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Professor Marvellous Mhloyi and Dr Stanzia Moyo, University of Zimbabwe, Faculty of Social Studies, Centre for Population Studies
Covid-19 has affected the entire globe with every country reporting some infections except 10-15 countries; Zimbabwe is not spared. The absence of cases in Covid-19-free countries might partly be explained by the secretive nature of governments, high levels of press censorship, a lack of appropriate testing facilities and also a lack of knowledge to operate compatible testing kits.
Zimbabwe, as of April 16 2020, reported a total of 24 infections with one recovery and three deaths. This might be an underestimate of the incidence and prevalence of the disease given the limited testing facilities and the incomplete death registration in the country. However, the projected estimates produced by Ferguson et al. (2020) might also be a gross overestimate. Ensuing is a discussion of Ferguson et al. (2020) findings.
The team estimated that in the worst scenario, Zimbabwe will have 13 981 038 infections, and 8 370 104 infections in the best scenario in 250 days. These estimates translate into crude Covid-19 infection rates of 564 to 942 infections per thousand people in Zimbabwe in 250 days. Simply, almost every Zimbabwean will be infected in the worst scenario. How plausible are these estimates?
First, it should be noted that projections are mathematical applications of models. Fairly robust models are often based on empirical observations recorded over a period of time. Two common models that can be quoted are the Demographic Transition Theory and the Epidemiological Transition Theory propounded by Thompson and Omran, respectively.
The Demographic Transition Theory shows the general stages a country’s population growth rate will shift from a stationary situation due to fluctuating high fertility and mortality to another stationary situation due to fluctuating low fertility and mortality; data from European countries were the basis of this theory. It has been observed over the years that the model did not even work effectively for European countries whose rates the theory was based. It definitely did not hold in developing countries. The conclusion was that demographic transition is country specific. The theory also shows that once the post-transition stationeary situation of low fertility and mortality has been reached, the rates are irreversible. Yet the Covid-19 disease is reversing mortality trends globally today.
The Epidemiological Transition Theory’s main tenet is that as a country moves from high mortality to low mortality, a shift from infectious diseases to degenerative diseases typifies the mortality pattern. Current pandemics, indeed the Covid-19 pandemic, defy this argument. And the defiance will differ across countries and regions.
The point is, it is extremely important that when making projections aimed at guiding a nation for effective planning, such projections must be based on assumptions and data from the respective countries. This is because while the scientific transmission of Covid-19 is similar across human populations, its progression and spread will inevitably vary between and within countries due to the variable socio-economic nexi within which the progression of the virus will take place.
Observations thus far show that the Covid-19 experience is country specific. If the assumptions for the projections on Zimbabwe were based on Zimbabwean data, results from such projections would be more accurate, acceptable and useful to the nation. However, the assumptions made in these projections were precariously based on general global patterns of progression and specific features applicable to less developing countries. This combination of assumptions is inherently erroneous.
Second, partly because the assumptions used as a basis for the projections are not based on Zimbabwean data, they are flawed. It is interesting to note that infection rates of the 10 leading countries, as of April 16 2020, range from 0,06/ in China to 3,8/1 000 in Spain. The assumed rates used for the projection of the best and worst scenarios for Zimbabwe’s infection rates in 250 days are 9 400 and 15 700 times the rates of the least infection rate of China, the better off country among the leading countries; and 148 and 248 times higher than the Spanish rate, which is currently the worst among the leading countries.
The current crude infection rate for Zimbabwe is 0,002/1 000. If it can be argued that the crude infection rate for Zimbabwe is underestimated a hundred times, translating into about 2 400 cases, this rate would be 0,2/1 000 people, still much lower than the leading countries. The implied differentials of infection rates between the developed countries with developed socio-economic contexts, and Zimbabwe with its undeveloped “fragile” economy are highly implausible. In addition to these faulty assumptions, there are a number of reasons why the projected scenario may not hold.
Recent experience has shown that emerging epidemics do not necessarily affect all countries in a similar fashion. HIV swept the globe but with extremely variable rates of infection and mortality. Severe Acute Respiratory Syndome (SARS) virus did not cover the globe but affected about 26 countries largely in Asia (WHO 2004). Ebola remained to a very large extent in a number of African countries with a few countries dotted across the globe. Necrotising fasciitis was reported mostly in a number of developed countries for about a decade; however, it has not yet reached pandemic levels. Covid-19 virus has spread very fast, but one cannot rule out the possibility of reduced virulence as it sweeps over other continents and countries. Africa, Zimbabwe included, might have such an experience with Covid-19; at best the pattern is far from being known.
