Richard Wamai Oral History, 2020/06/29

This is an Oral History interview with Dr. Richard Wamai by interviewer Christina Lefebvre from June 29, 2020. Dr. Wamai speaks about the epidemiology of COVID and the global response to it versus other epidemic, as well response comparisons between Africa and the United States.

06/29/2020

Christina Lefebvre

Richard Wamai

Christina Lefebvre

Northeastern University

audio interview

English Healthcare

English Public Health & Hospitals

English Science

English Technology

English Government Federal

Africa

WHO

CDC

Kenya

HIV

Malawi

South Africa

vaccine

global health

infectious diseases

model

visceral leishmaniasis

Vaccine Stories

Deathways

07/20/2020

10/21/2020

11/17/2020

01/30/21

01/30/2021

03/02/2021

05/01/2022

05/17/2022

09/01/2022

09/07/2022

06/29/2020

Christina Lefebvre

Richard Wamai

Malden

Massachusetts

United States of the America

Audio

English

01:17:53

Richard Wamai is an associate professor in the Department of Cultural Societies and Global Studies and Northeastern University where his focus is global health. In this interview, he answers questions about the global COVID-19 response in comparison to past epidemics. He also talks about the response to COVID-19 in Africa compared to the response in the United States. Additionally, he also talks about what he hopes society learns from this pandemic that could be helpful in the future.

Richard Wamai 00:00:03
My name is Richard Wamai. I am an associate professor in the Department of Cultural Societies and Global Studies here at Northeastern. My area of work is global health. It's a large field, but I have specific projects that I focus on and specific methodologies that I use in my work. So I work on infectious diseases, primarily HIV, neglected tropical diseases, primarily, visceral leishmaniasis. I also work on modeling, including new work now more for COVID-19 pandemic. We have a team of colleagues from the African region and they also do work on economic evolution and health systems, evaluation. I also work on non-communicable diseases and they're my specific disease of interest, its modeling the epidemiology of some of the NCDs [non-communicable diseases] like diabetes and hypertension in context of HIV and AIDS. So looking where the global pandemics might be heading towards in the African region, specifically in the next decade. Yeah, and my project on visceral leishmaniasis is much specific and unique because I last year opened up a center for research and treatment for visceral leishmaniasis, a highly neglected disease in the North, Northern Kenya region. And so we have a center there and the center used to conduct research to conduct clinical interventions, as well as other other operations in, in population health. And the COVID-19 has had specific impact on specifically that work because my team for example, I have a team in Nairobi and the team has regularly been going to the Research Center, which is about seven hours away a road trip. But they haven't been able to go back since February because they are restrictions on on travel movement from outside Nairobi to, outside Nairobi to any part of the country. And so for this reason, my team has not been able to go to the research field some activities like training of clinicians, the health workers, conducting surveillance and also, field screenings through integrated mobile clinics have not been able to be to be conducted. The clinic of course, the hospital is running because you have a clinical team there but having my team not able to travel has had substantive impact on delaying completion of specific projects within the timeline that we have had. And so that means extending grants timelines for setting grants to support this project, working with the grant managers to allow for these extended time. And of course, it has also covered has also impacted the global supply chain for treatment for leishmaniasis as well as test kits. We use rapid diagnostic tests, which cost about $9 apiece to diagnose, unless it's a rapid test that detects antibodies within 10 minutes. But for several months now there's a shortage. The global supply chain is delayed. We've been told by the WTO [World Health Organization] in Geneva that some donated supplies on the way but they The likes of my clinic are the conditions and are able to use the to use these tested. So they are using a new, rather, a different approach which is in the algorithm for testing for visceral leishmaniasis will be the last thing to do, which is to do a splenic aspirate, essentially taking tissue of the spleen from suspected cases. And then using a microscope to diagnose the disease. Normally you do clinical symptoms, assessment to triage patients and then you do the rapid test. And now without the rapid test, then you move on to the splenic aspirate is more invasive, a few people who are trained to do that. Or be it it's one way we have had to adjust with the impact of COVID-19.

Christina Lefebvre 00:05:04
Right. And I think you've touched on this a little bit in the Northeastern News, the issue that health systems are having to focus less on other diseases. You talked a little bit about the immunization effect in Africa. Could you talk a little bit more about the impact that covid is having on public health measures and initiatives in Africa or Kenya specifically?

Richard Wamai 00:05:30
Yeah, I think it's a big question. And it's a big, big topic and subject of conversation. So I as I observed in that video, the WHO had estimated over 100 million children missing out on immunizations, childhood immunization because COVID-19 when it hit the WHO committee that advises on global vaccine programs agreed to effectively postpone or hold these immunization programs which are mostly, mostly we’re allowed to catch up children who are born outside the health facilities. Then I usually reach through mass immunization campaigns. So, you know, you mobilize a clinical team or community team to go from house to house or to go through to schools or to go to other community sites, and then they will immunize children there and these are diseases like polio, and many others measles, yellow fever, meningitis, and so on and so forth. And so, because of these global decision to hold these mass immunization campaigns, then you have no doubt and effect where many children are then not treated with, with that kind of vaccines specifically. For example, in my research site, we know that in our community, which is a community of about 150,000 people, and so, the only way that these children are reached is through these mass immunization campaigns. And so, without these programs happening in meeting are reaching children with immunization, then that means that some of the timeline for when you should know children should be immunized, then all I have completed past there is no way to catch up with that, with those missed opportunities, the decline in in vaccine delivery, even in health facilities such as happens mostly in the US has been observed. So, we have seen a reduction in, in childhood immunization for many, many vaccines, even here in the US, so called pediatric vaccines have dropped precipitously over time in the month of April, particularly in March and April. And so, I mean, that is happening in, in routine immunization in hospitals here in the US is happening, obviously, across Sub Saharan Africa and that is one specific impact of COVID regarding childhood vaccines, infectious diseases, and so on and so forth. So, clearly COVID-19 has had an effect and be the outcome of his effect will will remain to be seen in time. But we do know that when we have had these type of outbreaks and pandemic disease that demand concentrated focus on that specific disease, then you have increased mortality from other other diseases. The primary example we can give would be the West Africa Ebola outbreak in 2014-15. Where you had increased mortality due to malaria, TB, HIV, compared to Ebola deaths, in all the three countries that are affected by Ebola that Guinea, Liberia and Sierra Leone, they had more people who died from these other diseases that died from Ebola. And that's really attributable to a failure of these health systems. You know, so, and that is, you know, that's, that's a big scenario where, you know, so parents don't want to take their children to the hospitals, for whatever reason for immunization. Or even as we have had in this country where there has been a dramatic reduction in emergency hospital visits, and so on and so forth. People have avoided to go to hospitals. Because of, you know, fear of contamination, we export it to COVID. And so we expect that that happens across across the board.

