By Wadei Powell
In response to the growing caseload of COVID-19 infections, on Friday, April 10, at 11:59 p.m., as announced by the Liberian President, the three-week extendable State of Emergency began. Consistent with the Liberian Constitution, the President must formally inform the Liberian Legislature, within seven days of the declaration, in order to enable the Legislature to review the measures outlined by the President within three days of being informed of the existence of a state of emergency in the country. As we anticipate the completion of these protocols, we believe that there are valuable lessons to be learned from numerous examples of successes in the fight against COVID-19 in other countries from which the ensuing Legislative review process can benefit. These examples should provide a basis on which we can draw to enable our success in the fight against the coronavirus pandemic.
In the case of China, research shows that a multi-pronged approach resulted in its current success. Of special note is the case of Wuhan, the Capitol of the Chinese Province of Hubei, where the virus is believed to have begun. Very early on, China recognized that simply locking down Wuhan and implementing mitigations such as traffic bans and home quarantines would not be enough, and that it actually had the potential to increase transmissions among family members, close contacts, and the community, primarily because it was challenging to seek medical attention due to traffic bans and also placed a huge burden on access to food. China realized that restrictions in movements would not work without addressing the presenting needs as well as the factors impeding the realization of those needs. Therefore, the country shifted toward the implementation of a more holistic, multi-pronged and strategic approach to fighting the virus. This included Lockdown/Mitigation + Screening/Mitigation + Suppression/Mitigation.
LOCKDOWN & MITIGATION
In January 2020, Wuhan (11 million residents) was completely locked down. Only after several weeks were residents allowed to leave their homes, once every three days, for food and medical needs. In addition to the lockdown, Wuhan implemented multi-pronged mitigation measures including mandatory traffic/travel suspension, public engagement and communication, social distancing, home quarantine, and control of visits to markets.
Although it may have proven to be a difficult task for the Chinese authorities, a traditionally secretive society, regular and reliable engagements and communication with the public proved to be crucial. They found a way to effectively keep citizens informed of the measures being put in place, remained resolute and vigilant in their response efforts, and galvanized the support of the entire country to help in the fight. However, the most challenging of these mitigations were home quarantine and controlling market visitations because the measures, intended to curb the spread of the virus, effectively restricted access to food. This brought about the need to find solutions that aided in the fight and, at the same time, minimized the inconvenience and threat to the livelihood of residents.
Wuhan’s mitigation response to this challenge was to increase the use of group-buying and food delivery services. Using the Chinese messaging app “WeChat”, market sellers set up buying services for items like meat and vegetables, supermarkets offered more food options, restaurants offered options for cooked food, and pharmacies offered medical supplies. Food and supplies were delivered to residents via government-approved transportation and people paid upon receipt. Additionally, the government also arranged and delivered free food to authorized distribution centers for packaging and distribution to the most vulnerable society members. Hundreds of thousands of citizen volunteers and community people assisted in buying food and supplies, preparing packages, and delivering to local residents. Many of the delivery people were also used to provide temperature readings to customers and report back to the Response Team.
This approach was successful because it considered both the need to fight the virus and the natural human need for food. By ensuring this, implementing additional accompanying measures were met with cooperation and support from citizens.
SCREENING & MITIGATION
Equally as important in the multi-pronged approach was the establishment of an early detection mechanism. China assumed that 60% of its population was undiagnosed and asymptomatic but could possibly infect others. Therefore, in dealing with undiagnosed cases, and in light of the low testing capacity, they strengthened their mechanisms for early diagnosis for home-quarantined people. This was achieved by training people who would: (1) check every household, door-to-door, on a regular basis, for people with symptoms and (2) conduct contact tracing of all close contacts of confirmed cases to find people who were presenting symptoms. Those persons presenting with symptoms were then taken for testing. It is important to note that this early detection intervention is one of the main mechanisms that positively impacted the fight in light of the low testing capacity.
This approach was successful also because it largely prevented the fast progression of the virus by detecting it in its early stages. Early detections enabled early isolations and treatments, and thereby reduced the strain on the healthcare system. This also helped to decrease the requirement of expensive and unavailable equipment, such as ventilators, which are needed for treatment of advanced cases.
