“The thing that is massively important is, please, please listen to government advice on staying in. Don’t go out unnecessarily, don’t pop to the corner shop just to buy some milk. Please, please adhere to the advice, because at the minute we’ve got things just about under control, in two weeks’ time, if infection rates rise even further, this is going to be a very different situation, and it’s going to be frightening, people really need to heed that advice…”
These words will sound familiar to most Rwandans, but they do not come from any Rwanda official, or indeed anyone in Rwanda. They are from someone about whom no Rwandan has ever heard, Dr David Hepburn, a Consultant in intensive care medicine, at one of Britain’s major hospitals, the Royal Gwent Hospital.
Dr Hepburn was responding to a question about what he, as someone on the frontline in the battle against Covid-19, would like to say to the public. His words echo those of Noella Bigirimana, a consultant in public health, who has worked with the World Health Organisation (WHO), and is now with the Rwanda Biomedical Centre (RBC), as a strategic adviser to the Director-General.
“When you are compelling people to stay at home” she says, “what you are doing is breaking the chain of transmission. You are actually reducing the pressure that may come after…”
To date, Rwanda has 105 confirmed cases of Covid-19 infections. Seven of them have recovered so far. They will be asked to self isolate at home for a further two weeks, after which they will be tested again, before being taken off the watch list.
All the known cases are either foreign nationals, or Rwandans returning from other parts of the world. The only case of local transmission can be traced to one or other of these cases from abroad. And it is tracing, testing, quarantining that has prevented, and continues to prevent cases of infection from rising exponentially.
So far, more than 1,500 people, who in one way or another came into contact with any of the 105 individuals, have been traced, and isolated, or quarantined, until it is medically determined, whether they are free of the virus, or are to be admitted as patients.
Rwanda has luckily not had any deaths from Covid-19. But the luck has been of the country’s own making. Measures to prevent the spread of the virus were put in place as early as January, as soon as WHO issued guidelines to the world community.
All arrivals at Kanombe International airport went through thermal screening. Those travelling from any of the countries which at the time were deemed to be high risk, were quarantined for the recommended fourteen days, during which time, they were tested. Immigration officials interviewed passengers about their travel history, to determine the likelihood of exposure to infection. The same tests were conducted with passengers in transit. It is primarily from those in quarantine that the 105 cases have come.
Rwanda receives a great many visitors from around the world. It is one of the most successful countries in attracting investment from so called MICE (Meetings, incentives, conferencing, exhibitions). It is highly likely that without these timely measures, the high volume of visitors would have contributed to greater rates of infection.
Community engagement, explaining the threat, and the measures necessary to contain it, begun at the same time. In accordance with scientific advice, the stay at home measures were put in place, as the epidemic was declared a pandemic and infections around the world climbed. These measures were gradually tightened, with the initial two week period of lockdown, now extended for a further fifteen days.
Unlike many poorer nations, especially those on the African continent, Rwanda has a healthcare system that works for almost the entire population, irrespective of income, or lack of it. Unlike other countries however, like every other institution in Rwanda, the system has had to be established within the last twenty years or so, and would come under almost intolerable pressure, were cases of Covid-19 to rise much higher than they are now.
“The government is prepared for every eventuality” says Bigirimana, “but it is up to every one of us to follow the guidelines to avoid the possibility of the system being overwhelmed.”
By and large, people in Rwanda are heeding the advice. It is impossible to walk into any shop, without a firm request that you wash your hands, and rarely does anyone complain, even when they have only just washed their hands at the shop next door. Even markets provide hand washing facilities. Normally congested roads are all but empty, even during what would be rush hour.
But there is a minority who seem to see the measures put in place for their safety, as a challenge to their ingenuity on how to avoid being safe. The Rwanda National Police (RNP) issues regular messages pleading with people to listen to the guidelines, reminding them that lying to the Police will draw a fine, arrest, or both. But not even these seem to deter some.
Offenders range from those for whom home was only ever just a place to sleep, bored young people, to most unlikely, a Bishop, although admittedly, the only one so far.
Bishop Liliane Mukabadege it seems could not stay away from her Church, and decided to hop into her car, and drive there to see what its walls might confide to her. It is unfortunate for the good Bishop that the Police stopped her before she got there, the walls might have advised her not to fib to the Police. When asked where she was going, she claimed she was on her way to a radio broadcast.
Provided they are sensible about it, journalists are among those allowed to work away from home, the government having decided that the public has both a need, and a right to news and information. Policing in Rwanda is almost entirely community policing, with the majority of officers walking their beat.
Mukabadege happened to try to hoodwink one of the few police officers with a vehicle, who, unconvinced by her story, followed her at a distance noting that instead of a radio studio, she went to her Church.
All public gatherings, including places of worship, are prohibited, worshippers asked to pray from home. She now faces a fine, confiscation of her car for the duration of the stay at home period, and one suspects, a great deal of embarrassment.
It is all too easy to underestimate the seriousness of contravening the stay at home guidelines, but they can mean the difference between life and death for some people, the difference between containment of the virus, or contributing to the health system being overwhelmed.