Christina Lefebvre 00:10:20
Right. You also spoke about consequences for neglected diseases in Time Magazine, when you were talking about Trump's defunding of the WHO, could you talk more about that decision and the impacts that it will have globally?

Richard Wamai 00:10:40
Yeah. So, the the article that and in that specific discussion we had in Time was that there is this, this point, which is that, you know, with the US removing or withholding funding from the WHO, what is the consequence for that? While clearly primary consequences are then the the funds WHO has available is then reduced. And so then you can look at so what, what funding level has the US been providing to the WHO? It's significant proportion of the WHO budget comes from the US. So their overall annual budget of it, which is about $4 billion. It's not a lot of money, but even $500 million withheld from the US. That's a huge, a huge hole that hopefully it could be filled by others. And I know there's a conversation going on about that, but we can [inaudible] though. So in the WHO, the WHO has the primary responsibility for the global polio eradication, and then goes into Somalia and then goes into the rest of the Horn of Africa, which is Kenya and Ethiopia. And so because hold these WHO find that I use for polio eradication, the US contribution to that fund and so withholding the availability of these funds for polio programming means that we will have increased cases of polio will have increased large numbers of people have children will not be rich with these polio vaccines. Another point is that, WHO was 60% of the WHO fund-funding and programming is in Sub Saharan Africa. that's a that's a huge proportion of WHO programming and work within one region and so withdrawing funds. US is withdrawing funds from WHO means that the effectiveness of these WHO programs in the US will be affected and and that is worrying. Because for a long time the African region has been dealing with, with outbreaks of diseases outbreak of infectious diseases, we need to be strengthening health systems we need to be strengthening surveillance for diseases in the African region, not weakening it. So, having a WHO that is not well resourced means that we have a weaker health system surveillance that is heavily supported by WHO in the African region and so, that means, almost taking a step back with infectious disease achievement that we have made, there is already an estimate of what the effect of HIV is regarding COVID-19. So, you know, we estimate the increased number of of mortality for HIV will arise from way increasing even, you know, with a stoppage and, you know, the slowness of these programs for HIV and AIDS where you have people unable to access the treatment as frequently as they did, then you can have all kinds of things happen including non-adherence, you know, drug resistance could result when these are reasonable to use properly and so on and so forth. So, there are many consequential effects of the COVID pandemic to HIV program as well as consequential effects of US withholding funding from the WHO for infectious diseases in the African region. The magnitude of these effects will obviously, you know, be seen in the future, you know, which is aligned progress of, you know, tackling infectious diseases. Yeah.

Christina Lefebvre 00:14:59
During the Connect-a-thon, you mentioned that while, the US healthcare system is largely focused on responding to non-communicable diseases, African countries are constantly facing infectious disease. Are there any ways in which that experience with infectious disease has assisted in response to COVID?

Richard Wamai 00:15:24
For the Africa region, most certainly, yes. You know, I think we could say that the, the lessons in fighting with infectious diseases in the African region can be drawn for the continent regarding how the continent is responding, or has been successful in mitigating, you know, huge consequential mortality or health effects from COVID, specifically. You can take this content, which is currently we have the who Africa region which is based in in Congo Brazzaville. And they track disease outbreaks on the continent. So you know, as we speak in in the in the week of April, for example, the end of May, we had in the African region 48 disease outbreaks or disease event from all kinds of diseases, whether it's visceral leishmaniasis, whether it's cholera, or it's polio, whether it's measles, and so on, so forth, and so on and so forth. Right. So I'm saying that to try and get the point, which is that for a very long time, the African region has been dealing with infectious diseases. The continent has learned and has created an infrastructure for responding to, to these outbreaks. You know, what lessons could we drove, for example from Sierra Leone or Liberia or Guinea, the way they tackled the Ebola outbreak So we created lots of networks. Imagine, for example, contact placing networks, or even social distancing measures that were learned in the Ebola outbreak in West Africa. You know, social distancing is not a new thing in the continent has been practiced for, for hundreds of years. Even in pre-colonial Africa, communities knew how to deal with the-with conditions. They did not understand by isolating villages, isolating themselves or isolating households, and so on, so forth. So these build up a whole army of community health workers in many countries who are the primary frontline health workers who have been trained to conduct, you know, regular population health missions, whether it's distributing mosquito nets, whether it's distributing vaccines like smallpox, and smallpox obviously in olden times, but polio vaccine today. Whether they are responding to programs for water sanitation and hygiene, you have a huge army of community health workers who have been trained and equipped to be respond to, to the building of the primary healthcare infrastructure on the continent. That I think explains an existing capacity to deal with infectious diseases, to deal with diseases that require community mobilization, diseases that require that you have a large, a large pool of people who can be quickly mobilized as well as rapid response teams. So we have that infrastructure, overall. I think or another another thing that is very helpful for the, you know, that has been very helpful for the African region, which is a lesson that can be drawn here is the point that, you know, nations, countries do not need to be wealthy to stay healthy. You know, policies matter a lot. Policies matter a lot. Smart policies, like Ali action. I mean, consider, for example, the Africa CDC [Centres for Disease Control and Prevention], which is based in Addis Ababa, had already created a strategic team in response to COVID before, there was a single case, a whole one week before there was a single case on the entire continent of Africa. There was already a response team created the Africa CDC in Addis Ababa, but many countries locked down before you had a single case. Uganda shut down its school before you had any single case reported in the country. And so these policies, Ali(?) policies, in early action was very instrumental in, in stemming the epidemic in the African continent. And it just means that it's not about the the economies or health system that can deal with the, with a pandemic in terms of critical care patients. But that even these, these vast network of committed health workers, engage communities matter a whole lot in responding to a pandemic like this. And these are the lessons that the rest of the world can learn from the, from the African countries. Certainly, as far as policies are concerned, as far as having a unified policy, US has not had a very robust unified federal policy regarding whether it's, you know, closure of institutions, whether it's wear a mask or whether it's social distancing, whether it's a new structure for testing and so on and so forth. And then of course, as I mentioned, and you mentioned that in your question, which is that for many decades, since the 1930s, in this country, when infectious diseases ceased to be the leading cause of death in the US, and then you had infectious diseases become the leading cause of death from the 1930s, then the whole system has been basically been twice responding to non communicable diseases. And so that means large infrastructure as large expensive hospitals, and very little, even non existent primary health, or even public health measures and in this country, spends about 2.4% of the entire health expenditure is on public health. And so we have very little in terms of any kind of infrastructure, you know, population health or public health measures that are in place. So that's one way to say well, if you look where the money is being spent in the healthcare system here. And what kind of infrastructure we have been. There is no memory of dealing with infectious disease, there is no infrastructure of dealing with pandemic outbreaks in this country.

