Note: The original version of this blog post was published by African Arguments – Debating Ideas on 22/04/2020.
The COVID-19 pandemic has reached Africa later than elsewhere, but it is clear that it won’t leave the region unaffected. With confirmed cases in all African countries except Lesotho totaling over 15,000 infections (as of 22 April 2020), and mounting evidence that the virus is spreading beyond the major capital cities, Africans are bracing for what is ahead.
Unlike other epidemics of African origin (e.g. Ebola and AIDS), African governments now have the ‘luxury’ of seeing the responses of governments in Asia, Europe and the Americas and can assess why some are more effective than others. Several policy examples have been set, ranging from Sweden’s lax regulations, Israel’s early self-quarantining approach, Trump’s long denial, to the stringent measures taken by South Korea and Singapore. What is the best model for African countries?
So far, countries that have rapidly acknowledged the ferocity of the corona virus and swiftly adopted a hands-on approach (widespread testing, enforced quarantine of the infected, stringent lock-down, app tracing) seem to have fared better than ones that initially treated COVID-19 as another type of ‘seasonal flu’. In this respect, most African governments have responded more effectively than many of their Western counterparts. With early impositions of border-entry controls and lockdowns they have likely slowed-down transmission rates. Yet, navigating from these short-term measures to a long-term strategy is a far more complicated issue. What does a long-term strategy look like that can save as many lives as possible among the millions that are at risk?
In the industrialized world, the long-term strategy now seems to be clear: shielding relatively well-functioning health systems from an overload of patients, thereby avoiding a worst-case scenario where hospitals would have to ration care. To ‘flatten the curve’ of the infection rate, governments have implemented rigorous lock-down measures, resulting in a near-closing of the economy outside the vital sectors. Once the initial outbreak is under control, governments plan to move to a second phase of a temporary ‘new normal’. While some preventive measures will likely be maintained in this phase – maintaining physical distance, wearing mouth masks, washing hands, and restrictions on large-scale events and international mobility – economic life is to be (cautiously) restored and schools are to re-open.
The hope is that growing ability to test for both the disease and immunity to it will make it easier to control COVID-19 in the year ahead. While recurring outbreak ‘waves’ may still lie ahead and force governments to impose new rounds of quarantining, these will likely become shorter and less restrictive over time. While playing this whack-the-mole game is economically costly and disruptive to everyday life, many developed economies have embraced this scenario over the alternative: a rapid build-up of herd immunity at the expense of many more lives lost in the short-run. Governments embark on these short- and medium-term paths though, with the expectation of long-term relief in the form of a durable vaccine, possibly combined with more effective treatment options. As it is, most health experts estimate that such a vaccine could at the earliest be available a year from now.
Africa’s comparative advantage in their COVID-19 response
How would the interlocking short- and long-term strategies of developed economies play out in Africa? Before turning to this question, let us first highlight three comparative advantages that African countries may capitalize upon. First, as many commentators have pointed out, with a median age below 20, the age composition of Africa’s population is favorable. All available COVID-19 statistics point out that, ceteris paribus, the youth face much lower risks of developing the severe symptoms of COVID-19 than the elderly. Where 25.6% of Europe’s population is over the age of 60, this share is only 5.5% in Africa (UN Population statistics, 2020 estimates).
Second, as research on historical pandemics reminds us (Chandra et al. 2013), the spatial distribution of population matters. Densely populated areas, and especially overcrowded and well-connected cities, are virtually always hit harder than more isolated rural areas. Although Africa’s urban and rural populations are growing fast, Africa remains the least urbanized region of the world, with roughly 60% of the population living and working in the countryside (WDI 2020). Population densities in Africa (51 people/km2) remain well under European (128 people/km2) and (South) Asian averages (380 people/km2). Simply put, there is across the board more space to practice physical distancing.
