“In a continent where resources are already scarce, you can imagine how serious the problem is going to be.”
Preparing for COVID-19 in Rwanda and Ethiopia
Dr. Abebe Bekele is general and thoracic surgeon from Ethiopia now based in Kigali, Rwanda, where he is Dean and Deputy Vice Chancellor of Academic and Research Affairs at the University of Global Health Equity (UGHE). He speaks with Lifebox consulting medical officer, Dr. Tom Weiser, a trauma surgeon at Stanford University about the preparations for COVID-19 in both Rwanda and Ethiopia. Recorded on 31 March 2020. Below is a rough transcript of the interview.
Tom Weiser: Abebe, we’ve known each other for quite a while, but I’m going to start by asking: why don’t you tell us your name, what your title is and where you work, and then how we know each other and how you know Lifebox.
Abebe Bekele: Yes, thank you Tom. My name is Abebe Bekele, I am an Ethiopian, I am a general and thoracic surgeon from Ethiopia. I am now based in Rwanda—Kigali—I am dean and deputy vice chancellor of academic and research affairs at the university of global health equity in Rwanda. Our relationship goes back to—five to six years back—when we started the implementation of the clean cut project. Initially in jimma, then we brought the project to Addis Ababa to Menelik hospital in Addis Ababa university. This is how I knew lifebox and started working closely with Lifebox. I served as the clinical lead for this project in Ethiopia in July of 2018. But my relationship with you goes back to our surgeon days a few years before that.
TW: Indeed, well, thank you for taking the time to speak with us. And you said now that you’re currently in Kigali. Can you tell me a little about what’s the current situation for COVID in Kigali, and then in Rwanda more generally, and then I’ll also ask you about that in Ethiopia—what your understanding is. Let me start with Kigali specifically and then Rwanda more generally—what’s the situation?
AB: COVID is reported from Rwanda, 2 weeks ago, last night the report from the MOH is that there are about 70 cases—confirmed cases—in Rwanda. The communication at midnight last night showed cases close to 75. The majority of these cases are travelers from either Dubai, or other European—mainly from Dubai. There are a few horizontal transmissions from exposed people here in Rwanda, quite a handful of people. All the cases have been reported in Kigali, there are no cases reported so far from outside the capital city. Since last Saturday, I think about 11 days ago, Rwanda has implemented serious social distancing, homeschools, work is completely shut down, kids are staying at home, all of us are working from home, all elective surgeries are cancelled, we are waiting for elective cases. There is a serious implementation of social distancing—there is serious leadership here in Rwanda, so social distancing is implemented very seriously. Since four days ago, the government has also started distributing food to the poor in the country. Obviously in a continent like Africa, you don’t expect people to stay at home and get paid, they have to earn their living. So, at least they should be able to eat—that’s what the government is doing at the moment. There is a very good COVID diagnostic and treatment system here led by the Rwanda biomedical center, which is under the ministry of health. Very strong contact tracing, very strong testing, and a treatment facility so far. The system has not yet been overwhelmed.
In Ethiopia, the information I had until last night was there are 25 confirmed cases, again the majority coming from abroad—coming from Dubai, from India, from Japan, from other countries, and very few—very handful of cases—of horizontal transmission. Cases are reported mainly from Addis Ababa, the capital city. 3 cases from Adama, about a 100 kilometers away from Addis, and 1 in Amhara region, about 760 kilometers away from Addis. Again, there is a good testing structure in Ethiopia. All the main regions are at PCR capacity. As you know, PCR is technique intensive, logistic intensive; but there is testing capacity. Again, the countries not yet overwhelmed with cases, there is some preparation going on. Ethiopia has also implemented social distance, all schools are out, people are advised to work from home, however, as compared to Rwanda, the implementation of social distancing has been a challenge. I can see that there is a serious challenge—people are still walking together, walking to cafes, theaters, so the implementation of social distancing is not yet strong, as in Rwanda.
TW: So it sounds actually that there is a plan for testing—do you have a sense of whether there is either widespread testing or a plan for widespread testing in either Rwanda or in Ethiopia?
AB: I’m very sure that there is a plan, but as you know, these are poor countries, though the entire Africa is resource-constrained. You heard about the donation by the CEO of Alibaba? 20,000 test kits for most African countries. Countries are using that at the moment, and they were able to get some from WHO and from their own resources. But, it can never be enough. Ethiopia has 110 million people, Rwanda has 11 million people, and even if they wanted to do wide-scale testing, I think it would be a challenge. PCR—Ethiopia has I think 7 or 8 centers that can do PCR, so even if they wanted to do wide scale screening, I don’t think that’s going to be possible.
