We need context-specific evidence to inform public health pandemic strategies in low-resource settings: A consideration of lockdowns

Dr Wilber Sabiiti, PhD

Senior Research fellow in Medicine University of St Andrews

Co-Chair COVID-19 Clinical Research Coalition Virology, Immunology and Diagnostics Working Group

 

The emergence of COVID-19 has had an unprecedented negative impact on health systems, health service provision and clinical care, and economies, and has even threatened the stability of nations. No sector has been immune to the pandemic. Clinical research was equally affected, causing interruptions in research processes, from ethical review to project execution, affecting participant follow-up and measurement of critical outcomes in some cases.

In many parts of the world, high-, low- and middle-income countries alike, the default response to the COVID-19 pandemic was nationwide lockdown to limit disease transmission and save healthcare systems from being overwhelmed by severely ill people. In this article, I highlight the diverging lockdown approaches taken by two African countries in response to the COVID-19 pandemic, Uganda and Tanzania, and attempt to assess the impact that the differing approaches had in each country.

The impact of locking down or not locking down – the available evidence

Uganda instituted a nationwide lockdown on March 18, 2020, resulting in economic shutdown, movement restrictions, school closures, and interruptions in all public services and trade, including the cross-border movement of raw materials and goods. In Tanzania, schools were closed briefly, and health research was halted, but public services and trade continued. This had a ripple effect in various sectors as discussed below.

Research: This was suspended in both countries from March 2020 but re-started in June 2020 when the national research ethics committees issued guidelines on the conduct of research during the COVID-19 pandemic. Unlike Uganda, however, Tanzania did not allow any research on COVID-19 until President Samia Suluhu Hassan came into office in March 2021 and lifted this restriction. Reports of COVID-19 test results, morbidity, and mortality remain inaccessible to the Tanzanian public and the world at large. Meanwhile, Uganda has consistently reported on and contributed substantially to COVID-19 therapeutics, diagnostics, genomics, clinical management, and socio-behavioural research. However, despite Uganda’s data sharing and research engagement, it is postulated that there might be underreporting due to under-testing, i.e., a testing rate of 37.3 tests per 1000 people [1] in a population of over 40 million.

One analysis found that 45 weeks of school closures in Uganda had led to a 56% learning loss.

Education: After a short closure of three months, by the end of June 2020 all schools in Tanzania were back in business and never closed again. It was not until October 2020 that Uganda began a phased opening of schools, with the older children first, but no sooner had the last group resumed school in May 2021, the second lockdown was instituted, and school closures were again announced. As of November 2021, schools in Uganda were still closed, with the youngest age group of kindergarten-goers having been continuously out of school since March 2020. In her education address, the Ugandan education minister said, “Nurseries will open when COVID ends”. Ugandans are asking, when will it end?  Angrist et al analysed 13 versus 45 weeks of school closures in Tanzania and Uganda and found that this led to a 16% and 56% learning loss in the two countries, respectively.1 This loss will continue to increase in Uganda as the government keeps schools closed. Half of Ugandan students belong to private schools, most of which are low-cost private schools.  The future of these schools is uncertain as they face permanent closure due to unmet bank loan obligations, which will consequently lead to a reduction in learning spaces and teacher job loss.2, 3

Preservation of life: The first COVID-19 death in Tanzania was announced on March 31, 2020 and by April 29, 2020 when the country stopped reporting to the WHO COVID-19 dashboard, 50 people had died. In Uganda where tough lockdown was implemented, no COVID-19 specific death was recorded until July 24, 2020 following easing of the first lockdown. Tanzania has had three COVID-19 waves (March-July 2020, Jan-March 2021, and June-Aug 2021) which, according to anecdotal reports, have all had high fatalities. Uganda has had only two waves (March-July 2020 & May-July 2021). The second and third waves in Uganda and Tanzania respectively were driven by the delta variant (first reported in India), causing high morbidity and mortality. Two-thirds of total confirmed COVID-19 cases and deaths in Uganda were during the second wave. Reuters in Tanzania reported a 300% increase in cases between June and July 2021.4  It appears the benefit of the lockdown in Uganda was to prolong the interval between first and second wave and perhaps shield the most vulnerable to survive for another day while giving the fragile health system a chance to lessen additional burden. The fact that Tanzania is still experiencing fatal COVID-19 waves after a long duration of wide community exposure brings into question the concept of COVID-19 herd immunity following natural infection. The impact of vaccination is yet to be fully measured, but it provides hope for conferring immunity and a return to normal life.

