The economic effects of social distancing measures in Africa would drastically differ from those in Europe and other parts of the world. With the potential for widespread starvation, epidemiologists and economists should together put as much effort into estimating the case fatality rate for social distancing measures as into estimating it for Covid-19 itself.
Suppose you had the choice between two health policies, A and B. Policy A would result in the death of a lot of elderly people. Policy B would result in the death of a lot of children, especially infants. Which would you choose?
Right now we are facing a choice between more or less drastic measures to slow the spread of COVID-19, a virus which, at time of writing, has yet to claim a life under 10, and claims very few lives under 30, with the risk rising exponentially with age. We are putting in place measures that will lead to malnutrition and starvation for millions of people, and for these horrors, children and especially infants are the most at risk. And very many of those infants are born, and will die, in Africa.
Yet there is little discussion of the consequences for human health of the measures we are taking. Nor is there discussion of how the major differences between Africa and America, Europe and Asia might matter. The World Health Organisation (WHO) website contains no technical guidance on how African governments should approach their considerably different contexts. The advice is the same globally, but the context is not.
Failure to recognise that one size does not fit all could have lethal consequences in this region, maybe even more lethal than those of the virus itself.
Social distancing may cost lives in Africa
In Africa, millions will starve if the global economy enters a protracted downturn. We must ask whether the number will be more than COVID-19 will kill in a region where only 6.09% of the population is over 65.
After the 2008 recession, 1 billion people were malnourished, and 5 million more children were hungry in 2010 than they would have been if the recession had not happened. We are only seeing the start of the economic disaster, and therefore the health disaster, that is going to engulf us as a consequence of social distancing measures.
And it’s not just the plunge of some abstract stock market. Tourism employs 1 in 23 employed South Africans. It has evaporated overnight. Bars and restaurants are empty, and, where they serve alcohol, must close early or limit numbers. Football has been shut for the season, and football clubs will go bust. And so on.
Unemployment in South Africa was already nearly 30% in the fourth quarter of 2019. The government lacks both the means and the competence to swiftly dish out grants to SMEs, such as the GBP10,000.00 (about South African R200,000.00) offered by the British government. South African SMEs are already vulnerable. Their employees mostly have no savings, no access to credit (creating hospitable waters for loan sharks), limited assets, and a support network consisting of people in the same boat. Mass unemployment means mass poverty, which means mass starvation.
The crunch question is this: what is the case fatality rate of social distancing in Africa? We have no idea; but that is the figure that should be considered when implementing social distancing measures. The scientific community, including both epidemiologists and economists working together, should be putting as much effort into estimating that case fatality rate as into estimating it for COVID-19.
Social distancing might not work in Africa
It’s not even clear that the social distancing measures will curb the spread of disease here. We know from award winning work on HIV transmission by South African epidemiologists that local social context can neuter a health intervention that is effective elsewhere. So it may be with social distancing.
In a South African township, living conditions are extremely crowded. Socialising is unavoidable. You might as well tell people to emigrate to Mars. In the bubonic plague, the aristocracy left London for the countryside; the poor of London could not isolate themselves, and so they died. This may be our situation.
It is similarly fantastical to expect people who cannot afford food – as will soon be the case for many more – to practice personal hygiene. You can’t eat soap. If you are starving, you won’t buy it.
Thus the major components of the recommended public health measures – social distancing and hygiene – are extremely difficult to implement effectively in much of Africa. The net effect of measures that seek to enforce social distancing may thus be to prevent people from working, without actually achieving the distancing that would slow the spread of the virus. If that is true, then we must consider whether we would be better off without them.
Not all these measures are the same, and nor are preventive measures an all-or-nothing measure. Some degree of social distancing may be possible. Elbow greetings may slow things down. But it’s a fantasy to suppose that the virus can be contained anywhere, and the cost of measures must be proportioned to their likely benefit. The cost of an elbow greeting is low, but the cost of shutting a school is huge.
But even if social distancing here will “flatten the curve”, will it make a difference? The logic of flattening the curve is to bring the peak of the pandemic (the highest number of sick at any one time) down to a manageable level. But this assumes access to healthcare in the first place.
In much of Africa, public healthcare is inaccessible to a huge proportion of the population. Without a miraculously fast overhaul of the continent’s healthcare provision, flattening the curve will make no difference to the majority. Cute as the meme is, its logic does not apply to much of Africa.
What about the children?
Children evoke strong emotions in most of us. Those with children may be worried about their welfare. But children are at very low direct risk from the virus, although of course they are at indirect risk from the economic consequences of pandemic and the death of elderly care-givers. And, in a famine, they are at very high risk of malnutrition and starvation.
We, personally, have elderly relatives whom we care about deeply. But would we actively move children who are otherwise at a minimal risk into a high risk situation, in an attempt to prolong the life of some of those elderly? Would we do so when the effectiveness of those measures is questionable, and the economic effects of those measures (famine) also puts the elderly themselves at risk?