Christina Lefebvre 00:22:25
Right. Shifting gears a little bit, I wanted to ask about your work with the COVID in Africa Data Science Initiative, and kind of the process for developing some of those models and any of the challenges you faced in doing so.

Richard Wamai 00:22:43
Yeah. So yeah, thank you. Thank you Hope. So, early on in the pandemic, we closed down the University, I think it was like March 18 or there abouts. I haven't you know, since I left the office didn't get to go back there but and then we all went into online mode, online teaching, online learning, and colleagues that I have been engaged with previously on, you know, modeling work or taking care of technical efficiency studies for health systems. You then had a conversation about what can we do we are seeing that in the African region, the space for modeling is limited. And so you know, we got together to-my colleague, Yohannes Kinfu is in-He's in, he's an economic, health economics professor in Australia in Canberra. Together with that, as Lawrence Were who was formerly a PhD, I was in his dissertation committee of Brown University and in others, you know, from Botswana, to Nairobi, to Rwanda to Ethiopia, and here in the US. Three of us are here based in the US. Tom Achoki is also health econ, economist and then we, we have others two others in, in Australia. So we build this model as a fast modeling to predict to the epidemic in the African region. And our our modeling predicted that the by the end of June this month, which is tomorrow, June 30, we would have in the African region 16.2 million cases of COVID and the number of deaths would be 34,000 by the end of this month, by the end of this month are in danger. So, of course, in modeling, you use a lot of parameters to create models like this. So, you know, between two approaches one which is agent based modeling, where you know precisely the reproductive rate factor or R0 [pronounced R naught] factor that we've heard about quite often. And then that disease agent, that specific agent, then themselves becomes the person who then transmits and spread the disease. And that's an agent based model, but good to use when you have very good data when the R0 is well known, well defined by so we use the second covariance(?) based model, which is, you know, taking into account variables. We took a whole group of variables like place, location, so you take the African continent and all countries and ask yourself, where do people live? Do people live in urban and rural areas? What's the proportion of people in these regions? And then we take another set of variables like livelihood, so the social demographic index, which means income levels, education levels, all of those type of factors household. We take population factors like density. How close to one another do people live? The age, of age distribution of the population. And then household size, those are population parameters. You might have heard that regarding the the, this, this age distribution dimension in the US the average age, about 35 years, in the African region about 18 years. So the US average age is not that different from Europe, it's probably high in Europe, compared to the US, I would think. But that means that you have a much younger population in the African in the African region and you have, you know, among all the things that are being discussed regarding why or how Africa has been able to avoid, you know, high cases or mortality, this age factor is a very important one. But we think household size also plays a role. There's even other variables You can add there regarding, for example, the frequency of contact at the household level, or typical person in the African region, what's the frequent times of contact they have, like when it came to skin contact or close proximity contacts and so on. So that's why you understand, you know, sort of including household size matters a lot. Another set of variables include there, the burden of disease, so that means comorbidities, right, we look at other diseases in the population. So, I know for example, in the US, about 60% of the American population has one condition. One other condition like diabetes, hypertension. So the comorbidity is extremely high in the population here about 60%. We don't know what that is in the African region, but we know based on population studies, for example, the distribution of non communicable diseases for some countries that have done the surveys or even observational study. We have an observational survey about, let's say, diabetes in Nairobi or Johannesburg. And you know another type of survey like that in a rural village. We can always compare based on the totality of the available information and understand this issue of the comorbidity or burden of disease. And of course, HIV, malaria, malnutrition, all of those are components of the burden of disease. And then another set of variables are health systems, or systems in general. So part of the systems is the health system. The other one is connectivity. You can think of connectivity in terms of infrastructure, let's say roads, or even airport. In all of those parameters, for example, the connectivity with the African region is higher in Egypt has a higher connectivity with Middle East and when South Africa has a higher air traffic travel in South Africa and then you take East Africa Kenya will be one, but then you go to Central Africa like Central African Republic or Chad and much less air travel, so that the element of connectivity. See what I mean, right? So, if-

Christina Lefebvre 00:29:30
Yeah, yeah.