Economy: Tanzania’s economy shrank by 2.2%, possibly driven by the drop in tourism revenues and diminished trade with neighbouring countries.5 Guloba et al reported a 4.6% fall in Uganda’s GDP by the fourth quarter of 2020, which recovered slightly beginning in quarter one 2021.6 This fragile recovery was most likely jeopardised by the June 2021 nationwide lockdown. In July 2020, in the midst of COVID-19, Tanzania achieved lower-middle-income country status, which remains an aspiration for Uganda. Both countries were red-listed for travel by UK, EU, and USA, which implies that sought-after Western tourists and other business agents hardly travelled to these countries.

Net benefit

In the absence of morbidity and mortality data from Tanzania, it is difficult to fully assess and compare the net benefit of lockdown versus no lockdown between the two countries. In general, the lockdown approach in Uganda most likely prevented more lives from being lost to COVID-19. A Swedish study has shown that a lockdown would have prevented 75% of infections and 38% of deaths in Sweden.7 For countries like Uganda, this advantage may have been offset by mortality from other diseases or conditions where access to healthcare was difficult during the lockdowns. Secondly, early acceptance and actively engaging in COVID-19 response enabled Uganda to leverage the existing epidemic alert system and enhance their pandemic healthcare and research capabilities.  On the other hand, by not shutting down, Tanzania may have lost less in terms of economy and education. A thriving economy and education sector inevitably have an important impact on population health, in the immediate and long term. These countries could benefit from a systematic cost-benefit analysis of their COVID-19 responses, with careful consideration of the impact of lockdowns in contexts with fewer social safety nets and reduced capacity of the population to work or school from home. Findings would be valuable in informing next steps in managing future epidemics as well as the current COVID-19 pandemic, which is far from over. The proportion of fully vaccinated people is only 1.7% and 2.1% in Tanzania and Uganda, respectively. [2] Both countries still have a long way to go to escape the heavy impacts of COVID-19.

There are glaring gaps in health and economic assessments, gaps which, if filled, would provide the evidence to inform country-specific strategies in both the current and future pandemics.

Low- and middle-income countries have been plagued by insufficient data capturing systems for decades. Vital statistics such as mortality and disease-specific data are often punctuated with gaps. In the absence of robust data capturing mechanisms, the true impact of strategies employed by individual governments are difficult to assess. There are glaring gaps in health and economic assessments, gaps which, if filled, would provide the evidence to inform country specific strategies in both the current and future pandemics. Local evidence generation is paramount, research is a vital component of any strategy, and the immediate- and long-term costs of some of the approaches taken by higher-income countries, such as stringent lockdowns, may prove not to be appropriate in low-resource settings.

References

1           Angrist N, de Barros A, Bhula R, et al. Building back better to avert a learning catastrophe: Estimating learning loss from COVID-19 school shutdowns in Africa and facilitating short-term and long-term learning recovery. International Journal of Educational Development 2021; 84. DOI:10.1016/j.ijedudev.2021.102397.

2           Journalist at Newvision Uganda. 1,000 private schools face auction over debts – New Vision Official. Newvision. 2021; published online June 15.

3           Alam A, Tiwari P. Implications of COVID-19 for Low-cost Private Schools. Office of Global Insight and Policy 2021; 1–11.

4           Ng’wanakilala F. Markets Tanzania Sees 300% Increase in Covid-19 Cases in Two Weeks. New York, 2021 https://www.bloomberg.com/news/articles/2021-07-10/tanzania-sees-300-increase-in-covid-19-cases-in-two-weeks.

5           World Bank. Tanzania Economic Update _ Addressing the Impact of COVID-19. 2020.

6           Guloba MM, Kakuru M, Ssewanyana SN. The impact of COVID-19 on industries without smokestacks in Uganda. Kampala, 2021.

7           Born B, Dietrich AM, Müller GJ. The lockdown effect: A counterfactual for Sweden. PLoS ONE 2021; 16. DOI:10.1371/journal.pone.0249732.

[1] https://ourworldindata.org/coronavirus-testing?country=#tests-per-confirmed-case Accessed 25th Oct 2021

[2] New York Times. Tracking Coronavirus Vaccinations Around the World. https://www.nytimes.com/interactive/2021/world/covid-vaccinations-tracker.html Accessed 24 Nov. 2021

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