Summary of evidence
Globally, it has been established that sufficient preparedness for pandemics by countries is a crucial investment since the cost is comparatively smaller than an unmitigated impact of health emergencies like COVID-19. For instance, the global financing gap for health emergency preparedness, estimated at US$4·5 billion per year, is miniscule compared with estimated pandemic costs of $570 billion per year [26]. Health emergency preparedness activities in Africa with more fragile health systems are particularly crucial because of increasing urban populations and the attendant public health implications [27]. Opportunities in urban environments thus need to be leveraged to enhance the preparedness of urban settings for health emergencies like COVID-19. Table 2 presents the challenges and opportunities for urban settings in raising preparedness for public health emergencies in Africa.
In many parts of Europe and the Americas strict COVID-19 prevention and control measures have been enforced including total lockdowns. Unfortunately, many African countries spontaneously adopted same lockdown measures without requisite knowledge of the COVID-19 infection rate and the context-specific relevance of these measures. Ghana for instance observed two weeks partial lockdown in the two most urbanized regions as part of the early control measures without sufficient evidence. Unlike other continents, Africa was fortunate to record COVID-19 cases months after other countries recorded cases. The continent thus had the benefit of time and hindsight to prepare and respond differently to the pandemic based on lessons learnt. However, reviewed literature predominantly suggests Africa’s response strategies were largely not context-specific. Africa’s response strategies can best be described as a carbon copy of interventions adopted in China, other Asian countries, Europe and the Americas, albeit the circumstances and epidemiology of the virus were different. In effect, a “one-size-fit-all” approach was spontaneously adopted. Indeed, some of the COVID-19 response measures were needless and turned out to be ineffective.
Restrictions in social gatherings have also been imposed to control the spread of the virus particularly church activities, funerals, weddings and closure of schools [38]. Compulsory wearing face masks and use of hand sanitizers is another pervasive COVID-19 preventive measure in Africa even though strict compliance remains problematic due to ignorance, poverty, resource constraints and unfavorable belief systems [39–43]. Although some successes have been achieved in respect of these response strategies, critics have described them as “one-size-fit-all” and “Western elitist” approach because of irrelevance to Africa’s local settings via-a-vis trends in other parts of the world. In many African countries, hand sanitizers have been misconceived as a replacement for regular hand hygiene mainly due to ignorance and lack of education. Likewise, enforcement of social distancing in crowded urban communities is proving to be impracticable just like self-isolation in congested households. These measures have largely been ineffective partly due to poor living standard particularly in urban slums. Also, the “work from home” mantra immediately embraced by already fragile economies in Africa is equally ineffective and unreasonable relative to more resilient economies outside Africa. Over 70% Africa’s workforce is in the informal sector and predominantly engaged in manual labour. In view of this huge informal sector in Africa, the “work from home” policy at the initial phase of the pandemic rather worsen the plight of many citizens already in the lower wealth quintile [44–47].
Other COVID-19 mitigating measures questioned and heavily criticized in Africa are mass closure of schools without established e-learning systems and infrastructure; enforcement of handwashing protocols when over 50% of households in Africa don’t have access to portable water [37]; temperature checks of travelers at borders and airports without accounting for asymptomatic carriers of the virus and mass testing capacities.
Moreover, many countries in Africa are still battling with fear-based messaging and misinformation on COVID-19 [48] similar to Ebola and HIV/AIDS [13]. Available literature maintains that misinformation and fear-based communication cause anxiety and possibly deaths [49] of which COVID-19 is not an exception. Over the years, in pandemics response, fear has rarely been a good motivator for people’s adherence to safety precautions. Indeed, people generally respond better to calm and fact-based messages/information [49]. Unfortunately, many countries in Africa have not performed optimally in respect of COVID-19, Ebola and HIV/AIDS and stigma management. In effect, misinformation and fear-based messaging associated with COVID-19 continues to bread stigma which is discouraging infected persons to declare their status which potentially promotes community spread of the virus.
Notwithstanding these lapses Africa is praised for some positives in the COVID-19 fight. For instance, countries with more recent experience with Ebola appear to be leveraging this expertise in response to COVID-19. Liberia, Sierra Leone, Democratic Republic of Congo (DRC) and Guinea are currently re-purposing existing structures used during Ebola as COVID-19 isolation and treatment centres [28, 29]. In DRC single-patient-transparent cubes originally designed for isolation of Ebola cases re-purposed for COVID-19 isolation and treatment centres [30]. Similarly, inter-sectoral collaboration with non-governmental organizations (NGOs), industry players and national security agencies. Likewise, educational institutions, government ministries and religious bodies is being leveraged fight the battle against COVID-19 in many African countries [12,31−36]. The role of the media and civil society in propagating health education and communication on COVID-19 prevention and control has equally been phenomenal in Africa [35]. In addition, the ingenuity of many African countries in developing locally manufactured handwashing devices and personal protective equipment (PPEs) is especially commended in the bit to promote self-reliance and sustainability in the wake of COVID-19 [37].
Finally, lessons learnt from Ebola in West Africa show that balancing urgent clinical care with the general well-being of the community is the best prescription for containing pandemic outbreaks. In light of this, some African countries incorporated community engagement approach in the prevention and control of COVID-19 [29,50−52]. Some reports suggest that lockdown impositions in Africa were executed with human considerations and social support for the less privileged through community mobilization. These community-centered response strategies have contributed to high compliance with the COVID-19 preventive measures in some countries [53, 54].
Irrespective of these important achievements chalked in Africa, the reviewed literature also reports instances of spillover effects arising from the COVID-19 mitigation measures. First, urban dwellers working in the informal sector (and are predominantly labour migrants) are so far the worst affected by COVID-19 in Africa since approximately 85% of workers in Africa are not on regular wages and do not have the option to work from home [55]. During the lockdowns, for these underprivilege majority did not earn a wage throughout the period. The story of the Kenyan widow of many children boiling stones for her children during the lockdown elucidates this point [56].
Furthermore, many countries in Africa recorded an interruption in food chain especially in urban cities which often relied on rural communities for food supplies. Countries like Ghana witnessed an escalation in food prices by nearly 30% during the partial lockdowns [57, 58] due to panic buying and disruptions in food supply chain. Even though lockdowns might have helped curb the virus transmission, these measures also pushed millions of people into extreme poverty to the extent that hunger, rather than COVID-19, had a greater chance of killing already impoverished individuals during the lockdowns. Human rights abuses during lockdowns [39, 59] are also excesses that emanated from the COVID-19 response measures in many parts of Africa.
Finally, another spillover effect of the COVID-19 response measures in Africa was the effect on already fragile health systems. Neglect of the public health needs of populations in the wake of COVID-19 has already been reported with unprecedented reduction in health service utilization including HIV/AIDS services [60]. Utilization of mental health [61–63], maternal/child health and related outpatient department (OPD) services [64, 65] have equally been adversely affected in Africa imminent worst consequences post-COVID-19.