Ensuring access to food and water during lockdowns is a must to avoid the spread of the COVID-19 pandemic in Africa
Abstract: Community transmission of COVID-19 is now happening in many parts of Africa. There is no evidence that warm climate will slow down the epidemic. According to estimations, at least 2.6 million people (and probably much more) may die in Sub-Saharan Africa due to COVID-19 in the upcoming months. Strict social distance measures (‘lockdowns’) are needed to reduce the transmission and mortality rates of the pandemic, but these processes will require a careful planning of how the poor will access food (with differentiated approaches for rural and in urban contexts) during the lockdowns. There are probably still a few weeks’ window of opportunity to contain COVID-19 in Sub-Saharan Africa. But unless decisive measures are undertaken to secure the food security of the poor, it will remain impossible to implement appropriate quarantine measures, and many lives will be lost.
Millions at risk
As of 31 March 2020, and according to the 5,287 total COVID-19 cases and 172 deaths have been reported in
48 African countries. In fact, case numbers of COVID-19 are i
ncreasing exponentially in the region . The possibility of
unreported cases is also a matter of concern, given the weak health-care systems of most countries in the continent, and limited availability of testing facilities .
Current
evidence does not support the hypothesis that the coronavirus will spread more slowly in countries with warmer climates, so it is anticipated that the spread rates will be similar to those we have seen in China or what we see in Europe or US now. Africa may start facing the severe impact of the pandemic in late April or early May.
The calculator developed by the University of East Anglia estimates that COVID-19 deaths in Sub-Saharan Africa may reach
2,6 Million people, based on a 50% total infection rates.
The calculator applies the relevant mortality rates for each age group. In that regard, the total death rate for Africa is significantly lower than in China, Europe or US, where the percentage of the elderly is higher. However, the calculator does not consider the potential of higher-than-average mortality rates by patients with pre-existing medical conditions particularly predominant in Africa, such as HIV-positive population (
34 million people in Sub-Saharan Africa ). Although there is not yet specific information about the risk of COVID-19 in people with HIV, it seems that the HIV-positive population is
more likely to require hospitalization for influenza-linked pneumonia. High levels of endemic malaria might also be a serious complication for COVID-1 cases. The calculator does not consider, neither, many COVID-19 fatalities that are avoidable in contexts of well-developed health systems (like China, Europe or US) but will not be avoided in Africa: between
1 and 2% of COVID-19 patients need respiratory ventilators for life support and many more need access to Intensive Care Units (ICUs) -without which they would likely die. Most African countries have very limited access to these facilities/equipment (e.g.:
Uganda has only 55 ICUs and only 13 nurses in the whole country with training in critical care nursing) and so, with high infection rates, the mortality rate in the region could in fact be much higher to what we see in Europe or China, and the total number of deaths in Sub-Saharan as high as
5 Million people.
In short:
African countries should not expect a ‘mild’ version of the disease.
To avoid millions of deaths, it will be critically important to slow down the spread of the epidemic (to protect limited health resources, so that hospitals are not rapidly overwhelmed) and to protect vulnerable groups .
Social distancing saves lives
A combined approach of physical distancing - comprising quarantine, school closure, and workplace measures - is
the most effective way at reducing the number of novel coronavirus cases.
Social distancing is a term used by epidemiologists to refer to a conscious effort to reduce close contact between people to minimize or stop community transmission of the virus.
Introducing social distancing measures early in an outbreak of COVID-19 delays the introduction of the pandemic to a country or area or may delay the peak of an epidemic in an area where local transmission is ongoing, or both and hence,
contribute to reduce the number of deaths. What has happened in China shows that quarantine, social distancing for the entire population via home confinement, and isolation of infected populations
can contain the epidemic. The purpose of these drastic measures is to
reduce the number of people each confirmed case infects.
Should strict social distance measures (including home confinement for the entire population) be applied in Sub-Saharan Africa in the same fashion as in China’s Hubei province, European countries and now in most US States, the infection rate of coronavirus could be minimized to a 10% infection rate or bellow, given the still relatively early stage of the pandemic spread in the continent. As per the East Anglia University calculator, that would mean that mortality rate would be reduced by 80% in Sub-saharan Africa (521,000 people would die compare to the at least 2,6 Million deaths in a non-quarantine scenario). Furthermore, that would also reduce the number of cases that would require intensive medical care and hospitalization, helping to avoid the collapse of the already weak health systems in African countries.
