Ethiopia’s COVID-19 quandary

Uncertainty shrouds the actual spread of the virus so far and the most appropriate method of tackling it in the Ethiopian context

As COVID-19 spreads around the globe, governments everywhere face a trade-off between economic well-being and containment. Ethiopia faces a greater and more dangerous challenge than many other places, given that interrupting daily economic life would threaten fragile livelihoods for tens of millions of people already living in precarious conditions. On the other hand, allowing the status quo to continue, meaning that working, traveling and worshiping practices would go on as usual, would be to proceed amid the reality that Ethiopia is unusually fertile ground for this highly contagious and potentially deadly coronavirus.

The Ethiopia Public Health Institute (EPHI) confirmed the first case of COVID-19 on 13 March. Three days later, as the fifth one was announced, the government suspended schools, sport events, and large gatherings for 15 days. But, as the case numbers edge upward by the day, many assume the virus has already spread to a significantly greater extent in Ethiopia than confirmed so far.

The authorities have provided public information about confirmed COVID-19 cases and how people can prevent infection. By 1 April, it had announced 29 cases in Addis Ababa, Dire Dawa, Oromia, and Amhara, often stating that those infected had recently traveled abroad. 

Since the virus arrived, it has been the primary discussion topic among Ethiopians. Some talk about prevention techniques; others about the nature of COVID-19 itself. Yet there is a dearth of reliable data about how many people are infected, or whether any Ethiopians have died from the virus. While unreliable statistics are undoubtedly being disseminated  in many other countries, including some of the world’s wealthiest, the uncertainty is arguably more pronounced in under-developed nations like Ethiopia. For example, by 31 March, the EHPI had tested just over 1,000 samples, which is a similar number to Kenya.

Moreover, the fact is, Ethiopia is not in a good position to respond. Little preparation was made before the first COVID-19 case. The government initially made do mainly with passing on prevention advice from the WHO. According to World Bank data, there are just 0.3 hospital beds for every 1,000 people in Ethiopia, compared to 3.4 in Italy, 6.5 in France, and 2.9 in the U.S.. Only a few hundred intensive care units are believed to be available along with  435 ventilators. There may soon be a need for tens of thousands.

So far, very little testing has been done; flights to and from countries hit early by the pandemic such as China and Italy are still flying; checks at Bole airport were not ramped up quickly after the virus was first reported by China on 31 December, and the environment across Ethiopia, especially in urban areas, is rife for rapid transmission. With around 40 percent of households without water access, sanitary conditions are basic for many people, who often live in crowded, multi-generational households. Despite some orders to reduce occupancy levels, public transport is jam-packed with commuters, and large numbers still flock to religious gatherings in this highly devout country.

Harmful traditional practices

Although hand-washing stations and COVID-19 posters are now common in Addis Ababa, some cultural traits are challenging the country’s ability to respond. Ethiopians tend to ignore advice that goes against their culture of communal living and offering physical greetings, such as sharing food or embracing. Religious institutions and markets also represent a challenge, because people are more concerned about the implication of not practicing their religious beliefs and millions are not financially capable of storing food. 

Along with the failure to adopt widespread social distancing measures, many Ethiopians are still not taking the outbreak of the novel virus seriously. Some joke that “corona is the disease of the rich people so there is no way I can be infected”. People might get offended if there is no hand shake, as they perceive they are being suspected of infection. Others think that those wearing masks have the virus and so steer clear while remaining close to people without protective gear. In light of this context, which also includes a considerable degree of misinformation, the Health and Technology and Innovation ministries caused dismay on 27 March when they announced progress with a COVID-19 remedy that has been developed with traditional medicine experts.

Fear of being identified as a carrier of the virus is also a problem in Ethiopia. It is therefore unlikely that all people with symptoms will seek medical attention, even if services are available to them. For example, a person who came back to Ethiopia from Saudi Arabia with symptoms escaped from the ambulance taking him from the airport to the health center. He was found after spending a night with his sister in Addis Ababa and a night in Dessie, then catching a bus to his home area.

After the majority of the first confirmed cases were foreigners, there was a spate of minor attacks, such as stone-throwing and verbal abuse, on non-Ethiopians, mainly in Addis Ababa. Although that trend seems to have abated, deteriorating economic conditions combined with existing political tensions could induce panic and lead to wider social and political disorder, especially if supplies of basic commodities or essential services are threatened.

