Three questions to ask about epidemic control policies in Africa
This essay suggests three basic considerations for planning COVID-19 responses in Africa: (1) anticipate the country-specific demographic pattern of the national epidemic; (2) examine the conditions required for the standard “lockdown” policy to succeed; and (3) make a consultative political assessment of the epidemic response and its impacts on the economy, society and governance.
The same three considerations should inform democracy activists, community leaders and citizens.
The main conclusion is that any emergency epidemic response can only work if it is designed and implemented in consultation with the affected communities. As African countries go into lockdown mode, the initial period of lockdown should be used to conduct consultations; to provide the essential epidemiological facts to communities (experts shouldn’t worry: people will understand); and to ask communities to propose their own, locally-suitable versions of transmission control, along with how they propose to monitor and enforce them.
Every epidemic is different; government responses are usually the same regardless. Many governments apply what they think are the “lessons learned” from a previous pandemic to a new pandemic. Experts on pandemics think this is an error. A global pandemic unfolds in different ways in different countries, but governments usually adopt a standardized set of interventions regardless of their differences.
One doctrine is useful in all situations: “know your epidemic, act on its politics.” This was learned the hard way. Drawing on the experience of HIV and AIDS—a pandemic that manifested in national epidemics with different characteristics depending on mode of transmission, social and economic conditions, and demographics—Kent Buse, Claire Dickinson and Michel Sidibé write:
The ‘know your epidemic, know your response’ is an increasingly well-known rallying cry to put evidence at the heart of national AIDS programmes. While this is welcome, it is unlikely to be sufficient to deliver evidence-informed responses. In our view, it is equally important that national programmes routinely seek to understand and address the political determinants of whether and how evidence is used to guide policies and national programmes. We make this case because politics, ideology and ignorance have, in many countries, proved far more influential on HIV policy than evidence and best practice guidance.
How should these principles be applied in Africa today? African governments are following the model of East Asia, Europe and North America and going into lockdown mode. Is this because controlling people’s movement will help them with managing the crisis? Or is it because at the current time of international panic and lack of leadership, a lockdown is the only reputable thing for a government to do, if it wishes to retain its international standing? Or because these measures provide an opportunity to achieve other goals, such as greater police powers?
Epidemic control policies require voluntary compliance. This requires that experts and common people have a shared understanding of the epidemiology of the infection. Given that transmission patterns are determined by social factors that are local and intimate, which epidemiologists cannot learn in real time but which community members know, this requires joint learning between experts and affected communities.
“Know your (country’s specific) epidemic”
COVID-19 can no longer be suppressed, it can only be mitigated. Every country faces an epidemic; the only question is timing, trajectory and impact.
Africa’s imminent COVID-19 epidemic will be shaped by the continent’s demography. Four elements in this stand out.
First, Africa’s age distribution is younger than that of other continents. One reason for Italy’s high mortality rates has been that it has a large proportion of elderly people—23 percent aged 65 of over—who are most at risk should they contract the disease. By contrast, Africa has under 2 percent in that age cohort. For this reason alone, the COVID-19 overall mortality rate will be lower, though that is little consolation to at-risk elderly Africans.
Second, Africa is the least urbanized continent, with 56 percent rural. All outbreaks of COVID-19 thus far have begun in urban centers. Infectious diseases spread more slowly in rural areas. Africa’s majority rural population may already have the same kind of epidemiological buffer that is provided by social distancing and isolation in developed countries. Meanwhile, most of Africa’s urban population consists of larger families living in high-density settlements, where social distancing is impractical. Only a small proportion live in nuclear families, socially distanced from their neighbors, characteristic of developed countries. We might therefore expect different epidemic patterns among these three population segments.
Three, the spatial and age distribution patterns, and mobility patterns differ greatly from one country to the next, and within countries. This micro-level information will be crucial for the local epidemic response. It may be impractical for public health planners to gather these data in good time, but each community can make its own risk assessment based on what its members know.
Four, African populations have specific risk factors. Many countries have a significant number of people with compromised immune systems, living with HIV and AIDS and reliant on anti-retroviral therapies. There are other disease burdens. We do not know how these will interact with COVID-19, but they are likely to increase morbidity and mortality.
“Know your epidemic response”
The rationale for lockdown as a mitigation strategy is based on “flattening the curve”, i.e. slowing the rate of infection so that the number of gravely ill patients seeking hospital treatment at any one time is reduced. This allows time for the country to increase hospital capacity (intensive care, respirators, specialist staff trained) while spreading the admissions over a longer time period. Equally importantly, it allows time for mass testing to be introduced so that more precise measures of infection reduction through individual contact tracing can be introduced.