Instituting quarantines is a measure of last resort but one that, in the context of COVID-19, Africa will unfortunately have to apply.
Livelihoods at risk
Quarantines involve restricting people's liberty and freedom of movement, as well as access to their livelihoods, and to healthcare, food, and water. International human rights law requires that any restriction to human rights in the name of public health meet certain requirements, as laid out in the
Siracusa Principles. The Siracusa Principles sets that States imposing these measures have “burden of justifying such serious measures,” i.e. they must demonstrate that the restrictive measures are necessary to curb the spread of infectious disease.
Although quarantines have been praised by WHO as a mean to reduce the spread of COVID-19, the possibility of imposing these measures in less developed countries, raises
important questions. Quarantines have been used effectively in Africa in the past to contain the spread of Ebola, and other infectious diseases. In 2014, under the threat of Ebola, a number of rural communities in Sierra Leone successfully kept out cases of the disease through vigilant community control of local borders. Reduction in the number of Ebola cases in certain areas of Sierra Leone was largely attributed to quarantine strategies. But there were also significant
challenges and
ethical considerations . Home confinement may cause severe negative impacts, including insufficient access to food and medical care. People need to secure their livelihoods during quarantines. In fact, the Siracuse Principles set that when quarantines are imposed, governments have an obligation to ensure access to food, water, and healthcare.
With modern supply chains and home delivery, and governments able to guarantee incomes for a period, countries such as China, Italy or Spain have been able to impose home quarantine for many weeks, that are now successfully flattering the spread of the disease and reducing the number of further potential deaths. But in Africa, for most people no work means potential starvation for many within a matter of days.
WHO recognizes that ‘if a decision to implement quarantine is taken, the authorities should ensure that the quarantine setting is appropriate and that adequate food, water, and hygiene provisions can be made for the quarantine period’.
Since late March 2020, many Sub-Saharan African countries started imposing lockdowns and social distancing norms, often in a non-planed and disordered manner. In
DRC a three-week lockdown imposed in Kinshasa had to be postponed amid fear of price speculation on basic goods and increased insecurity in the city . In
Kenya excess use of force deployed to enforce the curfew aimed at combating spread of the virus resulted in shootings and deaths . In
South Africa, police shoot rubber bullets and water cannons to disperse homeless people lining up for food. Similar situations have been also reported in
Uganda, Zimbabwe and
various other countries. As written in a recent media article, ‘currently the only model available to governments in this part of the world is restricting movement, but this has already backfired spectacularly’ .
On the other side of the spectrum, some countries in the region have been slow to respond. Until
Burundi recorded its first two cases on March 31, the government claimed it was protected from the virus because it “put God first” and
Tanzania refused for too long to undertake some basic control measures such as to close massive gatherings for worship .
Top-down curfews that don’t consider the needs of the people during the lockdown are not an option. Neither is an option not to act. Countries in Sub-Saharan Africa require feasible social distance measures that can avoid the spread of the pandemic, while
ensuring the basic livelihoods of the population at the same time.
Ensuring food security during the quarantine
Rural contexts: Village-level community quarantine
During the 2014 Ebola outbreak in Sierra Leone, quarantines were imposed on individual houses, neighborhood’s and villages (community quarantine), and in a few cases in entire administrative districts. In practice, quarantines normally lasted for 21 days.
In
community quarantine, the movement of people is limited to accessing basic services and going to work within the limits of a certain geographical area, generally the village (including the farmlands around). The use of community quarantines proved very helpful in holding back the 2014 Ebola outbreak in Sierra Leone. Compared with household-quarantine, community quarantine allows the community to continue accessing the water sources and keep the farming activities.
In village-level community quarantine, movement restrictions apply to communications with those outside the village, which are limited to cases of emergency, but not within-the community (excepting in the cases of symptomatic or tested positive cases, which should undertake home confinement if the symptoms are mild, or have to be referred to health facilities if they require intensive care).
Given that most rural communities in Sub-Saharan Africa are engaged in primary production, community quarantine allows to preserve basic food security during the lockdown period, which should normally take between 4 to 6 weeks.