SUPPRESSION & MITIGATION
Equally as important in the multi-pronged approach was the establishment of adequately-equipped designated isolation and quarantine centers, as well as a feasible and viable operating mechanism. In addition to locking down and screening, China implemented a rigorous Suppression Intervention and this, coupled with all the other measures, is what invariably helped to stop the spread. The Suppression Intervention essentially focused on reducing and preventing community transmission through the implementation of a Centralized Quarantine Strategy that organized the population into 4 categories of people, and created a separate management approach for each category:
- Confirmed Cases – Once a person was tested and confirmed, they were immediately transferred to designated treatment centers. If the case progressed or became more critical, they were sent to a designated hospital or ICU. When successfully treated, they were released. All confirmed persons received medical treatment and were provided with adequate food and care while under quarantine.
- Presumptive Cases – Persons presumed to have the virus were centrally quarantined, not left at home, and were separated from those confirmed. They were closely monitored and treated. If subsequently confirmed, they were transferred to Group 1, and followed the procedures for that Group. If not, they were monitored for the prescribed period and then released. Once released, they were still subject to the daily monitoring because, as it came to be known, there is no evidence that a person cannot become re-infected, or infect others after being treated and cleared. All presumed persons received medical treatment and were provided with adequate food and care while under quarantine.
- Cases with Fever – Persons presenting with fever were centrally quarantined, not left at home, and were separated from those confirmed or presumed. They were closely monitored/treated. If confirmed, they were transferred to Group 1 and followed the procedure. If not, they were monitored for the prescribed period and then released. All persons with fever received medical treatment and were provided with adequate food and care while under quarantine.
- Close Contacts – Close contacts of persons in Groups 1, 2, and 3 were centrally quarantined, not left at home, and were separated from those confirmed, presumed, or presenting with fever. They were closely If confirmed, they were transferred to Group 1 and followed the procedure. If not, they were monitored for the prescribed period and then released. All close contacts received medical treatment and were provided with adequate food and care while under quarantine.
The strategy also included specific mitigations for healthcare workers and essential staff working closely with the infected populations. These included:
- Provision of hotels to protect from spread to families, friends and contacts;
- Provision of comprehensive PPEs including protective suits, goggles, caps, face shield, masks, and gloves,
- Provision of proper training in the use of PPEs (We saw the effects of the proper use of PPE during the Ebola crisis).
- Provision of adequate testing and supplies.
This approach was successful because it allowed for people to receive medical attention immediately in a manner that reduced the potential for transmission and slowed the potential for the progression of the virus from mild to critical stages. Additionally, when progression occurred, it was quickly recognized, separated and treated. It also enabled those putting their lives on the line in the fight to have a sense of comfort that they would not be unnecessarily exposed to infection or transmission. Combined, these interventions greatly relieved the burden on the healthcare system by reducing the need for ICUs and critical treatment PPEs which were in short supply.
Undoubtedly, the measures were tough and exacting. However, by taking these measures, on March 18, 2020, Wuhan announced that it recorded no new cases for the first time since the pandemic began in January 2020. China implemented this system country-wide, and thankfully, has reported that the number of new cases has fallen dramatically in recent days even as infections are surging in other countries. Surprisingly, China, the country that was accused of concealing and mismanaging the initial outbreak, is one of the only countries that appears to be bringing it under control at the moment.
ACHIEVING THE INTENTIONS OF THE STATE OF EMERGENCY
Before making the case for the application of China’s blueprint to Liberia, it is important to recognize Liberia’s particular environment.
- The population is largely distrustful of their government. This distrust naturally flows to experts and authorities in the employ of the government leading to unusual complications in national decision-making concerning novel illnesses, even when lives are threatened. As if oblivious to this fact, the government tends to dig in and rely on the opinions of their inner circles, so-called loyalists, and kitchen cabinets when confronted with crises, and thereby, further fuel a systemic inability to listen to experts, and to learn from others. Hopefully, the gravity of the threat we collectively face will not make us to give in to that mode of operating at this time. We would be wise, in trying to save lives, by researching the immense knowledge and expertise available from around the world and locally, contextually considering what has worked and what has not, and applying it to our particular needs in Liberia.
- A piecemeal approach to this pandemic will not work! Only a comprehensive plan that addresses all critical factors can reasonably be expected to produce success. We have all seen the rapid exponential spread of the virus across the globe. What started as a few cases in a specific area very quickly multiplied to a daily increase of over 100%. Simply put, there is no way to use the “data of the day” to accurately predict what will happen tomorrow. As such, our approach to this fight cannot be to simply follow its trend but rather to preventit from spreading. And the interventions must be holistic!
- Indeed, Liberia is not China. From financial to human capital development, the two countries are light years apart. Notwithstanding this fact, Liberia’s comparative advantage is in the size of its population – Wuhan’s 11 million people is easily more than twice Liberia’s population, even with our most liberal estimates. Therefore, we have far less people to deal with and this presupposes that we can do a lot with the meager resources that we have, IF MANAGED PROPERLY.
