By Matias Guente*
*Original published by Canal de Moçambique the [transcribed & translated – h2n responsible for any errors in translation]
The Mozambican government had marked 27 July for the return to school. But everything indicates that the group of influencers who promote panic and fear of Covid-19 spoke more loudly and pressured the President of the Republic, who changed the decision in a nationwide address. Arild Drivdal, a Norwegian who resides and works in Mozambique, specialist in public health and trained at Harvard University, understands the panic towards a new disease, but says that contact tracing studies that have been carried out in different countries show that there is no or practically no spread among school children. In an interview with Canal, he said that based on the studies currently available, it seems that the fear that many parents have is based more on emotion than science. Arild Drivdal, who is technical adviser at h2n, a non-governmental organization that works with access to information and health, said that it is necessary to find ways to continue to live within the new context, and he fears what he calls “secondary effects”, which can have a devastating impact on people’s lives, such as loss of employment or income, which in turn can reinforce economic inequality. He does not doubt that gyms and all other activities can open. “We cannot close everything forever, so the question is how to function in a way that is as safe as possible for as many people as possible,” he said. Read the interview in its entirety.
Canal: Parents fear letting the children return to school, allegedly because of the risk of the children becoming infected. Does this fear have any scientific basis or is it just fear?
Arild Drivdal: We should always bear in mind that researchers are still learning about the new coronavirus and that there is a lot that we do not know yet, so most questions cannot be answered with full certainty. When it comes to school closings and school openings, there is no perfect answer. First, it depends on where a country is in the trajectory of the pandemic. It makes sense to keep the schools closed if there is uncontrolled community spread, like we are seeing in some countries like Brazil and the United States, but we have not yet seen that here. This is why some countries in Europe closed down the schools at first and then opened them once the community spread was under control. In all these cases, the decision to close or open was based on the circumstances in each country. Contract tracing studies that have been carried out in different countries show that there is no or practically no spread among school children and therefore that the general risk is low. Based on the studies that are currently available, therefore, it appears that the fear that many parents feel is based on emotion rather than science. The fear is a natural and understandable psychological reaction, but it does not seem to be based on any scientific research that we currently have.
Canal: Should we have closed the schools?
Arild Drivdal: On balance, it was probably a correct decision to close the schools early in the pandemic because there were so many unknown factors. If you don’t know exactly what the risks are, it is usually better to be careful. The decision to close the schools was based on caution, therefore, which is fair enough, but the decision to open is based on a different kind of analysis, which includes an assessment of the actual risks, the consequences of keeping children out of school and the need for society to adapt to the pandemic for the long term. We are no longer acting out of precaution but rather adapting to a long-term situation.
Canal: By the numbers we see in the West most of the dead are elderly people who had other underlying diseases and who were in nursing homes and assisted living facilities. Where should the prevention effort be concentrated or what should our concern be in a country like Mozambique, where people do not live for as many years as in those countries?
Arild Drivdal: Because elderly people are so much more vulnerable than the younger population, it is very important to take every possible measure to protect them. These are our grandfathers and grandmothers, our fathers and mothers. The first line of protection comes from the family members, who can make sure that they wear masks, keep distance to the older people and help them with their day-to-day tasks. Special care should also be taken by people who are obese or have cardiovascular disease, diabetes or respiratory conditions. Overall, the main focus should continue to be on prevention, so that we can slow down and prevent the transmission of the virus. We should take some comfort in the fact that Mozambique has a very young population, which means that death rates will be much lower than in the western countries.
Canal: As other diseases, even individually, kill more people than Covid-19, what has led to so much panic?
Arild Drivdal: The new coronavirus came very suddenly and spread very quickly, so it shocked us. The virus can also infect anyone, so leaders who were used to being protected or could travel to other countries for medical treatment no longer had that option. When the rich and powerful feel vulnerable, they have a tendency to overreact, which can lead to panic. I am not talking about Mozambique specifically, but in general. Much also comes down to communication. If the authorities feed a belief that you will die if you get the virus, then people will tend to believe that and get scared. That is how communication works. This is why it is important to be measured, factual and consistent in the communication about the pandemic response, including an issue like opening the schools.
Canal: Preventive measures were basically imported from the West and did not take into consideration the specificities of a country like Mozambique. If you were to decide, what preventive measures would you take?
