID-19 pandemic represented a new event, for which there was little knowledge and evidence even within the medical field, not only about the new virus, but also how to respond.

The closest event to this, had happened over 100 years ago in 1918 during the Spanish flu; and perhaps longer for plague in Europe.

Similarly, the differences in the stage of the pandemic in various geographic areas as the disease spread were in, at any one time a heterogeneous admixture without any one size fit all response strategy. The disease manifestation also varied widely, with the majority infected having mild symptoms (85%) and only a few, largely unpredictable, having severe (10%) and fatal (5%) outcomes.

The controversies around the effectiveness of some of the simple and easily accessible drugs like hydroxychloroquine and ivermectin, remain even within the medical field.

The continued evolution of the virus between dangerous variants and variants that are highly transmissible, but cause only mild symptoms; continues to be a focus of controversy with some predicting gradual reduction in virulence and normalisation; and others still expecting a dangerous mutant or recombinant to emerge.

Lastly, was this virus manufactured in the laboratory, or as some say, it only spilled over from bats?

First, one needs to understand the state of Uganda’s health system and its potential fragility in face of the nationwide epidemic that COVID-19 threatened to be. From the need for emergency medical response-EMR to critical care capacities, the country was wanting.

But that was not all the gap there was; but one reference facility for virus testing (UVRI), there were no dedicated COVID-19 care centers and specialists.

At the same time, there was also limited evidence on the manner of spread, pathobiology and risk factors for severe or fatal outcomes. And of course people still ask, why was Africa spared of the maim seen in places like Italy and Spain, contrary to the Armageddon predictions made due to the poor state of Africa’s health systems?

As such, Uganda’s initial response was akin to what the President simplified as the response of security personnel to the sound of a gunshot, ‘to take cover, get on your knees, wait and observe the surroundings”.

In terms of public health rationale; the slowing down of social activities was two edged, to slow the importation and local spread of the bug in the community, and to allow time to prepare, strengthen and align the necessary response infrastructure and measures ranging from laboratories to test, surveillance teams to trace infected people and their contacts, EMR teams to move the very sick, setup care centers with dedicated experts and medicines, including oxygen and community awareness.

The many TV and radio addresses by MOH and the President were largely aimed at ensuring the community is aware of not only the dangers, but emerging evidence on how to protect self and others. The phased opening and sudden return to lockdown, were all meant to titrate the number of cases to the available care capacities built.

Because COVID-19 originated in China and spread gradually to other parts of the world as a direct proportion of globalisation and urbanisation of the country at hand, it took a little longer for the less globalised countries, particularly those of sub-Saharan Africa, to report cases.

In simple terms, the number of cases reported and peak of the surges at any one time was a direct factor of the country's involvement in the global village—quick travel; and urbanisation.

So, countries like South Africa, Egypt, Algeria, Morocco, Nigeria etc all had higher numbers of cases at any one time relative to the less globalised and urbanised ones.

That said, it also meant that different countries were at different stages of the pandemic at any one time; much as some could be used as a proxy to predict what was coming, say South Africa and Kenya for Uganda.

This meant that, for example, when many European countries were locking down, we were lifting restrictions and vice versa.

Thus, the response of each country was tailored to local statistics, such that there was no one size fits all.

This made some imagine that perhaps, the local authorities were doing things contrary and unlike other countries or the prevailing body of evidence. It, therefore, suffices to let people know that each measure undertaken in Uganda was based on local data and evidence; of course with case studies from other proxy countries. For example, after the introduction of vaccines and attainment of more than 75% vaccination coverage in Europe, Europe lifted many of the restriction measures.

Many travellers from Europe then, therefore, kept questioning why Uganda, and other less developed countries still maintained restrictions. Many were unaware of the hounding and inequity surrounding vaccine access, and thereby the slow process to attain the mandated coverage for lifting restriction measures.

