There is a school of thought which holds the view that mass community testing is a necessity if we are to win the war against the COVID-19 pandemic. Another holds the view that targeted testing is sufficient. I subscribe to the latter view for reasons I shall discuss herein.
First is the issue of the cost of the tests as opposed to their value. Unfortunately, I am not aware of the cost per test in Botswana. I shall use the case of South Africa for two reasons.
Firstly, at the beginning of the pandemic, our samples were taken there for testing. Secondly, though the Botswana Pula is stronger than the South African Rand, the cost of the COVID-19 test is unlikely to vary much because of the proximity of the two countries.
According to Dr. Nathi Mdladla, Associate Professor and Head of Intensive Care Unit (ICU) at Sefako Makgatho University, the cost of a COVID-19 test in South Africa per capita is ZAR 1 200.00. This is equivalent to BWP 811.63.
To put the issue of cost into perspective, we need to consider Botswana’s COVID-19 statistics. As at 23rd June 2020, Botswana had 33919 tests performed and resulted; 33830 negative cases; 89 confirmed cases; 10 new confirmed cases; 1 death and 25 recoveries.
If we use the amount of BWP 811.63 per test, it means we spent BWP 27, 529,677.97 on tests out of which there were only 89 confirmed cases and the rest were negative. From these 89 confirmed cases, only 1 died.
If we had been conducting mass community testing as some people suggest, we could have tested, say, 120,000 people by now at a staggering cost of BWP 97, 395,600.00.
According to Dr. Mdladla, when embarking on a medical test of any sort regard must be had to, inter alia, the indication of the test, that is is there any value derived from testing? Here, the question is: are you testing for a particular value or you are testing for the sake of testing?
It is common cause that COVID-19 neither has a vaccine nor a cure. If you take HIV/AIDS for instance, though it has no cure, it has treatment in the form of Anti-Retroviral (ARVs) drugs.
So, if there were to be mass community testing for HIV/AIDS, for instance, one of the values of such tests would be to enrol those who test positive on ARV treatment.
The fact is, due to resource constraints, the hundreds or thousands who may test positive for COVID-19 from mass community testing cannot even all be put in quarantine or isolation even if they are symptomatic. No country can have such capacity.
In my view, the only benefit that can be derived from mass community testing is awareness of the prevalence of the pandemic, and perhaps the most affected areas. The question is: what further value can be derived from that?
Proponents of mass community testing argue that this information is useful for the country to decide on its allocation of resources for procurement of ventilators, PPE equipment and hospital beds.
In my view, a country does not need to spend millions in mass community testing for such a purpose. The same result can be achieved through scenario planning and modelling, something which all countries have done or ought to have done.
In my view, instead of spending millions in mass community testing, the country should assume the worst-case scenario and use such money to procure ventilators, PPE equipment and hospital beds. In any case, even if the worst case scenario does not materialise, such resources can be used for future medical eventualities.
The other consideration which Dr. Mdladla says should be taken into account when conducting medical tests is accuracy of a test . That is, the test must have a high specificity and high sensitivity. It must have very low false negatives and low false positives.
In early April, the President, Vice President, some cabinet ministers, Members of Parliament and some journalists were put in quarantine following a case involving a nurse who had contact with them, which some argue may have been a false positive.
About one week ago, the Greater Gaborone COVID-19 zone was put on lock down because of false positive results at a private hospital.
In my view, given the possible false COVID-19 results, it would not be prudent to conduct mass community testing. Imagine if the tests return thousands of false positives!
The other consideration which Dr. Mdladla says should be taken into account when conducting medical tests is that the test must be meaningful for wide-spread use, for instance, if a cure exists and where knowing the status has impact on disease/population management then the test is useful.
We have already argued that since COVID-19 has no cure, mass community testing would be of little value, if any. Dr. Mdladla argues that knowing that one’s status is positive does not change anything for the majority of patients who are not sick as the disease is self-limiting, but it is useful in those presenting with moderate to severe symptoms.
He also argues that even if one tests negative there is a possibility that this could be wrong and one need not drop their guard. In his view, therefore, it is better to assume that everyone is positive and to test only those who are symptomatic for focused management. I agree.
