Dr Loice Ombajo: It will get worse before it gets better

What you need to know:

  • I know Kenyans are asking why we don’t yet have 5,000 infections as predicted. You do not want to be at 5,000.

  • The modelling tells us in which areas we’re likely to have so many cases and what capacity we require in terms of hospital or ICU beds.

  • The hope is that we do not get to many mortalities, but it really depends on how the outbreak holds.

Dr Loice Achieng Ombajo, a senior lecturer in the Department of Medicine, at the University of Nairobi, is a consultant at Kenyatta National Hospital where she heads the Infectious Disease Unit. She spoke to Daily Nation Executive Editor Pamella Sittoni on the state of Covid-19 in Kenya.

What’s your assessment of Kenya’s levels of infections, recoveries and mortalities? Is the curve progressing as per the initial models?

The initial models were of a worst case scenario, and on assumption of nothing being done to curb the spread. If nothing had been done, we would probably have several thousand confirmed cases by now. However, we took some measures, such as closing schools, churches and banning gatherings. With these measures, we made significant gains in the fight against Covid-19. In one country, the first two cases were in a church. One of them went to a family gathering. One of the people in that gathering went to another church and that just set off outbreaks. Contact tracing was another step, because we’ve seen that when one case interacts with five people, two of them may get the infection. These two go on to interact with 10 other people and before long, the infections snowball.

So the stringent measures put in place in the first instance have helped us to be where we are now. Going forward we probably will see more cases. It will get a little worse before it finally gets better.

With the measures that have been put in place, are you convinced we could get to 30,000 deaths as has been forecasted by the Ministry of Health?

First a disclaimer: That models are just that. They make certain assumptions. They may underestimate or overestimate. They’re rarely accurate. What they do is help with planning.

I know Kenyans are asking why we don’t yet have 5,000 infections as predicted. You do not want to be at 5,000. The modelling tells us in which areas we’re likely to have so many cases and what capacity we require in terms of hospital or ICU beds. That’s the essence of modelling.

The hope is that we do not get to many mortalities, but it really depends on how the outbreak holds. If right now Kenyans decided: “We’re tired! Let's all go back to work,” then we're likely to reach the peak sooner rather than later. It really is dependent on how the population responds to the cases that we have. By saying we’re flattening this curve, it doesn't mean that people will not get infection. It means that instead of a sharp curve, it’s broader and flatter, and the infections at the peak do not overwhelm the healthcare capacity. That’s what is important. If it overcomes healthcare capacity, then you lose the battle, and a lot more people die because we’re not able to take care of them.

In countries that have enforced strict lockdown measures, how long did it take for them to get over the worst?

This is yet to be determined. This disease has been with us for only three or so months. In some of the countries that were very strict initially, they reduced, but when they opened up, they witnessed a slight bump in the number of cases. This is likely to be seen in many places. No single answer will sort out the problem. Every country will have to weigh its options and decide when to relax or tighten measures. Restrictions are good, but they can’t work forever because there are social and economic consequences to deal with. So it’s about finding that balance that allows people to resume some level of normalcy without increasing the level of mortalities.

At what point do you think we’ll know we’re at the peak?

You really can’t know that you're at a peak until the peak has passed. You realise you’ve passed the peak when you start to see a decline in cases. One thing that happens is that the more people are infected, the lower the pool of susceptible people, assuming that those who were infected end up with some level of immunity to infection. That was the whole concept around herd immunity. It’s only that herd immunity can come at a significant cost because of mortality. If you have everyone infected at the same time, then many people die at once and the healthcare system is overwhelmed.

If you overwhelm the healthcare system, it means you also can’t take care of other diseases as well, so people die both from Covid-19 and from pneumonia, childbirth complications, malaria and vaccine-preventable diseases, because the country is so overwhelmed, it can’t run some of those programmes. Lowering the peak would enable the country to still have some level of function.

When do you predict we’ll get to the peak?

If we were both modelling, you’d get slightly different figures from what I would get. So some would say is it coming around June or September and some have predicted maybe early 2021. I think by around August-September, we’ll have an idea. Having said that, it doesn’t mean that everything has to shut down until that time. It’s about a balance — what can we ease while protecting the most vulnerable members of society? Over the next few months, the aim will be to ease restrictions to allow people to work and earn some money and eat, but make sure the most vulnerable are protected from disease.

As a member of the national taskforce on Covid-19, what’s your assessment of the country’s level of preparedness? Would our system cope with a full-blown outbreak of, say, 10,000 infections?

This is a question for the government. But I think it’s hard to reach that level of preparedness at once. It’s a dynamic process. Many counties, such as Mombasa, have done an incredible job. At first, it had 10 ICU beds. Then it expanded to 100 beds, and identified an institution to manage mild cases. This is what’s happening in all the counties. They’re identifying facilities that can be used to manage this disease. The aim is to manage it without losing the ball on other diseases. For Nairobi, the capacity still has to be expanded. With a population of four million, the available facilities cannot take in all the sick people.

What’s the cost of treating a Covid-19 patient?

 If you have serious illness, there’s a medical cost for your care in a hospital bed. You’re being fed, you’re getting treatment, there’s the healthcare personnel — nurses who are taking care of you, a doctor, a physiotherapist, a nutritionist and someone who is cleaning your room. There’s also the cost of protecting the healthcare workers (PPEs).

The sickest people also require more lab testing and, if someone has many organs affected, they may need support to breathe, or dialysis or support for the heart. There is the cost of oxygen in addition to the cost of medicines.

Who pays for all that at KNH?

It’s a discussion that has to be held very carefully because people may not necessarily afford that treatment, but if it is all free, then it will not be sustainable. So again it’s an issue of balance. Health economists have to come in and work out that balance.

For now, the concern for most patients would be: “But I don’t have symptoms. Why are you putting me in a hospital and then you want to charge me?”

That is a cost of public health because you’re paying the cost of protecting other people. So if the government takes that up, it’s an understanding that by taking care of this person, it is avoiding the cost of taking care of 10 other people who could have been infected by the individual. Public health is not necessarily cheap, but it’s cheaper than having full-blown outbreaks.

At a personal level, what has had to change in your life since coronavirus was reported in Kenya?

Well, I could do with a little more sleep. It has been a very busy and frightening time. We were a little scared when it started because it was totally unknown and we didn’t necessarily know what to expect. Even for us as doctors, we’d seen the picture that our colleagues had shared from other countries and read reports of colleagues getting infected.

Dealing with Covid-19 has also taken away from family time because I’m always on the run. I just read about people finding new games to play with their children and spouses finding new ways to bond. My family is finding new ways to support me as I do this.