The public’s slowness to change its behavior reflects a lack of urgency and also a concern that enforcing lockdown measures seen in other countries will make life more difficult for Ethiopians because few people can work from home and many are living on narrow margins and so cannot afford to take time off work. The public’s hesitancy to embrace necessary changes in habits also corresponds with a tendency by officials to downplay the potential impact, as we have seen in the government health sector’s inability or inaction in not aggressively testing for COVID-19, in the view of one former government emergency worker. Especially in rural areas, cases of the coronavirus would be unlikely to be suspected and reported, while routinely in Ethiopia autopsies are not conducted when elderly people die, he said.

Hand-washing station in Bella, Addis Ababa; 1 April; William Davison

Although tragically, the virus’ human cost might eventually become unavoidable, many people with COVID-19 and underlying causes or old age may die without their deaths being attributed to the virus. World Bank data show that a relatively large number of both confirmed COVID-19 cases and deaths correlate with a higher national GDP per capita, presumably partly reflecting varying detection capacities.

As a demonstration of Ethiopia’s challenging health situation, the COVID-19 epidemic is spreading  alongside a yellow fever outbreak in Gurage Zone of Southern Nations and cholera episodes in Southern Nations and Oromia, including Hawassa and Shashemene towns, and  in the Somali region. There are also ongoing measles outbreaks across Ethiopia, with Oromia the worst affected. Yellow fever reappeared in Ethiopia in 2012 after a 50-year absence.

Lower respiratory infections—which COVID-19 can cause—are perennially the third-most prevalent cause of death in Ethiopia after neonatal disorders and diarrhoea, according to the U.S. Center for Disease Control. According to an academic study using Global Burden of Disease Study data, in 2015, 677,000 Ethiopian died in that year, a number that reflects significant progress in reducing the number of  people dying from communicable diseases over the last few decades. The study showed that life expectancy in Ethiopia increased from 47 in 1990 to 65.8 in 2017, with diarrhoea, lower respiratory infections, and other common infectious diseases collectively declining by 79 percent from 1990 to 2015. 

In 2015, lower respiratory infections were the second most common cause of death in Ethiopia, with a rate of 98 per 100,000 people. That reflects a reduction of 56 percent since 1990, although the ailment was responsible for the most “years of life lost” in 2015, according to the study. Still, that rate was significantly lower than the mean of nine comparable African countries, according to Global Burden of Disease data.

In terms of health infrastructure to combat an epidemic, project documents for a $150 million loan were agreed in December to support African Center for Disease Control operations in Ethiopia by building a national laboratory and improving other disease-control operations. At the time, the World Bank said: “Ethiopia’s proximity to multiple fragile states and its status as a major land and air transportation hub greatly exacerbates its own vulnerability to epidemic disease simultaneously with exposing the African continent to the potential undetected rapid spread of such diseases.”

Given the situation, COVID-19 may have entered Ethiopia late last year from China, spread, and started contributing to deaths from respiratory infections and other illnesses, according to the  former emergency worker quoted earlier. This would mean it will be impossible to know where Ethiopia is on the curve revealing the spread of the virus. Another medic, who spoke on condition of anonymity, claimed it’s “impossible” that the number of cases is  so low. Projections suggest tens of millions of Ethiopians could be infected within months if the virus arrived in mid-March and transmits as expected given the context here.

The medic pointed out that it will be very difficult to confirm the impact of COVID-19 in Ethiopia because respiratory tract infections are so common. “We also know that Ethiopia’s surveillance system is not sensitive enough to capture changes in the trends of disease, and the lack of testing tools and setting might have hampered the country’s capacity to detect cases on time and accurately track index cases,” he said, adding that political motives to suppress information about the virus’ spread in Ethiopia support the suggestion that COVID-19 was present in the country before the 13 March announcement of the first case. 

Some people are taking precautions in Bella, Addis Ababa; 1 April; William Davison

A doctor in Mekele, Tigray’s capital, said only 5 to 10 percent of possible cases in the country are being tested and all 28 samples of suspected infection from Tigray sent to EHPI have proved negative, an outcome he described as “questionable”. Nationally, Health Minister Lia Tadesse said on 31 March that out of 1,013 tests, 25 had been positive. 

The Mekele doctor said that from those 25 confirmed positive cases, six were the result of community transmission, which indicates that the case burden in the country is way higher than the official figure. “My suspicion is there are probably thousands of infections inside the country that have yet to be detected.” He added that an uptick in pneumonia-types illnesses had been anecdotally noted in Addis Ababa, Adama, and Assela by physicians. There are similar but better evidenced Kenyan concerns based on monthly data from the National Registry of Diseases.