He posits the question: if 80% of the population has mild disease that does not require admission, what is the value of knowing that people are positive when they can’t be treated, especially in the face of high false negatives?
In his view, it would be cost effective to assume that everyone is positive and continue practices aimed at limiting the spread of the virus. I agree. This is where our resources should go to, not to mass community testing.
The other consideration which Dr. Mdladla says should be taken into account when conducting medical tests is that they must be cheap and easy to perform and interpret.
In my view, if a single COVID-19 test can cost about BWP 811.63, it is not cheap. Some people earn that much as a monthly salary which takes care of an entire household. The fact that the test is so costly suggests that it is not easy to perform and interpret.
The other consideration which Dr. Mdladla says should be taken into account when conducting medical tests is that they should require minimal expertise in the remote population settings.
Clearly, considering the cost of a COVID-19 test, and the fact that the tests can only be conducted by experts using specialised equipment, it can be safely concluded that the test requires high expertise, making it difficult to conduct in remote population settings.
It is common cause that Botswana’s population is mainly based in rural and remote arears, posing a challenge for mass community testing if it were ever to be government policy.
The other consideration which Dr. Mdladla says should be taken into account when conducting medical tests is that they should be less invasive, giving an example of a pregnancy test which one can conduct on their own. It appears to me that the COVID-19 test fails this test since it must be conducted by an expert.
The other consideration which Dr. Mdladla says should be taken into account when conducting medical tests is that they should entail short processing time to allow an appropriate intervention in the shortest time.
It appears to me that the COVID-19 test passes this test since the results can be available within 48 hours though a second test must be made about two days apart to confirm the initial result.
In view of the aforegoing, I conclude that government of Botswana’s decision to conduct targeted COVID-19 testing as opposed to mass community testing is well advised.
*Ndulamo Anthony Morima, LLM(NWU); LLB(UNISA); DSE(UB); CoP (BAC); CoP (IISA) is the proprietor of Morima Attorneys. He can be contacted at 71410352 or firstname.lastname@example.org
The great Thomas Edison, who logged a total of 1093 patents singly or jointly in his 84-year lifespan and who was the driving force behind a whole host of innovations which included the incandescent light bulb, once said, “I’d put my money on the sun and solar energy.
What a source of power! I hope we don’t have to wait until oil and coal run out before we tackle that.” At the onset of the still-in-force NDP 11, which runs from April 2017 to March 2023, government hived off P2.25 billion (a move engendered by the irregular, if not corrupt, depletion of the National Petroleum Fund) from the BPC subsidy budget pertaining to that time horizon and re-oriented it toward the development of the bulk petroleum product storage terminal at Tshele Hills near Rasesa village in Kgatleng District.
Both the two contenders for the Egyptian throne, General Atiku, had made their case and it was now up to the Wise Men to pass a vote indicating whose deposition had convinced them.
To Ramesses’ surprise, General, the Wise Men all voted for Moses. The vote was indicated by bowing their knees in front of Moses, thus confirming that he had a superior claim to the throne. Sadly, Ramesses was not having any of that. He immediately put his army on the alert and when word seeped through that Moses was to be the new Pharaoh, Zaru erupted into jubilation on the streets.
The Human Immunodeficiency Virus (HIV) was first detected in Botswana in 1985. The coronavirus that causes Covid-19 was detected in 2020. Both viruses were new, and it was their global occurrence that led to their classification as pandemics.
They have both been traced to animals, something not surprising as most new viruses are actually cross-overs from animals. A virus crosses species, in this case to humans, and its subsequent behaviour depends on how it adapts to the new species. Many are “dead-ends”, the virus cannot multiply or be transmitted between members of the new species.
In the case of the two which are our subject in this paper, the viruses adapted to the new species (human) and underwent mutations that allowed them to be easily transmitted between humans, hence the rapid spread.
The two viruses, HIV and the Covid-19 virus are very different, hence their mode of spread is different and their mechanisms of disease causation and epidemiology are very different. The approach to their control is of necessity very different. To illustrate their difference, HIV is transmitted mainly by sexual intercourse, Covid-19 virus mainly by the droplet method through the respiratory tract.
