2020

I was hoping to have started 2020 better than this. For starters, I have totally procrastinated and abandoned this blog for quite some time. I've missed writing up a couple of movie reviews, and then the knockout punch came with the demise of one of my favourite artists - Lyle Mays. Being the glue that held the Pat Metheny Group together, I'd hoped that they would eventually bless us with another album that could stand the chance of eclipsing their 2005 Magnus opus "The Way Up". Sadly, we won't get that opportunity. However, Pat Metheny released a new album "From This Place"in February, which, it turns out, is the first album I've ever pre-ordered. I'll be sure to talk about that in another post.

However, another matter has us occupied altogether. Seems like Mother Nature turned on us in the  starkest of ways, unleashing on us the ongoing COVID-19 pandemic. Now, as a clinician, my mind is always prepared for this kind of an incident (at least in theory); when we had a teen die of Acute Respiratory Distress Syndrome (ARDS) secondary to the flu at a local hospital last year, we braced ourselves for what we thought might be the next big thing. It really took till the end of 2019 for us to develop the challenge that we've always felt lurked out there.

It would behoove me to blame Mother Nature for this specific occurrence; also, unlike conspiracy theorists, I DO NOT believe that this new virus (SARS-CoV-2) is a bioweapon. It's very insidious, and once you pair that with it's ability to "return-back-to-sender" you understand that it makes for a very dreadfully poor bioweapon. The problem here is that wildlife trade that going on in parts of China. Let me clarify that this is not me launching an attack on people's food choices, vast as they may be. While we're on the subject, I remember that (while I was in med school) one of my Mandarin Language teachers used to recite a long held gem of wisdom about food choices in Guangdong (Southern China)

"If it moves on the ground, apart from bicycles and cars, and if it flies with the exception of airplanes, then it is considered edible".

I have paraphrased it slightly, but that was the general gist. Though it was uttered in jest, living in China basically exposed us to a fair share of "exotic" delicacies. Digging into the history of the country reveals that some of these cuisine options came about in times of hardship, and we can't begrudge them that part of their past.

What is problematic, however, is how those animals are handled prior to slaughter. We've known for a long time about zoonoses/zoonotic diseases that can spread between species because we sometimes end up as unwitting sufferers of such conditions. This continues to be a relevant matter as we encroach further into other environments like forests, caves, etc. that we've been relatively isolated from. The wildlife trade in China actually complicated things a bit because by all admissions all manner of animals were held in pretty close proximity to each other; this created the perfect petri dish for a zoonosis to spread between the species, and maybe along the way it run into a multiplier species that set off this whole issue. Due to the fact that we are in the middle of a pandemic all this is a matter of speculation. Consensus seems to suggest that the virus probably originated within Bats, but the missing link in the chain prior to it making its way to humans is still a matter of research (people have suggested a Pangolin).

Regardless of the way in which this thing came into existence, the rate at which it has been able to spread so prolifically has accentuated just how much of a "Global Village" the world has really become. We saw it take root in China, and watched as it spread first to adjacent Asian countries, then made its way across the world to everyone's doorsteps. It's not unrealistic to say that it surprised everyone, but what has come to the fore is that some people have been better at dealing with this situation. The fact that Italy, Spain and France have taken quite the walloping despite their remarkably high level of healthcare is a truly sobering fact. The United States' response has, however, proved to be quite the conudrum; coupled with its late response, its president's "unique" personality, bipartisan distrust and its administrative composition, we are being treated to widespread confusion on a massive scale. In hindsight, Trump and the Republicans might be forced to admit that their "hack-and-slash" treatment of measures already put in place by previous administrations might very well be the country's undoing. Also, maybe they also need to accept that this is not a problem that can be dealt with from a strictly "capitalistic" point-of-view; this virus will not bend to accommodate our inclinations, and therefore our systems must ideally be molded for the best outcomes. 

The US, however, is not an isolated incident; here in Kenya we are suffering something similar, but on a smaller scale. Granted, this COVID-19 situation is a one-of-a-kind occurrence, and better equipped countries have also found themselves overwhelmed, what is going on in Kenya is a mess of our own making. The government won't outright admit it, but there was a particularly slow response to closing of our borders when you consider that a China Southern plane was allowed to bring 239 passengers from mainland China in late February before China had gotten control of the pandemic on its end. When pressed for answers, government officials only seemed to focus on the fallout of failing to let the economy progress in business as usual fashion; it's also likely that they feared retaliation from China if we didn't allow their flights into Kenya (I fear that our overwhelming debt owed to the Chinese doesn't give us much room to negotiate). It must be poetic justice to note now that China has its COVID-19 situation under control, it has forthright banned foreigners in possession of valid visas from returning to the mainland; they are basically doing the right thing to safeguard their borders and prevent importation of the virus back into their country.

We are currently waiting for the COVID-19 pulse to hit the country. Thus far the government has locked down the borders, stopped all international flights as of midnight March 25th (with the exception of "evacuation flights"), put in place "social distancing" measures and has initiated a dusk-to-dawn curfew (7pm - 5am); recently, concerned that 81% of confirmed cases were within the vicinity of Nairobi, they've initiated a lockdown of the Nairobi Metropolitan area to prevent the virus from spreading to the rural areas where it is felt that it might be particularly passed on to grandparents and similarly aged individuals.

