Ahmed is a retired civil servant in his early 70s, and for the last 12 months he and his wife Nawal, in her mid-60s, have been extremely cautious about mixing with others for fear of contracting the coronavirus. From the beginning when Egypt officially announced its first case of the virus in mid-February 2020, Ahmed and Nawal went into a kind of self-imposed social exile that for four months only saw a single visit from their cleaning lady each month. They would keep their masks on while she was doing her tasks, as “unmasked it would be impossible”, and there was only one supermarket and pharmacy delivery every two weeks. It was only in late July 2020, with recorded cases seeing a decline, that the couple decided to ease the restrictions but even so never fully. When autumn and winter came, they went back into the same strict routine. “We noticed from the social circles that we keep in touch with through phone calls that the virus had become a lot more aggressive. It seemed to be spreading faster and killing more people. We decided it was safer to get bored at home than to risk getting infected,” Ahmed said. Today, he added, as he enjoyed the morning sun at an early hour in one of Cairo's sporting clubs, he and his wife “are impatiently waiting for the vaccine.” “This is the only way we can go back to a normal life, but we have no idea when this will happen or how we can get it. We keep hearing statements, and I keep looking for information in the press, but it is not at all clear,” he said. Ahmed a few weeks back tried to register his name and that of Nawal on a website that the Ministry of Health operated for a few days for people who wished to get the vaccine. “I had no idea which vaccine would be available. I heard there was a Chinese or a Russian one — or something else. I spoke to Nawal, and we thought that whatever becomes available first we would go for it,” Ahmed said. However, his aspirations lasted for only a few days. When Ahmed tried to check the website for updated information, he realised that the site had been suspended. He thought he would get a call to explain the situation to him or to notify him of a date and place for vaccination, “but instead there was nothing,” he said. “I just don't know when or where or how we will get the vaccine,” he lamented. In recent press statements, Minister of Health Hala Zayed said that Egypt was planning to get 100 million shots of the vaccine to be able to provide them to all Egyptian citizens and all foreigners with permanent residence in Egypt who wished to have them. But the figure came with no dates and no specifications. In view of the fact that Zayed had previously made promises to provide millions of vaccine shots, first from Russia and then from China and the UK, the recent statement made more room for speculation than for confidence. At the Ministry of Health, there is still no clear answer as to what is really happening with the vaccination plans. According to informed sources, both governmental and private, Egypt has a long way to go before it manages to secure even the few million shots of the vaccine that are required for medical workers, people over 60, and people with a chronic illness. The reason is simple: to be able to secure the vaccines, a country has to be able to make the necessary financial deposits to the pharmaceutical companies making them. Egypt, a developing country, is not an LDC (least developed country), which would make it eligible to get free vaccines. It could, however, make sure that its demands are not overlooked. The minister of health said that the Tahiya Masr Fund would be “the financing arm” for the purchase of the vaccines. REACTIONS: For Hatem, a doctor at one of the public hospitals in Giza, this statement was “very strange”, however. “Vaccines are funded from the state budget. If we are talking about a fund, that means we are waiting for donations, and that means quite a long wait for an intensive vaccination plan which is desperately needed in our country. The restrictive measures are not always observed, and many hospitals, and for that matter doctors, are tired after the two waves of the virus,” he said. A few leading businessmen have announced donations to the Fund. But according to one informed independent source, the donations made so far would barely suffice to provide the least-expensive vaccines for people benefitting from state social security coverage. The minister of health announced during a TV appearance late last month that the state would provide vaccines for all “economically challenged citizens” while the rest would pay “symbolic fees of no more than LE200.” The price of the vaccine, according to government sources, will most likely vary because purchasing prices vary considerably. As Egypt battles to curb the spread of the second wave of the coronavirus, doctors on the frontlines are being inoculated According to Hatem, “any vaccine would be better than no vaccine. Different countries are providing different types of vaccines, and this is not the problem. The problem is that if the government does not manage the situation well, we could be faced with problems like a black market for vaccines or counterfeits,” he said. For Hatem and other