Many African countries have introduced lockdowns in order to halt the spread of coronavirus, but, as Alex de Waal and Paul Richards argue, ordinary people have to be involved in choosing the solutions that will work for them.
Countries on the continent have learned much from tackling epidemics such as HIV and Ebola that should be put to good use as they face the impact of Covid-19.
The most important lesson is that communities must be at the forefront of responding.
This is not a pious mantra but fact of life.
First, infectious disease outbreaks unfold differently in different communities, according to social conditions that only local people can know.
Second, no control measures, for example, lockdowns, can be imposed without the consent of the people affected. It is only when local people are fully involved in planning and implementing epidemic control measures, that they can work.
Public health officials developed a useful guide during the Aids epidemic: “Know your epidemic, know your response, and act on its politics.”
It is useful to think of Covid-19 not as a single global pandemic, but as a simultaneous outbreak of innumerable local epidemics, each one slightly different.
The basic transmission mechanisms of the virus are the same everywhere. But the speed and pattern of spread vary from place to place.
A densely populated township will have a different trajectory to a middle-class suburb or a village. The epidemic will spread differently again in refugee camps and among nomadic peoples.
Africa’s disease burden is different
In each case, the key factors are social behaviours such as greetings, mingling among the generations, hand washing, or maintaining physical distance.
Experts can build their models based on assumptions and averages, but only communities can know what these mean for their particular circumstances.
Africa has a burden of diseases different from other continents.
There are good reasons to fear that Covid-19 will be particularly dangerous to tens of millions of people with tuberculosis or whose immune systems are compromised by HIV.
Little is known about what infection with the coronavirus means for people who have malaria or are malnourished.
On the other hand, Africa’s population is young.
One reason given for Italy’s high mortality rates has been that it has a large proportion of elderly people – 23% of the population is over the age of 65 – who are most at risk should they contract the disease.
By contrast, less than 2% of Africa’s population is over 65. For this reason alone, the virus’ mortality rate may be lower on the continent.
It is clear that each African country will have to design its own response, suitable for its own need.
Why governments need to talk to the people
Governments do not have the data and models for precise expert prediction, and will not get them quickly enough.
But there is a better method, tried and tested: talking with the communities. Doctors and epidemiologists can provide the medical facts, communities can provide the contextual details and knowledge of what has worked for them in the past.
China, Europe and North America all adopted much the same epidemic control policy: lockdown.
African governments followed suit, but in general lockdowns may be simply unworkable in the continent. Only a few African countries, such as Rwanda and South Africa, have the capacity to administer a centralised strategy.
For people living from day to day, reliant on earning cash in the market to buy food, a few days’ lockdown is the difference between poverty and starvation.
For people already suffering hardship because of unemployment, drought or a swarm of locusts, social welfare is provided by relatives. If a lockdown cuts these social ties, adversity becomes destitution.
Lockdowns also threaten to interrupt supply chains of essential drugs to treat TB, HIV and other diseases.
If any form of lockdown is to work, emergency assistance measures are needed.
The lockdown which didn’t work
These include aid to those who have lost either their jobs or the money they received from family in Europe and America to keep food and fuel supply chains open.
Some countries, for example, Uganda and Rwanda, are distributing free food. Ghana has announced free electricity, water and a tax holiday. But African governments simply do not have the funds to sustain these kinds of measures without international aid.
If basic livelihoods cannot be secured, a comprehensive lockdown is not practical. Poor people will prefer the lottery of infection over the certainty of starvation.
In the Ebola epidemic, when the Liberian government ordered the army to impose isolation on West Point in the capital, Monrovia, in 2014, it discovered within a few days that the lockdown was so unpopular as to be unfeasible. It did not stop transmission either.
Very quickly the government shifted to a policy of asking community leaders to design and enforce their own control policies.
The simple lesson that public health works by consent was learned in Sierra Leone too. Communities took the lead in designing their own quarantine measures, which were then adopted by international agencies.
What is needed in Africa
The key lessons for epidemic response are to act fast but act locally. That is what African countries should be doing.
Africa’s health systems are already overstretched. Covid-19 demands an emergency response at scale and that begins with governments.
African hospitals need testing kits, basic materials for hygiene, personal protective equipment for the professional health workers, and equipment for assisted breathing.
There is a global shortage of all of these and a shameful scramble among developed countries to get their own supplies – relegating Africa to the back of the queue.
But as the international response gains momentum, African governments should coordinate their needs assessments and supplies.
A second pressing need is to set up field hospitals for the surge of cases that will arrive at the peak of the epidemic, which seems to typically be about eight weeks after transmission in the community first becomes evident.
Of necessity, these must be very simple: tents in a school field or even thatched sheds in the bush.
There simply will not be enough respirators or intensive care units. The modest aim is to ensure that family members can nurse patients with Covid-19 without disabling local hospitals or health centres.
Keeping health facilities open to groups such as mothers and babies, free of cross-infection with Covid-19, is another key aim or else the increased illness and death from other causes could outrank the virus itself.
Communities can help by finding sites, constructing camps and nursing patients according to a home-care protocol for the virus, with health professional supervising from a safe distance.
An even bigger challenge will be keeping economies functional and stopping a slide into destitution and hunger.
African countries cannot close its fresh produce markets or people will starve. But market goers can readily work out how to reduce the risks of transmission, through measures such as better hygiene, crowd control, and physical barriers such as polythene sheeting at point of sale.
Another proposal is that each household should designate a single person to buy food, and the market authorities provide that person with an identifier such as a coloured bangle. The designated shopper would then be isolated from other household members on returning home. Some markets could be temporarily relocated to safer sites.
In some countries, a switch to cashless mobile phone transactions may be workable; in others, companies that send remittances home can be enlisted.
What is most important is not a list of good ideas, but proper discussion with traders, customers, market authorities, chiefs and local government. They are the ones who will know what will work for them, and how it can be monitored and enforced.
Lockdowns have the potential to create a serious social crisis. This is not just in terms of creating poverty, hunger and resentment, but also endangers the roll out of workable epidemic control measures.
‘No time to lose’
Today, public health experts have not proposed alternatives to comprehensive lockdown.
They have not explored local variants of isolation, movement restriction, contact tracing and quarantine. That is because they have not yet asked local communities for their proposals.
There is no time to lose and community consultations should begin now.
The experience of handling epidemics such as HIV and Ebola provide an encouraging lesson. Ordinary people are not the problem, rather they are the solution.
The good news is that communities can quickly learn to think like epidemiologists provided that epidemiologists are ready to think like communities.