The government is perhaps scared to admit its folly in this matter. A lot of medical professionals (myself included) will openly admit that the virus has already achieved nationwide sustained community spread. The numbers of confirmed cases remain low because of one factor alone: testing. This is a scientific endeavour, and the only real way for us to quantify how well we are doing in this situation is by our ability to measure the situation. The truest measure is to pinpoint the infected and to keep the infection from spreading. If we wait too long, there are other quantities of measure that will start to surface - Deaths! Ideally, we cannot afford to wait that long. The government thus far, because of the shortage of testing kits, is stuck testing those people it had forcibly quarantined as well as the symptomatic cases that are coming in to hospitals; this comes to an average of ~300 tests in a day.

I applaud the government for what they have done thus far, and for where they are headed. However, they need to set their sights higher. They already lost the first battle to keep the virus out of our borders, and we have to move on. People were not busy sitting in Nairobi as we awaited the government's "Will-it/Won't it" decision to place the country under lockdown; people already panicked and traveled beforehand to the rural areas. As insidious as this virus is (in comparison to something like Ebola), we have no idea what a COVID-19 sufferer looks like. A majority of people will suffer anything from no symptoms to mild symptoms. That is a vast range including anything from a seemingly normal person to simple upper respiratory tract symptoms (coughing, sneezing, runny nose, itchy eyes/ears/nose, loss of taste and smell, sore throat and voice hoarseness) to flu symptoms (fever, headaches, malaise, chills and rigours, muscle and joint aches, nausea, diarrhoea and vomiting).

I can't help but smile everytime the WHO/CDC adds another symptom to the list. Those of us who treat Cold and Flus on a regular basis recognize that there's nothing unique that distinguishes COVID-19 from regular flus and colds. Between the dust and pollen in the air, we also have seasonal allergies (Allergic Rhinitis) and asthma to deal with. The few people who will develop the characteristic severe symptoms will find themselves in an extremely unlucky position characterized by medical personnel's worst bunch of condition:

1. Acute Respiratory Distress Syndrome (ARDS)
2. Kidney Failure
3. Sepsis
4. Multiple Organ Dysfunction Syndrome (MODS)
5.  Death

This is a unique time in medicine because a lot of us are basically flying blind. Thanks to a bottleneck in testing, we don't know how many infected we are actually dealing with. We have no vaccines and no particularly proven treatments for this specific disease, so we are relying on measures that have saved us in the past and hoping that the experience of countries that have been hard-hit by the pandemic will provide us the answers we need.

However, with hindsight from the past 2 or so months, some measures appear to be better than others.

• Social distancing is helping
• Hand hygiene is DEFINITELY helping
• Decongesting hospitals by keeping the mildly symptomatic people away is the wisest of all options.
• Isolating the infected at home, provided they are stable, goes hand-in-hand with the above mentioned measure.

Some things are still in doubt

• Hydroxychloroquine and Azithromycin are not quite the cures people were looking for. Both drugs have their proponents and opponents in equal measure, but there is nothing conclusive in the water.
• Wearing masks is also just as contentious. The CDC is all for it, but the WHO is against it. And being a long time wearer of surgical masks, I am honestly worried about the quality of masks that are currently in the market. The masks are ill-fitting (*I favour the tie-ons to the elastic banded ones), people are not wearing them the right way, and at upto sh. 100 ($1) per disposable mask, people have been recycling them, thus rendering them useless. *In light of current shortages, hoarding and the exploitative prices, I would pray that the government rescinds this order and looks for a more workable solution

Other things don't even need to be mentioned.

• Walking around with disposable gloves all day is one of the most disgusting habits ever. Saw this introduced at Carrefour for shoppers, and the same shoppers proceeded to take those gloves everywhere. This is an infection control failure.
• Police bundling people into crowded vehicles or cells is a plus for COVID-19 all the way. (at the end of this debacle, we are going to need to have a serious conversation as a country about using police officers with zero PR training and comprehension skills, and equally poor demeanors to enforce important government directives)
• Any religious folk claiming they can heal COVID-19 sufferers should be locked up in their lavish abodes and be forbidden from contacting any of their religious faithful. THERE IS NO TIME FOR THIS KIND OF NONSENSE. Tithes can also be humbly directed to the medical efforts or to feed and take care of the less fortunate in society.

There is still a lingering question concerning the low fatality rates occurring in Africa thus far. People might say that we are probably at an early stage of the infection of the populace, and not quite at the "Critical mass" level. I am silently hoping for a genetic/environmental advantage. Realistically speaking though, we need more testing. Initially, we've been doing PCR testing, but eventually we will move on to rapid kit testing. Eventually, we should get to Serology testing where we detect antibodies. At that phase, we'd be able to know patients in the acute phase, and more importantly those who've already developed long term immunity to the virus. Such testing would obviously push our numbers through the roof, but then it would provide another bit of ammo for us in this fight. Let's not forget that plasma from immune individuals could technically be used to confer passive immunity on direly sick COVID-19 individuals as a stop-gap measure until we are able to produce a vaccine.

It has been quite the crazy start to the year, but I'm hopeful that things will get better. I would like to salute all essential staff at this time, particularly the healthcare and allied professionals: the doctors, nurses, physiotherapists, pharmacists, cashiers, cooks, cleaners, etc. This one pandemic will shine a spotlight on an oft-neglected sector, and will become a rallying call for us to fund it and fix it as much as we can. To ignore it any further is tantamount to disaster.

Be safe and God Bless.