The pervasive distrust of governments in Liberia is not a new phenomenon. We witnessed its harmful effects during the Ebola crisis. We must ensure that the Liberian people, over time, build a level of confidence and trust in the proposed measures. This will only come through the display of the right leadership examples, adequate communication and clear mechanisms of accountability. Therefore, the government must not ask the people to do what it is itself not willing to do and support. Of course, make no promises that it is unable or unwilling to keep, nor rules that are to be selectively enforced.
Given the above contexts, here are a few thoughts for urgent considerations:
LOCKDOWN & MITIGATION
- Paid Annual and Sick Leave – The government has ordered the closure of all non-essential operations. This means that a large majority of those employed will not be working and thus, not earning salary. However, under our Labor Laws, all employers are required to provide, and all workers are entitled to receive, paid annual and sick leave. The actual amount of days allocated for each individual varies, primarily depending on length of employment. Additionally, those who have not yet met the one-year employment mark also have not yet accrued vacation.
Proposal: A government mandate that all legitimately registered employers, including government, regardless of length of employment, pay all full-time workers for annual and sick leave as allocated by law. In the case that the employee has accrued leave(s), then that leave will be mandatorily applied during this period. In the case of employees who have already consumed their leave(s) for the current year or have not yet accrued leave due to length of employment, this may (1) be applied to leave to be taken during the following year (meaning that the employee will not be entitled to leave in 2021 or (2) the government can provide 100% tax credit for employers who pay employees for emergency annual and sick leave. This payment would be applicable to employees who have been mandated to stay at home due to the State of Emergency, or those who have been mandated by quarantine orders;
- Unemployment Benefits – In developed societies, unemployment benefits are offered to employees through a system of deductions from salaries – much like what is done for social security and disability benefits. This measure helps to provide temporary remedy in emergency cases where the employee loses his/her job for various reasons.
Proposal: While we may not have any established instruments for “unemployment” in the common sense of the term, under Liberia’s social security law, there are provisions for payments of benefits for Temporary Disability. While it may be a stretch of the imagination and legal interpretation, it should be possible for the government to mandate that these provisions be applied to temporarily disabled workers, resulting the SOE and lockdown. This could be done on a salary percentage basis for a specified period of time, considering the government’s financial capacity. A funding mechanism for this could be the budget allocations that have been made for projects and expenditures (like travel, allowances, etc.) which, we are certain, will not be expended during this period due to the lockdown.
- Food Provisions – We have been informed by the Minister of Agriculture that we currently have enough inventory of imported rice in country for approximately six (6) months. We also know that we have supplies of locally grown rice. We have also been told by the Cassava Planters Association that there is a large quantity of cassava available throughout the country. And we know that we have locally produced oils (palm, palm kernel, coconut, etc.) aded to a large inventory of imported vegetable oil. We also know that the UNFPA is actively working in Liberia to provide food supplies to the many disadvantaged and vulnerable persons.
Proposal: The government should engage all manufacturers and importers of these staple commodities, and work out a purchasing scheme that will enable food supplies to the vulnerable members of society, specifically those in Montserrado, Margibi, Nimba, and Grand Kru that have been mandatorily locked down. The government should also engage the UNFPA to strategically divert its feeding efforts to these areas during this time.
- Running Water – We are all aware of the role that access to water plays in the prevention of illnesses, generally. This role and need are further exacerbated during this time.
Proposal: Government should suspend the disconnection of LWSC services throughout this period and prioritize uninterrupted supply of water to all who will need it.
- Electricity – With the mandate of the lockdown comes the increased need for electricity in homes. With most of the large consumers of state-provided electricity (businesses and government houses) being closed at this time, the demand on the national grid is greatly lessened. Additionally, with government’s non-essential employees being mandated to stay home, and thus not commuting to work, there also exists a lesser need for the fuel allowances to government employees.
Proposal: The government must ensure service provision and reliability of electricity, with a reasonable amount of free kilo watt allocation to homes that are currently on the national grid. All allocations of fuel allowances should be suspended during this period to free up funding in order to provide diesel to power the national grid. Additionally, a portion of the Road Fund should be redirected to support LEC in providing this service. Lastly, the Ministries of Finance, Commerce and the Liberia Petroleum Refinery Corporation must work out a means with importers and retailers, including tax credits and suspensions of tariffs, to ensure the supply of gasoline and diesel at reduced prices to power homes that are otherwise reliant on private generators.
