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Opinion World

When Lockdown Becomes a Death Sentence: The Coronavirus Response in the Developing World

The order came down from the Malawi High Court the afternoon of Friday, April 17. The country’s 21-day lockdown, declared three days earlier by President Peter Mutharika in a bid to contain the spread of coronavirus, had been enjoined. In the first successful legal challenge to a national coronavirus lockdown, Malawians were now free to go to work, trade in open-air food markets, and attend religious gatherings. Malawi’s embattled president—whose legitimacy hangs in the balance as he stands to face a rerun of last year’s nullified election and whose announcement was met with mass protests throughout the country—had been rebuked.

As the coronavirus progresses through high-income countries, stay-at-home orders have been a cornerstone of the political response. Though they have forced hundreds of millions of people to accept dramatic disruptions to their daily lives and substantial economic losses, these orders have been largely vindicated by falling case numbers—an indication that the stringent measures are saving lives. Still, they have drawn the ire of a host of different groups, from conspiracy theorists to civil liberties activists, who have taken to the streets to protest the restrictions as infringements on their personal and economic freedoms.

In the developing world, however, the coronavirus response portends a different story. Imposing strict lockdowns in poor countries will have dire consequences for millions of people who depend on daily hands-on labor to feed their families. Indeed, in Malawi, the quarantine injunction was not filed by far-right protesters, coronavirus denialists, or religious zealots. It was filed by the Human Rights Defenders Coalition.

Lottery and Certainty

In a twist on the conventional path of infectious diseases, the novel coronavirus pandemic began not in the Global South, but in developed countries better equipped to deal with its repercussions. Although they too have struggled with the virus, these nations enjoy relative affluence, strong institutions, and effective health care systems. Thus, the public health response prescribed by epidemiologists has been fairly consistent: lock down borders, ramp up testing, impose aggressive social distancing measures, and attempt to “flatten the curve” to delay and reduce the peak burden on medical systems.

In turn, many poor countries have emulated these steps, often even more quickly than their wealthier counterparts. On February 3—weeks before coronavirus touched down on the continent—the Africa Centers for Disease Control and Prevention established a task force to prepare for the virus. In Latin America, Venezuela, Peru, and Argentina all enacted countrywide lockdowns within days of their first cases, while El Salvador announced its own 30-day national quarantine before any known cases were detected. By contrast, while the first U.S. case was reported on January 20, the first statewide stay-at-home orders were announced on March 19.

Perhaps, these responses reflect lessons learned from major disease outbreaks like Ebola and cholera. Perhaps, however, as Lee Crawfurd of the Center for Global Development suggests, they are indicative of “global mimicry,” as public health authorities are simply imitating the advice of the rich world and the World Health Organization (WHO) without regard for country-specific considerations.

In many ways, lockdowns are an artifact of privilege. The policies of social distancing that have become ubiquitous and familiar to us all are underpinned by certain assumptions about our society and the way it operates. Our supermarkets will not run out of produce. We don’t have to think twice about the water we use to wash our hands. We will be paid for remote work. And, in cases where those conditions are not met, our government will step in and provide assistance.  That is the idea, at least.

In many parts of the developing world, however, these assumptions could not be further from the truth. In Sub-Saharan Africa, 70 percent of the population works in the informal economy and many need to work every day to put food on the table. Without a buffer of savings or the ability to store large amounts of food for weeks on end, they are wholly reliant on both day wages and a daily trip to the market for survival. Water, too, costs money and, for the 2.1 billion people without access to potable water at home, the only source remains communal wells and water treatment facilities. Washing one’s hands for 20 seconds becomes harder to do when a family has to weigh nourishment against sanitation.

All of this means that for billions around the globe, staying home for even a few days to avoid spreading or contracting the coronavirus is not an option. In these cases, a lockdown becomes a death sentence. And, as African health experts Alex de Waal and Paul Richards explained to BBC, “poor people will prefer the lottery of infection over the certainty of starvation.”

Thus, lockdowns have been met with resistance and desperation across the developing world.  Protests have erupted in South Africa, Lebanon, and Iraq. In El Salvador, crowds of people swarmed the capital begging for government aid, while in Kenya’s largest slum, thousands desperate to eat set off a violent stampede at a food distribution site. And in Malawi, the Human Rights Defenders Coalition sued the government to delay the implementation of a national lockdown until it could outline a social safety net to support the poor.