medical sources, both official and independent, the private sector should be allowed to import or, at a later stage, to manufacture vaccines. Distribution and vaccination should be a state prerogative to avoid any illicit dealings that could be catastrophic. The statements of the minister suggest that the state will be in control of supplies and vaccinations “when the vaccines are available.” Thus far, the state has officially secured 100,000 doses of the vaccine. Half of these are of the Chinese-formulated and UAE-produced Sinopharm vaccine, used in Egypt in phase three trials, and the other half are the Oxford-AstraZeneca vaccine. The Sinopharm vaccine had already been used for medical teams in isolation hospitals. A doctor and a nurse who work in one of these said, on condition of anonymity, that not many people had agreed to get the Sinopharm vaccine, themselves included, however. “We don't know enough about the trials. The results of the third phase of testing, on people, were never fully shared by the Chinese, and this is not reassuring. It would be safer to wait for a vaccine with a more credible profile,” the doctor said. Egypt, according to official statements, has committed to securing its vaccine stock from Sinopharm, Oxford-AstraZeneca, and the Russian Sputnik V vaccines. According to sources in the pharmaceutical industry, there are plans for two leading companies to get licenses to manufacture at least two of these three vaccines. Egypt is also expected to get some further donations from China and possibly from the UAE. But for many in the medical field, the situation is too ambiguous to be tolerated at a time of a pandemic. In a series of commentaries on his Facebook page, Mohamed Abul-Ghar, a doctor who takes an interest in public affairs, has appealed for a more pragmatic approach. The government, he said, should allow for a parallel-track approach in which it incorporates the private sector to import and provide the vaccines at a state-monitored price, while the government acts to promptly provide the vaccines for those who cannot afford to pay for them. QUESTIONS: Questions over the clarity of the management of the coronavirus situation in Egypt are not new. Over the past 12 months, and after a Chinese resident of Egypt tested positive following a visit from a relative from China, there have been many queries. One big question is about the mortality rate of Covid-19 in Egypt. Officially, the Ministry of Health puts the death rate of both waves of the coronavirus at under 10,000. But this number makes some doctors laugh or cry. In the words of one, “this figure cannot be anywhere near the real figure. The second wave has been especially lethal and not just for older people and people with chronic diseases.” The debate over the mortality rate is complicated, according to government sources. They admit that after the first four months, the regulations have been that deaths from co-morbidities should not be registered as coronavirus mortalities. One ministry source argued that in the beginning this might have had to do with a government wish to avoid “exaggerating” the mortality rate, but with the debate over complications involved in the burials of people dying of Covid-19, the trend has been to reduce the numbers as much as possible to allow families to have traditional burial procedures. The question, however, according to a source in an international body that monitors Egypt's management of the coronavirus, is not just about the mortality rate but also about overall recorded cases over the past 12 months. “In the first three months, we thought that Egypt was doing well enough. There was a sufficient amount of transparency, an attempt to apply necessary testing, and prompt action on the side of the government to at least minimise the risk of uncontained community transmission,” he said. “Unfortunately, however, this hard work was not sustainable.” Critics of the Egyptian government's management of the coronavirus pandemic, both from local and international medical and health quarters, argue that one mistake was insufficient testing. Originally, PCR tests were only available at central labs managed by the Ministry of Health. However, as early as late May last year, or 14 weeks after the official announcement of the first Covid-19 case in Egypt, some labs affiliated to the Ministry of Higher Education were allowed to do the PCR tests, even though their figures were not incorporated in the numbers put out by the Ministry of Health of infections recorded in the country. With the cost of a single PCR test at around LE2,500 back then, and in view of the fact that every patient who tested positive would need at least two extra PCR tests to make sure they had subsequently tested negative, the government decided to go for rapid tests that are not as accurate as PCR. At a later stage, chest X-rays and blood tests were introduced to help doctors decide on cases. With the spikes of both waves of the virus, the Ministry of Health decided to treat any suspected Covid-19 patient as positive even without tests and to provide the necessary medication. Adel Khattab, a pulmonologist, argues that the combined use of PCRs, X-rays, blood tests, and rapid