Richard Wamai 00:29:31
-your field connectivity in those regions and therefore, you can be able to predict if an area has higher connectivity than the likelihood or the spread of be more right. And then, you know, connectivity also factors into, you know, the where do people leave people, most people in like Kenya 75% live in rural areas. Right? And in rural areas, the density is less compared to let's say, Nairobi. We take a big city like Nairobi and take care Kibera as a slum area. Kibera, you have a much higher density population, so the degree of probable spread with exposure in high density areas will be higher compared to rural areas. One last pillar in this sort of covariance model is the governance question. And here, you know, so particularly that in here we can say maybe they say the, the policies. Right? So some countries like I was speaking to earlier, adopted their policies, my child and they're much more, you know, they're much more policy oriented, like, you know, national policy. This is what we are going to do, or their specific policies about, you know, social distancing or whether it is wearing masks, and then combining that in legislation. To speak to that point a bit, for example, in my country Kenya, it is mandatory as a national policy to wear a mask whenever it goes out, and that is enshrined in law. Compared to that here in the US. The application on our policy is by no means. There's no national application or policy like that, right? It's very fragmented in states or even in cities within states, and so on so forth. And so I mean, policy regarding restriction of travel. Right. So we've had in Nairobi a restriction of freedom of movement from Nairobi, into Nairobi, almost going to the third month now. Can you imagine having a policy that restricts travel to New York for three months? Anybody from New York should not leave anybody from from rotation, not come into that type of an adoption of policy? And then you have community support to that, right. So there are many, many rivals you include in this in this idea of modeling, right? Yeah. So when we it's a long way to, you know, to explain the methodological approach to explain how you came up with these numbers that I mentioned earlier. Right? The other thing is, of course, a sofa, if you look at the, the African continent, the number of cases, as reported, you know, today, for example, and it varies a lot, but it's pretty much our model is, is is reflective of the current statistics. So from current cases as of June, June last yesterday about 380,000 cases in the African region, the depth about 9000. So, if you take the measurement, the number of deaths in the African continent is about 1.5%, or maybe less than 2% of all the global That's right. The number of aces is probably 3% of all the global deaths. Right? Again, you have a higher, higher case load overall in southern Africa, meaning South Africa. Specifically, and then the North African agent, so very much commenced with our model that we had established whereby you'd have higher cases in the Africa north, including Egypt, including areas like Morocco, Vine in southern Africa, South Africa overall. And then you have pockets in between which have fewer cases, right. So in view of that, we say, well, we haven't yet reached there is no record or report. In current case, cases which are detected, we don't have 16 million cases detected. Tomorrow is a June 30, we will have probably 400,000 cases detected who knows maybe by tomorrow, so but that would mean that based on our model, we have only been able to test this much. See that. So if our model was accurate, it just means this is how much we have been able to Test, and this is the number of deaths we've been able to ascertain. Okay. However, what we know is that modeling, modeling is, is a prediction is based on hypotheticals, so no model would be accurate, but we know also that most persons infected with the disease and exposed to the disease will not have been tested. So far the testing levels where we are is very low in Africa. But that means we are not reaching everybody who is infected, not everybody who is infected has been tested. So, that's why I look at model prediction and the current cases Okay, not that we would have in fact 60 million cases tested by tomorrow, or that it will be positive by tomorrow, but there is a difference between the number of cases tested to date and the predicted number. You might have heard that in the US CDC released a report last week, I think the end of last week where the director was saying that the the estimated number of infected persons in the US is about 20 million compared to is a 2.5 million today that are tested positive. And so you will always have that difference between the predicted cases and the number of actual cases which are detected. Our primary concern, if you were to ask me the primary concern that we have me as the model and my team, and we have had a conversation with the Africa CDC director, we have even had a side by side model comparison. You might have heard of the of the model from Imperial College London, and the HIV model, University of Washington in other models. So we had my colleague Yohannes came for a presentation at the Africa CDC scientific working group, where these three models were presented. That is our model and the three other models and then discuss by the, you know, the scientific committee and community there. And so, because of the different approaches that I used in modeling and also the new ones says that the modelers have, you will have these differences in estimation. So, what is of interest is that as, as a group of African have advantages, nuances of understanding the continent, than other people who have no [unintelligible], either not not been raised there or grown there, spend substantive time or they are walk away or have families there, this breadth of knowledge, which cannot be gained by looking from outside so those nuances have helped us to have a superior prediction model that was more widely received and acceptable within the Africa CDC as a probable prediction model. And so having that type of insight is very, very helpful. The concern for me and my group and all the people that we know and are working with is the mortality. Okay? So the concern that A) we don't have an increase are vastly increased cases, case detection, that then you have an increased hospitalization. And then you have an increased mortality because of the poor or weak health system that have no that don't have as extensive capacity to cope with increased number of hospitalization or demand, for example, for ventilators and so on so far, so, so far. It's already been how many, three months? So I think we are going to the fourth month of the epidemic or the pandemic. And we have not seen, we have not seen hospitals being overwhelmed or hospital being, you know, heavily, heavily overused by COVID patients, or even other patients. I was speaking on Friday, just last Friday, with my colleague Caroline Karutu she was my PhD student at BU and she's running a program a large $65 million program of the USAID in eastern Uganda, the health system program to build and strengthen health system in eastern Uganda. So she's responsible. She's in charge of a vast number of health facilities, from low level facilities, community level facilities, to tertiary hospitals. And she was telling me that she has not seen they have not seen any any concerning increases of hospitalization or any kind of demand or increased mortality from any cause. So that is very reassuring. And, and then I also spoke with a lab technician and her name is Ruth Momo, who is working with the Minister of Health. Minister of Health in Kenya has two mobile laboratories to screen for COVID. One is situated in the border area with Tanzania. And the other one is in the Rift Valley, on a route used by truck drivers long distance truck drivers. And she said that the majority by far the majority of people on these truck drivers who are turning positive, have no symptoms, no or very mild symptoms. So all be able to say that as predicted by a model. We will have large number of people who are infected and even exposed, but many people are not developing symptoms, and they may very well go on and infect others. But the, the sort of the funnel that is, you know, funneling upwards of, you know, severe cases for hospitalization or even critical care patient is very, very small, that funnel is very, very narrow. So we know seeing these, these numbers of increases. Okay,

Christina Lefebvre 00:40:45
That's really interesting. The number of asymptomatic cases is that high?