In some countries, the response has been violence, as governments deploy police and military units to enforce state policies. Even so, it is unclear that stringent lockdowns would mitigate the spread of the virus in the world’s most vulnerable regions. The Center for Global Development reports that there are 1.2 billion people globally living in informal slums up to thirty times as dense as New York City, often in tight quarters with older people and others with underlying conditions. Moreover, for the 18 million Africans driven from their homes by conflict, climate change, and natural disasters, packed refugee camps represent ticking time bombs for coronavirus outbreaks.

Taken together, many experts fear that, unless they chart a new course, developing countries are staring down the worst of both worlds: mass starvation from shutdowns and mass death from the virus.

A False Choice

But what is this new course? While some have cited reasons for optimism—young populations, institutional knowledge of disease, warm climates—the developing world remains horrifically unprepared for a major coronavirus surge.

The numbers are terrifying. The WHO reports that in most parts of Africa, there are fewer than five intensive care beds per one million people, compared to over 4,000 per one million in Europe. While the U.S. has been complaining about ventilator shortages while sitting on its 170,000-ventilator stockpile, there are fewer than 2,000 functional ventilators across Africa’s 41 countries, including ten countries with zero.

Statistics like these only reinforce what most Westerners already know, even if they don’t want to think about it: while China, Europe, and the United States have all struggled with the virus, the countries of Africa, Latin America, and South Asia are sitting on a fuse. Provisional modeling suggests that cases in Africa alone could surge to ten million within three to six months, while estimates of deaths range from a best-case scenario of 300,000 to a worst-case scenario of 3.3 million. And this is to say nothing of the UN’s prediction of a famine of “biblical proportions” that will push an additional 130 million people to the brink of starvation by the end of this year.

These prognostications have presented impossible moral dilemmas for both governments and individuals. In the U.S. and Europe, much has been made of the morality of our distancing choices. The young and healthy have sacrificed for the old and sick. Personal hoarding of virus essentials has been curtailed. Medical personnel have worked tirelessly—at great personal risk—to save the lives of people they have never met. These choices are just that, however: choices. Our behavior is predicated on the understanding that we are assuming acceptable personal costs for the good of the many and, specifically, for the good of the vulnerable. As such, there is a kind of altruistic utilitarianism to our logic.

But what moral principle should one rely on when making the (false) “choice” between exposure and starvation? And what happens to societies when everyone makes the (logical) “choice” to go out and fend for their families, virus be damned? In these cases, the level of personal cost to comply with government restrictions is unacceptable; the level of personal risk is extreme. Acting for the good of the vulnerable means acting for oneself. And the preventable consequence that lockdowns are trying to avoid—mass death—is present either way.

This is the predicament that governments throughout much of the world now face. Here, the moral dilemma is compounded because inherent in the imperative to save oneself lurks the threat that one’s actions may endanger many others. How can governments legislate around this conundrum? How can they reconcile the idea that the very people whom lockdowns are trying to save are the ones protesting them most vehemently? Preventative measures to contain the spread of the virus cannot be scrapped. But the one-size-fits-all approach that has been endorsed by the WHO and enacted across Africa and Latin America must be discarded.

Breaking the Box

Like any good ethics thought experiment, the answer to this coronavirus conundrum can come from thinking outside the box. But it can also come from breaking the box entirely. In this case, “breaking the box” would not require thinking that is all that novel—only a commitment to truly global cooperation.

Of course, in developed countries hit by coronavirus, not all citizens have been able to hunker down and wait out the storm. With thousands of businesses shuttered, unemployment claims reaching record highs, and warnings of an economic recession growing louder by the day, the impacts of the pandemic are already being felt in force, particularly by marginalized populations. However, the difference is that governments in wealthy countries have helped citizens stay on their feet. Enormous economic relief packages have been passed in the U.S., EU, and Japan to guarantee employee salaries, extend emergency credit to small businesses, and bail out struggling industries.

What these responses demonstrate is that policies of social distancing and disease suppression rely on effective government support systems to aid citizens through hardship. While these systems are a given in the majority of countries devastated by the virus so far, this is not the case throughout most of the developing world. Many governments in Africa and Central America barely have the resources to provide basic social services in healthy times, let alone send stimulus checks to all their citizens. And while some African countries have committed to emergency measures like free water and electricity, governments simply do not have the funds to sustain this kind of spending without help.

