By Mohamed Gibril Sesay
This is an argument for African countries, including Sierra Leone, given scare resources, to focus on the particularly vulnerable in efforts to do physical distancing and isolation as a means of flattening the coronavirus disease infection curve. The particularly vulnerable, given current epidemiological data, are people above 60 and those – young or old – with underlying conditions especially diabetes, respiratory illnesses, high blood pressure, and heart conditions. We draw lessons for Sierra Leone and other African countries from three emerging models for combatting the disease, and look at how certain societal conditions and under-resourced state capacities in the continent may require some nuancing of strategies and tactics in Africa’s battle with the coronavirus pandemic.
A number of epidemiological models are emerging in the fight against the coronavirus disease. Three are discernible right now: the Chinese Model, The Alternative Asian Model, and the Occidental or Western Model.
The Chinese Model imposes a total, decisive and top down lockdown of society. When the virus manifested itself in Wuhan, Hubei Province in China, there was an initial attempt to downplay its extent and deal with it quietly. But once it became obvious that it was an extraordinary crisis, decisive steps were taken to impose social distancing through a lockdown of the entire Hubei Province; putting in place massive restrictions on the movement of hundreds of millions of people in other part of the country; and deploying the enormous infrastructural, economic, and other capacities of the world’s second biggest economy.
The Alternative Asian Model is as implemented in Singapore, South Korea, and Hong Kong. Theirs were not a total lockdown of society. Rather, the approach was based on massive but targeted testing, contact tracing, and overwhelming communication about hand washing, staying away from crowds, and isolation in cases where a person is having such symptoms as sneezing and coughing. This was a more surgical approach designed to isolate those sickened by the virus and those who might have been in contact with them.
The third approach is as seen in Italy and other Western countries. It is based on initial hesitance, and reluctance to restrict civil liberties or disrupt the economic order. It was not until the virus lodged itself firmly in the countries that an adhockery of measures were taken, often in sequentially sub-optimal ways. Decisions taken during the initial steps were left to a motley of private and sub-national entities –sporting associations closing down their leagues; cultural institutions locking down their museums, theatres and art centers; some work places asking their workers to work from home; mayors ordering pubs and clubs to reduce their opening hours; governors closing down schools. And finally the national governments rushed in – a sort of diffuse decision-making processes that reflect the character of Western countries.
Compared to Africa, the societies implementing the afore-mentioned models are richer and have more capabilities to move forward with their chosen strategies. Secondly, their social distancing orders ultimately hinge on their household comprising nuclear families, or single individuals, living in self contained residential units that do not share such facilities as kitchens, toilets, and taps with other households – which is quite different from the situation in Sierra Leone and many other parts in Africa.
The differences between the three models are based on their governance patterns and wider societal norms relating to obeying extra-ordinary measures. China’s governance model is authoritarian, stringent and with greater emphases on order over freedom. South Korea and Singapore are democracies but authoritarian values (what Lee Kuan Yew called Asian values and others refer to as Confucian values) loom large over general society, which makes adjustments of their population to overwhelming extra-ordinary orders easier. Western societies are libertarian, the cult of the individual trumping other concerns, and they are less used to obeying orders that push aside individual rights (and sometimes frivolities) in favor of communal concerns and safety. Scenes of partying persons and beachgoers that we saw in Australia, Italy, and the United States were hardly seen in South Korea, Japan, Hong Kong and Singapore. Also whilst there were initially delays to reckoning with the virus in both China and Western Societies, China, as opposed to Western societies, moved more decisively once the extent of the crisis became apparent, deploying the full capacities of the Chinese state, from it its extensive surveillance prowess, to its clamping-down mechanisms, and its vast state owned productive and infrastructural capabilities.
Singapore, South Korea, and Hong Kong activated their models before the disease became widespread in their societies. This early activation may be the result of memories of how some almost similar epidemics, SARS and MERS rattled those Asian societies, memories that were institutionalized in better state epidemic preparedness and openness about passing on information; and internalized in general society’s willingness – again because of remembrances of the huge suffering during those earlier epidemic – to defer to and obey orders from health professionals. It has been noted that the United States unspool its memory about epidemics. This could be seen in its disbanding of the global pandemic unit within its national security system. Furthermore the current US administration’s recoil from multi-lateral visioning obnubilate its seeing the emerging pandemic as a global threat that could reach its shores with devastating consequences. It is no coincidence that, against World Health Organization’s guidelines, a number of American leaders would call the coronavirus the foreign virus, the Chinese virus and the Wuhan virus. They justify this widely condemned stance by bringing up the global consensus, as at now, that the hypothetical first zoonotic transmission of the virus took place in Wuhan, a charge a Chinese high official denied, instead claiming that the disease entered Wuhan through an American army team.