Many countries in the world took too long to introduce protective measures against Covid-19, and the price has been high. The Rwandan government may look back and conclude that there are things it might have done differently, but it will have reason to be gratified with its speedy response. The importance of this quick reaction cannot be overstated.
Countries around the world with many times the resources Rwanda has, are concerned about the real possibility of their healthcare systems being overwhelmed. Italy’s medical professionals have had to ration care, having to make heart breaking decisions that have left medical staff in tears.
To put things in perspective, Italy is one of the world’s richest nations, with an annual GDP of nearly $2trillion. Britain, where Dr Hepburn works, the health budget for one region alone, NHS England (National Health Service) is around 130bn pounds sterling. Rwanda’s GDP is around $10billion. If these countries worry about being overwhelmed, how much more so Rwanda, however well prepared the country might be.
It is in cognizance of the need to work within its means, that the government quickly rose to the challenge, and from the outset, has followed scientific advice, to the letter. And there is no doubt the quick action has protected the nation.
Like most governments around the world, the government in Rwanda does not want to unduly alarm people, but there is a danger that some might get complacent, or over confident that their government will manage the pandemic, whatever the circumstances, so why not relax a little.
And there is no cause for alarm, if people do as their governments advise. Those who are inclined to complacency, might like to hear Dr Hepburn’s description of what could face them, their family and friends, if they continue to think playing cat and mouse with the police amusing. He is perhaps best placed of anyone to know what Covid-19 does to a person. Not only is he a specialist in intensive care medicine, he is one of the many physicians who contracted the disease, and thankfully survived.
“What we know” he begins, “is that Coronavirus primarily causes respiratory failure. When it spreads to the lungs it causes what we call pneumonitis, when the lungs become wet and water logged inside, so the normal mechanisms that keep fluid in the blood, break down, membranes and tissues in the bases of the lungs become porous, and that allows fluid to leak in from the circulation into the lungs. Almost like drowning.”
“One of the things we provide with the ventilators” he continues “is we can provide pressure which pushes some of that fluid out, and helps to keep the lungs open. People can become exhausted, because the work of breathing is so great, that they basically become exhausted and die.”
“So, if you imagine your lungs are normally like a nice light sponge…if you ever pulled a sponge out of a bucket of water, you know how heavy and wet it can become, it’s exactly the same thing. If your lungs are absolutely sodden, then it’s very, very difficult to breath, and what happens over time, is that people’s oxygen levels fall, levels of carbon dioxide rise in the blood, that makes you even more drowsy, has a narcotic effect, and people will slowly develop worsening respiratory failure, and eventually they become unconscious, and their breathing become more shallow and they will die.”
That, Dr Hepburn explains, is what would happen if you were left alone, without medical intervention. Medical help, with a ventilator prevents that from happening. But, he explains, “the deaths vary from multi-organ failure, which is basically a progressive shut down of all your organs, including your kidneys, your circulation, failure of your liver, as well as your lungs…”
And you are not necessarily out of the woods, when they have kept you alive with a ventilator.
“We’ve also seen patients develop a thing called myocarditis” he says, “often when they are starting to recover, the heart can become very adversely affected by the virus and they develop heart failure, and that’s been probably the leading cause of death in the Covid patients that we’ve seen.”
And of his own experience surviving the virus, he recalls, “it started off quite innocuously, I had a burning sensation in my nose, I lost the ability to smell, even though my nose was clear, it wasn’t bunged up. I didn’t feel too bad for the first three days, and I thought if this is as bad as it’s going to be, then it should be OK. As the week went on, I became worse…I developed terrible muscle pains, joint pains, I was exhausted…even walking up the stairs I was getting short of breath and having to lie down.
A number of people who are ignoring the stay at home advice, are young people who go out exercising, often in groups. They may perhaps feel immune, having learnt that Covid-19 affects particularly the elderly, and people with pre-existing conditions, Diabetes, or heart problems.
There is good and bad news for them. The good news is that if they follow the guidelines, they should be fine but we will let Dr Hepburn share the bad news.
“The pattern of patients we’ve seen in Gwent is much younger patients than we were expecting. All the patients we’ve got in intensive care at the moment are in their fifties, or younger. Our youngest patient is in their early twenties…there is a chap who is a fitness professional, a lot of patients who do not have any pre-existing medical conditions.”
“Be aware that you can get this at any age. Don’t think that you are too young and healthy, and cannot develop this illness. You can get it at any age. We’ve seen people again and again, developing this illness, when they’ve had no medical problems at all. It doesn’t care about your age, your profession, your medical status…”
As Dr Hepburn spoke, the intensive care Unit at the Royal Gwent Hospital was full to capacity, and he was worried that if more cases developed, they would not only be short of space, but crucially, they would also be short of staff.
Back in Rwanda, when a policeman follows a fibbing Bishop, and confiscates her car, or tells a group of young people to go and exercise at home, this is the scenario they are asking you to help them avoid.
Rwandans have so far been protected by the early measures instituted by their government. They are now being called to help the government to continue protecting them, by staying at home, until it is judged safe to gradually, start allowing normal movement.