It has been shown that agglomeration of people enhances the spread of infectious diseases such as flus. It follows that countries with a large urban population might have higher chances of having higher infection rates due to the difficulty of achieving the social distancing necessary for the reduction of the spread of Covid-19. Note that while the proportion of the population which is urban in the 10 leading countries ranges from 59 percent in China to 98 percent in Belgium, it is 32 percent in Zimbabwe (Figure 1).
Note that the highest proportion of reported Covid-19 cases in USA as of April 7, 43 percent, were in New York State; and 75 percent of the New York deaths were reported in New York City (CDC Covid Response Team, 2020). Thus, the limited agglomeration of people in Zimbabwe compared to developed nations which are dominated by urban areas will help curtail the spread of Covid-19 in the country. However, in Zimbabwe, social distancing has shown to be a very serious challenge especially in low-income sections of urban areas, and in rural areas where there are shared amenities such as water points.
The population of Zimbabwe is mainly youthful when compared to developed countries, note the difference between the population pyramids of Zimbabwe and Italy in Figure 2. It has been shown that Covid-19 is more lethal among the elderly, those above 65 years whose immune systems might be compromised by other pre-existing conditions such as diabetes, hypertension, cancers and many others. Consistently, the majority of deaths so far are largely among those who are at least 65 years. It is important to note that while the proportion of the population which is at least 65 years ranges from 8 percentin Turkey to 23 percent in Italy, it is only 2,8 percent in Zimbabwe (Figure 3). Thus, the youthfulness of the Zimbabwean population might help mitigate the impact of Covid-19.
Zimbabwe has been experiencing an economic downturn since the turn of the century. The health care system has been declining in consequence, poverty and food insecurity have been increasing. However, it is important to note that Zimbabwe’s life expectancy increased to about 62 years in the 1980s, it declined to 45 years in the 2000s due to HIV and AIDS, but creeped up to the current 61 years (United Nations Population Division, 2019), albeit within the prevailing economic situation and health system. However, there has been a number of targeted interventions that have contributed to the decline in mortality which should be carefully sustained.
Summary
The projections of Covid-19 deaths for Zimbabwe of at least 8 370 104 is a gross overestimate given that the assumed rates for Zimbabwe do not even meaningfully mirror the progression of Covid-19 in those countries which are further ahead in this pandemic and whose data are supposedly the basis of the projections. Assumed rates are not informed by what little data are available in Zimbabwe. Zimbabwean rates might also be lower than projected rates due to the youthfulness of the Zimbabwean population.
In addition, the Zimbabwe progression might be overestimated given that the assumed rates are from developed nations with about two thirds of their populations being urban compared to 32 percent of Zimbabwe’s. In addition, pandemics, indeed disease patterns and trends are country specific demanding country specific data for use as the basis for projections. Granted that the Zimbabwean life expectancy increased within the current economic challenges, with collapsing health structure, increasing poverty and food insecurity, there seems to be other factors that are helping in sustaining the health of Zimbabweans; perhaps partly the targeted interventions, use of the heritage-based means of treating diseases; and often perceived as remote, prayer. Prayer has always been considered irrational by scientists; unfortunately death and dying are never totally in the hands of rational scientists, but in the hands of a power that transcends scientific reasoning; it is a tale of two completely different disciplines.
Granted that there is no model that is sacrosanct, erroneous assumptions negatively affect the projections that might be derived. Furgeson et. al projections happen to miss the target and should be dismissed with the appreciation they deserve.
Implications
Zimbabwe must never be comforted by the discussion above. There is need for yet another modelling that might be closer to the Zimbabwean situation using Zimbabwean data. Once the testing has increased, and data on infections, recoveries and deaths in Zimbabwe are available, such a projection will yield better results.
There is an imminent humanitarian crisis that will arise from the lockdown especially because the majority of the Zimbabwean population survives from hand-to-mouth. The food insecurity is inevitably exacerbated by the lockdown in the country, with most companies being unable to pay non-productive workers. And the inflows of remittances from external sources are further reduced granted the global nature of the problem — a global lockdown means respective countries are largely on their own.
It should also be noted that mortality might increase from other causes of death largely because of increased malnutrition which will further compromise people’s immune systems. The increased malnutrition will arise from the lockdown which curtails the majority of the population which survives from hand to mouth from working within an economy which has challenges in sustaining meaningful food subsidies.
In addition, mortality might increase if resources are diverted from the prevention and treatment of existing health needs to Covid-19. The social distancing intervention will inevitably be differentially practised, less so in poorer communities; such populations will remain sources of infections. In poor communities, and eventually the entire population, the imminent starvation will cause people to ignore social distancing intervention in order to search for means of survival. It is also important to note that upon the announcement of the lockdown, there was significant rural-urban migration and immigration of residents from neighbouring countries. There has not been proper surveillance of such people; a potential source of infections. Staying with unknown cases facilitates the silent spread of the virus like a carcinoma.