This help must come from the international community. The global nature of the coronavirus pandemic has precluded the surge of aid to developing nations that has accompanied past outbreaks. Indeed, throwing money and resources at poorer countries is undoubtedly a difficult sell when so much is needed at home. But just as we have looked out for the needs of vulnerable populations within our own borders, that altruism must extend to other parts of the world.

This virus has signaled that, whether we like it or not, the forces of globalization have overwhelmed us. Instead of running from this globalized reality, as many populist leaders have done, we must embrace it. In a coronavirus-infused world where borders will become increasingly arbitrary, we have a chance to redefine the moral limits of our politics. While the liberal world order may be dead, even a pragmatic multilateralism in which countries work together to curb the spread of the disease for selfish reasons could form the ethical foundation of the next era of global cooperation.

Balancing Acts

Thus, the first and most obvious step in enabling an effective coronavirus response in developing countries is providing capital. Most countries across Africa and South America are already on fragile fiscal footing, buried under large debts owed to the U.S., China, and European nations. Without large-scale and long-term debt relief, experts say there is little chance these countries will be able to construct, on the fly, the social welfare infrastructure necessary to make disease suppression feasible. 

Some efforts have already been made. On April 15, the world’s 20 largest economies agreed to a 12-month freeze on debt repayment. The International Monetary Fund has likewise said it is prepared to deploy its full one trillion dollar lending capacity to needy nations. But, in the end, full commitment from both wealthy governments and international organizations is necessary.  Days’ or weeks’ worth of aid will not be enough to hold people in their homes. To truly halt the spread of the virus, people in poor countries need to be given the same choice to distance that people in rich ones are. And that means authorizing comprehensive aid packages that can bolster welfare states to provide long-term support for impoverished workers and ensure that hunger is not the consequence of following government orders.

Wealthy nations must also end the competitive mindset they have adopted toward virus response. As the U.S. and Europe compete in a global scrum for medical equipment, poor countries are the ones getting outbid—and dangerously losing out on materials they will need. This, combined with the export restrictions on medical items enacted by more than seventy countries, has put developing countries in a perilous position when it comes to acquiring vital supplies.

A more equitable approach is necessary. Just as U.S. states have begun lending ventilators to one another, developed countries should create international fora to facilitate the donation of masks, testing kits, assisted breathing equipment, and other medical gear to countries in need, in addition to ending export quotas and the stockpiling of materials. Likewise, instead of prioritizing their own citizenry once treatments and vaccines are developed, wealthy countries ought to simultaneously supply low and middle-income nations to alleviate their far more urgent suffering.

Finally, the international community must work with developing nations to craft long-term policy solutions with the recognition that the virus could be present for years to come. To do so, it must accept that Western-style social distancing might not be the answer. During the 2014 Ebola epidemic, when the Liberian government ordered a quarantine of a hard-hit slum in the capital of Monrovia, it quickly realized that such a measure was unsustainable. In Sierra Leone, their much-heralded national lockdown lasted for only 72 hours. What these countries learned is that public health only works by consent, and reducing the risk of viral transmission without endangering the livelihoods of populations in extreme poverty requires a careful balancing act.

These lessons must be applied now, too. Governments of Africa, Latin America, and South Asia need to divorce themselves from international guidelines and explore alternative policies that will allow people to minimize their risk of infection while preserving their ability to put food on the table. Some of these solutions are structural, like improving access to water and setting up field hospitals. But others will simply require careful thought.  Universal face-covering requirements, bans on social and religious gatherings, and targeted isolation of at-risk groups may be feasible in low-income settings for long periods of time. Strict curfews and national lockdowns, enforced at gunpoint no less, will not. And in all of this, governments must engage in diligent cost-benefit analyses of the health benefits of policy proposals against the economic risks, which must be undertaken with a sense of moral responsibility befitting of the weight of these decisions.

Often in our society, difficult ethical problems like these eventually become legal ones, and nowhere has this been more obvious than in Malawi. On Tuesday, April 28, 11 days after its initial ruling, the High Court extended its injunction of the nation’s lockdown policy. In his ruling, Judge Kenyatta Nyirenda noted that, despite over half of its population living below the poverty line, the government had failed to announce measures to cushion the poor from the effects of the lockdown. Malawi will not be able to solve this impossible puzzle alone. But perhaps that is what coronavirus will teach us after all.