With Alagie Manneh
Ramou Njie is a Gambian-born, UK-trained gastroenterologist and hepatologist. She did her primary medical degree at the College of Medicine, University of Lagos, Nigeria. This was followed by nearly 2 decades in the UK where she pursued post-graduate specialist training in Internal Medicine, Gastroenterology and Hepatology as well as advanced scientific training in viral immunology at centres of excellence in the UK.
Her scientific carrier began as an MRC (UK) Clinical Research Training Fellow which led to the award of a PhD in viral immunology at the CRUK Institute of Cancer Studies in Birmingham University. Dr Njie worked as a substantive NHS consultant Gastroenterologist and Hepatologist in the UK for three years where she was responsiblefor setting up a viral hepatitis treatment clinic, teaching medical students and junior doctors in the diagnosis and treatment of gastrointestinal disorders including in performing advanced endoscopic procedures, before returning home to The Gambia in 2011. In The Gambia she headed the Gambia Hepatitis Intervention Study(GHIS).
The GHIS was a long-running collaboration between the World Health Organisation’s International Agency for Research on Cancer (WHO-IARC), The Gambia Government, and the MRC in The Gambia. Dr Njie is a practising clinician scientist with research interests in viral hepatitis, immunology, infections and cancer. She is an active member of several professional bodies which include: The British Society of Gastroenterology (BSG), the European Association for the Study of the Liver (EASL), the American Association for Cancer Research (AACR) regional committee for Africa, The African Organisation for Research and Treatment in Cancer (AORTIC), among others. She has several publications on Hepatitis B virus and has been a guest speaker at many national, regional and international conferences. Following the current outbreak of the Covid-19, Dr Njie was invited by The Gambia Government to serve as an adviser on the national Covid-19 response. In this edition of Bantaba she talks with Alagie Manneh about coronavirus and related health matters.
As the only testing facility in the country, does MRC have the capacity to do a mass testing of Covid-19?
I’m not sure what you mean by mass testing for the virus. If you mean population-based testing, MRC can do what’s known as PCR, which takes a couple of hours and you have to go through a number of steps and you need a specialised equipment in a lab that has the right safety features. The other facility that has that is the National Public Health Labs in Kotu. So, they are working with MRC so that they too can start testing. Now, what we need, or what we would really ideally like, is to do testing that is more rapid than PCR which takes few hours. Rapid test, something like that can take half-an-hour to 45 minutes. What we hope is that we would get rapid tests that can use some of the existing equipment that we have. We have some equipment called GeneXpert machines that are already in the country and each region has one. They use cartridges which are simple to use. If we can get those cartridges then we can do mass screening in the URR, LRR and down here in the Kombos.
There were concerns that systems that we had in place at our airport and other entry points may not really be working and because of that a number of potential cases clearly eluded authorities putting us all at risk. How serious is this?
Before the airport was closed, clearly some people who were infected could have gone through. Even with airports screening, you can only screen people who have a temperature. So, people who are carrying the virus but do not have a temperature will not be picked up by airport screening. So, airport screening is not full proof. The way countries like Singapore did it, was to say okay there is this outbreak and it is very near us, so anybody who actually comes through the airport gets quarantined and tested before they are released into the community. That would have been a tighter way to do it but you know, we are limited by the fact that we have limited resources. Singapore is a rich country. Right now, I think what we have to do is to find out within the country from among those who have tested positive, what their contacts are, where they have been and who they interacted with. If we can do more widespread community screening, we can pick people up, isolate them and stop the virus if, it is in our communities, from spreading further.
What is the probability that the number of cases in the country could now be dozens, if not hundreds because these people who seem to have eluded screening at entry points, and those who escaped quarantine?
It’s difficult to say. I think the general consensus is that we haven’t tested enough.If we’ve tested more, we would discover more. In Senegal, they have over 300 cases.It’s difficult to say but, the general feeling is that we have more cases than we’ve detected so far.
Health experts in Africa and around the world cast doubt over the number of cases said to be in Africa. They are concern that Africa does not have the resources or capacity to give an exact figure on how many people could be infected with Covid-19.
