Why lockdowns aren't a one-size-fits-all solution to the pandemic

LONDON — While countries in the global north were sluggish in responding to the coronavirus, governments in many lower-income countries were much faster to enact lockdowns.

Particularly in parts of sub-Saharan Africa — with the memory of Ebola outbreaks in recent history — many governments moved swiftly, putting in place measures previously thought impossible and bringing societies to a halt.

South Africa, Rwanda, Kenya, Uganda, and major areas of Nigeria all declared lockdowns, restricting movement, and closing businesses. Many fear what the impact of a large-scale outbreak would be in contexts with limited access to health care, where capacity would be quickly overwhelmed.

But questions have equally been raised by some public health experts over the suitability of nationwide lockdowns in areas with weak health systems and fragile economies, where the possibility of working from home doesn’t exist for most people.

Collateral damage caused by lockdowns — enforced in some places with brute force — is a key concern, in part because some governments are unable to offer the kind of safety nets seen in the global north, more people work in the informal sector, and health systems are less resilient.

“The mortality attributable to the lockdown itself [because of disruption to health services and the economy] … may overtake lives saved due to lockdown mediated slowing of COVID-19 progression,” according to a statement by India’s Joint COVID-19 Task Force, made up of 16 public health experts. The country shut down between March 25 and May 31.

The group was strongly critical of the Indian government’s “incoherent” coronavirus response and said that stopping migrant workers from traveling home prior to a “draconian” lockdown — when there was a smaller number of cases — has worsened the situation, as more are now carrying the disease around the country.

Collateral damage has also hit countries in sub-Saharan Africa hard. “The cost has been heavy,” said Dr. Nazarius Tumwesigye, associate professor in the department of epidemiology and biostatistics at the Makerere University School of Public Health in Kampala, Uganda. “For countries which are not sure of their health system, a lockdown could help at the beginning, but entered into too much can also be disastrous,” he said.

Tumwesigye supported an early lockdown in Uganda as an “essential, important action.” But now, he said, children have missed routine immunizations, mothers have died in childbirth because they were unable to travel to hospital without a permit, and there are concerns about people being unable to access medications for diseases such as malaria and HIV.

“Uganda has not lost one person from COVID but has definitely lost many people indirectly from COVID because of [a lack of] access to health facilities,” he said.

Across the continent, there have also been reports of people going hungry and losing work because of lockdowns.

As a result, in South Africa, President Cyril Ramaphosa announced an easing of the country’s lockdown — one of the continent’s strictest — starting Monday, despite telling citizens the outbreak would become worse.

Uganda's lockdown is also set to ease Tuesday, with exceptions for stadiums, churches, and other crowded places.

“This [pandemic] won’t be solved by a [purely] medical ... approach,” argued Dr. Mukesh Kapila, professor of global health and humanitarian affairs at The University of Manchester. He defined a medical approach to tackling disease as one that takes place in a controlled, institutional environment, whereas public health tries to achieve “the greatest good of the greatest number of people.”

“We will need a combination of public health and social policy” to tackle the virus, he said.

Kapila argued that a very institutionalized response was “the last thing you want in Africa,” since hospitals become “incubators for disease” without proper infection and sanitization controls and personal protective equipment for staff. The invasive treatments for COVID-19 with “poor outcomes” also take up valuable bed space for those who have suffered heart attacks or have other conditions that are better suited to a medicalized response, he added.

Kapila described strict and lengthy nationwide lockdowns in all countries as a “blunt instrument.” Along with the collateral damage, he suggested they are deferring mortality caused by the coronavirus to future waves of the disease, when the virus might be more virulent. “The costs of that [lockdowns] are going to be greater than the benefits,” he argued.

Coming out of lockdown will, however, require different approaches in different contexts, according to the experts. Efforts should be focused on educating people about minimizing the risks of COVID-19 in their own circumstances. In crowded refugee camps, for example, that might mean keeping 9 inches away from other people instead of 6 inches or washing hands twice a day instead of once every two days, Kapila suggested.

“From a policy angle, we don’t want millions of people not to get infected; we want small incremental improvements,” Kapila said. “The public health approach is much more feasible in developing countries than [a] one-size-fits-all distancing mantra copied everywhere.”

Tumwesigye also expressed worry about deferred mortalities. He said that the lockdown was useful as an initial buffer for up to two months but that Ugandan health officials should now be focused on coronavirus cases coming through the country’s borders — mainly via truckers — and community transmission. “We need a good surveillance system. A person should know who to ring if there is a problem,” he said.

Targeting smaller areas is likely to be a step forward. Cordons sanitaires could be established, allowing unrestricted activity in areas known to be free of the virus, said Dr. Andrew Lee, reader in global public health at The University of Sheffield. “The pandemic is not everywhere. It’s in Brazil but not all of Brazil. There are parts of the country you could cordon off and allow economic activity to continue,” he said.

In India, where there has been severe disruption to routine health care services, the Joint COVID-19 Task Force recommended that the nationwide lockdown be replaced with “cluster restrictions” based on epidemiological assessments, that all routine public health services be resumed, and that the public health system overall be strengthened, particularly intensive care capacity.

Oommen C. Kurian, a health and development policy researcher at the Observer Research Foundation in New Delhi, said India’s exit from lockdown would be the most difficult stage of the pandemic for the country so far, after having bought valuable preparation time. An “aggressive ‘test, isolate, and trace’ strategy early on to prevent spread to unmanageable levels like in Mumbai will be the mainstay of the approach,” he said.

But Kurian said he expected India will need to rely on voluntary compliance with social distancing, which would need “regular risk communication from the highest political leadership from now on.”

The unprecedented challenges thrown up by the pandemic have forced governments to make seismic policy decisions in a fast-paced and uncertain atmosphere. As Lee put it, governments are “stuck between the devil and the deep blue sea.”

Despite the fallout of the lockdown in India, “given the weak health care delivery system, probably it was the only option available at the time,” Kurian said.

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