We are seeing a copying of the three epidemiological models in several other societies. The model being utilized in Australia is akin to the Alternative Asian Model, as is also the case with certain Nordic countries. However, it seems like a convergence is taking place, with many countries moving towards the Chinese model of total lockdown of society. These total lockdowns are happening in countries with exponential increases in cases like Italy, Spain, and the United States, and those with few cases, including the Nordic countries. However, it should be noted that these societies lately converging on the Chinese model generally have strong and very well resourced state capacities. Denmark, for instance, has committed almost 42 billion dollars to pay up to 75% of workers’ salaries in the private sector to ease the economic disruptions of stay at home orders; America is working on over a trillion dollars package to shore up the lockdown economy; and the prudent Germans are throwing their famed fidelity to governments balancing their budget by pumping 160 billion dollars into ameliorating the effects of the virus.
How do these models play out in Sierra Leone and Africa generally? First, Africa does not have the economic resources and state capabilities to impose the total lockdown implemented in Wuhan, and that are increasingly seen as the way forward in a number of Western countries. Most African countries, including Sierra Leone do, not have the health infrastructure – testing capacities, surveillance mechanisms for quick and robust contact tracing and more- that are at the heart of the Alternative Asian Model. Also, the civil populace in Sierra Leone and most other African countries do not have the means to stock up resources at home for the weeks of lock down that are now emerging as the go-to final strategy to defeat the pandemic. Also, housing patterns in most Africa countries involve multi-generational extended family clustered together, and especially in urban areas, often living with other extended families in the same compounds and using the same communal facilities like toilets and kitchens. These are the living situations in the stilted Makoko slums with over 300,00 homes in the Lagos lagoon of Nigeria; with the crowded Alexandria township in Johannesburg, South Africa; Kibera in Nairobi, Kenya; Pekine in Dakar, Senegal; and the seaside slums of Big Wharf, Susan’s Bay, Tombo, Crab Town and many others like Moyiba, Looking Town and Kamanda Farm clinging to the hillsides of Freetown. These sorts of housing and social arrangements makes it very difficult to get the social distance that lock downs or shelter in place orders could bring about in Western and other societies.
One would say memories of the Ebola epidemic that struck Sierra Leone, Liberia and Guinea barely six years ago would have put the country in a better stead to combat the current pandemic. Perhaps. But ours is memory without institutionalization, remembrance couched in comic retellings and slangs, some knowledge without capabilities, and with some of the rented capacities of international health experts and consultants now tied up with the health crises in their countries and unavailable. And general society seems too busy with eking out their living in dire economic times than dragging along Ebola memories. In fact, one often hears about unproven conspiratorial theories of the state wanting coronavirus in the country to cash in on international financial support to fight it. Society, in essence, is hardly prepared for the fight ahead.
Of course, contrary to widely held assumptions in non-African nations Africa is not a country. There are plenty variations between regions in Africa, between countries and within countries. But certain questions need asking to stress-test, at the conceptual and practical levels, any emerging model to fight a virus that could well be closing in on the continent. First there may be need to look at state capacities to enforce total lockdown (the Chinese model); do extensive testing and surveillance (the Alternative Asian model) or the hesitant but ultimately resource gobbling Occidental model. Second, we may want to interrogate whether certain basic assumptions about the society in the countries mentioned above are the same as in Africa – assumptions relating to residence patterns, community settlements, family systems and housing structures? Do African communities and families have the resources to obey lockdown, shelter in place and other orders relating to fighting diseases? Obeying lock down orders involve costs on communities and individuals, do communities, families, households and individuals have the resources to meet up such costs as stocking up on food, sanitary supplies and other essential items? Or to forgo incomes for days on end, when as we all know informal economies dominate livelihood activities for people, the majority of whom rely on what they eke out every day to buy food for that very day? If the poor in the United States are those that live from pay check to pay check (often two weeks or a month duration), those in Africa, in far greater percentages live from hand to mouth on a daily basis. American households have at least two weeks or a month to hold on, and duration is being extended by proposals to give struggling households over a thousands dollars, suspend mortgage payments and other welfare support. Most Africa households – especially in its cities – have but a day to hold on, and government’s unlike what the Chinese Government did in Wuhan during the outbreak, lack the resources and logistics to make essential supplies meet locked down homesteads.
