COVID-19 responses in Africa: Ok, one size doesn’t fit all. Now what?
Discussions must move beyond the pros and cons of lockdowns. They must confront the real challenge: African states’ disconnect from ordinary people.
Since the COVID-19 pandemic started spreading, it has been clear that the societies of the developing world face dreadful challenges. Even in wealthy countries, where health systems are relatively strong and foreign reserves are deep, the health and economic impacts of the crisis are daunting. How should governments of poorer, less industrialised countries respond?
From the beginning, it has been evident that “copy-pasting” the responses available to wealthier nations is a non-starter. South Korea might be able to do large scale testing, contact tracing, social distancing, and palliative care. Zimbabwe can’t. Even South Africa will struggle.
Much of the debate on the politics and economics of lockdown in Africa has, however, remained simplistic. A case in point is James Fairhead and Melissa Leach’s recent article in African Arguments, where they stated that “African elites’” should be aware that “one size fits all” responses are not enough and that lockdowns are therefore not “Africa’s best bet”. Unfortunately, their piece does little except repeat the points of (mostly right-wing) commentators worried about the economic impact of the lockdown and who frame the crisis as a choice between the lives of the old and the livelihoods of the young. More importantly, it does not say anything significant about alternatives.
The key issue with the COVID-19 pandemic in sub-Saharan Africa is not, as they would have it, that the population is young and that there are therefore not that many susceptible people. That is, in any case, a highly dubious assumption. With high rates of TB, untreated HIV, diabetes, hypertension and malnourishment in many parts of the continent, it may be the case that large numbers of younger people are exposed to risk. South Africa’s rapid and extreme lockdown was not implemented because of a concern for wealthy older people in the middle-class suburbs. It was imposed due to the terrifying prospect of the disease tearing through informal settlements already ravaged by disease and poverty.
The key issue is rather that the social distancing measures that can be effective in highly regulated built environments of the Global North don’t work in conditions of urban overcrowding and poor infrastructure. It is impossible to “shelter in place” when there is no adequate sanitation, governmental authority is weak, and the media environment is awash with misinformation. Those factors make a China-style lockdown impossible whether the population is mostly young or whether it contains a large proportion of over-75s.
We need to go beyond the notion that “one size fits all” solutions are not enough. We’ve known that for a month already. If one size doesn’t fit all, what are the other “sizes”?
Doctors don’t flatten curves, movements do
Instead of getting caught in these (by now uninteresting) discussions, we need to do much more thinking about public health movements. It’s not doctors that flatten curves, it’s social organisation.
There are some important lessons from history here: the last great European cholera epidemic, for instance, was not simply eradicated by medical science. Robert Koch’s path-breaking work on the origins of the disease was crucial. But what made the real difference in Hamburg at the end of the 19th century was a workers’ public health movement led by socialist parties in poor neighbourhoods, teaching people about hygiene, washing hands and boiling water.
Similarly, HIV/AIDS in South Africa was not simply contained by the roll-out of antiretrovirals. It was the Treatment Action Campaign that turned the corner. This activist organisation created a democratic, gender-aware and rights-based social movement that destigmatised the disease and supported profound changes in sexual behaviour. A crucial part of its success was that it was not simply a biomedical intervention. It built a movement for health that linked a campaign for access to medicine to a broader call for social justice. It connected research and advocacy to widespread mobilisation around the social conditions of ill-health.
Treating people as citizens
This kind of intervention seems to be sorely absent from our current armoury of responses. In South Africa’s COVID-19 response, poor and vulnerable people have too often been treated merely as the objects of intervention. The government’s biomedical response has been exemplary – for example in the roll out of community testing – but it has done less well in engaging with the cultural and behavioural aspects of lockdown. Beyond broad injunctions to wash hands, maintain social distance, and remain at home (all three pretty much impossible in the average informal settlement), the first three weeks of lock-down were characterised by poorly coordinated food aid programmes, often dependent on middle-class beneficence, and brutal repression at the hands of police and soldiers.
More recently, the government announced some important if limited fiscal measures to ease the economic pain. But who is engaging with South Africa’s poor people as citizens, not as subjects? Who is spreading the messages within poor and working-class communities about wearing masks, not touching hands, and social distancing?
Without a broad-based social health movement changing the practices of ordinary behaviour in poor communities, we will not be able to contain the spread. Rather than coercive, military-style interventions from above, what is needed is what worked so well in the struggle against HIV: a social activism based on a recognition of local realities and practices, on a respect for human rights, and on a broader struggle for social change.
In order to achieve that, the discussion must move beyond the pros and cons of lockdown. It must confront the real challenge: the weakness of African states and their disconnection from poor and ordinary people after thirty years of structural adjustment and elite capture.