Richard Wamai 00:40:51
Mm hmm. Yeah. That is where we are on the continent. We know that the the cases will continue to increase, most certainly will will have increased you know, case detection will also have increased number of death. But it is very slow and very low, low lagging on the continent. What, what is ahead of us, Hope, if I can speculate, the fact that many countries in the African continent have implemented as, as other countries have implemented or these which are called non pharmaceutical interventions. So, social distancing you know advises obviously, that is very hard to implement in, in certain urban areas with high population concentrations, wearing masks certainly or even you know, sanitation, washing hands and so on, and so on. So, some areas in some cities have been able to implement very robust systems such as those like you know, hand washing and so on so forth. For example, in urban or suburban where my my [unintelligible] when they go to the bank, for example, outside the building the bank hall, there is a water tank with soap and everybody washes their hands before we go in restaurant and or even a hospital they do that. I mean, we hear hear of that, you know, you should wash your hands. But if those systems and are provided when people can't have them, then you can't. It's a useless policy to say right. And so that is really good. So where we are headed to is the fact that soon enough government in the continent in Africa will begin to relax these restrictions. We we we expect that in Kenya for example, President Uhuru will remove the restriction of movement of travel from Nairobi and from Mombasa, the two cities in which these restrictions have been placed. Next week, I think, as a July for about a month, he will be making an announcement about whether indeed he's going to remove this restriction. We think that you know, is good to be in the month of July will be a critical month for these these leaders to make these determinations and decisions. There is a very high and convincing argument for removing these restrictions and those arguments are economic argument, okay?

Christina Lefebvre 00:43:31
Yes.

Richard Wamai 00:43:32
But we can also make them, you know, you know, population health argument. Here's, here's a way to connect the two and take the example of a country of Malawi. So Malawi has, and just yesterday that they have a new president, and he's the first opposition president to win an election in the African continent, by the way. Most opposition candidates hardly win this election. Yeah. But But, but Malawi has about 22.000 people die of HIV Malawi. If we take the Imperial College College London model of prediction of mortality for COVID in Malawi. There was about 7000 to be realized in Malawi, okay, for due to COVID. Okay, but now compare 7000 deaths of COVID and 22,000 deaths of HIV is a huge difference. So, what is more merit is it merited to save 7000 lives or 22,000 lives. The argument simple I mean for any policy in any person in the sense of a mind will say no, no, we will save more people. Plus, you can save 22,000 lines of HIV at a much cheaper costs compared to the cost that is being implemented to save 7000 lives on COVID. in Malawi, about a billion or one year of GDP, of GDP in Malawi will be lost. In these measures this restriction and the, you know, lockdown majors do to COVID in, in, in Malawi. And then you save another lives, but the economic costs is stratospheric right? Compared to compared to these, you know, saving the lives of over 22,000 people. So they can only argument does not it in no way, no way is there an economic argument that can be made that these closures make sense, okay. And even in the predicted mortality estimates due to COVID and due to other diseases, they really don't come close. And so if I was a policy advisor to the government in Kenya, these are the discussions we'll be having be having predictive models of economic impact. What is a factor of children missing schooling for half a year late and missing schooling for half a year in a time that they will never be able to recover or cannot be recovered because in terms of age. I mean, I guess it's also like students like, you know, you if you were to lose half a year of education or a year of education, that means, you know, the years are going by so you kind of delaying things you could do later on. But it's also having these large baggage, of uneducated, or kids who missed out on education on people who missed out on being reached by antiretroviral drugs, and all are the demands of the healthcare system that I was speaking to. So I think this is where the debate is now going to move towards the argument where economic argument and this institute in Copenhagen, Denmark, the Copenhagen consensus, and they they did some estimates for Malawi and for Ghana. So this specific figures giving is from the Copenhagen consensus regarding the priorities that governments need to implement. Yeah.

Christina Lefebvre 00:47:11
Got it. Um, I do have a few more questions. Are you okay on time?

Richard Wamai 00:47:17
Sure that we can we can we can do another? I don't know, maybe half an hour, 15 minutes or so.

Christina Lefebvre 00:47:22
That'll be great. Thank you so much. So in the United States COVID clearly further exposed the health disparities in our system.

Richard Wamai 00:47:34
Right.

Christina Lefebvre 00:47:35
There have been any similar experiences in Kenya or Africa because I know you talked about some of the marginalized communities in your paper?

Richard Wamai 00:47:44
Right. Um, yeah. So I think I think what we see here, I will take us back to you know, a comment. I guess this is anecdotal. My former PhD student I mentioned and they're Carol Karutu in Uganda her husband is is called Charles(?) who's South Sudanese and he's an economist. The development economist. And he mentioned in the conversation on Friday that what he's hearing in South Sudan is that is that people are saying that the COVID has, has become an equalizer. I think, I think there was something some moise like that Alia here in this country, maybe, maybe in the beginning or there was in the beginning of the of the pandemic, there was these things we used. I had heard about people saying that, oh, Africans are being spared, you know, African Americans are being spared of COVID and, and you know, soon enough, it was clearly not the case.

