The politics of easing restrictions: balancing public health action against the impacts of measures

The current dilemmas faced by African governments—as elsewhere—bring to the fore the reality that epidemic preparedness and response are not neutral, scientific processes but deeply political and social as well. Decision makers are inevitably influenced by politics and economics, in addition to scientific data. Indeed, amidst the great scientific and societal uncertainty that an emergent pathogen generates, it may be politically easier to pursue standardised routes of preparedness and response, which prioritise containment through top-down, disease-specific, state-led interventions.8 The political responses across African countries have been complex and diverse and reflect national and geopolitical tensions, as elsewhere. Definitive ‘lockdowns’ can have political meaning and even gain for governments that wish to be seen to act swiftly and take strong control in a crisis. In the extreme, some have been accused of using the pandemic to legitimate excessively authoritarian responses.9 Stringent measures might have delayed outbreaks initially or even contained them in some contexts, but the secondary impacts on economies, livelihoods and health have necessitated a weighing up of the relative effects of an outbreak surge against those of the restrictions. These decisions have become even more difficult as several African countries have experienced a second wave of COVID-19 that has proven to be more deadly than the first and as mutations have increased transmissibility of the virus.

In May, Africa CDC issued guidance on the easing of restrictions while warning also that it was likely Africa would yet become a frontier of the pandemic10 with community transmission increasing in some countries. These apparently paradoxical messages highlighted that such easing, too, involved consideration of political and economic factors as well as epidemiological ones—the lifting of lockdowns in Africa became necessary to save lives, economies and livelihoods, as was made explicit in the launch of an African Union campaign ‘Africa against COVID-19’ in mid-August 2020. Social and economic vulnerability on the continent is exacerbated by high reliance on informal economic activity and on local markets for food, a lack of social protection safety nets11 and living conditions in densely populated and poorly serviced urban settlements where physical distancing, isolation and hygiene measures are difficult to achieve.12 Sustaining livelihoods is ultimately linked to saving lives but easing restrictions also saves lives more directly. In addition to food insecurity causing malnutrition, the prioritisation of responses to COVID-19 has disrupted essential health services, such as for immunisation and care of other prevalent diseases. Contributing factors include issues of supply (disruption of flows of drugs and equipment, illness or redeployment of staff) and access (lack of transport to reach services and fear of breaching restrictions).13

One size does not fit all: adaptation and localisation of responses is key

These realities point to a strong argument for responses that are adapted and proportionate to local contexts and epidemiology. With the easing of more extreme containment measures, national-level interventions for reducing community transmission that minimise impact on broader aspects of socioeconomic well-being have become more important. At local levels, it has become necessary to adapt physical distancing, hand washing, isolation and community-based care to prevalent realities such as multi-occupancy in crowded dwellings or the absence of running water.

As restrictions ease for general publics, a further key question is how to protect those particularly vulnerable to COVID-19. Strategies may include developing practicable means for ‘shielding’ the clinically vulnerable14 in multigenerational households, medication delivery for the chronically ill to reduce exposure or food and cash relief for those who are suffering economically.

In this respect, initiatives developed at community level, led by a range of local actors, are likely to be a vital aspect of localisation and adaptation of standardised outbreak response guidelines. The 2013–2016 West Africa Ebola outbreak provided clear evidence that local-level action can be significant in turning epidemics around. For example, citizens applied insights and past experience of disease control to protect themselves15 and to arrange safe burials and morally acceptable care of kin.16 Harnessing mobilisation, knowledge and inventiveness ‘on the ground’ and hearing from local people about their priorities, or concerns about other prevalent health and livelihood issues, is key to a proportionate and effective response that people understand and trust. Local organisations can document conditions, such as inequalities in availability of services, and provide access to a spectrum of information that can be vital for moving forward effectively. This can include epidemiologically relevant reports, given the lack of testing or recording of deaths in some settings. Localisation can also enable a response that is attentive to social differences and vulnerabilities.

A typology of emerging locally adaptive responses

At this juncture, it is critical to share learning widely. To this end, we have distilled emerging domains for interventions, drawn from our knowledge and presented in a preliminary typology of adapted responses with localised examples (table 1). This table is not exhaustive but envisaged as an illustrative starter on a range of adapted alternatives, so that these can be documented and disseminated.

Supporting interconnections between state-led responses and mobilisation ‘on the ground’

A range of actors have been involved in localised interventions, including community-based and faith-based and other non-governmental organisations and the private sector, sometimes in partnership with central government, local authorities or international agencies. Other initiatives involve networks and federations, such as of informal settlement residents, or civil society groups. Furthermore, local organisation by those with informal authority can help in a crisis like COVID-19, as indeed occurred with Ebola in West Africa.16 Limitations in government capacities highlight the importance of coordinated activity between state responses and those ‘from below’, and interconnections and synergies between local experience and action, and government-led public health responses. The nature of existing governance structures can help determine which actors are best placed to coordinate efforts. Community-based actors with recognised local authority can act as key interlocutors and improve dialogue and trust.12

In arguing for adaptation and localisation, we are not proposing that the lion’s share of responsibility for preventing community transmission, mitigating socioeconomic impacts or protecting the vulnerable should fall on ‘communities’ or that responsibility to reduce infection risk should be construed as located with individuals alone. When extensive state-enforced restrictions are eased, it is easy for governments to resort to transferring responsibility for preventing infections to individuals or local leaders. This is especially problematic in contexts characterised by structural violence and where people’s living conditions make public health measures challenging to meet. It can lead to the blaming of groups and individuals who are marginalised, further intensifying inequalities that COVID-19 has laid bare. National, municipal and local authorities have important roles to play in partnering with community and grassroots groups to support and enable their efforts. Local-level action can play a further role in holding the state to account, if the political environment is favourable.