TW: So I’m going to pivot a little—so you’re a surgeon, you’re obviously dean, so you have a lot of administrative responsibilities, but I’m curious as to what the response has been like and the organization, in the hospital in Rwanda. What things are you seeing, what kind of things are you doing as a clinician, and what things are the hospital doing to prepare for COVID?
AB: Mmhmm. Yes, as I said the first case was reported two weeks ago, and the next day, we decided to shut, to force all our employees to work from home, we shutdown the Kigali office completely. Everyone is now working from home. And we completely isolated the campus in Butaro, our campus is located 2 hours drive away from Kigali, so we completely isolated it. We have 52 students in the campus, about 95% of our students are in the campus, and most of our staff and faculty are in the campus, but it’s completely shut down. In fact, they are just finishing their two weeks of isolation tomorrow. I’m happy to see no student, no staff, no faculty has any symptoms or has tested positive. Classes are changed to online teaching. We did not miss even a single day of teaching. We are teaching through Zoom, and other e-learning resources are there. The only thing that’s missing is the laboratory experience and dissection experience for the medical students. But we are even doing oral exams, written exams online; everything is transformed. We have set up support systems for our staff: psychosocial, mental, and other supports are already communicated through the staff, and we have active communication of staff, faculty, and students. We have set up an emergency response team about three weeks ago, chaired by myself. Nine people are in it, including students. We communicate with the team every day. Communication comes only from me to the entire staff, approved by the committee. And we have prohibited anyone from posting anything on the website, in our Whatsapp group, in the faculty group to avoid confusions and wrong information spread. So, any information approved by us is being transmitted. We have routine communication with the parents of our students, our donors, our staff and faculty. We’re also extending our support to the government of Rwanda. We have epidemiologists and health experts among us, as well as members of the national committee. All of us are on standby—anytime needed, we are ready to assist. And we have volunteer students, faculty, and alumni who are now working at the airport, who were working at the airport when screening passengers as soon as Rwanda banned all travel—that was stopped. So, we are in a fairly good position, no cases, no problems so far, and we have, I hope, good leadership in place to manage the crisis.
TW: And how about the hospitals, what are the hospitals doing to prepare?
AB: Yes, about five minutes away from our campus is the Butaro District Hospital. That’s our teaching hospital. And I also offered my services to the central hospital university in Kigali. My colleagues there have completely stopped doing elective surgeries; they’re only handling emergencies. Preparations are being made to prepare for the massive influx of patients. Maybe when the peak arrives, the peak is expected to be in 10-14 days time for now. Of course, in Africa, not just in Rwanda. Training is being given to professionals, especially doctors, nurses and others. As you can imagine, I don’t even know how to prepare for COVID. The amount of resources, human resources you have versus the expected patients—I can’t even (CUTOUT)
TW: We lost you there a little bit, but I wanted to follow up that—because you’re a surgeon—what things are surgeons in particular doing, and what concerns do surgeons have with respect to COVID preparation and possible, even the need for, treatment. What kind of concerns do you as a surgeon have?
AB: Yeah, two or three major concerns. Number one is are we prepared to handle the crisis? COVID is a system-wide issue; it touches health systems, defense, national security, food security, everything—electricity, water supply—everything. So, are we prepared to handle this—this really worries me. When it comes specifically to surgery, as I said, all electives are already cancelled. This means in a continent where the backlog is more than six months, we are adding to this serious backlog. Most of our cancer patients are not getting operated. So, delay plus cancer is a close-to-death sentence. Most of our pediatric patients are almost cancelled. So, we are worsening an already existing access to surgery question. Number two, the resources we have. Everything is now diverted to being prepared for the pandemic. Surgical gloves, ventilators, anesthesia machines… the likelihood that operating theaters will convert to ICUs is there. So every resource we have now is now—should be used to tackle this problem. In a continent where resources are already scarce, you can imagine how serious the problem is going to be. Italy, over the past three weeks, lost more than 50 professionals because of the disease. I mean, this is going to happen in Africa. We are going to lose professionals.
Add that up to the serious lack of personal protective equipment, testing kits, resources, and other protective gadgets–they are really expensive, in high, high, high demand all over the world. There is no country that spares a few ventilators or a few PPEs. So, you’re kind of alone, because everybody has the same problem. And the third reason—I’m glad to see the African cities, the AU, and the African leaders are coming together to discuss some of the problems—but, central leadership I haven’t yet seen. Maybe one or two countries might be the hardest hit at the moment, like South Africa, like Rwanda—we have 75 cases now. But, few are reported from let’s say Ethiopia, or Burundi. Perhaps it’s now time to focus on the hardest hit countries and maybe support them human-resource wise, equipment resource-wise. Our time will also come, we also need their support. So, such inter-country collaboration support; prioritization I haven’t yet seen. That worries me. But as I said, as far as surgery is concerned, we are already few. And the threat that we will lose some of our colleagues is still there. Resources will be completely depleted. Already existing lack of access to surgery for elective cases is going to double or triple very shortly. And, Africa already has people that are really seriously affected by malnutrition, TB, HIV: already compromised. So being young and fit in Africa is not a guarantee that you won’t die from the disease. Those are really the threats to us.