One of the most confusing things about COVID-19 earlier in the epidemic, was the asymptomatic nature of the infection in some of the people purported to be infected. The dancing and partying by truck drivers in quarantine, caused trouble for the health authorities as they contradicted or watered down the picture of risk associated with COVID-19, that had been communicated. It took us months to gain insight, that the risk for severe disease was partly defined by advanced age and presence of comorbidities.

Slowly by slowly, we learned that those at highest risk for severe and fatal outcomes were the elderly and those with comorbidities. Risk communication was equally slowly refined and targeted; but the confusion remained. Some who lost their relatives to COVID-19, who had comorbidities like diabetes and hypertension; further accused the authorities of fabricating cases of COVID-19 by including deaths due to other causes for the interest of justifying continued restrictions. Little did they know, severe COVID-19 was selective for people with these underlying diseases.

But even within the medical field, we are only beginning to understand the depth of genetic differences that make some people susceptible to severe or fatal COVID-19 outcomes while some people are literally protected. While many have argued that Africans might be rich in these rare variants, it is probably more of the under globalisation, low urbanisation and Africa’s largely young population, that made COVID-19 less catastrophic on the continent, compared to Europe and the America’s that are demographically different.

Another issue that has caused confusion if not unease is the hurried manner in which COVID-19 vaccines were developed and approved for deployment.

Unlike for diseases that are not declared as a public health emergency, COVID-19 received special attention and concerted effort between stakeholders and industry was made to fast track vaccine development so as to save lives and end the pandemic.

It is, therefore, true in some instances that the extent of testing and monitoring was limited, say, for safety; but it passed the required yardstick. Phase one safety trials require about only 30 to 50 healthy volunteers while phase IIA expands to just 100 to 200. With just one trial, the regulatory bodies will offer licensure for emergency use, in face of a pandemic.

This is like a risk benefit balance that the regulators have to make to save lives.

The idiosyncrasy associated with side effects, the short period of protection, and of course sometimes deaths following vaccination have all led to a conflicted body of knowledge, that drives a polarized debate to date.

Within the medical world, evidence for the effectiveness of some drugs such as hydroxychloroquine and ivermectin was largely equivocal, with some studies showing promise and others negating any benefit.

It is important to understand that, even the pathology or disease process of COVID-19 is a complex spectrum starting off with inflammation, followed by a storm of immune modulators called cytokines, inflammation of small vessels and clot formation, and organ damage.

It is possible that the benefit of these drugs depends on when the drug is administered. It is also possible that there is no physiologic benefit but the psychological hype and hope that something has been done; what the doctors call the placebo effect.

The continued mutation of the virus that yields new variants with unpredictable abilities, is still a source of confusion for many. For example, as cases of omicron were growing in Uganda, we continued to lift the restrictions and open schools; but that was because we knew from evidence derived mostly in South Africa that the omicron variant—though highly transmissible, mostly caused mild illness.

Indeed, the continued mutation of omicron with emergence of variants that are more immune evasive and transmissible, leaves the world wondering where we shall end. Shall the virus eventually burn out or run out of options for mutating; or will we have another delta version emerge. This perhaps explains the caution position taken by the WHO when declaring the epidemic over; tasking countries to continue monitor and report the circulating variants at any one time.

It remains controversial whether or not; the virus emerged and spilled over from the wild, say in bats; or it was manufactured in the laboratory starting by manipulating and enhancing a naive bat virus? Both postulates are strong and based in evidence; with indication that coronaviruses live among bats and other mammals like camels; and of course linkage to on-going gain of function in laboratories across the world; that aimed to improve bat viruses and make them able to infect and cause disease in other animal including humans.

However, it remains difficult to coin a specific number event of either of the two, as the source of the virus. Research analysing the genetic sequences of the virus has remained inconclusive to this effect.

To conclude, COVID-19 presented both a source of controversy and learning; ever challenging us to expand our thinking reasoning to accommodate a more complex approach to things in life, rather than a simple or direct cause effect.

The writer is the Chair—Ministry of Health Ministerial Scientific Advisory Committee on COVID19 and epidemics