What is the probability that a lot of people in the country have coronavirus and may not know it?
I think you would need to ask my epidemiology colleagues that question, the statistic of probability that many have it and don’t know it. In fact, some epidemiologists have come up with some mathematical models of how many cases we have and potentially over the next few weeks, how many we may have based on what we know about the few cases that we have identified already.
So far, how would you rate The Gambia Government’s response to the Covid-19 pandemic?
Certainly, the Ministry of Health – I can’t talk about the rest of the government – within the resources that they have, have tried their best to bring in advisers such as myself and other senior colleagues who have public health knowledge to try to formulate a strategy to deal with this epidemic. I would say, we are hampered by the fact that we’ve had a weak health system to start with, anyway. Within the limits of the resources that we have, I would say the Ministry of Health is trying its best and if everybody joins, we can actually deal with this pandemic together, more effectively.
What would you advise them to do from now on?
My advice is to work with other partners. I understand that the private sector has come together and, also contacted the UN system in The Gambia to work with government in a tripartite agreement. I think when there are more people, there is a variety of skills to call upon, there are more ideas…so, the coordination of the response needs to be strengthened for sure, and they need to work with other partners if we are to deal with this pandemic. It cannot be dealt with by the health ministry alone.
Even before Covid-19, you have always been saying to anyone who cared to listen that unless and until we eradicate extreme poverty in The Gambia, and radically re-structure and reform our poor healthcare systems, we all remain open to pandemics and social upheaval. Can you be specific?
Health does not exist in isolation; I mean you can only be healthy if you have good food to eat, if you live in a proper house with good ventilation and access to clean water. If you don’t have those, which are all hallmarks of extreme poverty that we have here, then you cannot expect your population to be healthy. Two, we have a Ministry of Health and this is known by everybody and so many external consultants have said the same. We have a Ministry of Health that has, I don’t know nine, or 16 directors. This is for a small country with two million people. Compare that with Uganda, which has 40 million people, they only have three directors. So, we have a bloated ministry, with a lot of duplication, and a lot of resources that are used up in administrative processes that can actually be diverted to frontline healthcare. So, by restructuring I mean, streamlining the ministry so that the resources are actually channelled to where they are most needed. And not having these many directorates which are scattered in different buildings. I know it’s a difficult task, but if we don’t do that, it will be very difficult to get the results that we want.
You were one of the people advocating for the closure of our borders, are you disappointed that that hasn’t been done on time?
It has been done now, and that’s what matters. I think there are many of my colleagues who felt that if we didn’t have the means to do quarantine which we didn’t have in the beginning, the best thing would have been to coordinate our action with Senegal because The Gambia is inside Senegal, it’s one geographical entity. But it’s better late than never. Now, what we have to concentrate on is to look at what we can do from now on. What can we do to identify people who are infected and by testing them to isolate them and to make sure we stop any community transmission. That’s what all of us should be focusing on, not looking back.
What is social-distancing and how does it help prevent Covid-19?
Although we said social-distancing, what we mean is physical-distancing, to just keep space between yourself and other people than you normally would. This is important because the coronavirus actually relies on person-to-person contact and it is transmitted by people…
Looking at our social settings, ‘social distancing’ is problematic. How will these circumstances challenge the fight against coronavirus in The Gambia?
Physical and social-distancing become very challenging when you have people living in very crowded situations. You have public transport that is very crowded and for us, how would you stop somebody from infecting a whole van traveling from Banjul to Tabokoto? This challenge of physical-distancing has resulted in this call for so-called masks for all, especially those who have respiratory symptoms. It has to be one of the ways in which we fight this. Even if you say to the driver take half the number of people, I have been going around and I see that this is not really being observed, so we have to think of other ways in addition to physical-distancing.
How can we improve our hygiene behaviour?
This improvement in hygiene behaviour is the duty of all of us, and you guys in the media have an important role to play by reminding and urging people to observe respiratory hygiene, to not cough into the open and cough into their elbow or into a tissue which they have to throw inside the bin and not by the roadside or anywhere. We have to show people the right way to wash their hands but also, to make it easy for people to do that. We have to provide water and washing stations that people can wash their hands with soap and water. We have to go to all our communities and emphasise these things. Especially with Ramadan coming, we must try to discourage spitting anywhere including the coughing and sneezing anyhow.