Third, Africans may have greater experience with the threats of infectious disease than most Westerners had before they were confronted with COVID-19. After World War II, most Western public health initiatives saw a gradual reorientation from infectious towards chronic diseases (e.g. cancer, cardiovascular), redirecting attention to the adverse effects of smoking, drugs, alcohol, fat, and sugar. The focus of African health campaigns, however, has stayed more squarely focused on the recognition and prevention of infectious disease (Deaton 2013). In Africa, COVID-19 takes its place in a long series of recent disease epidemics including Ebola, cholera, tuberculosis, plague, not to mention the omnipresence of malaria and HIV/AIDS. For instance, there is hope that countries that suffered badly from Ebola, such as the Republic of Congo and Sierra Leone, are able to use the medical infrastructure and trust in community care centres to isolate and treat the infected and lower transmission rates.
The reasons for concern, however, are undeniably longer and will make it more difficult – if not completely unfeasible – for African countries to pursue a long-term strategy of recurring ‘shelter in place’ policies until a vaccine offers protection. For one, to follow the playbook in which all efforts are focused on preventing hospitals from being overwhelmed, Africa’s COVID-19 curve would need to be much ‘flatter’ than those in the US, France, or South Korea. The number of ventilators available are so despairingly low – in some places such as CAR, South Sudan and Liberia less than a handful – that demand will vastly exceed supply. Despite some recent aid from Chinese billionaire Jack Ma, who is stepping in a void of limited international aid to the region, the alarming shortage of PPE for doctors and nurses could speed up infection rates instead of driving them down.
Second, both public and private means to weather the immediate income shock and the looming economic storm are limited. With circa 80% of Africans living on less than $6 a day, and more than 55% living in slums (World Bank 2020), the vast majority Africa’s 1.2 billion people lack the personal resources (savings, food stocks, private access to drinking water) to endure a lockdown for even short periods of time. Especially large groups of urban dwellers that make ends meet through hustling jobs in the informal sector are at risk of immediate food shortages when their sources of income (temporarily) disappear. While the stringent lockdown measures in Uganda, Nigeria and various other African countries may be applauded as a sign of governments’ hands-on approach, these drastic measures are also a very risky experiment as nobody knows whether this strategy will minimize the total loss of lives. Do we know how many people will be put at risk of starvation? And what does COVID-19 do with an increasingly undernourished population?
Hoarding, price-hikes and distorted markets
In the short-term stringent lockdown measures are particularly harmful to the urban poor who instantly lose critical purchasing power. Of especial concern is the risk of food price-hikes. Consumers across the world have been stockpiling antimalarial drugs (chloroquine and hydroxychloroquine) in the hope these may offer some protection. Such hoarding is creating shortages at the expense of malaria patients who cannot do without and can result in dramatic price hikes. COVID-related hoarding is happening everywhere, and while this creates less of a problem when supplies are abundant, in cases where supplies are tight and subject to seasonal fluctuations, rapid price-hikes can have devastating effects. While some African governments are pairing lock-down measures with food distribution schemes, the large demand for such relief measures and the general sense of economic insecurity have already led to crowding, rioting, and uncoordinated food hand-outs, achieving the exact opposite of social distancing. Moreover, food relief hardly ever reaches everybody who needs it. Violence was used to contain hungry people congregating for food distribution in Nairobi’s Kibera slum.
In the longer-term, lockdowns are likely to damage the millions of farmers and food traders that uphold Africa’s single-largest economic sector. Even if governments are able to organize food relief in an orderly manner – e.g. guaranteeing physical distancing –, distortions to local food markets could leave them without much-needed sources of income, thereby raising the number of relief-dependent in the months ahead. Restrictions on mobility and shifting consumer preferences among hoarding urban residents affect the size and marketability of today’s harvests. Lack of access to fertilizer and other agricultural inputs will affect harvests and incomes in the months ahead.