SCREENING & MITIGATION
- Community Monitoring & Policing – With every crisis comes the benefits of learning and preparing for the future. This is one of the benefits that the Ebola crisis provided but, unfortunately, we seem to not be adequately making use of the existing resources available to us. Although we got off to an extremely rocky start during Ebola, essentially because we had never experienced such a crisis, we were eventually able to get it together largely due to the international assistance, organized leadership, and the use of community structures. Hundreds of healthcare workers were trained in contact tracing, testing, and treatment. Thousands of community leaders were trained in awareness, monitoring, reporting, and general response mechanisms. A Call Center was established that proved to be successful in fielding and routing calls from citizens – albeit the response was somewhat challenging in the beginning.
Proposal: The beauty of our current situation is that the blueprint for the Ebola fight is still available and many of those actively involved in that fight are still around. There is no need to re-invent the wheel. Instead of bringing all new people in who have no experience in this environment, government should make use of existing experts and trained personnel used during the Ebola crisis. Most of these folks came from the various communities, engendered a certain amount of trust within the communities, and are still around. All that is needed is to put out a nationwide call for these people to come forward and help during this crisis. It is also important that they are received without the usual political suspicions – certainly, if not with hugs, then more likely with open arms. It is time to send the message that we are all in this fight together.
- Early Detection – At this time, one of the major concerns on every Liberian’s mind is the “real capacity” of the government to detect, test for, and treat the virus. In the past month, it is fair to say, some major gaps have been witnessed in the government’s ability to properly execute the announced preventive We have witnessed government officials disregard and circumvent the established RIA protocols for returning travelers by allowing certain persons to bypass the process. We have seen the shuffling of blames between the government’s medical and security personnel as to exactly who was responsible for enforcement of the RIA protocols. We have seen a video in which a renowned medical practitioner informed the public that initial testing supplies provided by the US CDC may not have been effective because it gave false-positive and false-negative results. We have heard that WHO has made available additional testing supplies but the public is yet to be informed about the quantities and capabilities of these testing supplies. We have heard stories from people who contacted the medical authorities asking to be tested because they experienced symptoms but were told to simply go home and self-quarantine because there were no testing supplies. We have witnessed the lack of information, distorted information, and delayed information on case reporting. And importantly also, we have seen the government try to shut down gatherings even as itself gathers to conduct business in a somewhat business-as-usual fashion. The list goes on about the mistakes that have been made so far, and all of these lead to one question: In light of the State of Emergency and lockdown that has been mandated specifically to prevent the spread, and the growing concerns around the implications of restrictions on movement; does the government have the capacity and capability to effectively prevent the spread of this virus through this lockdown measure?
Proposal: The answers to this question can only be given through the government’s answers to some very specific questions. The Legislature needs to ask and get reasonable answers to the following: 1. What mechanism does the government have in place, if any, for early detection? 2. What is the inventory of testing supplies? 3. How is that inventory being resupplied? 4. Where did these tests come from? 5. What are the current reliability for these tests? 6. What is the current inventory of PPEs for healthcare workers and other essential supporters? 7. What is the plan to procure additional tests and PPEs? Amidst rumors that WHO has made available funding to the government for this response, it is important to curb public speculation concerning this contribution, and importantly, build public trust around accountability. Accordingly, the Legislature also needs to inquire about the exact amount, and what portion of it is being allocated for early detection as a means of preventing the spread, procurement of tests, PPE, ventilators, and medical supplies.
- Response Team and Financial Accountability – This was a critical effort during Ebola to ensure that donated resources for the response were properly accounted for and distributed as needed, and to keep at bay unnecessary interferences from “political persons” seeking to use the influence of their offices to direct resource disbursements. This cannot be the time to exploit the threat to public health for personal political gains. To mitigate this, during Ebola, all of the international partners and local private sector funneled their donations through the Response Team. Disbursements were guided by data and instructions from the medical and field experts. Logistics were arranged and tracked by this team. While this system was mostly successful in accounting for non-monetary donations, there was colossal failure in the accountability and disbursement of funds allocated for Ebola response, which led to widespread allegations of corruption and misappropriation. While I am happy to see that a Response Team has been constituted for COVID-19, having been an integral part of the Ebola Response Team, I however see an emergence of the repetition of behaviors that gave rise to the lack of accountability, communication and, ultimately, public trust and unwanted allegations surrounding the Ebola response effort. Similarly, the pronouncement by Monrovia City Mayor on the intended critical role of the MCC in this response, is noteworthy especially because eventhough there is no mention of it in the President’s Address on the Declaration of a State of Emergency, we know that the Task Force is already engaged in Covid-19 “active tracing”. We are seeing dissention in an understanding of which security agencies are a part of the Joint Security Task Force with the LNP saying that the Monrovia City Police (MCP) is not a part and the MCP saying that it is a part. Knowing that we do not have anywhere near the access to outside assistance as we did during Ebola, it is of the utmost importance that every intervention, however well-intentioned, be adequately prepared for, managed in close consultations and collaborations with the relevant health authorities, and the proper mechanisms put in place to avoid a further decline in public confidence and trust, as well as an escalation in the transmission.