A lot of Gambians here are low-income earners who need to work daily to make ends meet, how is this going to challenge social-distancing?
So many people have to go out on a daily basis to earn their living and many people live from hand-to-mouth.So if you tell them to stay home, and you don’t provide any food or sustenance, so, it was very clear from the beginning, certainly, that a lockdown can only work if it is combined with a concerted effort by government, working with other non-governmental agencies, the private sector, everybody and, having a coordinated programme that can target every region in the country. That is what it will take because otherwise people will come out on the streets as you see them, looking for food.
A lot of people thought that Africa will be worst hit by this virus because of our poor health care systems and social set-up, why hasn’t that happened?
Well, we’ve had our share, Alagie, we’ve had our share of pandemics. We’ve had Ebola.So I sincerely hope that this pandemic does not ravage through our communities in the same way the virus started in or was first discovered in Wuhan [China]and, because of how mobile people are, it rapidly spread to Asia, Europe, America. Also, because of tourism, we’ve had many of these viruses and we’ve had a few outbreaks of really severe flu that we were not able to test but associated with the tourist season. But it is not yet clear why we’ve had so few cases of Covid-19, and it is not clear also that we have completely escaped this pandemic because most of the predictions that the statisticians are making, are saying that our cases will peak later, like during the rainy season. So, I would say we should put all our efforts, every single one of us, on prevention so that the predictions that the statisticians are making, would not come to pass. If we change our behaviour, I think this may happen, but again, it’s too early to say, ‘oh we have been untouched’, because the pandemic is still ongoing.
Even in The Gambia here, conspiracy theories persist about Covid-19, like for example, that it doesn’t exist;that it is government attempting to misappropriate funds, and so forth.
The virus is very real. It is here. We have detected it in The Gambia. It is real and so we need to educate our population to understand that all human populations are susceptible to this virus. It does not discriminate between black or white, African or American. This is a myth we have to dispel, and we need to try and get our information from credible sources like the WHO, the [US] Centre for Disease Control because there are many, many people some of them I have to say, are motivated by mischief, peddling a lot of myths on the Internet. A lot of people don’t necessarily listen or research what is being said, they just pass on the information. The virus is real. We probably don’t know the full extent of it but we are able to do something about it if we change our behaviour. You and your colleagues have a duty to make sure that you dispel myths and tell people the right information for their own protection and safety.
Not long ago, you were conferred the She Awards ‘Most Outstanding Woman in STEM’, how did that spur you to mobilise women in that area to see how best they can join the fight against Coronavirus?
Medicine and science are my passion. So getting recognised for doing something I love was a bonus. I mentor many young Gambian women in STEM and also non-STEM disciplines. All of the other phenomenal women who received awards that night did so because our parents decided to send us to school. Girls’ education is important and I am very passionate about it.
Research has shown that women were more affected than men in the aftermath of the Ebola crisis. How will this Covid-19 affect our petty traders and farmers who are mainly women?
Even though I am not an economist, one of the first things that caught my eye was a posting by Strive Masiyiwa [a London-based Zimbabwean billionaire businessman and philanthropist] about the economic impacts of coronavirus on Africans. As you say, most of the petty traders and entrepreneurs in The Gambia are women, so the effect on women and families will be devastating. The government should bring together the private sector and other economists and be thinking of how to mitigate this hardship that this virus will bring on our communities. Women will be obviously disproportionately affected and so we need to find schemes, work with the private sector and other NGOs that will help women with either small loans to start small businesses or like other women like Kumba Daffeh-Kah [Tresor Women] is doing. We must do some economic activity that would actually generate income. We have to do that in a deliberate way, and not leave it to chance.
Is there a saturation point for The Gambia in the fight against Covid-19? In other words, at what level will be too much for The Gambia to handle?
Difficult question. Which is why we need a multi-sectoral approach and not just leave it to health. [The ministries of] Education, Agriculture, Finance & Economic Affairs, NGOs, private sector, et cetera all need to come together.
