SAN FRANCISCO — As Nigeria lifts its COVID-19 lockdowns, the government is facing the knock-on consequences of the response.
“The restriction in movement created a lot of issues, particularly for a lot of daily wage earners and those who live from hand to mouth,” Dr. Osagie Ehanire, Nigeria’s minister of health, said at the World Economic Forum’s Sustainable Development Impact Summit.
The country is working to ensure compliance with social distancing protocols as it reopens, he said, referencing the importance of saving lives as well as livelihoods.
The pandemic brought many countries to a standstill. But in sub-Saharan Africa, where the fatality rates have been much lower than in other parts of the world, the socioeconomic impacts of the lockdowns have been particularly devastating. Some models and forecasts have indicated that the response to the pandemic could do more damage than the disease itself.
As countries reopen, governments have another opportunity to weigh the health and economic impacts of every decision and develop a response that makes sense for their contexts.
Contextualizing pandemic response
As African governments locked down in response to COVID-19, people living in poverty suffered disproportionately, said Andre Ndayambaje, health services coordinator at the University of Global Health Equity, in Rwanda.
“[African] governments face a difficult dilemma and must find the right balance between saving lives and protecting livelihoods. They risk a cure that’s worse than the disease if they don’t.”— Tim Bromfield, regional director for eastern and southern Africa, Tony Blair Institute for Global Change
“When governments shut down or limit public transport, the rich people will use their own cars and go to the hospitals for life-saving treatment, while those who depend on public transport and have no alternative will die at home,” he said.
He emphasized the importance of studies on the social and economic burden of the virus to ensure that governments respond to the pandemic and future outbreaks without causing what he described as “fatal unintended consequences.”
Researchers studying COVID-19 in Uganda predict the public health lockdown, and its impact on diseases including malaria and HIV/AIDS, will prove to be more deadly than an extensive COVID-19 outbreak would have been.
“Sub-Saharan African countries could be ‘protected’ from COVID-19 mortality by an age structure differing significantly from countries where mortality has been particularly high,” reads the recent paper from The American Journal of Tropical Medicine and Hygiene.
While there is disagreement among researchers over whether other factors, including weak health systems, outweigh young demographics when it comes to COVID-19 risks in Africa, this paper builds on a body of evidence about the ripple effects of the response to the virus.
Early predictive models for COVID-19 were based on European populations and have failed to play out in Africa. Now, experts are calling for more regional data and analysis to understand the trends.
Uganda, like several other African countries, adopted COVID-19 mitigation measures from other countries without putting them in the context of its own population structure or existing burden of disease, said Agnes Kiragga, head of statistics and data management unit and senior research scientist at the Infectious Diseases Institute in Kampala, Uganda, and one of the co-authors of the AJTMH paper.
“To my knowledge, the country’s response was not informed by modeling exercises,” she said in an email to Devex.
Kiragga joined other researchers in developing policy briefs outlining how scenarios derived from models could inform decisions on lifting the lockdown in Uganda.
While this led members of the scientific advisory committee of the COVID-19 National Task Force to increase their modeling activities, the government has not fully embraced the potential of modeling to inform policy response, she said.
Forming partnerships and building capacity
A lack of data can make it challenging for decision-makers in low- and middle-income countries to make evidence-based decisions about reopening.
But countries can and should take a quantitative approach to safely reopen their economies, explains a recent paper from the Institute for Disease Modeling, part of the Bill & Melinda Gates Foundation’s global health division.
Marita Zimmermann and Brittany Hagedorn of IDM call for collaboration between local researchers and policymakers to find the best solutions for each context, an effort they said should be led by partners in these countries, with support as needed from outside analysts.
For example, IDM’s team working on models for COVID-19 response has an ongoing collaboration with policymakers in Kenya. The country closed all schools in March, with plans to reopen schools in January. But as Kenya has seen decreasing cases, and is likely past the peak of infection, policymakers are running their own models in consultation with IDM to decide whether to reopen schools sooner.
Zimmerman said the lack of disease modelers with the experience needed to quickly run scenarios in response to a pandemic is a global challenge not limited to the African continent and added that IDM is having an ongoing internal conversation about ways to help scientists across a range of disciplines to develop this skill set.
In August, the Africa Centres for Disease Control and Prevention and African Risk Capacity, a specialized agency of the African Union, launched two COVID-19 modeling tools to help countries evaluate the potential impact of COVID-19 in their countries and respond accordingly.
It remains to be seen how widely used the tool will be.
The fact remains that many African countries imposed lockdowns even when data did not support their decision to do so, given the predicted and actual low mortality rate from COVID-19 relative to other diseases and to high-income countries, said David Bell, a global health technology expert and co-author of the AJTMH Uganda paper.
“I think in the end it’s largely that a lot of people got excited, panicked, and forgot basic public health methodology, and partly now peer pressure and fear of looking stupid,” he told Devex via email.
Bell said that predictions of catastrophe have been published without supporting data, and he and his co-authors have been surprised by the lack of voices making the case that the response may be more deadly than the disease.
Leveraging modeling in reopening plans
The transition from lockdowns to more sustainable COVID-19 responses offers an opportunity for African governments to leverage modeling in their decision-making.
The Tony Blair Institute for Global Change put together an ad hoc modeling analytics team to support its policy advisory work to African governments responding to COVID-19.
“African nations must choose their own path to save as many lives as possible from both COVID-19 and other causes of mortality. Governments face a difficult dilemma and must find the right balance between saving lives and protecting livelihoods. They risk a cure that’s worse than the disease if they don’t,” said Tim Bromfield, regional director for eastern and southern Africa at the Tony Blair Institute for Global Change.
Lockdowns are unsustainable in the long term, not only because they are costly to enforce, but also because they can have damaging psychological impacts, drive social unrest, and disrupt livelihoods and economies, the institute explained in a guide it recently sent to governments it advises across Africa.
The institute suggests that governments combine social distancing for the general public and more targeted shielding for sensitive groups, meaning that elderly people and people with underlying conditions who are at an elevated risk of COVID-19 stay away from others in order to protect themselves from the virus.
While modeling efforts in Africa have typically depended on results from modelers in the United States and United Kingdom, there is growing recognition on the continent about the need to develop models that contextualize the needs of each country, IDI’s Kiragga said.
Rwanda may have lessons to offer from its COVID-19 response, said professor Agnes Binagwaho, vice chancellor at UGHE and the former Rwandan minister of health.
The country reviewed the science on the virus as well as daily data on disease spread in the country, developed evidence based interventions, and maintained a focus on primary care such as maternal child health and vaccinations, she said in a recent presentation on the COVID-19 impact in Africa.
She called for more partnerships between African countries and with external partners, emphasizing the importance of mutual respect and mentioning the The International COVID-19 Data Research Alliance, a new forum for researchers to collaborate on data, as one opportunity for collaboration.