Proposal: Amidst rumors that WHO has made available funding to the government for this response, the exact amount of which is yet to be made public thereby contributing to widespread speculations and distrusts, it is imperative that the government communicates to the public the exact amount that has been provided by WHO, both disbursed and undisbursed. Additionally, the government must reveal the exact methodology of the response and what the Liberian people can expect. Also, the government must provide accurate and adequate information on the make-up of the Response Team, including the security apparatus, their functions, reporting chain, and the mechanisms put in place to ensure financial transparency and accountability. The government must explain the exact and official role of the MCC in this response, if any, and provide justifications as well as assurances how it will prove to be helpful. Lastly, the government must establish a mechanism by which the Response Team presents frequent updates to both the Executive and the Legislature, and the public at large.
SUPPRESSION & MITIGATION
- Quarantine Centers – As cases began to emerge in Liberia, we witnessed the lack of government support to the quarantine centers. There are reports pointing to the lack of testing supplies, food, cleaning supplies, medical supplies, and electricity. We saw the immense gratitude for the little donations that were made to the quarantine centers largely by members of the private sector. We saw that workers at the quarantine centers were not provided with PPEs. There was no segregation of cases based on symptoms and data. Everyone was lumped into one category and placed in quarantine facilities simply on the basis of availability of space. Contact tracing proved to be difficult due to the lack of resources. We can chalk all of that up to initial shocks. However, the question that must be answered now is: How do we go forward to properly manage and adequately respond to the growing reality of the exponential increase in new cases, which is an unerring global characteristic of the virus?
Proposal: The Executive must present the country through the Legislature, a Comprehensive Quarantine Plan (CQP). The CQP must be vetted and approved by the medical and relevant healthcare experts, and it must consider the various categories of symptoms in the population. There must be an immediate budget re-allocation exercise to divert unused and other previously-allocated funds whose importance now pales in comparison to the existence of this State of Emergency. All must now be directed toward this fight. Winning this fight must be matched by a plan which includes serious attention to details, as well as actions that show it is being equally prioritized in the budget. We will not win without supporting the fight, and we cannot support the fight without a knowledge of the plan. The Legislature must therefore ensure that the plan considers and includes all necessary material provision requirements – both medical and non-medical – and provide for its adequate funding through budgetary allocations. There must be a joint team constituted between the Executive and Legislature to ensure checks and balances are in place and that the process is monitored for compliance and adjustments, as necessary. The Legislature should create direct communication and monitoring avenues to the healthcare institutions. There must be a procurement plan that is thoroughly vetted by all stakeholders and a mechanism put in place to ensure compliance.
In closing, while there can be extensive debates as to which intervention is more important, there ought to be no debate about what truly characterized China’s successful response: The SIMULTANEOUS and effective deployment of multiple interventions and measures. Testing is only effective when combined rigorously with contact tracing. Contact Tracing is only effective when combined with an effective communication system for collecting and disseminating information on potentially infected people, without stigmatizing them. Lockdown is only effective if it is comprehensive and ensures that the human needs, such as access to food and medical assistance, are provided for and met. Isolation and quarantine can only be effective if adequately-equipped facilities are in place to both treat the virus and prevent the spread.
Again, none of these are easy, and each is mutually reinforcing. Taken alone, none will work against the virus. They must be applied comprehensively, simultaneously, and together. This, in essence, is the REALITY of the nature of this virus. This, too, is the REALITY of the fight against COVID-19. As we know, reality does not adjust to man; it is man who must always adjust to reality. Therefore, to survive this fight and minimize the attending death toll, we must adjust to this reality, and have our adjustments properly reflected and prioritized in our response interventions. It is time to invite all with actual expertise and experience to the front and center of this fight. Let us act determinedly, plan comprehensively, and fight inclusively, to achieve the intended objectives of the lockdown which is to prevent further transmissions, and to treat the infected. Alas, to do otherwise would be to risk achieving the unintended: Increasing the spread of the virus, risking Liberian lives, and or creating a standoff between the citizens and the government.