HIV causes ill health a long time after infection, which can run from about two years to many years (incubation period); the incubation period of Covid-19 is a few days, estimated at between 10 and 14 days. HIV infection leads to the destruction of the immune system, and when the victim gets ill, it can be from any of a wide variety of diseases caused by “opportunistic infections or even cancers”, hence the name Acquired Human Immunodeficiency Syndrome (AIDS).
Covid-19 on the other hand presents generally as an upper respiratory tract infection (URTI) although there are some presenting differently, especially with lower respiratory infection (lungs affected) in the more severe cases. Another but very important difference is that, while Covid-19 is generally an acute, self-limiting illness, with most patients recovering fully within a few weeks, and in fact many showing no symptoms, HIV/AIDS is a chronic condition; once the patient starts signs and symptoms, usually years after infection, this leads invariably to death from one of the opportunistic infections or diseases.
This last scenario used to be the case in the first decades of HIV/AIDS, but has fortunately changed after the development of drugs that in combination are referred to as Highly Active Anti-Retroviral Therapy (HAART, now known as ART).
HIV/AIDS is now treatable and no longer a death sentence, although treatment lasts for life as the drugs do not eliminate the virus from the body but suppress it. As for Covid-19, there is currently, as is the case generally with viral infections, no effective antibiotic or antiviral drug that kills the virus or eliminates it from the body.
Where does this put us? We are essentially dealing with two diseases or pandemics that are very different from each other. I did my post-graduate studies in Public Health during the last years of smallpox eradication, actually I finished the studies in 1978, the year Smallpox eradication was certified in Botswana.
What used to be emphasized, why the world succeeded in eradicating Smallpox was that it had epidemiological characteristics that supported eradication: it was easy to diagnose, even by lay people; it had a consistent incubation period of about 10 days; it virtually had a 100% manifestation rate (everybody infected showed typical signs and symptoms); there was a vaccine against it that was virtually 100% effective. Unfortunately, there have been few diseases with such favourable characteristics for eradication. Hence the next disease targeted for eradication, Polio, is almost done but still causing some problems.
Response to the HIV/AIDS and Covid-19 pandemics in Botswana
When HIV was detected in Botswana in 1985, the world had been aware of the existence of AIDS for about five years, that is, since the outbreaks among gays in America in 1981. By 1985 the virus had been identified but little was known about it; it was still a subject of intense research. However we knew that it caused AIDS and was no longer just transmitted in gay sex, but that most transmission in Africa was through heterosexual sex, and that sexual transmission was responsible for more than 90% of transmission occurring in Africa.
Some African countries were already experiencing severe HIV/AIDS epidemics, especially in Central and East Africa. In some of them (Uganda is sometimes quoted) people started dying in large numbers before the cause was known, only for people to move to neighbouring villages and infect others there!
The Botswana HIV epidemic, as well as those of SACU countries generally, was later than those of Central and East Africa. The latter had already experienced high disease and mortality rates for some years. In the late 1980s, Botswana was experiencing a big economic boom, and this attracted professionals, technicians and artisans from African countries badly affected by HIV/AIDS, and this really speeded up transmission in the country.
When the first seropositive people were identified in 1985, I was Assistant Director of Health Services responsible for Primary Health Care. So, Disease Control fell in my Department, and I had the responsibility of reporting to my seniors at the Ministry and hence to the country that we now had HIV.
Control measures were started immediately, such as screening all blood donated for transfusion and putting together with the help of WHO, the first short-term control plan. A unit was created which was headed by an appropriate professional. In 1986 I became Director of Health Services and Deputy Permanent Secretary, and in January 1990 I became Permanent Secretary.
In all these positions I was intimately involved in HIV/AIDS control, working intimately with those directly responsible for the unit/programme, and also doing at least one assignment with Global Programme on AIDS (GPA) when it was still with WHO before UNAIDS was created to share the AIDS programme with other UN Agencies. In the same manner, here at home we started pushing for the multisectoral approach to HIV/AIDS control in the early 1990s, that resulted in the formation of the National AIDS Council and eventually NACA.
The Ministry of Health undertook a very intensive public education from early in the HIV epidemic. The Ministry warned the people of Botswana (through and including the political, traditional and community leaders) about what was going to happen, the impending doom of high morbidity and mortality. What was needed was change is sexual behaviour.