Recommendations
While the Zimbabwean Government has worked extremely hard in an effort to minimise the spread of Covid-19 in the country, more still needs to be done. There is need for more efficient use of available resources for the prevention of Covid-19, and the much needed prevention, treatment and care of existing health care needs, a challenging yet indispensable balancing exercise. This is necessary if mortality from other diseases is to be at least sustained at the pre-Covid-19 levels.
Consistently, it is important to continue undertaking the repairing of the health care system currently underway. There is need for the maximum involvement of all frontline experts in the health care system, where such experts must be adequately armed with personal protective equipment. In addition, there is need for rapid decentralisation of testing which will assist in a number of ways.
First, identification of positive cases will assist to enhance the prevention and management of Covid-19 cases. The limited knowledge of the seriousness of the virus, and the limited perceived personal risk of contracting the virus make some people purposely defy the interventions of social distancing. People are still distancing the virus from them and their families; such distancing undermines the appreciation and practice of the social distancing intervention. Knowledge of positive cases which might be in the community will bring Covid-19 home, thereby demanding personal prevention.
There is need to further scale-up information education and communication (IEC) on Covid-19, down to grassroots communities. Scaling up of IEC will not only facilitate knowledge about the causes, transmission and signs and symptoms about the disease, but also demystify myths and misconceptions associated with the disease.
In IEC programmes, people will be educated about how the virus is transmitted, how it can be prevented and the seriousness of the pandemic. Reality with regards to the untreatable nature of the virus, and the limited capacity of the health sector must be tactfully and effectively communicated. Such will empower the community with the knowledge that once infected there is minimal assistance one can get except to hope and pray for God’s intervention.
Prevention will be appreciated. Henceforth communities can be assisted to come up with guided interventions that they will monitor themselves granted that they will feel ownership of such interventions. Members of Parliament (MPs) and chiefs can be trained to undertake these community IEC interventions. These cadres have the experience and mandate of working with the communities. Note that community involvement in the design and implementation of interventions will limit disgruntlement against well intended interventions by Government by the people who could be having a myriad of economic problems.
The basic fact is that poverty has been there before Covid-19; it will obviously be worse after Covid-19, but one has to be alive to be able to experience the worse poverty, thus ensuring one’s protection from Covid-19 becomes the priority. There must be advocacy bearing in mind the levels of understanding of our population on the aetiology of diseases. Yes, advocacy. And it calls for another cadre whocan be teamed with the MPs and chiefs.
It is clear that social distancing is a double-edged sword with one side enhancing prevention, and the other side undermining the very resources needed to make social distancing viable. It is therefore recommended that there be selective well monitored social distancing. While food is a critical service, its manufacturing, cultivation and distribution must be well monitored to enhance social distancing. It is also necessary to ensure that the most vulnerable people receive food subsidies first. And the distribution of such food must enhance the preventive intervention of social distancing. In addition, continued increased provision of safe water points will not only enhance social distancing needed for the prevention of Covid-19 infections; it will also reduce morbidity and mortality from water-borne diseases which are still a menace.
Granted that the majority of the Zimbabwean population is self-employed, such people have to continue to fend for themselves especially because the country’s limited economic prowess is not good enough to afford subsidies to everyone in need. Medical practitioners, public health practitioners and social scientists should work on Zimbabwe-specific interventions that will help not only the prevention of the spread of the Covid-19 virus, but also the sustenance of essential productivity.
It is necessary for rapid collection, collation and analysis of existing and new data on morbidity and mortality. Such will be input into the projection of the pandemic in Zimbabwe. Intervention efforts will be more informed by such data.
The pandemic is in Zimbabwe, mortality will increase from both Covid-19 and possibly other causes due to the synergistic relationship between the needed efforts and diseases. Zimbabwe can limit these negative impacts by carefully considered interventions. The country has enough brains that should be marshalled into small teams which can design different components of this fight. This means unprecedented collaboration between Government, non-governmental organizsations including community based organisations and the church, the private sector and academia.
References
CDC COVID-19 Response Team. (2020). Geographic Differences in COVID-19 Cases, Deaths, and Incidence — United States, February 12–April 7, 2020 Weekly / April 17, 2020 / 69(15).p.465–471
Ferguson, N. et.al. (2020) Covid Crisis: Outline threat for Zimbabwe. London: Imperial College.
United Nations Geoscheme. (2020)Reported Cases and Deaths by Country, Territory, or Conveyance. New York: Worldmeter’s Covid-19 Data.
United Nations Statistics Division. (2018) Demographic Year Book. New York: United Nations Statistics Division.
WHO. (2004) International Health and Travel. Geneva: WHO: Geneva
World Bank, (2019) Urban Population. Washington D.C: World Bank.
World Population Prospects. (2019)Population Estimates and Projections: The 2019 Revision. New York: United Nations Department of Economic and Social Affairs.
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