Lock-down may be the right solution in Europe and America, but not in crowded urban settlements in Sub-Saharan Africa.

The problem of COVID-19 has the potential to rapidly overwhelm health systems in Africa, and the effect on the population may be similar to that seen during warfare. The measures that are currently advocated to control the infection in Europe, America and even China, are blunt instruments that may do more harm than good in some places, such as urban Sub-Saharan Africa, for a number of reasons:

1. The widespread practice of personal hygiene and physical distancing – frequent hand washing, using hand sanitisers, maintaining distance from others – sound simple, but they are very difficult to put into practice in crowded slums, which lack sufficient water for domestic use (running water is a luxury). Improving water supply and sanitation in these settlements will take time. In the meantime hygiene measures may be the best bet.
2. Requiring that the population stay in their homes (lock-downs) may be effective in impeding the spread of the disease, but there are huge practical problems. Income is earned on a daily basis in urban settlements and most workers are in the informal sector. Not going out to work on a single day may translate to the family not having any food for that day. Over time, that has implications for the maintenance of civil order. Lockdowns are just being started in Nigeria and already there is evidence of suffering in large population centres according to newspaper reports. In these lock-down situations, the population has to be supplied with essentials, much in the same way as refugees from conflicts and natural disasters. And they will still need to leave their homes to access food banks, medicines and lavatories.
3. Provision of temporary health facilities (field hospitals) may become necessary as the caseload rises. Admission to facilities should be limited to those people who really can benefit, in order to limit spread of the disease. It will be difficult to provide sufficient ventilators and people to provide intensive care. But some people will need facility care, for example to manage secondary infections. It is therefore essential for facilities to be equipped with personal protective equipment, masks, disinfectants and essential medication. We are deeply sceptical of some medicines, such as hydroxychloroquine, but if other trials currently underway identify effective medicines, then these should be made rapidly available in low- and middleincome countries (LMICs). However, where possible it would be better to distribute the medicines in communities, rather than assemble people in hospital settings where they would pose a danger to others.
4. Training and retraining of various cadres of health personnel in control of infection methods and treatment of affected patients, is an urgent requirement. Since travelling is impractical, training should be packaged into videos that can be disseminated to different centres. These materials may be used for localised on-site training by local trainers for greater effect.
5. Most important is the issue of testing. Thus far, fewer than 200 people have been tested in Nigeria, with 46 testing positive and 1 death. This is likely to be a huge underestimate. There is a need to roll out testing rapidly. The genomics-based test (at about $120 per test) detects those having the virus and presumably shedding it, while we understand that an antibody-based test (both IgM and IgG) has been developed that can identify those who had already been infected and who are therefore likely to be immune. Whatever can be done to make both types of tests available in LMICs will make the fight against the virus better focused. The antibody-based test will make it easier to identify health workers who have developed an immune response, and these workers will thus be more effective as care givers since their risk from exposure to infected patients is less.

The fight against COVID-19 in countries with well-developed intensive care facilities has been mainly aimed at smoothing the rate of new cases so that the health care system does not get overwhelmed, rather than materially reducing the total number infected. The case for delaying spread is a logistic one, assuming that we are not going to have an effective vaccine any time soon. We very cautiously suggest that this argument loses force in a place that not only has poor intensive care facilities, but that cannot rapidly expand such facilities. In addition, the effect of lock-down, it must be assumed, is likely to be less effective in crowded urban communities, for reasons given above.

None of this should be taken to mean that people living in cities should not be empowered to defend themselves and their families. Our survey work across seven urban settlements in four countries of Asia and Africa has shown that the settlements are served by an extensive network of medicine sellers and pharmacists. In many countries, they are poorly stocked but our household surveys show that they are widely used. We think that this existing infrastructure could be harnessed to disseminate materials and good hygiene practice. People have to leave their homes to access lavatories where they are exposed to the virus, which remains infective for about 24 hours on surfaces. Worse still, reports from S Korea show that people may shed the virus in stool for up to five weeks after infection. People should be supplied with plenty of soap and be instructed on using facilities without touching surfaces. It is perhaps fortunate that, as shown by our surveys, only a limited number of old people remain in slums. Those who remain would be well advised to return to their villages where this is possible.

However, drastic lock-downs are likely to do great harm among poor people in crowded settlements; they may well be self-defeating and may become fertile ground for fomenting civil disorder.

Akinyinka Omigbodun, Professor of Gynaecology & Obstetrics
Richard Lilford, ARC WM Director