We don’t know. It depends on the data. But we do believe that this is a conversation that we must be brave enough to have.
Many leaders are doubtless aware of their dilemma, but their ability to express this and their ability to make choices is restricted, as the treatment of British leadership shows. In Africa, it’s questionable whether leaders have a political choice, given intense pressure from an international community that isn’t thinking about the differences of the African context, and a WHO offering no region-specific technical advice.
Leaders need to be given the space to say shocking things, to be upfront about what might go wrong, to change their minds in the face of new evidence, and to pick the lesser of two evils.
Doctors face such choices every day, and they are horrible. But they are unavoidable. Without a proper estimation of the costs as well as the benefits of the measures currently being implemented, no rational assessment of their merit can be made.
Photo: President of South Africa Cyril Ramaphosa. Credit: GCIS. Licensed under creative commons (CC BY-ND 2.0).
This article was first published on The Conversation.
This sounds like a sophisticated perspective on the surface but talking about context here is a luxury humanity cannot afford. I disagree with these authors. The experience so far is a sharp spike in the infections follow after initial low numbers. Countries that don’t act fast get overwhelmed like Italy.
The world needs to act fast in unison to help with food and needs. This is not a fight for one country or continent. The contagion rate is unique and unprecedented. You don’t win this fight by winning it in one locality and leaving others to perish.
A paradigm shift is needed and very fast. Time is of the essence!
Good and thought provoking article. However, some additional points need to be considered. E.g. ” We must ask whether the number will be more than COVID-19 will kill in a region where only 6.09% of the population is over 65.” – but we also need to factor in the % of the population with underlying conditions that also put them at risk – e.g. % who are HIV positive, % with diabetes – probably even the % who are ALREADY malnourished, which would also impact the strength of their immune system. The proportion of the population at risk due to these additional risk factors will make COVID a far more significant threat that described here? This doesn’t necessarily negate the multiple points made in the article, but also shouldn’t be ignored.
Unfortunately the lockdown herd is stampeding, and cool, rational advice like this is considered blasphemous. You will only be able to say “I told you so” but even then you will be whistling in the wind.
Factor in the low mortality rate in Africa, as well as the fact that we are in summer right now and would probably be better off being hit now than in winter, and the current response becomes truly absurd. But like I said, the herd is stampeding…
Good considerations. On the comment about a lack of regional guidance from WHO, just a note that Africa CDC has many COVID-19-specific resources on their website, which are intended to be region-specific.
“Suppose you had the choice between two health policies, A and B. Policy A would result in the death of a lot of elderly people. Policy B would result in the death of a lot of children, especially infants. Which would you choose?”
What a joke. There aren’t choices to make here. You shouldn’t put yourself in a position where you have to make such a choice. you objective is to address the whole spectrum. anything else you might do is 100% not going to achieve what you imagine you would.
saying that these are the choices that you have mean that you have given up before you even started.
Thank you for daring to ask the real hard questions here. Important perspective you offer.
The solution for Africa needs to be homegrown , its between day 3 and 5 of the lock down ..for different countries in Southern Africa. Food and water reserves for an average township family are running dry. We need to go back to street to vend , and hunt. Social distancing and lock down , unfortunately , may not be for us.
Well written article and very thought provoking. I don’t think there is a simple answer to this. My question remains what will happen when the lockdown ends and the flattened curve resumes it’s trend to spike up.
All of us have families of all ages, I can honestly not say that I would be heart broken regardless of whether my 90 year old ‘fairly healthy’ grandmother or my 7 year old son (with mild symptoms of asthma) gets infected.
Children do speak their minds though and there is a missing element here that isn’t addressed in the article. My children worry about never seeing my grandmother again and the social distancing is having a massive negative effect on all of us.
There is good and bad on both sides of the argument, hospitals need to be able to handle patient loads though because it’s not only COVID-19 emergencies that require treatment. And similarly our economy is slowly slipping into it’s own form of ICU.
Thank you for all this thoughtful issues. The problem is that all these assumptions are missing one aspect. No one is looking at the fact that allowing the health system to be overwhelemed will also lead to excess mortality. If the health system is overwhelmed then very sick children, the malnourished and pregnant women will not be able to recieve the timely care they need. As a result, in addition to COVID19 deaths you will have excess mortality. Immunization and treatment for acute malnutrtion will not be possible.
Therefore the painful, and trade off options that African countries are taking to contain the virus are the best options. Contain the pandemic in early stages and avoid community transmission. Despite the doom predicted, most of these countries have a large rural population that does not live on daily income except for the few urban poor. These are are the ones who need mitigation during the lockdowns. These lockdowns have actually contributed to sensitization of the communities of danger of COVID19. Countries that have taken these drastic steps have saved more deaths than the doom predictors who are telling them let Africans die after all they die everyday. This sort of narrative should stop. Thanks to the flight of the so called experts back to their countrues which has allowed us local scientists to make better informed decisions.
Policy and Public Health Specialist, Uganda