A consensus is emerging that lockdowns are not suitable or sustainable for much of sub-Saharan Africa – Ouagadougou is not Wuhan, Lilongwe is not London. African governments should not engage in mimicry of the global North but find their own ways to handle the crisis.
Lockdowns in the global North seek to keep transmission within the capacity of the health system to respond to, but in much of Africa, health systems are already at capacity and mass testing is out of reach. Lockdowns – which exist in various forms across Africa – can only buy time to allow governments to prepare for what is coming. Their utility is to create a pause for countries where weak health systems are already at capacity, well before the outbreak is approaching its peak, where many people must go out to earn every day to put food on their family table and where governments cannot afford the scale of social protection and service delivery required to keep people safely compliant with lockdowns for long periods.
There is obviously much we don’t know about Covid-19 in Africa – the real value of the trade-offs at play, whether the young age of populations will result in lower mortality or whether the high disease burden including tuberculosis and acute malnutrition will exacerbate mortality, exactly how badly non-Covid health care will be affected.
Yet Africa’s leaders nonetheless witness the economic and social challenges of maintaining even partial lockdowns and they have the facts to hand on health-system capacity and public finances. They know that they cannot sustain a prolonged lockdown and that their people cannot survive if they try. This situation has already led to unrest in the likes of Uganda, South Africa and Kenya. When governments can no longer afford to pay for food supplies for high-density urban populations, many more countries will be added to that list.
For now, border closures, lockdowns and broader social-distancing policies are buying African governments some time. This is not about buying time until a vaccine is available – much of Africa can not afford to suppress economies and livelihoods for so long. Leaders are buying time to track the outbreak and prepare their health systems, their economies and their people.
There is no doubt that leaders must prepare for the worst. As South Africa’s Ministerial Advisory Committee Chair, Dr Salim Abdool Karim, outlined in a regular public briefing this week, there is no solid evidence to suggest Africa will escape the same exponential fate as others. Once lockdowns end, we have to expect case numbers will rise significantly, though to what level of the population we just don’t know. It will be a hidden crisis for many months as testing capacity remains woefully inadequate in the majority of countries.
This is a deeply political moment for these leaders, especially those in the midst of hard lockdowns, and with no reliable data or evidence to go on. They will be considering whether relaxing restrictions now might look like a policy reversal and might be misinterpreted as the end, rather than the beginning, of the crisis.
It is therefore critical that leaders plan now and have a framework for making tough choices. There are five steps that African governments should prioritise now, to give them the best chance to prepare:
Get Covid surveillance, contact tracing, and testing strategies and systems in order. Have you made contact and mapped all cases and their contacts to create a picture of the outbreak to date? Does your system have the capacity to keep up with the contact tracing required? Are you making best use of technologies available that are suitable for your country?
Prepare the health system as best you can and protect health workers. Is there sufficient PPE for health workers for the next six weeks, and is there enough coming in the pipeline? Are there enough isolation and ICU beds and have health workers received Covid-specific training?
Plan how to protect vulnerable groups, prioritise health care and maintain non-Covid health care. How should health facilities minimise exposure while maintaining general health care, especially to women and children? What are the clinical guidelines in health facilities for prioritising critical care? How will Covid-vulnerable groups such as the elderly and tuberculosis patients be shielded from the virus? What will be the role of community health workers?
Plan economic-stimulus and social-protection measures to protect livelihoods. Even after lockdowns are lifted, African economies will continue to suffer the consequences of the demand shock caused by the wider global crisis. Scaling up existing social-protection mechanisms and making cash transfers and food widely available, while looking at support for employment-sustaining businesses, including access to finance, are key ways to support livelihoods. Repurposing manufacturing to support medical equipment and supplies such as PPE is also a win-win.
Engage citizens and communities on ongoing social-distancing approaches that will apply after lockdown and mobilise the population to change their behaviours accordingly (known as “social mobilisation” in public-health parlance). What baseline evidence do you have on the level of community and local authority acceptance of the behaviour changes required to achieve social distancing? What will be the measures for public transport, markets, schools, offices and places of worship? Are curfews a better way to limit contact and send a signal to the public about the state of crisis?
Moving beyond lockdown
Moving beyond lockdowns doesn’t mean a return to business as usual, while coronavirus wreaks havoc through the population. It’s an evolution and a calibration not a binary choice. The key word in this period will be vigilance. I know from my time working for the President of Sierra Leone during the Ebola crisis how important and yet how difficult that vigilance is going to be – it took almost exactly 12 months from the peak of the Ebola outbreak until the country was declared Ebola free, in November 2015.
In addition to maintaining the benchmarks above, vigilance will be needed by communities to adjust to any ongoing social-distancing policies governments put in place. Permitting public transport but limiting the number of passengers will allow the economy to function while still having some benefit in reducing the spread of the virus. Maintaining some social-distancing rules – such as use of masks in public spaces – also sends a clear signal to the public that there is an ongoing crisis and provides important political cover to governments who have complex and perhaps grim policy decisions ahead of them on the health and economic front. By far the most critical factor in this period will be citizens themselves. Behaviour change happens at a local and community level and this is where vigilance will be achieved. Governments must engage their communities and its various leaders – religious leaders, village headmen, market women, moto taxi union leaders, celebrities and politicians all – to achieve acceptance of the new realities and the changing of social norms.
The coming weeks will require previously unimaginable choices by most African leaders, especially regarding the provision of critical but now extremely limited health care. Prolonged lockdowns will not allow them to save the most lives, but using the five benchmarks presented above, they will be equipped to know when they are ready to ease restrictions and their systems and people will be better prepared and better protected for the next phase of this crisis.