The 2014 Ebola Virus outbreak in West Africa wreaked havoc on a number of already fragile states - Liberia, Sierra Leone, Guinea, and the Democratic Republic of Congo. At the peak, people were lying dead in the streets and in their homes. It felt like the end of the world. No country wants a repeat of that sort of horror. The justifiable haste to avert that sort of scenario has led many Sub-Saharan Africa states to copy the lockdown approach in responding to the COVID-19 pandemic.
There have been debates about the workability of the lockdown on the largely informal economies of Sub-Saharan Africa (SSA). The concern is that the majority of the population in these countries are informal sector workers who essentially live from hand-to-mouth. Furthermore, the absence of reliable databases of individual and family incomes, traceable home and business addresses make it nearly impossible to effectively deploy government palliatives to those who really need them. Added to the debates is the weak capacity of health systems in SSA countries.
It does appear that the virus is not as transmissible in Sub-Saharan Africa as it is in North America and Europe. Experts have sought to explain why this is so. However, it is not only because of inadequate testing. As of April 27, 2020, Ghana has conducted 100,622 tests, 1,550 of which are positive. Ghana has recorded 11 deaths so far. We would be seeing an upsurge in unexplained Ebola outbreak-style deaths in communities if the low numbers of cases and low case fatality ratio could be explained by low test numbers alone.
So, what should these countries do? Do they relax movement restrictions and risk unrestrained spread of the virus, or do they maintain lockdowns and risk civil unrest? I propose a different approach that combines containment (COVID-19 control measures with minimal disruption of economic activity) and suppression (a total lockdown, driven by local context at the state level and governed by appropriate authorities).
A containment strategy requires public health authorities to institute a responsive surveillance system that can quickly identify, test and isolate positive cases and their contacts. Once a suspected case is reported by the public, the individual is quickly reached and tested. If they test positive, they will be required to isolate while their contacts are traced and tested.
Where should cases be isolated?
A few questions will need to be answered: can the individual and close household contacts remain at home without making any contact with other people? No going out to fetch water, buy fuel for the generator, buy phone recharge card, buy food? Can they be reached quickly with an appropriate ambulance to convey them to a treatment facility if their situation worsens? If the answer to any of these is no, then isolate in a designated isolation centre.
In the containment phase, the farmer and the cobbler can continue to work; the petty trader and the seamstress can open shop; the mason and the carpenter can continue to earn income. Most businesses should be able to stay open with modifications to keep people apart as much as possible. Schools may reopen with staggered classes and school days for different categories of students.
What is required for this to work?
Governments, either at state or regional level, will need to embark on massive social and behavioral change communication activities to discourage practices that facilitate the spread of the virus. This will include discouraging social gatherings, avoidance of crowds, discouraging all non-essential travels, restricting non-essential contact with old people and those with underlying illnesses, avoidance of handshakes and hugs, and generally encouraging physical distancing measures. Practices like frequent hand washing, use of hand sanitizers, staying home when feeling unwell will have to be continually emphasised. Mandatory use of face masks -even cloth facemasks- when leaving home will need to be put in place.
Trust is imperative and citizens should be encouraged to quickly report any suspected case. Authorities would need to work with communities, traditional institutions, market unions and trade groups to promote physical distancing procedures and establish mechanisms to discourage the violation of public health measures put in place.
What if containment fails?
Each state or regional authority will need to set a threshold for moving from containment to suppression. That threshold should be based on number of new cases per day which in turn depends on estimates of case reproduction numbers. To determine the threshold, the following will need to be taken into account:
The proportion of cases that are likely to require hospitalisation
The proportion of hospitalised cases that are likely to require intensive care and mechanical ventilation
The number of ventilators available
The number of intensive care spaces available
The number of designated hospital beds available
The number of frontline health workers available
Other local considerations
Once that threshold is reached, the authorities will as a necessity scale up to suppression.
Suppression is the disruptive lockdown phase that we have all become familiar with. Any state that reaches its containment threshold will reintroduce a lockdown phase and keep same in place until the case load drops below the threshold number.
Walking a fine line
At every stage of the process, public health authorities will need to provide daily updates using means that are appropriate for each state/region. Residents of Sub-Saharan African countries will need to realize that the price to pay to avoid the pain of the suppression phase is compliance with the inconveniences of the containment phase. Until an effective vaccine or treatment becomes available, governments in SSA will need to walk a fine line between total societal breakdown from an out-of-control virus or an out-of-control hungry populace.
Have you heard of other measures that might fit the Sub-Sahara African context? Let us know on our social media platforms, at @nighealthwatch on Twitter and @nigeriahealthwatch on Facebook and Instagram.
Author's Bio: Ikedichi Arnold Okpani, MB; BS, MSc, is a public health practitioner with interest in primary health care systems development, maternal and child health, and health systems research. He is a PhD student in the School of Population and Public Health, University of British Columbia, Vancouver, Canada. He received his medical degree from Ebonyi State University, Nigeria, and his masters' degree in Public Health in Developing Countries from the London School of Hygiene and Tropical Medicine, United Kingdom. He is a fellow of the International Program in Public Health Leadership of the Evans School of Public Policy and Governance of the University of Washington, Seattle, USA. He tweets as @IA_Okpani