/ 13 April 2020

Lockdown or no lockdown: we face hard choices for complex times

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A general view of Long Street, usually one of the busiest and most popular entertainment areas with bars, clubs and restaurants in the city, with a billboard reading Stay Home, in Cape Town. (Rodger Bosch/AFP)

The Mail & Guardian’s article by Alex Broadbent arguing that Africa cannot afford lockdown is a strikingly unhelpful contribution to the debate. South Africa is on a knife edge. Its people are being asked to do something unprecedented and very difficult. We need a careful understanding of the costs of the terrible choices we face. 

Here we do not want to engage in the “Africa is a country” style of analysis featured in Broadbent’s piece. Unlike Broadbent, we are not confident in our knowledge of the complex interaction of epidemiology, social, economic and population health factors and other complications — in, for example, Uganda, Ghana, Libya, Egypt and Madagascar — to prescribe one model to the continent. So we will simply engage with his arguments as they apply to South Africa.

It is hardly news that all countries face desperately difficult decisions about the economic consequences of Covid-19. As the world attempts to use physical distancing to slow the spread of the virus, much of the globe is under some form of lockdown. Although there are variations between softer and more voluntary models (such as Sweden), and the strictest of all (in New Zealand, which looks to be actually on course to eliminating the spread), there is unprecedented devastation of economies everywhere. Like other countries, South Africa faces difficult decisions about how and when to relax these measures and how to save the economy.

At this crucial moment, Broadbent confidently writes that the cost-benefit analysis shows that lockdown is the wrong answer for (all of) Africa. Perhaps thinking our best infectious disease experts and epidemiologists have failed to notice it, he points out that African countries are poor and people need to eat, and that economic downturn means more people below the poverty line. He argues that Africa’s population is young, while the fatality rate of the disease is spread towards the elderly, and says that the international concern about Covid-19 is a function of the fact that it threatens rich people and countries, but that it is not a significant threat in Africa. In what we regard as a dangerous (because not based on evidence) assertion, he says that there is evidence that HIV is protective against severe Covid-19 rather than a risk factor for it. 

Broadbent’s cost-benefit analysis leaves out many of the costs, appeals to speculative data and is  not based on careful and detailed modelling of the sort that is needed for an actual cost-benefit analysis. Most significantly, he leaves out the cost of the economic, social and political consequences of overwhelming and possibly breaking the healthcare system. He rightly points out fatalities in Africa from other causes, such as malaria. But the challenge with Covid-19 is not primarily the annual fatality rate, but the fact of the compressed and immediate time frame in which people could die, and the social and economic costs of such a catastrophe. This, and not the overall fatality rate, is most of what lockdown is about. 

All options have serious economic costs

African countries are poor, and it is easy to point out the undoubtedly terrible economic costs of lockdown. But there are no available options that do not have serious economic costs. There are severe economic costs to not containing the spread of coronavirus. There are potentially devastating economic costs (including to poor people) to breaking our already weak healthcare system, as well fundamental threats to our fragile social and political system. What happens to tourism when there is no containment? If we lift the lockdown, restaurants will not go straight back to normal functioning. There is going to be an unprecedented and brutal downturn, and lifting the lockdown will not save us from this. There is also a danger that lifting the lockdown too soon would result in the worst of all worlds, in which we have already taken the economic hit and then also suffer the uncontained spread of the disease.

We very much would like Broadbent to be right that HIV is protective, but unfortunately there is currently no evidence for this. We asked him for the evidence for his claim, but he was unable to provide anything other than anecdotal website evidence from a doctor in Spain. The situation we are in is urgent, but that does not mean we should abandon evidence (witness the action of the United States President Donald Trump recommending hydroxychloroquine without evidence). Making assertions that Covid-19 is not a severe threat in Africa because HIV is protective against it (or severe consequences of it) without very solid evidence is dangerous. 

The rest of Broadbent’s population health claims are sweeping and imprecise, concerning complex factors we do not yet know enough about. He asserts that “the comorbidities we find with Covid-19 are diseases of age”. Since he is keen on questioning whether we should assume that what is true in Europe translates into our context, he should be more careful about assuming that what is true in Europe is true everywhere. There are dramatic racial disparities emerging with respect to the death rate in the US, where black Americans are dying at significantly higher rates than white Americans. It is not yet clear what is responsible for this, whether it is lack of insurance, closer living conditions, or higher rates of hypertension, diabetes and obesity. 

We need a lot more information to make confident assertions about the likely course of the disease in South Africa. But Broadbent makes no reference to modelling about the effect of diabetes, hypertension, obesity, and tuberculosis-induced lung disease in his confident assertion that the disease will not have a high fatality rate in South Africa. What about the effect of the death rate among the elderly on grandparent-headed families in South Africa? In the light of these uncertainties and the terrible choices we face, it is hard to see how anyone can be so confident one way or another. 

Listening to experts in South Africa

Broadbent concludes that Africa’s leaders need better advisors — ones who, as he puts it, are “awake to the differences between Africa and the places where lockdown was conceived”. He seems to think our policymakers are not aware that there is poverty in Africa, are not aware of the difficulties of physical distancing in informal settlements, and are not aware that the lockdown has brutal economic consequences. The people advising our government include internationally acclaimed infectious diseases and epidemiology experts, many leading the world’s largest HIV programme, and actuarial scientists conducting highly detailed and specific modelling for our government on what the lockdown has achieved so far. 

We are lucky to have a government that is listening to experts and that is acting swiftly and decisively (witness again, the US). The lockdown potentially has limited the spread of the virus, reducing infection rates and delaying the onset of the peak. Hopefully, it has bought us time, and hopefully we can and will use that time effectively. We are lucky to have a large and experienced HIV programme with capacity and experience in large-scale testing. We are all desperately hoping that the data about the TB vaccine is protective turns out to be right and it will be wonderful if it does turn out that HIV is not a risk factor. 

But the difficulty of our situation can hardly be overstated. We have a weak state, disastrous inequality, and obvious problems with the police force. It is indisputable that we have to find a way of lifting lockdown and dealing with its economic consequences, as well as the systemic economic problems we had independently of coronavirus. Broadbent broadly appeals to the wisdom of village leaders. Our country’s response won’t work without community involvement and input, but this must be within the parameters of economic and public health policy informed by expertise and based on evidence not speculation.

Some superb people are putting their minds to the details of these questions such as this excellent piece, coauthored by academics from different disciplines at the University of the Witwatersrand, which, unlike Broadbent, argues that the lockdown was prudent, but that we cannot continue it much longer, and provides careful and detailed recommendations for coming out of it. Others have given carefully worked out suggestions for how Africans can implement social distancing

And very important questions about trust, among other issues, have been raised by Mark Heywood. This is the kind of analysis and debate we need.

Lucy Allais, is a professor of Philosophy at the University of the Witwatersrand and University of California, San Diego. She is also the director of the Wits Centre for Ethics. Francois Venter is a professor at Ezintsha in the Faculty of Health Sciences, University of the Witwatersrand