There is, of course, no way yet to confirm much of this anecdotal information. Nevertheless, after the electoral board on 31 March postponed elections that had been set for 29 August, the rampant uncertainty, the rising number of confirmed cases, and the accompanying pressure might force the government to declare a State of Emergency (SoE) within weeks or even days. This might help it enforce the measures it has announced, though it might also aggravate pre-existing political volatility, especially if the election delay is not well managed.

In addition to existing opposition complaints about being prevented from political campaigning, many Oromo, as well as local and international human rights advocacy organizations, have been concerned about the millions of people in western Oromia, where the government disconnected phone and internet services on 3 January. While telecom services were restored on March 31, that only occurred after officials shunned appeals to relax the cutoff for more than two weeks after the first case of COVID-19. Shimelis Abdisa, President of Oromia, said that the government has resumed the telecom service because peace in the area had been restored after its operations against the Oromo Liberation Army (OLA).

Responding to a social media campaign calling for an end to the blackout, Taye Dandea, Prosperity Party Oromia branch spokesperson, wrote on Facebook that there is no chance COVID-19 will spread to western Oromia since the area is unstable and no foreigner would dare go.“There is no fool who is going to save ‘Shane’ the extremely dangerous virus, in an attempt to prevent the small Corona (COVID-19),” he wrote about the OLA.

Stately response

For now though, as shown by the election postponement, the focus must shift from politics to how to respond most effectively to the virus. 

International donors have led the way on this front—although Ethiopia’s leader wants much more. On March 24, in advance of the G20 meeting of global leaders, the Prime Minister’s Office proposed a $150 billion emergency financing package for Africa to control the spread of COVID-19, including comprehensive debt relief and emergency health assistance. The UN trade agency called for a $2.5 trillion rescue package of investment, aid, and debt relief for emerging economies.

On 15 March, in a public relations coup for both parties, Abiy secured COVID-19 support for Africa from the founder of Alibaba, Jack Ma, who agreed to distribute 20,000 testing kits, over 100,000 masks, and guidelines on how to treat patients for each country. The first shipment arrived in Ethiopia on 22 March. There has also been other support coming from China: BGI Group, a life sciences company, donated 1,000 testing kits to EPHI and the China-Africa Business Council contributed 500 testing kits and a testing machine.

Domestically, the federal government announced three sets of measures on March 16, 23 and 27. The first said large gatherings, meetings and sporting events were suspended for two weeks, and small gatherings are to be held after consulting the Health Ministry, while religious gatherings should be limited. Efforts got underway to set up regional quarantine centres. 

Ethio Telecom, the state-owned monopoly, took the welcome measure of playing a COVID-19 awareness message each time a call is made. This has helped to increase public knowledge—apart from in western Oromia. Primary and secondary students were sent home for 15 days while university students were sent home a week later to do their course work online. This was extended for another two weeks on 27 March. Bars, nightclubs and other entertainment establishments in Addis Ababa were closed on March 23.  

Despite government measures, prisons and detention centers are vulnerable to exposure, especially since mass arrests occurred recently with large numbers kept in detention rooms. The government says correction facilities will be expanded and it will utilize other buildings to avoid overcrowding. New prisoners will be tested for the virus before being taken to these facilities, family visits paused, and prisoners who were jailed for minor offenses and are nearing their release date have been set free. 

The situation in overcrowded internally displaced (IDP) and refugee camps is also worrying. Currently, there are about two-million IDPs in locations mostly without  electricity and telephone services, with many in need of aid. Those numbers are in addition to the seven million Ethiopians who require a total of $1 billion humanitarian assistance this year, and another eight million citizens classified as food insecure who  receive ongoing support.

A COVID-19 National Ministerial Committee meeting  on 20 March said that all passengers arriving in Ethiopia would be subject to a 14-day quarantine period, while Ethiopian Airlines has suspended flights to 72 countries due to a variety of travel bans, quarantine procedures, and plummeting demand. The second raft of government measures announced on March 23 ordered security forces to enforce social distancing and disperse large gatherings. It also included shutting down all land borders to stop movement except for essential trade. In addition, the fire brigade sprayed streets in Addis Ababa with disinfectant on 29 March.

The authorities sprayed streets in Addis Ababa to try and disinfect them; 29 March; submitted

On March 26, Tigray’s government took assertive action, announcing a regional state of emergency. In addition to the federal measures, the region plans to ban inter-city buses and minibuses, while allowing traders to continue their activities. In urban areas, all public transport vehicles have been told  to carry a maximum of half their capacity. Amhara’s government banned all public transport from entering the region from all directions on March 29. A day later Southern Nations and Oromia’s administration announced similar measures, as have a number of cities.