One critical fact has come up in all the emerging epidemiological models is that they are based on buying time and flattening the curve. Scientists are in a race to find a cure or vaccine – God bless them. In the interim, countries want to make sure that their health systems are not overwhelmed by large numbers of persons getting sick at the same time. This buying of time sometimes work to truly suppress the virus, like we have seen in China, though it may be too early to do the George Bush and say mission accomplished whilst the pandemic is ravaging other parts of this interconnected world.
Lets do a reconstruction of the salient orientation of the emergent epidemiological models: In the absence of a vaccine or cure, the goal is to buy time – the way to buy time is social distancing – methods to pursue social distancing include total lock down, closure of schools and work places, shelter in place orders, limiting air travel, contact tracing, widespread testing – and several other orders that governments have capacities to implement and citizens the norms, discipline and resources to obey.
Sierra Leone and other African countries now have a small window to implement measures to deal with the virus. The Alternative Asian model was that which was relatively successful implemented in Singapore, Hong Kong, South Korea and Japan before the virus became widespread in those countries. Persons may be tempted to say that is the model that Africa countries where the virus is not widespread should adopt. But do Sierra Leone and other African countries have the resources for implementing wide spread testing (even with Jack Ma’s generous donations of tens of thousands of testing kits), or do they sophisticated surveillance and contact tracing processes? Are our societies used to obeying governments in ways that populations in those Asian countries do? In relation to the Chinese model, should – God forbid – the virus becomes widespread here, do the governments have the capacities, or the populace the resources to meet the costs of prolonged lockdowns? Or can we do the hesitating response witnessed in Western Societies who are now throwing hundreds of billions to ease the economic burdens of lockdowns on their populace, and procure respirators, masks, PPEs, and other materials to fight the pandemic?
Image: REUTERS/Baz RatnerREUTERS/Baz Ratner.
But a model is emerging in Africa- first, the big line of defense: canceling of flights, for it looks like for now the virus comes through planes. So no planes, no virus. Second we are seeing closures of schools and universities, banning of religious gatherings, shutting down of entertainment places. Third, there has been some uptick of advisories about washing hands, not touching faces and more. And fourth, there is talk of the Chinese-like total lockdown. But, as has been shown, the governance capacities and social systems of Africa and China are very different, and that model of enforcing social distancing may not work in this African society.
Corona is a moving target; things are still being learnt about it; data is still being collected about its ways –would it be like the influenza epidemic of a hundred years ago that came in phases with the second phase deadlier than the first? Is the virus mutating, how? What are the clinical and pharmacological protocols that tend to help the immune system ride out the disease? What underlying conditions contribute more to co-morbidities? How are livelihoods to be supported during the pandemic? How to make economies rebound? There are just too many gaps in knowledge about the virus and the disease it causes.
But epidemiological and other data are revealing certain key insights about the disease that could help countries in Africa design models that make for a better fight against the virus. The most important here are that the demographic most at risk of being brought down by the disease are those above 60, and persons with underlying conditions, particularly those with diabetes, high blood pressure, and respiratory illnesses. Second, the disease tends to spread more amongst closely interacting persons and what we may call communities of intimate interactions, especially family members. In our case these communities of intimate interactions would include extended family members in an household, neighbours in densely populated neighbourhood, or even cross border ethnic communities who freely interact with one another in spite of national borders. The other important data is that social distancing is the way to go to break the chains of transmission, and flatten the curve.
Social distancing is one of the unfortunate misnomers in the fight against the pandemic. What actually prevents transmission is physical distance and isolation, not social distance or isolation. If some one infected with the disease is close to you, and she is hunkering on her phone talking to a physically absent person, that social interaction with that physically absent person would not transmit the virus to that person. Rather she will transmit it to you who is physically closer to her. Breaking the chain of transmission is about taking measures to isolate that person from you or you from her. It takes the removal of one of you to ensure distance or isolation. Now it seems as if the total lock down model is about physically isolating everybody from every body else. However, what is does not take into account is isolating family members from other family members. Family members are locked down together with other family members in the same households. This is without regards for whether the persons so locked down together and interacting with others within the households are old, or have underlying conditions, or are young without underlying conditions, or are sick. It is what we would a call whole-of-society family-based lock-down interdiction. This may be great strategy where resources are available, and where households are not densely populated, and where communities do not share common areas like kitchens, toilets, laundries and other places integral to human shelters.
