It has been a little over six weeks since Kenya confirmed her first Covid-19 case.
On March 13, the Health ministry announced news of the patient, who had travelled to Kenya from the US through the UK on March 5.
Since then, the number of cases has been rising steadily and this has effectively left certain sections of the population at an increased risk of contracting the virus.
According to Dr Moses Masika, a virologist at the University of Nairobi, it was easier to tell the at-risk populations before the onset of the current phase of local transmissions.
RISK OF INFECTION
“The risk of infection was highest among those who were returning from overseas and people with whom they interacted,” says Dr Masika.
However, this has changed. With international flights into the country suspended, cases of coronavirus infections that involve foreign nationals and Kenyans with a history of travel have gone down.
The Health ministry’s daily briefings are now dominated by cases of local transmission.
In the first month since the emergence of Covid-19 in Kenya, geographical data on the infected people was limited to cases per county.
Nairobi, Mombasa, Kwale and Kilifi had the majority of the first cases and were declared hotspots. Mandera County was later added to this basket after seven people tested positive for the virus.
However, the lid on how far the virus had geographically spread was lifted on April 18 when the ministry began releasing data on areas that were reporting high number of infections.
Experts now worry that with areas that are congested and those that carry most of the urban poor now reporting cases, the risk of community transmission is even higher.
The first breakdown of data showing local transmissions by Health Cabinet Secretary Mutahi Kagwe suggested that the infections had transcended socio-economic boundaries.
For example, Pipeline had five cases, South C and Utawala had four cases, Kawangware three cases, Tassia, Kibra, Parklands, Kitisuru, and Buruburu had two cases each. Runda, Eastleigh, Donholm, Kasarani, Hurlingham, Madaraka, and Lavington had one case each.
“We have mapped the cases and zeroed in on areas of origin. In Nairobi, we have noticed that the cases are spread between almost all estates,” said Kagwe.
Additional data from the Ministry of Health revealed that more cases are now being reported in Mombasa County.
For example, on day 40 since the first case was confirmed, Mombasa recorded seven out of the fifteen cases that came out positive. Six were reported in Nairobi and two in Mandera County. None of these cases had a history of travel.
Dr Robert Rono, an epidemiologist working in Baringo County, says the emergence of Covid-19 across social and economic statuses presents diverse risk factors for the respective populations.
“An area like Kawangware is at an increased risk of virus spread than Kitisuru, Karen or Kilimani. This is mainly because of population density, sharing of utilities, and the inability to practise social distancing,” says Dr Rono.
He explains that upmarket areas like Karen are more spacious, have better planning, lower populations per square kilometre and limited human interactions and more financial capacity.
This increases the effectiveness of social distancing, affordability of quality and certified masks, sanitisers, and even fumigation. In turn, better containment of the virus spread is achieved.
“On the opposite extreme, a place like Kawangware or Kibra is socially and economically characterised by a combination of overwhelming human-to-human interactions, human congestion, poor planning and inadequate access to resources such as water and sanitisers,” says Dr Rono.
“An outbreak in such areas is more likely to spread faster and be harder to contain due to the way the socio-economic layout is designed.”
According to the population and housing census carried out by the Kenya National Bureau of Statistics (KNBS) in 2019, areas such as Kawangware, Kibra and Eastleigh that have all recorded cases have an average population of 234,000 people. Kawangware leads with a population of 291,565 people, Eastleigh has 225,815 while Kibra has 185,777 people.
These areas are congested because the land on which the people live is smaller compared to, say Karen, where the population occupies vast land.
Other low-to-middle income areas in Nairobi where population could be exposed to infections due to congestion include Embakasi, which is the most populated area in Nairobi with 988,808 people, Mukuru kwa Njenga, Kware, Pipeline, Tassia and the formal Imara Daima area. Mukuru kwa Njenga has a population of 242,941, Mathare has 206,564 people and Dandora has 295,670 people.
According to Dr Masika, the level of risk in lower income areas will also be determined by measures taken by the populations.
“You might find populations in Kibra and Mathare having different risk levels despite having the same socioeconomic statuses if the population in Kibra follows precautionary measures like wearing of masks and washing hands, but the population in Mathare does not,” he says.
This diversity is also reflected across the 47 counties. For example, Nairobi County is more densely populated than Marsabit County. With a population of 459,785 people in a land area of 70,944 square kilometres, Marsabit has six people per square kilometre.
On the other end, with a population of 4.3 million people in a land area of 703.9 square kilometres, Nairobi has 6,247 people per square kilometre. Despite this, you might find Nairobi doing better in keeping the disease at bay than Marsabit due to factors such as higher levels of awareness on hygiene measures and accessibility to this.