TW: Some of the clinicians I’ve spoken with and heard from, there is a lot of fear particularly around the concern of becoming infected and being vectors themselves, not just to their patients but obviously to their families. Certainly the concept of potentially being exposed to very very high viral loads without the proper equipment… Can you tell me a little bit about what you and perhaps some of your colleagues are feeling with respect to the fears around that.
AB: Yeah, absolutely, absolutely. PPEs are very important. Unfortunately, African countries have numbered PPEs, very few. You have to change masks every few hours, you have to change your gown every few hours, you need millions and millions of masks and PPEs to prepare for the disease. I’m very sure we don’t have that yet. Even the discussion about the usage of masks is not yet settled. What the CDC and WHO are recommending are kind of opposite. I know the background, I can understand the background, the scientific basis, and the availability of masks has something to do with it.. The implication here is that we don’t have those PPEs. And you just can’t say “I’m not going to treat someone just because I don’t have–” (CUTOUT)
TW: Sorry, I just lost you. You said simply that you can’t just say ‘i’m not going to treat you because I don’t have PPE.”
AB: No, it just doesn’t work like that.
TW: We know those providers are going to provide care regardless of whether or not they have good PPE.
A: Absolutely, absolutely. And the lesson we are learning from China and the US is that it doesn’t matter if you are rich or poor, it doesn’t matter if you have the money to buy the equipment, the equipment is not there for sale. Everybody wants it. I have seen some innovations in Ethiopia and in Rwanda: engineers trying to develop their own, locally, which really should be supported by the government, and trying to expand it. But we are really worried. We are worried. Even if you don’t have PPEs, you will continue to treat patients. That’s what our oath actually means.
TW: And so, I recognize that it’s soon that kids are going to need food and all the rest, since we’re both at home with our kids and our family. Let me try and end on a little bit of a positive note: what gives you the most hope around this? You mentioned some of the things around—there’s obviously the potential for an explosion of local innovation around some of the attention that will be paid to the entire surgical ecosystem; what gives you the most hope about what’s happening?
AB: The fact that we are now united as a world. This has been a common enemy, so everyone is united against the infection. People are understanding the importance of social distancing, even personal distancing, people are understanding the concept of isolation and quarantine, and are accepting it. I see lots and lots of African wealthy people donating money—thousands of USD, millions of USD in each country. I see governments ramping up their support. A big chunk of their annual budget to fight COVID. And countries like Rwanda are showing a real, real, real leadership. ‘This is what you have to do. We are going to enforce it. We have to save the people.’ So, the fact that we are now being united, understood, and we are learning from the experience of others—you know, wise people want to learn from others’ mistakes, fools want to make mistakes and learn from their own mistakes. So we are learning from China, Italy, the US, and this is very good—it gives me hope. Again as I said, there are many things that worry me, but this really, really inspires me.
TW: Well, listen, thank you so much for taking the time to talk to us and letting us video record this interview. As you know, we’ve known each other for quite a while, and I want to wish you the best to stay safe, to stay safe with your family. Please let’s keep in touch, one of things we’re trying to do at Lifebox is provide as much information, especially around some of the innovations that will be really important for subcontinent and other resource-poor settings. And I say resource-poor now, and NYC is a resource-poor setting in the sense that there is a lack of PPE, there are clearly not enough materials to treat the number of patients that are presenting. So, we’re going to need to come up with some very, very innovative and clever ways of overcoming this and getting through it. And, I’m really excited to see some of the innovations that come out of Rwanda, Ethiopia, and so when you hear of them and there are clever ways of preserving PPE, of using your ventilators to best capacity, of using you human resources, please share them because we would like to spread that learning as well. Unfortunately I think there’s going to be a lot of stressed learning right now, but hopefully we UNCLEAR and I really want to wish you and your family the best and I look forward to the next time that we can sit down over a cup of coffee when this is all over.
AB: Thank you very much, Tom. Thank you very much for reaching out, these are difficult times, unsettling times, but I’m very sure united we will prevail. I’m very confident that things will settle down, we’ll go back to normal. I know the world is not going to be the same moving on. Things will seriously change, but please give my regards to your family, keep safe, and let’s keep in touch.
TW: Thank you Abebe, you take care and we’ll talk soon.