Christina Lefebvre 00:48:48
Yeah, I remember that

Richard Wamai 00:48:50
Yeah, but the, the idea of COVID becoming an equalizer is this and his observation is that in South Sudan, for example, the Vice President Riek Machar was tested positive for for COVID and his wife. Okay. And, and then, and then, so there's the elite class and the ruling class so that he represents pretty much represent the elite and the ruling class in South Sudan. So for the vast majority of the points of Sudan who over 80, or even 90% of them live in rural areas, we're basically observing what's happening in the capital Juba scene who is being affected, which report being exposed. Because for now, as the restrictions are in place, by far the majority of people who are infected, tested positive in the African region, high in urban areas, and who lives in urban areas who lives in these wealthy areas. And I think we also saw that even here in the US alone, um, you had celebrities, you had people were infected. So there was no, there was almost this pattern, which which made it seem as though the African-Americans are not exposed, which is that I mean, the only people we had in the beginning were exposed to these sort of people who are connected in urban areas and cities and so on so forth. So the same type of [inaudible] in the console(?). So the thinking is that you have the disease affecting the wealthy and the elite ruling class in the masses of people in the rural rural areas are not affected by COVID. That clearly the epidemiology says as much in fact, for for most of the the sub Saharan African region. The disease hasn't really spread out into the villages, my mother lives in the farm, there is no there, is no case in that whole region. And so, and so, however, then you take back, you take back the conversation we were having earlier, which is that the effect of the pandemic, on the health system, on the availability of drugs, on the availability of vaccines. Right? Then will be great, greatly [unintelligible]. But [beeping sound] you know, rural health facilities, okay. Or in the case of these communities where women give birth in rural homes, right? And the kids are never immunized or at least been reached by these mass immunization campaigns. But that's to say that in the in the case where these rural populations reach the kids or the reach by immunization programs, or other, you know, integrated interventions like distribution of mosquito nets, or distribution of antiretroviral drugs in communities, then they'll be affected because the supply chain is not working as efficiently. I give you the example of my walk with visceral leishmaniasis. So that can mean that then these remote areas such as where I work with my visceral leishmaniasis program is that then the population is left farther behind, okay, is left farther behind where kids didn't get immunized where schools are closed, and so on and so forth and so on, so forth. The other element is this, which is that we see a pattern regarding, let's say, teen pregnancies. Okay, teenage pregnancies. And, you know, I can point to two sites where I work in Kenya, one is Western Kenya, we would have visited the site it's called Magori(?) is a community health program there. And then Kitui is a region in Kenya. So those areas have have been in the news recently regarding increased number of teen pregnancies. Now, we've always seen that teen pregnancies typically happen during school closures, during the school holidays. We have three school holidays in a country like Kenya. We have a holiday in April, we have a holiday in August, and then there's a holiday in November and December. Now, these periods, we always know that it is time to ramp up these programs from the pilot program, or programs to expand coverage of educational programs, to preventing pregnancy and so forth. So, we already seen these aspects happening we also seen so these pregnancies are largely happening in these communities, these marginalized communities is the [intelligible]. So you can imagine then, the fact of the consequential effect it would have on the education of these girls. As far as you know, some communities being left behind as a result of COVID pandemic. So there are those kinds of ways we can look at how the pandemic is affected certain communities and because of a failure of the health system or stoppage of immunization campaigns, or because you have large, you know, teenage population, who are then being exposed to these phenomenon, or long periods of time where schools are closed and then high teen pregnancies, and so on so far. One probably positive thing that we think pandemic will cause, you know, in terms of spurring the health system is that probably at the governor's level leaders in the welfare, particularly the leader, because they're the ones who can make these policy decisions, who are not able to us to freely travel to Asia to India or South Africa or Europe, London for medical procedures. And now are stuck in the region. You have the governor can ask for [unintelligible] As for example, you know, wherever they are, they cannot-they now cannot travel to to India or for medical, medical reasons that maybe this is a moment now and an opportunity for them to begin to build their regional health system and capacities in their hospitals to equip those hospitals to create hospitals with chronic care conditions. I know, for example, many areas have many areas that didn't have, for example, ventilators, or oxygen, or you know, capacity for ICU beds. That has happened in even eventually a small in small measure, but there are areas that didn't have those infrastructure that have now have those, you know, put into place.

Christina Lefebvre 00:56:02
That's a really interesting, positive impact. I didn't even think about that.

Richard Wamai 00:56:08
Yep. Yeah, absolutely. And I think also too, I mean, you can imagine in for a second being put into place is another way to look at the positive effect of COVID, which is, we've, you know, we think we've got to wash programs, these are water sanitation and hygiene programs. We think that a highly increased consciousness of sanitation, of the importance and value of washing hands, for example, we've been sanitizing surfaces and places whether they are you know, public transportation vehicles, or even these public spaces and so on and so far. I think that that will have an effect down the line. I mean, we can take diarrheal diseases, for example, or cholera or others that are, you know, primary contribution is this lack of these wash programs that could have in fact, positive effects of, you know, increase awareness and increase infrastructure or, you know, your development as well as these policies, so yeah, I think that there would be an increase, increase, you know, benefit in those areas. And also you can imagine with the, with the insistence of wearing a mask and effect, you know, that can have on other respiratory diseases, whether it's tuberculosis, you know, and so on and so forth. Right? So in a context where respiratory disease is transmitted, and you know, people wear masks to prevent, you know, COVID, then you have also the prevention of the other respiratory diseases, right?

Christina Lefebvre 00:57:48
Definitely.

Richard Wamai 00:57:51
Yeah.

Christina Lefebvre 00:57:53
What are some of your thoughts on timing for COVID vaccine development, and also accessibility and population acceptance once it is developed?

