One size fits all? Why lockdowns might not be Africa’s best bet.
If Uganda was 100 people, just two would be over 65. Over two-thirds would be under 25. Are costly lockdowns always the best option?
As cases of the coronavirus increased in Wuhan this January, China took the then drastic step of imposing a lockdown. In a country where over 23% of the population is over 55, the government introduced severe restrictions to mitigate the spread of the disease and avoid overwhelming the health system. As the disease spread to other parts of the world, the likes of Japan, Europe and the US – all of which have even older populations than China’s – employed the same strategy.
Many governments in Africa have also imposed lockdowns to deal with the pandemic. Yet these countries have radically different age demographics to those in Asia and Europe. Take two extremes. In Japan, 40% of people are over 55, and 28% are over 65. In Uganda, the equivalent figures are 5% and 2%. In Japan, 13% of the population is made of up children under 14. In Uganda, this figure is 48%.
These different age demographics are very important. Mortality rates for coronavirus start to increase for people aged 55 and higher. Meanwhile, young people are statistically highly unlikely to suffer severe symptoms. This means that in countries with a lower proportion of old people, the relative benefits of lockdown are more limited and are more likely to be outweighed by the downsides.
In many countries in Africa, these downsides are particularly significant. Poor countries are much less able to cushion the potentially devastating economic impacts produced by lockdowns. This is if they are feasible in the first place. Effective lockdowns are near impossible in crowded low-income settlements that lack taps and sewers.
Part of the lockdown strategy is also to “protect the health system” by “flattening the curve” and reserving resources for coronavirus cases. This approach not only has more marginal benefits when populations are young and there is a less of a system to protect, but it also diverts attention from addressing health that are dangerous to much of the population, such as malaria, measles and complications in childbirth.
It might be argued that poorer countries with less effective health systems will have a higher burden of underlying health conditions, thus increasing vulnerability to COVID-19. However, the pre-existing health problems most closely related to getting severe symptoms from coronavirus tend to be associated with age. Current evidence from Spain, for example, suggests that people living with HIV are not at increased risk of acquiring COVID-19 or developing severe symptoms. In fact, the opposite may be the case.
This is not to say that there are not susceptible groups in Africa. Though they make up less of overall populations, there are still many older people in African countries. Meanwhile, there may be significant numbers of people who are more vulnerable to COVID-19 due to more widespread diseases of poverty such as TB, though this is not certain.
Nonetheless, the best policies for countries with young populations may not be lockdowns. There may be better ways to save lives such as physically shielding and supporting the most vulnerable while allowing the wider population to gain immunity, whether through a vaccine when it arrives or by virtue of enough people catching and recovering from the virus itself.
Shielding the vulnerable could involve a mix of physical isolation, restrictions on their movement, and focused care, eventually by those who have recovered from the virus. These measures will work best when based on local innovations appropriate to particular social contexts and designed with input from those involved. These could build on practices of respect for the elderly and community organising in many African settings.
Countries – and even regions within them – vary enormously in terms of age profiles, health systems, living conditions, economic resilience, and much more. In some places, including in Africa, lockdowns may be the best policy on balance. In other areas, including even in the likes of Europe and America, there may be more appropriate alternatives to lockdown. It is unlikely, however, that a one-size-fits-all approach serves everyone’s interests equally.
Today, some version of the lockdown has become most countries’ response to the COVID-19 pandemic. In years to come, we may look back on this moment as one in which an ideological practice emanating from older and wealthier countries was misguidedly “copy and pasted” by elites in younger and poorer societies, leading to marginal benefits in tackling the coronavirus but with the effect of increasing poverty and mortality among the poor.
Read a response to this piece: COVID-19 responses in Africa: Ok, one size doesn’t fit all. Now what?