However, certain disruptions in the food supply are probably unavoidable: most rural communities depend, to one extend or another, on external food supplies to ensure nutrition diversity. Income may also be disrupted given the inability to reach the markets outside the community. Finally, access to seeds, fertilizers and other agriculture inputs will be affected during the quarantine weeks. But, in any case, all these negative impacts would be even more intense in a scenario of household-level quarantine. We also need to keep in mind that we are not talking about several months of quarantine, but some weeks, and that not ensuring social distancing means the threat of millions of lives lost.
More than 80 per cent of the food in Africa is produced on smallholder farms, so ensuring that the farmers can continue producing during quarantine weeks will be critically important for the food security during the recovery phased as well
.
The experience from the Sierra Leone Ebola pandemic demonstrated that involving local leaders during planning and implementation can help ensure community needs are met . It will also be important to announce the start of the quarantines well in advance, for communities to stock production and prepare themselves for the 4 to 6 weeks in isolation. Fundamental human rights should be respected and access to basic supplies should remain possible during the quarantine.
Village-level community quarantine is not a perfect solution, but is a realistic model to push back the pandemic expansion while preserving the basic rights of the communities and avoiding the much higher impact on the food security of the population that household confinement may entitle. Finally, it also provides better living conditions, helps social distancing for in-house suspected causes, reduces the impact of gender-based violence (compare to household-confinement) and preserves the social-cohesion fabric of the community: Village Saving and Lending groups, care groups and all other types of community organizations can continue meeting and providing support to their members during the quarantine.
The village-level community quarantine model should be applied as early as possible, once community transmission of COVID-19 starts in a territory. By a territory we mean either a country or, in case of large countries, the specific portion of the country where community transmission has started taking place.
Governments and donors should start now by providing production means to the communities (seeds, fertilizers, storage equipment) to enhance the ability of the community to remain self-sufficient during the quarantine period.
Urban contexts- Cash, vouchers and/or food aid for the poor
Most households in urban Africa depend on daily wages, so total lockdown is tantamount to starvation unless that loss of income is compensated by other means.
Urban areas, and specially crowded slums and refugee camps, however, will require different approaches than rural areas. Neighborhood-level controls in cities are difficult to apply. Furthermore, in most African countries, the majority of the COVID-19 community transmission cases are already happening all across urban settings, so clustering the population in specific neighborhoods with high incidence is probably not an option anymore. It seems that urban areas in Africa, especially large cities, will require at some point to apply households-confinements to contain the virus.
As the early examples of lockdown in DRC, Kenya and other countries have demonstrated, household confinement is not sustainable unless the basic needs of the poor (food, water, hygienic items) are granted during the quarantine. The poor lack savings and relay on their daily income to survive.
The only feasible way to make sure that they can remain home for a given number of weeks is to provide them access to their basic needs during that period. Most African countries lack the safety nets that could cover those needs during the quarantine.
Call for an African-wide 6 Billion food security program now
Implementing these initiatives will require decisive political will by African governments and the full support by the international community. They will also require mobilizing fast significant financial resources.
Two main continent-wide initiatives would be required:
-
A massive program to supply seeds, fertilizers and other means of production, aimed to support rural communities to undertake community village-level quarantines if and when needed: Cash and/or vouchers could be distributed to smallholders across Africa in the relevant regions. Around USD 3 Billion would -at least- be needed (50M smallholders’ households X USD 60 per household)
-
A cash, vouchers and/or food aid program to cover basic (food, water and hygiene) needs during quarantine for 50 million Africans households living in conditions of extreme urban poverty. Funding requirements than can be roughly estimated on USD 3 Billion too (50M x 30 days x USD 4 household family ration)
The cost of these massive initiatives is significant, but, with a joint effort with support from WB, AfDB, IFAD, regional development banks and bilateral donors (including USAID, EU and others), plus budgetary-allocations from the governments in the region (especially if there are
debt-relief measures granted) should make the effort possible.
There are probably still a few weeks’ window of opportunity to contain COVID-19 in Sub-Saharan Africa. But unless decisive measures are undertaken immediately to secure the food security of the poor, it will remain impossible to implement the type of strict social distance measures that containing the pandemic will require, and millions of lives will be lost.