Such realities place most African governments in an arduous position where they have to weigh how far they should go in enforcing quarantine compliance, especially if the lockdowns prove to be recurrent and/or of long duration. It is exactly the period until permanent relief – a vaccine – that could be further away in Africa than elsewhere. The ongoing geopolitical competition for scarce medical resources, offers little hope that – if left up to the market – Africans will be ‘first in line’ to receive vaccines once an effective one is found. Any delays in disseminating the vaccine to the region would further extend a costly and risky ‘off-and-on’ lock-down strategy. In short, to replicate the long-term strategy taken in developed economies, the world’s poorest may have to wait longest for relief and to endure the most stringent forms of economic shutdown to get the curve flat enough.
Alternatives
So, what is the alternative? Is there even an alternative? The moral and practical dilemmas that African countries face are enormous. While some countries may, to some degree, benefit from the lessons learned and infrastructure built in the fight against Ebola, the characteristics of COVID-19 present different trade-offs. The problem with COVID-19 is not that it is so lethal, but that it can spread under the radar as presymptomatic and even asymptomatic patients can be vectors. This mix of a comparatively low mortality rate combined with the hard-to-trace spread and limited economic means has presented African governments with a Gordian knot: are stringent containment policies more or less costly in human lives?
If African governments would decide against a lockdown strategy, or be forced to end it as a result of mass rioting and lack of compliance, what positive actions could they then take to mitigate the pain caused by the pandemic? Our list here is not exhaustive and is intended to stimulate debate.
First, abandoning a lockdown-until-vaccine strategy does not mean ending efforts to ensure physical distancing and protect the most vulnerable. The fight against transmission of COVID-19 takes place on a spectrum. Governments can impose a number of milder preventive policies that have less arduous effects on the economy, such as prohibiting gatherings that lead to unnecessary crowding (e.g. concerts, soccer matches, church services), requiring the wearing of (self-made) cotton masks, and facilitating 2-metre distancing in public spaces (e.g. physically spreading out open-air markets and rotating their use). African governments can also invest heavily in information campaigns to increase awareness about who are most at risk and how people can help protect them. Such information campaigns should especially be targeted at the transport sector, which, if allowed to operate with few restrictions, could become a central node in transmission.
Second, they can prioritize cooperation and building trust with citizens over repressive measures to enforce a quarantine. Above all, this is best done by providing accurate up-to-date information and not using the pandemic as an excuse to settle political scores. Instead of using repressive measures to enforce a quarantine from the top, successful physical distancing – especially in a context with many intergenerational households – would be heavily dependent on micro-solutions. As also emphasized in the African Arguments – Debating Ideas postings by Alex de Waal and Paul Richards, governments would have to invest their resources and energy in fostering close cooperation with local authorities. Local leaders – priests, imams, chiefs, mayors and village-heads – should be treated as equal partners in the fight against the pandemic and be given enough mandate to design the micro-solutions needed to isolate patients, care for the ill, and implement physical distancing. Central authorities can support such locally-driven efforts by importing and distributing items that cannot be produced in large enough quantities at home. Additionally, both central and local governments’ need to make sure that people can bury the dead in a dignified manner, avoiding a situation as recently seen in Guayaquil, Ecuador.
No matter what long-term strategy African governments decide to follow, there is a clear role for the international community, which should extend beyond Chinese solidarity. International lending institutions like the IMF can provide large packages of unconditional, interest-free loans to smoothen the import and distribution of medical supplies, soap, and, if necessary, food. In addition to such emergency assistance, it is essential that the WHO makes concrete plans with vaccine developers for a global allocation schedule. Any long-term strategy, and especially ones in developing economies, will benefit from clarity on how quickly citizens can get access to vaccines once these have been developed. Up to that point, ingenious use of public space may save more of the lives that are now at risk than lockdowns enforced with arms.
References
Deaton, A. (2013). The Great Escape: health, wealth, and the origins of inequality. Princeton, NJ: Princeton University Press.
Chandra, S., Kassens-Noor, E., Kuljanin, G. and J. Vertalka (2013). “A geographic analysis of population density thresholds in the influenza pandemic of 1918–19,” International Journal of Health Geographics 12(9): 1-10.
World Bank (2020). World Development Indicators. Washington D.C.