Richard Wamai 00:58:04
I think it's a very good question, especially the acceptance of the other vaccines, right? Yeah, um, I think on the one point about accept-acceptance of vaccines, I think it's fair to say that we have a higher vaccine acceptance in, in mostly low income settings or low income countries, compared to let's say, the United States as a unique example us is in a different level altogether. The anti-science movement, anti-vaccine movement is so strong here that some areas have a much lower level of coverage of vaccines compared to most countries in the African region. You know, so, so there is already this sort of these huge, vast network of conspiracy theories. And there was a paper that I read. I wish I could get it quickly now, but maybe not but it's a very interesting article that was published in the Journal Science recently. But says that looking at, you know, vaccine acceptance, and these anti-vaxxers and their network so, you know, uses an algorithm to estimate where on social media, messaging for vaccines, and and then, you know, messaging for anti-vaxxer. And apparently, you know, overall on social media, you have fewer people who are anti-vaccine, then you have those who are for vaccines. However, the anti-vaccine to vaccinators I guess we can call them that have a much vaster network within networks of vaccine promoters. And the article idea that in fact in about a decade, you will have much more wider presence in the social media of anti-vaxxers than you have for those who have or support vaccines. And I think that's a really scary, scary, you know, aspect because I mean, we have a much wider acceptance of anti of these anti-vaccine ideas, then you have all those pro-vaccines that has huge consequences in the future, not just for this pandemic, but for future pandemic. So quite clearly, even now, as we're seeing in the political debate, particularly in the US. There are those who don't wear a mask. So, once a vaccine is is produced, there was a will or not want to accept. But see, acceptance is very, very important and has to be approach, you know, very carefully, very methodically, with proper communication channels. We always say I mean, the African continent you you approach a topic that involves a community through the community leaders trusted sources in the community, those that community trust and listens to. It could be anybody, whether it's the local Imam or the local traditional herbalist, or today, or local teacher, or community organizer, or the head of the village, or the chief or whomever, or the local priest, you know, those are the ones that people listen to. So your approach, always in any intervention, as you know, the global health community has learned, as you know, for example, in the context of, you know, responding to Ebola that you cannot just go to the village and say, "yeah, we brought you this and this is what you'll take." No, it is through the community trusted voices, who can communicate local information. And those are the ones those are the channels to be used. You might remember, you might remember in our class, intro to global health, you had this case study of Malawi remember that?

Christina Lefebvre 01:02:10
Yes, I do remember.

Richard Wamai 01:02:12
Yeah. And you know tackling, you know, maternal and child mortality and until the area chiefs Chief Kwataine Masina case in the video was very instrumental. Yes, you have the political leadership at the top and then you have the whole interest in everybody all the entire leadership is on board. But if you have any dissenting voices or you have these kind of freedoms or exemptions that are there in a very individualistic society like the United States. Then you cannot have a universal coverage cannot be cannot be achieved. And so, you know, having a vaccine is one, but then having acceptance is another one. And then of course, the whole issue of distribution and supplies very important. A point about current vaccine development in the in the continent, in South Africa is, is in the clinical trial network as you may have heard of the solidarity tribe by the WHO for, for COVID. So you have a few, a few areas in South Africa, Egypt, Kenya, I think is also coming on board. And the thing about this is that these vaccine trials cannot be exempt from being included or cannot exempt the African continent from being included in the trial. There are some vaccines that in fact, exists for the global population that have been tested or either have even been originated in the African region. For example, one of the meningococcal vaccines, a meningitis vaccine is originated from the African continent. And so having you know, these trials take part take place in in these countries is important because one of the, one of the policy considerations when a vaccine is developed is the country or the population in which it is it was, you know, it was trying must be in the priority group of our population to receive it as the first group of people to receive the vaccine. So, if we didn't have any vaccine trial and going on in the African region for covenanting, that I mean, they'll be back of the line. And so, including these trials in those region is very important. For that reason and also for the fact that biologically, human populations are biological, they have specific genetic particularities or minor differences in these particularities that you know, a vaccine tried in one population may not necessarily be as good as in another population, because of these differences. So, therefore, having a vaccine trial, you know, encompasses the, you know, the entire population, or the whole distribution of the population across the globe is the ideal scenario.

Christina Lefebvre 01:05:08
Right. In another Northeastern News, you talked about the 10 to 90 gap in disease research and drug development. Could you explain the significance of that gap in the evolution and spreading of pandemics?

Richard Wamai 01:05:26
Well, yeah, I mean, the the idea is a very old idea that 1090 gap is an old idea, you know, where, you know, research for drugs for vaccine development and so on so forth, generally is driven by demand of health condition that affects a small proportion of the population. You know, so 90% of the funds in this case, the 1090 idea is that 90% of the funds are going to my disease that affects only 10% of the world's population. So there are many ways we can look at this. We can look at, for example, the global research budget, that would be well over $140 billion that is spent in global health research. It's a huge amount of money right? So which type of research is conducted on which type of diseases are conducted In this-with this kind of money? One example in the article that you mentioned here and the article is, was was speaking with my colleague, Professor Pollastriast of Northeastern College of Science. Which is that, you know, him and I work on neglected diseases and that they are neglected and these diseases are called neglected topical diseases. It's a whole group of an open ended list of, you know, 20 diseases or more, and they're neglected. That means there's very little research going into this very limited aside going into those diseases. If you have to look, for example, there are clinical trials, maybe less than 1% of all clinical trials go into this into this field. And so that's the whole point about the fact that we happen to makes we have large pandemic diseases for which we are not committing as much funds as we ought to, given the population affected, given the burden to the glo-to global health, right. So, you know, we could we can say, in context, which is that I mean, if we don't eliminate COVID-19, in low income settings, whether in Africa or, or Honduras, or, you know, I don't know, Vietnam or any of those countries, we will then not eliminate it globally. So there has to be a global approach. And, you know, we call for, you know, rebalancing of how global funding for research and, for health development is is currently organized so that we can remove the neglect from these group of diseases, for example. So, that means we should put more money into targeting infectious diseases and neglected diseases like you know, visceral leishmaniasis or schistosomiasis, or even yellow fever and even malaria and so on so forth and so on so forth. You know, we are seeing an increase, you know, growth, for example, early on speaking to the African region having 14 disease outbreaks, you know, variety of diseases. And but how much money are we actually putting into these programs? Whether it's yellow fever program, eradication program, or even polio, and polio is very close to be eradicated. But clearly now, with, with, with COVID, we undoubtedly will have to be playing catch up in immunizing for these diseases. Whether it's you know, polio, or yellow fever or meningitis or measles, and so on, so forth. So we are currently putting a lot of money into one basket for COVID. It makes sense from this sort of panic and fear consequence. But it doesn't make sense from a rational point. To, to, to, to then avoid or ignore all of these other diseases that we, we could be targeting.