tests almost saved the day for Egypt when there were simply not enough PCR tests to go around. This, he said, was particularly the case after the government decided that medical curfews and lockdowns were not sustainable, which meant that people were mixing more, sometimes without observing masks and social distancing. According to Jihan, a Cairo pharmacist, by late August “we had what we called the coronavirus group.” This was essentially medicines included in the designated protocol for mild and medium cases of Covid-19 that individuals were getting off the shelf, often upon detecting symptoms like a persistent fever or a bad cough or fatigue. “I know I should not be saying this, but it worked in many cases. It is too costly for most people to go for an LE2,500 PCR test, or to even pay half as much to get the necessary blood tests and chest X-rays,” Jihan said. “So, people would just call and say that they suspected they had Covid-19. We would send them the necessary medicines, an oximeter if we can get one, and two boxes of masks.” According to two pulmonologists and two intensivists spoken to by Al-Ahram Weekly, they have seen cases with chest complications in the wake of this self-treatment approach. “This new virus is very tricky. Sometimes people might think they are over it, but it leaves them with complications that if not immediately spotted and promptly treated could be dangerous,” said one intensivist. In the end, he added, “there were cases that were hospitalised and then released but that suffered terminal complications. The fact is that we don't know enough about the way this virus acts, not just us in Egypt, but I mean the medical community worldwide. This is one of the reasons behind the high mortality rates,” he said. MEDICAL TEAMS: One of the figures that is most certainly accurate is the mortality rate among medical workers including doctors. According to the count of the Doctors Syndicate, there have been over 360 doctors who have lost their lives due to the infection. In the first wave of the pandemic, doctors working at public hospitals spoke about shortages of PPE that had compromised their health. They spoke of cases of overusing surgical masks, of having to collect money to buy high-protection masks, of the lack of training for cleaning staff on disinfection practices, and exhausting working hours with possible high exposure to intense viral loads from patients who were neither wearing masks nor observing social distancing. This was not the case with the second wave, however. Doctors said that PPE was readily available and that medical leave was generally allowed for any suspected infection or excessive fatigue. However, the mortality rate remained high. Mona Mina, an activist for physicians' rights, argued that the management of infection measures in many public hospitals had put doctors in harm's way. This month, the Doctors Syndicate promised training sessions on the basics of infection prevention and control to help hospitals and doctors reduce risks that had left Egypt among countries having high rates of mortality among doctors. Gynaecologists have been particularly endangered. Salah Sallam, a Cairo-based gynecologist who has headed the Al-Arish branch of the Doctors Syndicate, said that gynaecologists were among the most exposed physicians to infection. “We deal with emergencies all the time where we cannot hesitate for a second because it is all about lives, and we are exposed to all sorts of body secretions and this increases the chance of infection,” he said. Without the experience that the medical community had had with the first wave of the virus, things could have been worse with the second wave that was “a lot more ferocious in terms of infection and mortality.” He is convinced that the most important thing to be done today is to provide the vaccine for as many doctors as possible. “All doctors are exposed to infection, not just those who work in isolation hospitals, and all doctors deserve to get the vaccine promptly to spare them from being infected and from being the carriers of the infection,” he said. Sallam said he was hopeful that by the end of next month the Ministry of Health would have provided enough vaccines to go around for medical workers, including doctors. He is not concerned about the question of which vaccine. “We need to move on as much as we can without wasting time, and for that matter lives, on unnecessary debates,” he said. At the end of the day, Sallam argued, there was no risk to be expected from any vaccine manufactured using a weakened virus that cannot replicate but that can allow for antibodies to be developed. As for efficacy, he argued, any vaccine is better than no vaccine. Until a vaccine is made available for doctors, some physicians have said that they may resort to anti-parasitic medications since it seems they can halt the replication of the Covid-19 virus. “This is what we have for now, and we will use it until a vaccine is available, also bearing in mind that distribution will likely take some time and will go through different categories of age and risk,” one doctor commented. *A version of this article appears in print in the 11 February , 2021 edition of Al-Ahram Weekly