Lockdown policy can work only if the measures of quasi-isolation are viable and can be monitored and enforced. In most low-income urban areas in Africa the current package of measures are not viable. In refugee camps they are not viable. Most African states lack the kind of policing capacity to enforce the measures. Attempts to implement an unpopular and intrinsically unenforceable policy are likely to lead to large-scale evasion and subversion, including bribing local officials and police officers to allow exemptions. Forcible imposition of lockdown will lead to confrontations between residents and the police. Standard police crowd control and crackdowns will lead to forced crowding in the streets and police stations—exactly the opposite of what is intended. It will also contribute to popular distrust of government motives (akin to a re-run of the 1830s “cholera riots” in European cities, which were sparked by forcible quarantine measures that created serious hardship among the poor).
Lockdown can only achieve its goal of delaying caseload and thereby reducing deaths, if the country can increase its capacity to treat the severely sick and it can implement mass testing and contract tracing. If the country cannot do these things within the time period, then the health outcome benefits of flattening the curve will be reduced.
Lockdown can only work if it has the consent of the people who are being locked down. This is not simply a matter of experts telling the public what is best for them, but consulting with communities about the specific risks they face, and the specific measures that would work in those communities. What might those measures be? Today, epidemiologists and public health planners don’t have alternatives to offer—but they haven’t yet asked communities for advice.
Any lockdown policy, tight or less tight, also requires a host of other measures such as remedial assistance to those who lose income or other forms of welfare (e.g. support from family members) and government efforts to keep essential services and supply chains operational.
If these conditions cannot all be met, comprehensive lockdown needs to be reconsidered. At an essential minimum, the modalities of lockdown should be developed with the active engagement and support of communities.
African countries have experience of community-based transmission control policies, developed from the grassroots. The best example of this is Ebola control in Liberia and Sierra Leone, which was developed by affected communities, and was adopted by international agencies. As Paul Richards has shown, dialogue between international health experts, local community leaders, and in-country social scientists studying the local measures, was productive in finding workable local measures that succeeded in bringing the 2014 Ebola epidemic to an end much more rapidly than international best practices on their own would have been able to do. He shows how it is both necessary and possible, in a short period of time, for communities to think like epidemiologists and epidemiologists to think like communities.
“Act on the politics of the pandemic”
As noted at the beginning of this memo, politics and ideology are more important drivers of epidemic response than evidence and best practice.
In Africa, the secondary impacts of the COVID-19 pandemic are likely to be much more significant for the health and wellbeing of Africans than morbidity and mortality due to the disease itself.
Africa is going to suffer from the global shutdown. The disruptions to commodity markets and supply chains; the collapse of travel and tourism; the global economic slowdown and reductions in FDI; and a decline in remittances from Africans working abroad.
Whatever policies are adopted to mitigate the transmission of the virus, there will be disruptions and negative impacts. Any form of shutdown will restrict agricultural production and marketing and cause food insecurity. There will be layoffs and bankruptcies in the service sector. Lockdowns will increase smuggling and corruption. Closing schools will reduce educational achievement; closing universities will disrupt the stream of graduates. As Jeeyon Kim and colleagues have argued, social networks that are essential to the livelihoods of the poor, and the coping strategies of those threatened by food insecurity, will be narrowed, with potentially devastating humanitarian consequences.
There may be serious adverse health and nutrition outcomes from the COVID-19 response, that cause greater illness and death than are caused by the coronavirus itself. This could happen if key health and nutrition services are neglected or disrupted. Many parts of Africa face humanitarian emergencies, including (among other things) locust infestations, refugee flows, localized climatic disasters such as droughts and floods, and other health crises.
The authoritarian policies of some governments in enforcing the lockdown, the uneven burden of coping with the pandemic as richer countries expel migrants or fire them from their jobs, the widespread beliefs that the coronavirus is brought by outsiders, and conspiracy theories concerning where COVID-19 came from, could all lead to a more conflictual and angry political environment.
COVID-19 is frightening and confusing; governments commonly make use of a situation in which people are fearful and uncertain to extend the range of their powers to intrude and impose. African citizens and democracy activists need to be aware of this threat; African governments need also to be aware of the resistance that they may generate through mistaken policies or clumsy and brutal implementation.
Community consultation can achieve what diktat cannot. This is where a distinctively African doctrine of epidemic mitigation could start. Building on the experience of managing epidemics such as HIV/AIDS and Ebola, African communities, activists and governments can develop practices of community consultation driven by evidence exchange: scientific evidence from the experts, contextual realities from the people.
Time and again in emergencies, those in positions of political power and scientific authority argue that there is no time to lose and the best practices must be implemented at once with minimum time given to consultation with the affected people. Time and again, when the emergency recedes, planners regret that they did not undertake those consultations, because crucial opportunities for timely learning were lost.
Currently, experts do not know what alternatives to comprehensive lockdown may exist, or what local variants of isolation, movement restriction, contact tracing and quarantine might be viable. That’s because they haven’t asked. There is no time to lose: community consultations should begin now. Communities may well find creative ways of protecting the most at risk. The widespread lockdowns across Africa are not just an opportunity to slow the spread of the coronavirus, but equally importantly, to design the kind of community-owned measures for epidemic control that are the continent’s best chance for mitigating COVID-19 and its secondary impacts.