The third round of federal measures on March 27 included efforts to boost the economy, such as import-tax exemptions and prioritization of hard currency for equipment to fight COVID-19. The Revenue Ministry will expedite VAT returns to support cash flows, while there’s a potentially inflationary plan for the central bank to provide 15 billion Birr ($457 million) liquidity for private lenders.

To reduce cash handling, which could be a virus transmitter, the Commercial Bank of Ethiopia will increase the amount people can transfer through mobile banking, while the central bank has removed the minimum flower shipment price to help ailing exporters. With preventive materials in scarce supply, many pharmacies with stock raised prices in response to wildly increased demand. In response, the authorities alleged illegal price hiking and shut down many  pharmacies and shops, including a total of 7,000 businesses. The Trade and Industry Ministry plans to strengthen price controls and tackle shortages. 

Economic and political symptoms 

The pandemic is already having a significant negative impact on an economy that depends on imports for key items like fuel, fertiliser, and medicine. Ethiopian Airlines, a major source of scarce foreign exchange, is set to be one of the main economic victims of the pandemic, already losing $190 million in the last two months.  That is despite its decision to keep flying routes that other airlines have cancelled, a vital service for governments trying to evacuate otherwise stranded citizens. Tourism revenues and flower exports are also being hit hard, and remittances are expected to decrease due to layoffs across the world. At Hawassa Industrial Park, 14,000 workers have been given paid leave as manufacturers assess how to protect workers from infection and adjust to reduced orders. Still, a flower exporter said on 1 April they were still producing at 70 percent of their capacity and had retained all employees, although other floriculture companies were operating at less than a third of their capacity. “It is important that there will be soft loans for working capital to help farms keep working and exporting so there is enough turnover to pay the workers,” he said.  

Overall, growth, which was already set to slip according to the International Monetary Fund,  is likely to be significantly reduced, dangerously increasing unemployment at a time when millions more jobs are needed to satisfy a youthful population. Ethiopia’s large current account deficit may not, however, worsen significantly, as imports will fall along with exports, albeit probably not in equal proportion. Additionally, Ethiopia’s national hard currency supplies will be boosted if global oil prices remain low, although that will not happen immediately as contracts have already been signed that lock in prices. 

In addition to higher unemployment, inflation is another critical risk. Already, the locust invasion and other factors had led to food price increases of over 20 percent in the last year. That is expected to increase if the pandemic takes hold. If there is hoarding and panic buying, that could mean further price rises amid shortages in a perennially supply-constrained economy.

In addition to  the government’s prioritization of security over health concerns in western Oromia by maintaining the communications blackout, the ruling party has also been putting political concerns first. For example, even after the announcement to suspend large gatherings, Prosperity Party was holding meeting in Oromia, Southern Nations and Amhara, the latter a five-day training for more than 10,000 cadres. This perhaps reflects the views of the top leadership: Abiy had said that it would be better to hold the election on schedule, if the initial COVID-19 outbreak is brought under control within a short period of time as in China. Elections, however, have now been postponed, though for how long depends on several factors, including the path of the outbreak, the ruling party’s approach, and political negotiations.

Depending  on the epidemic’s impact, there might well not be a vote this year. Preparations include training hundreds of thousands of election officers, since a large number of people are needed to man around 50,000 polling stations. Sending such numbers of poll workers around the country would be ill-advised in the middle of the outbreak.

Still, as long as the crisis persists, the opposition might refrain from any destabilizing reaction to the delay, meaning a volatile political scene would be temporarily becalmed. That is because all parties needed more time to prepare anyway, and look set to prioritize the health emergency for the forthcoming months. The Oromo Liberation Front had closed its office in response to COVID-19 and the Oromo Federalist Congress and EZEMA suspended meetings. Meanwhile, the National Movement of Amhara had already called for a one-year election delay as it pledged to help “combat the pandemic, alleviate its health, economic and social impacts, and surpass together the calamity looming over our country and people.”

(Correction, 1 April: In first paragraph of ‘Economic and political symptoms’ section, the reference to Hawassa Industrial Park workers being dismissed was corrected to them being given paid leave.)

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Editors: Peter Heinlein, William Davison. With assistance from Antoine Galindo, Chris Preager, and Gebrehiwot Ewnetu

Main photo: A hand-washing station in Bella, Addis Ababa; 1 April; William Davison

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