But where resources are not available, like is the case in most Africa countries; and where households are densely populated; and where families living together are multi-generational and extended; and where they share communal facilities from toilets to kitchen to taps; and where there is this huge demographic of what we may call functionally scattered residents – a person who may sleep in a particular house, but takes his bath in another, eats in a third, gets intimate in a fourth; and where communities of interactions do spill across national boundaries that may have different lockdown and other strategies – where we have all this, lock downs and family-based shelter-in-place orders may not bring about the physical isolation necessary for flattening the curve and breaking the back of the pandemic.
Isolation models then for Sierra Leone and other African countries may therefore call for different approaches. It may warrant approaches that isolate those who are at greater risk of being more sickened by the virus (the old and those with underlying conditions) from those who may be less so (the young without underlying conditions but who may also be asymptomatic carriers of the disease). We call this targeted age-disaggregated interdiction. It is based on age and co-morbidity profiles that the current insights single out as particularly vulnerable.
Sierra Leone has what demographers call a pyramidal age structure. There are more kids than youths, more youths below 35 than adults, and more middle age persons than those above 60. Those above 60 constitute about 5% percent of the population. Let us reiterate because it is at the crux of our suggestions: targeted interdiction in countries with enormous resource constraints, fragile state capabilities and dense households involves isolating the young from the old. The measures are about separating the vulnerable from the less so; geared towards isolating those who may be more sickened should they have the virus from those who may be less so. This involves prevention of physical interaction between the old and the young; it warrants separation of the elderly and those with underlying conditions from others that do not have those demographic and vulnerability profiles. Such separations and isolation may include creation of safe spaces within communities for the over 60s and those with underlying conditions. It may include massive public campaigns about the necessity for such safe spaces. It may include orders for them to stay put in those safe spaces. It may include allowing young people in residential colleges and boarding schools to continue to stay in those places and not come to their extended family households since that could increase the vulnerability, infectivity, and disease reproduction ratios; it may include asking those who know they have certain underlying conditions to get into safe spaces. These targeted physical distancing and isolation have advantages of being easier to enforce, may cost the society less, may not lead to total lockdown of the country’s economy, and may prevent a country’s health system from being overwhelmed by persons who should they catch the virus need more intensive care, who may take a longer time to recover and thus take up more space in hospitals, and who, even with intensive care, be more at risk of dying than others. Also, when capabilities increase, these particularly vulnerable may be the ones that are targeted, with other groups included as more resources are garnered.
This is not an argument about leaving out the under 60s; rather its is an argument for paying more attention to who may get more sickened by the virus. Children, youths, and adults below 60 are not easily felled by the virus. And they recover faster. And they may, as some epidemiologists are arguing (though more knowledge on this is required) contribute to herd immunity that might provide the basis for a more sustained breaking of the chains of infection. Data is emerging that the number of sickened people below the age of 60 are increasing; data scientists are looking into these figures to determine which sub-set amongst them are more prone to the disease. Innovative technology assisted analysis, big data, and the new algorithmic insights may aid this process and tease out the granularities of infection amongst the under 60s. However, even with these increasing numbers, the over 60s get more badly sickened, and die more from the coronavirus disease: 1 in 5 or 20% of those above 60 who get the virus, whilst the figure, as at now, for those below that age is about 1 percent. Younger persons, youths in particular, may look at these figures and say, ‘let us be, we are no more at risk of dying of this coronavirus than dying of malaria and the other maladies of our lives, so let life continue, let those who may die, die.’ Particular attention needs to be paid to this social type, with programmes that range from more public education to stringent sanctions.
A whole lot of nuancing is needed. Rural areas may have demographic ad morbidity profiles that may require different mixes of actions to ensure physical isolation of the vulnerable; rural areas may also have norms amenable to the interdiction orders, especially should such interdictions come from their traditional leaders who are more credible than central government officials; affluent areas in cities may have resources to go through lockdowns than places that are poorer and densely populated. Demographic – the national census, the demographic and health surveys, the schools census, and other – data may be brought to bear to aid the process. Of course, given the mutating nature of the pandemic, new resources, new insights and breakthrough may change the thrust of the model. These transformative development may include more capacities, availability of more testing facilities, more respirators for instance; or may include breakthrough, for instance the discovery of a vaccine or drug; or may include new insights, like say certain correlations – inverse or not – between humidity and the reproducibility and infectivity of the virus. No model looks watertight now, but we may need to plan for, build on existing knowledge, and optimally cut our responses according to our capacities and capabilities at both state and societal levels.
Mohamed Gibril Sesay is a senior lecturer in the Sociology Department at Fourah Bay College, University of Sierra Leone.