Everyone knows that the main message from the Ministry was “ABC” (abstain, be faithful, condomise), which had become a universal message especially in Africa was used by the Ministry. Put in other words, the message aimed at three things; i) delaying sexual debut, ii) avoiding multiple concurrent partners and iii) consistent condom use.
This message never made an impact on the Botswana population, so when the clinical cases started hitting the country after the several years of silent spread (the silent phase of HIV spread), the effect was disaster. We had a nasty surprise in the health system that while the countries in central Africa that had early HIV/AIDS epidemics had their HIV prevalence plateauing at 15% and we thought the same would happen here, in Botswana and Southern Africa prevalence rates went past 30%.
This was due partly to the sexual practices of our people but also to the HIV sub-type that was prevalent in our part of the world. By 1966 Botswana was declared as having the highest prevalence of HIV in the world.
The real heavy load of cases in Botswana started in the mid-1990s, and everybody remembers it; funerals and funerals and funerals. That time ARVs were still under development, and it was only at the end of the 1990s that they became available but very expensive, so most poor and middle income countries could not immediately afford them.
Thanks to India, Thailand and Brazil who broke the patents and manufactured the drugs, their availability to many developing countries would have taken a long time. Here in Botswana, it was due to the initiative of the then President that HAART became available for general use in Government facilities in 2002, with massive aid from PEPFAR and ACHAP (supplied by Merck Foundation and the Bill and Gates Foundation).
Otherwise there was talk of extinction, and the expected population pyramid produced by UNAIDS was frightening. Luckily because of ARV’s that scenario did not occur. The rest of Botswana’s HIV/AIDS trajectory up to now is history. I left Government service on 31st December 1996 after seven years as P.S. and joined WHO.
I had almost joined WHO in 1989 but deferred it when I was appointed PS and did not want to appear unpatriotic and disappoint President Masire and PSP Legwaila with both of whom I had very excellent relations. My initial job with WHO was in Tuberculosis, a disease that had been my passion since I did Public Health and took over its control as head of disease control in 1979.
No matter what post I held in the Ministry thereafter, I participated directly in Tuberculosis control. And as we all know. Tuberculosis became and is still one of the manifestations of HIV globally and in Botswana.
HIV/AIDS was and is a slow epidemic. So, the public did not really perceive it as a threat in Botswana, except perhaps in the late 1990s and early 2000s when it caused very high mortality in the country. The Covid-19 epidemic/pandemic is different. Although it doesn’t kill everybody who gets it like HIV-related disease did, we have seen in highly affected countries that the 2-5% it kills translate to large numbers, because this is an acute infection that spreads very quickly. So, it should be easy for the public to perceive its danger.
The surveillance and containment that has been employed so far in Botswana to control the spread of Covid-19 has been very effective. Those responsible, the Ministry of Health and Wellness and the Task Force deserve to be acknowledged and thanked for a job well done. I am confident that the health care system can also adjust itself and not be disrupted by this new threat.
Since the chances of developing a drug against such a virus seems a bit remote, we are all putting our hope on a vaccine. Many viral diseases have very effective vaccines, so this keeps our hope up. We also need to know if one attack of this disease results in life-long immunity (like measles, mumps, chicken pox etc.) or if one can be attacked more than once, implying that the virus keeps mutating and bringing up new sub-types.
We are still to see if the public will do better than they did with HIV/AIDS and follow the health education. Experience is what usually persuades people to change; that is why many believe the celebrated change in Uganda when people changed and HIV infections dropped was due to the large mortality they had experienced before they even knew what was killing them.
Regarding Covid-19, we are seeing in a number of badly affected countries, people ignoring or resisting social distancing measures and masks, sometimes encouraged by politicians! Here in Botswana we have not yet experienced large losses of lives from Covid-19, so it is still to be seen how the public will really conform to advice, especially on social distancing and other measures like masks and hand washing.
What one sees so far is not very encouraging -in combis, bars etc., and during weekends in homes. In health we talk of KAP (Knowledge, Attitude, Practice). We know that K does not always lead to change in A, and to P. We saw this plainly in HIV/AIDS, what is going to happen in Covid-19?