“This means that a one size fits all type of containment approach may not be very effective,” says Dr Rono.
In the same vein, economic disparities, lack of jobs and the low earning power might be spread-factors. A report by Oxfam International on the global economic impact of the disease estimates that the Covid-19 pandemic will be particularly harsh on poor populations. It will push up to half a billion people globally into poverty.
In Kenya, for instance, calls for a total lockdown to curb the spread have been met with fears of a total economic collapse for millions of livelihoods. This is because a significant part of Kenya’s population is either jobless or surviving on less than two dollars a day.
Data from the 2019 census shows that 5.3 million of the 13.8 million Kenyan youth are jobless. This represents 38.9 per cent of young Kenyans.
This, therefore, means that guidelines such as staying at home to prevent the spread of the virus become harder to implement among these populations.
It is this same populations, due to their low economic capacity, that use public transport to and from work.
By virtue of the high number of people they serve in a day, public transport modes such as matatus or ferries are a fertile ground for disease spread. The government has put in place measures such as limiting the number of people each matatu carries to avoid disease spread.
Data from the World Poverty Clock report shows that as of 2016, 8.6 per cent of Kenyans - representing 682,000 households - were extremely poor. A total of 16.4 million people were living below the poverty line while 17.6 million were living below two dollars (Sh200) per day.
Turkana had the largest number of people living below the poverty line at 87.4 per cent. Higher poverty levels were also recorded in Wajir (76 per cent), Busia (33.5 per cent), Kilifi (39.1 per cent), Narok (49 per cent) and (Kwale 41.3 per cent).
According to Rhodes Irungu, an economist and financial analyst, the populations living below the poverty line are not bound to give priority to Covid-19 safeguarding measures that might affect their already depleted resources.
“These populations do not have health insurance. Health facilities are also not readily accessible. Access to water and basic sanitisation products such as soap are a luxury that is not readily available or affordable. This means that the incentive for them not to adhere to the rules or go to a hospital even when they are symptomatic is high,” says Irungu.
His sentiments are echoed by Dr Rono, who says while risk disparities in countries such as the US are racial, the differences in Kenya are the case of rich versus poor. Take Leah Mutua.
The measures instituted to curb the spread of the virus have had a grave impact on her life.
“I cook chapattis and githeri, which I sell door-to-door in Mawanga, Nakuru County. I have been doing well, but my business is almost crashing,” says the mother of three.
Most of her customers now have time to cook their own meals and save on their budgets since they are working or staying at home.
The ban on food hawking during the coronavirus pandemic has made things worse, she says.
“I live in a rented one bedroom house for which I pay Sh3,000. I have to risk and go out, so that I can get rent. I don’t want my landlord to knock my door down or take away my roof,” she says.
Before the outbreak, Leah took home a profit of between Sh500 and Sh1,000 a day. Today, she is lucky if she makes Sh200.
Leah’s case plays out in many other small businesses whose owners are risking the wrath of the virus to survive.
For example, before the suspension of business in Eastleigh two weeks ago, hundreds of Kenyans who sell clothes for a living were sneaking in and out of Nairobi to access the cheap sales in Eastleigh. Movement from and into Nairobi has been banned.
One of the traders, who did not give her real name for fear of arrest, says she sneaked into Eastleigh twice.
“I know that Eastleigh is densely populated especially inside the shopping malls. I was aware that I might be arrested or infected, but people like me have no option. I need to pay rent for my shop and house, buy food and keep my life going. This is not the US where government is giving free cash. Ours is survival for the fittest,” says the trader, who runs a boutique in Engineer Township, Nyandarua.
Alarmingly, in the event of an infection, the ripple effect of these disparities will be the untamed spread of the virus and possible higher fatalities.
For instance, according to a medical study on coronavirus conducted by the University of Texas and published in the journal Emerging Infectious Diseases, the virus is most contagious before and during the first week of symptoms.
This means asymptomatic victims could be spreading the infection unknowingly.
According to Dr Masika, the onset of local transmission has now presented a new challenge in mapping out the worst hit and at-risk areas.
“It is now difficult to identify who is at risk unless with targeted mass testing,” he says.
The virologist adds that to identify those at risk, targeted mass testing could be done in areas with high cases and on people who by nature of their occupation and mode of transport used, may be exposed to infection.
“The testing of health workers is a good start. But, mass testing should be scaled up to randomly test and retest to determine prevalence,” he says.