The most critical piece of lifesaving equipment of the coronavirus pandemic is in desperately short supply in Africa: According to the World Health Organization, there are fewer than 2,000 ventilators across 41 countries that reported to it.
Somalia’s health ministry still doesn’t have a single one. Similarly, Somaliland also doesn’t have a single one. The Central African Republic has three. South Sudan, four. Liberia, five. Nigeria, with a population of two-thirds that of the United States, has fewer than 100.
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Officials say those numbers will change as ventilator donations trickle in. But even in countries with the machines on hand, few doctors have undergone intensive training to use them, and anesthesiologists, required in most cases to intubate patients or supervise that process, are scarce.
The inadequate equipment and training mean that Africa’s most vulnerable countries stand little chance of saving the lives of their most severe COVID-19 cases as the number of patients begins to spike. As of Friday, there were more than 19,000 confirmed coronavirus cases and 1,000 deaths across the continent.
“We are now failing. Let me use that word deliberately,” said Mahad Hassan, one of Somalia’s few epidemiologists and a member of the government’s coronavirus task force. “At our main treatment center, almost nothing is there. Last time I visited, beds, only beds. No oxygen, no ventilators.”
Somalia has just four intensive care unit beds, according to Abdirizak Yusuf, 35, who is in charge of the health ministry’s response. As of Friday, the country had confirmed 116 cases.
The government has tried to procure protective equipment and ventilators quickly, but everywhere they turn, they come up against countries that want to keep what they can for themselves. Ventilators are also expensive, costing at least $25,000 each.
A few ventilators and 200 ICU beds are on the way, Yusuf said, and should be in Somalia within two weeks. Jack Ma, a Chinese billionaire and owner of the e-commerce giant Alibaba, has donated 500 ventilators that will be divvied up among African countries.
In the meantime, Yusuf thinks coronavirus cases could be spiraling out of control. It was just last week that Somalia developed the capacity to domestically test samples for the virus.
“I think there can be even a million cases that we’re missing in Somalia,” he said, speaking from the country’s one isolation center, out of breath from a day of frantic work. “My colleagues are even testing positive. Our ministry people are testing positive. Most of the people we are testing are testing positive.”
Five COVID-19 patients have already died in Somalia, and Hassan said he is expecting “very, very painful weeks ahead.” All five needed intubation with a ventilator when the oxygen support that was available failed to improve their condition.
Somalia’s health care system is one of the poorest in the world. Yusuf estimates there is just one doctor for every 100,000 people. Those doctors are concentrated in the capital, Mogadishu, where the government runs its response out of a dilapidated hospital dating to the Italian colonial era. Beyond the city, the extremist group al-Shabab controls much of the country’s rural areas, making access nearly impossible.
“In those places, we can only reach them by phone to tell them how to prepare for COVID-19,” said Yusuf.
Even with ventilators, however, trained health workers are scarce.
Operating a ventilator requires intensive training and isn’t a one-person job. Most times, an anesthesiologist has to be involved. Most of Africa’s 54 countries have less than 1 per 100,000 people, according to the World Federation of Societies of Anaesthesiologists.
Such expertise, however, cannot be packed up and shipped over like a ventilator. Physicians used to board planes to help each other through crises, but now doctors trained to use ventilators are linking up with African counterparts on Zoom, Skype and WhatsApp. They sit six feet apart in hospital conference rooms, demonstrating techniques on human dummies with fake lungs.
Nurses in Sierra Leone have connected with doctors in Baltimore to record training sessions they hope to share with colleagues in Liberia, Ghana and Kenya.
“It is better than nothing,” said Seyoum Worku, one of two doctors in Liberia who is trained to use a ventilator and is leading six-hour crash courses with his colleagues.
“When you look at our health workforce, we are not talking about people who have done research, gotten grants, et cetera,” said Hassan, the task force member in Somalia. “The total number who have done so is less than almost any other country. You wouldn’t even compare us to a small American state.”
Right now, the lack of ventilators seems like a looming crisis in Somalia. The country is still trying to get its testing abilities off the ground.
Because Somalia developed testing capabilities so late, health workers fear that the country lost precious time in tracing the contacts of those who eventually tested positive. Before last week, samples had to be flown on infrequent charter flights to Nairobi in neighboring Kenya. It took weeks for some to get their results.
That has also created a lag in the Somali public’s understanding of the virus, said Marian Hassan Mohamud, who coordinates health workers for the International Rescue Committee, an international nonprofit that works across the country.
“Most Somalis haven’t realized that this thing even exists,” she said. “People still have misconceptions that our climate is too hot for the virus, or that only foreigners are susceptible to it.”
The delay in contact tracing means that many cases have surely moved beyond Mogadishu and Hargeisa, Somalia’s two biggest cities where nearly all the cases so far have been recorded, Mohamud said.
Depending on how quickly the health ministry can ramp up testing, the number of confirmed cases is expected to skyrocket in the coming week. By that point, patients should already be showing up at hospitals, many of whom will eventually need ventilators that just aren’t there.
“The best we will likely be able to do for most patients is isolate them,” said Mohamud. “Treatment? To be honest, there is no such thing yet.”