Botswana: How One ‘Shithole African Country’ Is Handling the Coronavirus Better than the United States

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As the COVID-19 pandemic spreads around the world or more accurately as more cases are identified with increased widespread testing, epidemiologists are looking at Africa as the next continent that will be hit with the crisis. While there are competing assessments of how the pandemic will affect the continent, in particular sub-Sharan Africa. There is a sense both culturally and politically in many of its countries that they may be uniquely positioned to prevent the pandemic from reaching numbers anywhere near those seen in much of the developing world, in particular Botswana

Botswana is one of the many “shithole African countries” that President Trump referred to in remarks in January of 2018.

On Friday The Atlantic published an article focused on the pandemic saying, “In late March an anonymous doctor in a New York hospital told CNN that he was working in “Third World” conditions, with patients coming in so fast, and so gravely incapacitated, that he and his colleagues would soon be overwhelmed.”

The use of the largely abandoned term “Third world” which was widely used in the 1980s when referring to sub-Saharan Africa, and represented  in Western media by photographs of skeletal, fly-bitten African children barefoot in the dirt outside their huts, appears to be specific.

It was code for, “That’s us now—or it will be soon,” the New York doctor’s comparison implied, “if we don’t control the spread of this disease.”

But the comparison invited a question: If America is now Africa, what is Africa? Africa is much better off than it was 30 years ago, but even today, most of the world’s extremely poor live on that continent, and its health-care systems are (with a few exceptions) a wreck. COVID-19 has been slow to arrive in Africa, or at least has been slow to be detected there. But the wave is coming. “Our health systems cannot absorb additional shocks,” Simon Antara, of the African Field Epidemiology Network, told me from his office in Kampala, Uganda. “We are preparing for disaster.”

No sub-Saharan country other than South Africa has more than 1,000 cases. And the countries where the highest  rates of transmission occurs “are those most connected with international travel, especially to France,” Morocco and Egypt in particular.

There are many factors contributing to the  anticipatory anxiety of a massive, widespread cascade of calamities yet to occur in Africa. Lack of medical equipment being paramount.

For example, “Sierra Leone (about the population of Washington State) has 13 ventilators. Central African Republic (CAR)  has three ventilators. Liberia also has only three, [while] South Sudan has four. Combine that with limited access to drugs to and a paucity of ICU beds. South Africa which is arguably the most developed has just over a 3,000  beds for patients requiring ICU care. Compare that to Somalia  who only “has 15 ICU beds for the entire country and where the eastern  region of the Democratic Republic of Congo has maybe a baker’s dozen.”

But ultimately what concerns the World Health Organization (WHO) the most is the only proven effective  treatment: social distancing.

That behavioral approach has proved to be the most successful  at “flattening the curve of transmission to more manageable levels, giving  doctors the ability to combat the disease aggressively leading eventually to a vaccine which would  preclude transmission  altogether. “In much of Africa,” the story continues, ” this strategy is absurd, because no amount of home quarantine will flatten the curve enough to let everyone have a turn at one of three ventilators.”

If the spread seems slow to develop, that may be because no African country has the same volume of international travel as the countries elsewhere that are already suffering.And  every country now has enough testing kits for their populations donated by the Chinese billionaire Jack Ma.

According to The Seattle Times  “there are several strengths going for Africa in the fight against COVID-19. First, the Ebola experience in West and Central Africa has helped develop capacity in disease surveillance, laboratory diagnostics and contact tracing. The Democratic Republic of Congo and Nigeria are in the middle of battling more deadly epidemics like Ebola and Lassa fever, respectively. Second, Africa has the youngest population in the world, with a median age of 19.7 years. This puts it in a favorable position in lessening the number of people who could die or require hospitalization from the disease.”

Quartz Africa  says that despite the headwinds of high population density in urban areas and widespread lack of potable water, do not make social distancing or hygiene measures any less necessary, but may be virtually impossible to implement.

“Cash-driven informal sectors are a huge share of the economy of most developing countries, particularly in Africa where between 30%  to 90% of all non-agricultural jobs are informal. Millions of Africans are unable to survive without some form of daily trade and don’t have the advantages of bank savings, credit cards and online commerce to be able to stay indoors or ‘social distance’ for extended periods.”

One model currently being talked about is Botswana’s approach to the virus.