Christina Lefebvre 01:09:36
Are there any important lessons that you hope we get as a global society take away from the pandemic?

Richard Wamai 01:09:46
Um, yeah, I mean, I think, I think yes, you know, absolutely. The, the reason why we have go to we have reached this point of a pandemic declaration is for one, you know, there are many failures, there is a lot of failures in the across the board in the so called global health infrastructure. You have had repeatedly about, you know, the call by President Bush in the first place. This was like an one that was a 2003. And then 2005. And then you had Obama make a call in 2010. And then and then you have Bill Gates who made a call in 2014. For, for these, you know, President Bush and President Obama and Bill Gates made a call at different times. I mean, in 2003, it was it was this SARS disease pandemic and then which was originally from Asia, South Asia, and then you had Obama make a call after the H1N1 influenza pandemic that also killed a large number of people. You know, the CDC estimates hundreds of thousands. And then you had Gates make a call in 2014 after 2014-15 after the West Africa Ebola pandemic, for what? For surveillance, for increased surveillance, for strengthening surveillance systems, right? strengthening disease surveillance. So that was so by that we mean being able to create an infrastructure where you have, you know, system that conduct assessments of disease outbreaks. I mentioned in the article that you mentioned earlier where I-by Northeastern, I talked about the 1090 gap about the USAID predict program, a program that that was, you know, was funded during the time of Bush or rather Obama, or under Bush, in fact, at the time that was created to identify new viruses and new outbreaks. That program that was supported and then, you know, infrastructure was was put into place all the way until, you know, the current President Donald Trump decided to shut it down. So, and now program had established over a short period of time over about a decade 1000 new viruses(?). So if we can, if we can, you know, strengthen these surveillance systems absolutely necessary, I think, well, we have these calls for streaming surveillance system from '03 you know, 2010 2015. I am convinced that this pandemic have made it abundantly clear to the two leaders of countries to global health infrastructure at WHO level and other regions that it is important it is time to heed the call and set up the surveillance system. You know, the estimate there was there was a commissioned set up the global health security commission that that you know, found out that you know, we we can create a robust surveillance system or a very small amount of money, you know, if you put $10 billion to a global surveillance system, how will it help us to be able to predict to be able to to support early any type of an unusual or new disease that comes comes up so I think the lesson to be drawn is that we cannot afford to not be prepared anymore. It is absolutely critical that the global community has to be prepared. I think another thing lesson in tandem with that is that infectious disease is very much of a global concern. We cannot be lax in in the developed world, were non communicable diseases have become, you know the leading cause of death. I mean, even globally the global deaths. Just about, you know 73% of the global data from non communicable diseases. Yes, we know that the burden of disease is tilted towards these non communicable diseases. However, we can see now that the impact of a global pandemic, global infectious disease pandemic is so huge that we cannot afford the economic effect is so huge. We're talking about trillions of dollars that we absolutely cannot afford to ignore infectious diseases and we need to be building, prepared. So I mentioned surveillance. Yeah, we need to build surveillance programs. And we need to build preparedness programs in the country like the US has to be prepared. It has been known for all the way from the SARS, influenza to H1N1, that there will be-there is a predictable probability of having an infectious respiratory disease. [unintelligible] that has been seen before. But what happened? Nothing. I mean, if we know that, you know, it's an influenza, it's a respiratory disease. So then what do you do in terms of preparedness? You know, hospital systems are put out, isolation sites are put up in, you know, PPEs not put in stock. And there's a whole preparedness structure that can be in place. Right. So that I think is a very, very critical lesson that we have to learn another lesson, I think, that is very poignant in the moment where we are is that no country can afford to work by themselves or to be to be driven by pride or that we can't accept test kits from country X because we need to develop our own. Or we can't accept, you know, these materials from this country because we need to develop our own. That is a disastrous kind of a thing, no country is alone. No country can, by itself prevent global pandemic from spreading. No wealth can prevent a country from being overwhelmed by an infectious disease and we have without question we have seen what what has happened in the US in that regard. So, as the saying goes, we are in this together and there is no there is no in fact, this is probably the best moment people can say yes, in fact, in this together, it could not be said so well so poignantly, so pointedly as we can see now. Because no country literally is spared and we are in this together. So we have to act together. And that's the lesson which is global health is one health of one world. And of course, you know, as you may recall, in our class, we talked about global health. And then we talked about planetary health. And so it's very important to be conscious of these developments in global health, global health of the human population, but, but we also are conscious of how our human population interacts with our environment, because that's where the diseases, a lot of these new infectious pandemics and this is coming from our contact with the environmental ecological systems, the animal world and so on, so forth. So, so we're really learning lessons in that we have to work together as a global human society.

7/11/2020 14:06