Arild Drivdal: There seems to be an understanding that the effective prevention measures are the same in all countries: wash hands, wear masks, keep distance and avoid large groups. In particular, the countries that implemented universal mask-wearing early, such as Hong Kong, have seen a very positive effect. In some cases, lockdowns were needed, but this was never a good solution for Mozambique because of the negative effect it would have had on poor people. Overall, the public health authorities in Mozambique have done a good job, and we should be grateful for that. They have found a reasonable and pragmatic middle ground without closing down everything. Equally important, we have been lucky to avoid the irrational politization of the pandemic we have seen for example in Brazil and the United States, which have led to a cascade of bad decisions and terrible outcomes in those countries. The challenge now is to make appropriate adjustments for the long term.
Canal: There are experts who say that the testing being carried out is misleading in that it detects when the virus is in the body and does not detect who has had it and who no longer has it. They indicate that serological testing would be used to assess the prevalence and that this would be more useful.
Arild Drivdal: Testing for the virus and testing for antibodies have different objectives. It is necessary to test for the virus in order to control the pandemic. It is the only way to know who is infected and how the pandemic is evolving, and it provides the information the authorities need in order to take appropriate measures. For example, if there are many positive cases in an area, the authorities need to do everything to prevent the virus from spreading. In advanced countries, testing is the first step in the testing, tracing and isolating approach, which some have called the golden standard of public health management. This is essential and should always be done wherever possible and when there are enough resources. The testing for antibodies on the other hand informs us about where the virus has been and whether there is any immunity emerging in the community. It can also give us an idea of the hidden or unseen part of the pandemic, since we will find people who have been infected but who were not tested. I don’t think we can say that serological testing is more or less useful. Both are useful but testing for the virus is more urgent because we are dealing with an active pandemic.
Canal: You recently wrote that it is necessary to control the secondary effects of Covid-19, which you classified as "devastating". What effects are these and how can they be avoided?
Arild Drivdal: There is a wide range of secondary effects, and these are becoming more visible as the pandemic evolves. In our context, the most important secondary effect is seen when routine vaccination of children and preventative medical care of mothers and newborns stop. This includes the distribution of bed nets to prevent malaria. The authorities must balance the needs created by the pandemic and the permanent health needs that are always there. Parents need to make a point of taking their children for vaccination and preventive care visits. They should not be afraid of going to the health center. Of course, there are other effects on the social level as well, and we must hope that the government will do everything it can to minimize the impact of the public health measures on people’s livelihoods, so people can feed their families.
Canal: [Speaking as a public health specialist], in a country where access to drinking water is a problem for most people, how can you fight a disease that is linked to hygiene in the first place?
Arild Drivdal: That is a very important question. Perhaps the best way to approach the issue is to see the pandemic as an opportunity to expand hygiene measures around the country. Increasing access to water, sanitation and hygiene will have a significant effect on the spread of the virus, but it will also help to prevent many other diseases. Of course, we cannot solve the basic infrastructure challenges overnight, but there are many things that can be done, for example making water and soap available in schools and health centers. As in everything else, we must do the best that we can do with the resources that are available.
Canal: What is your opinion about ventilators and disinfection tunnels?
Arild Drivdal: The disinfection tunnels are a joke and serve no practical purpose. In some cases, they even seem to have increased the risk or transmission. At the beginning of the pandemic, there was a huge focus on ventilators, but this focus has since changed. A high percentage of people who were put on ventilators died, while others suffered serious lung damage and other long-term effects. As clinicians have learnt more, their approaches have evolved and now there is a much bigger focus on alternative approaches that delay or avoid intubation.
Canal: There seems to be some misinterpretation about cigarettes and drinks. In Mozambique, for example, there is an anti-drinking campaign related to Covid-19 that is not very well explained. Does drinking have anything to do with Covid-19?
Arild Drivdal: I am not aware of any research that shows that drinking in itself affects the risk that people is facing from the virus. The risk comes from people being close to each other in a bar or engaging in behavior that puts them more at risk. Perhaps they forget to wash their hands or keep distance and drink in groups of people. The early spread in Austria and Italy almost all came from people drinking in bars after skiing in the mountains. In the United States, part of the recent increase in cases can also be linked to bars and parties. It is absolutely an appropriate strategy to close bars and nightclubs and prohibit parties with more than 5-10 people.
Canal: Some restrictive measures have been taken with the understanding that Covid-19 will pass. I refer for example to gyms, hotels and bars. What will happen if Covid-19 does not pass? Will we no longer have gyms and bars?
Arild Drivdal: A randomized controlled trial in Norway showed that there was no risk in opening gyms to the public. However, something like that of course depends on people taking relevant measures with regard to hygiene and social distancing. The underlying issue is that life must go on. We cannot close down everything forever, so the question is how to function in a way that is as safe as possible for as many people as possible. This always comes back to the prevention measures: wash hands, wear masks, keep distance and avoid large groups.