Botswana’s president Mokgweetsi Masisi declared a state of emergency, effective immediately April 6th, to last for no less than 6 months. It also closed its borders after neighboring Zimbabwe had its first death due to the virus in March when the country had zero recorded cases. The only exception to the border closings was South Africa, their largest trading partner and a vital supply line to the landlocked country.  South Africa is also the country with the most cases in the region. These measures were implemented in tandem with protocols for social distancing, non-essential business closures, and the 6 month self quarantine. Masisi and the country’s parliament also enacted legal measures prohibiting businesses closed due to the epidemic from firing workers and injecting cash into the economy to keep storefronts and businesses afloat during this period.

This was relatively easy given the landlocked southern African nation is largely rural and whose economy is largely based on agricultural development.

“Botswana’s government is treating the pandemic as an existential crisis,” says Dr. Kopano Mmalane. “It has the dubious distinction of having once had the highest rate of HIV transmissions in the world, when one in three women were HIV-positive. The national HIV prevalence rate among adults ages 15 to 49 is 25%, which is the third highest in the world, behind Lesotho and Swaziland.”

The Weekend Report said in 2017,  “HIV/AIDS which affects poor families in the society continues to contribute to the fact that Botswana have one of the lowest lifespans in the world: 55 years on average.”

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Mmalane also points out that there is growing scientific evidence suggesting that widespread use of the Bacillus Calmette-Guerin vaccine (BCG), a 100 year-old drug first developed to fight off tuberculosis may also be playing a role.

CBS News says, “Researchers have attempted to look at whether these countries with regular BCG vaccine administration have lower rates of COVID-19-related mortality. One studyby researchers in New York found an association between universal BCG vaccination policies in countries and reduced morbidity and mortality for COVID-19. The study has not been peer-reviewed or published in a medical journal.”

The vaccine has been available for more than 100 years and has proved to be relatively safe, according to Dr. Denise Faustman, director of immunobiology at Massachusetts General Hospital and associate professor of medicine at Harvard Medical School.  “BCG is heralded by the World Health Organization as the safest vaccine ever developed in the world,” she said. “Greater than 3 billion people have gotten it.”

“BCG  was initially  tested in most  of the developing countries in Africa many of whom adopted it as standard vaccination as TB is still a serious health concern in Africa,” Mmalane adds.

Mmalane also points out that Botswana’s agriculture and livestock protocols preclude the kind of cross species transmissions the virus is believed to have done in the open air markets like the ones that dot urban areas  in China’s Wuhan province where the first reported cases appeared in November..

“We don’t have ‘organic stores,” Mmalane explains,  “because our country doesn’t allow hormone injections and there is a ban on GMO foods. Most African countries don’t even have to take that stand because everyone eats from their own farms. We all have farms.”

Mmalane also notes that “our livestock aren’t kept in pens,  and a good portion of the Botswana’s public  land is is not for for sale or for development,. The government has to keep it because most people don’t have ranches and their livestock needs to graze. So there are grazing grounds, comprising a third of the country,  with another  third set aside as wildlife preserves. The remainder of the land belongs to citizens of the country, all of whom have self sustaining farms that they rely on for their own family intake.”

Mmalane says that it’s these conditions that some scientists point to as evidence for “why we haven’t  been so badly affected.”

But,  honestly she says, “think it’s health in general that is determining transmission and mortality rates.”

They’ve also been battling another pandemic for nearly 30 years, HIV.

Mmalane says it’s virtually impossible to have grown up in Botswana and not a had a personal story about HIV—at one point the nation had the highest growing HIV transmissions in the world “When I was young, in Botswana 33 percent of the population had HIV—and this was when I was 13, one out of  every 3 people was infected with HIV.”

“AIDS nearly decimated Botswana nearly 20 years-ago,” Mmalane says, ruefully ” In fact we were largely written off by the global medical community who predicted HIV would decimate the country. But my generation turned that around rather quickly so we know we can tackle a pandemic like this.”

In the midst of this the New York Times reports: Some lawmakers in Botswana have been moved to supervised quarantine after failing to observe an instruction to self-isolate as the country tries to curb the spread of the coronavirus, the government said on Friday. All of the country’s parliamentarians, including President Mokgweetsi Masisi, had been asked to quarantine for 14 days and be tested for the coronavirus, after a health worker screening lawmakers for the virus herself tested positive. Some members of parliament had since breached quarantine by going to supermarkets, “spreading the risk”, a statement posted on the government’s official Twitter account said. “This is regrettable and the public is informed that the MPs have been removed from home quarantine and will be quarantined under government supervised quarantine,” said the statement, from Malaki Tshipayagae, director of health services at the ministry of health.

Updates on how these factors contribute to the duration and government restrictions with its borders can be found on the U.S. Embassy in Botswana’s website here.