Unintended consequences of the COVID-19 pandemic in Africa
As we write this, a patient is in a local South African Hospital on a ventilator following a cardiac arrest after a massive pulmonary embolus. He recently returned from overseas. When he arrived, he had a cough and phoned his doctor, who instructed him to be tested for COVID-19 before a consultation. The results were delayed for a few days. Before the patient received the results which were negative, he had his pulmonary embolus, was admitted where he had a cardiac arrest with anoxic brain injury. This was an unintended and unreported consequence of the COVID-19 pandemic.
The law of intended consequences has been defined as “The actions of people, and especially of governments, always have effects that are unanticipated or unintended.”
UNINTENDED CONSEQUENCES OF THE COVID-19 PANDEMIC ON HEALTH
The COVID-19 pandemic has spread rapidly globally with almost 18.5 million cases and 700,000 deaths to date. With a few exceptions, mainly small islands, most countries have recorded cases. There are concerns that COVID-19 pandemic could overwhelm health care systems worldwide.
We must never forget that other diseases will continue during the pandemic. The large burden of both acute infectious diseases as well as chronic non-communicable diseases, remain pressing issues in Africa. Diversion of resources to treat the pandemic or closure of specific health facilities may impact other areas with worsening health. For example, lack of immunization in children, diversion of resources from areas like nutritional support, or postponement of follow-up for the many important conditions that foreshadow life-threatening events may lead to increased morbidity or even mortality. Stopping medical care for a far greater number of people with other problems out of fear of spreading COVID-19 is not a wise move.
During the 2014 West Africa Ebola epidemic, lack of routine care for malaria, HIV/AIDS, and tuberculosis led to an estimated 10,600 additional deaths in Guinea, Liberia, and Sierra Leone. This indirect death toll nearly equaled the 11,300 deaths directly caused by Ebola in those countries. In addition, diversion of funds, medical resources, and personnel led to a 30% decrease in routine childhood immunization rates in affected countries. During the 2009 influenza pandemic, a greater surge in hospital admissions for influenza and pneumonia was associated with statistically significant increases in deaths attributable to acute myocardial infarction and stroke. A study in Guinea found that the Ebola outbreak led to a 31% decrease in outpatient visits for routine maternal and child health services.
During the fear generated by the COVID-19, other diseases will progress. What is the best way to treat these diseases, including the fear of the virus in our patient’s mind?
The availability of healthcare workers will decrease as they themselves become infected, go into quarantine, and increased fear-driven absenteeism.
UNINTENDED CONSEQUENCES ON THE ECONOMY
The economies globally and especially in fragile economies in Africa has been severely impacted. Rates of unemployment have risen exponentially. The USA predicts an unemployment rate in the teens, Israel has already reached a figure of 24% (April 3, 2020), this is especially a concern in Africa where some countries such as South Africa, starts with a rate of 28%, which is expected to increase.
Pandemics will lead to significant human resource and staffing costs. New facilities are needed, and some are rapidly being constructed, increasing demand for consumables (medical supplies, personal protective equipment, and drugs) can greatly increase health system expenditures.
As unemployment grows, the tax base will decrease. Fear of crowds can be expected to affect retail trade, restaurants, and other social events such as sport, conferences, and weddings. All elements of the economy face disruption, leading to shortages, price increases and economic stresses for households, private companies, and the government. The informal sector is a major source of employment in Africa, and this has been devastated by the lockdowns with increasing poverty in the most vulnerable of our poorest communities.
The gross domestic product (GDP) can be expected to drop. The World Bank estimated a 5% drop in GDP in a severe pandemic. Aversive behaviors, such as the avoidance of travel, restaurants, and public spaces, as well as prophylactic workplace absenteeism, will have a major impact.
UNINTENDED SOCIAL AND POLITICAL IMPACTS
Historically, severe pandemics have decimated populations, such as smallpox in the Americas, leading to the collapse in their societies. In Africa, the Ebola outbreak with the imposition of quarantines was viewed with suspicion by opposition political leaders and the public and led to violent clashes with security forces. Many congresses and other international meetings and events have been canceled. Weddings, burials, religious ceremonies, and other celebrations have been postponed and, in many cases, canceled. Schools and tertiary institutions have been closed, which will affect the throughput of students and much-needed supply of skilled professionals and workers.
Pandemics can fuel xenophobia. Marginalized communities may be stigmatized and blamed for the disease and its consequences. The Chinese community has been ostracized. During the Black Death, Jewish communities in Europe faced discrimination, including expulsion and communal violence, due to stigma and blame for disease outbreaks.
A recent report in the Lancet on the psychological impact of quarantine report on the negative effects including post-traumatic stress symptoms, anxiety, and anger. Most people with depression will not commit suicide, but major depression can lead to suicide attempts.
During the 1st week of the lockdown in South Africa, 87,000 calls were made to the South African police reporting gender-related violence (ENCA news). Alcohol-related crimes and violence, however, have decreased. We can expect an increase in unwanted pregnancies (UN News), we can also expect an increase in malnutrition in the weeks ahead as the economy affects households, especially in countries with weaker social support systems.
Poverty kills. As the lockdown has progressed, the economy has been devastated. Millions of people have been added to the unemployed. How do we balance the need to control the pandemic with the need to sustain the economy? Africa is in crisis mode; quite rightly, however, we may be ignoring important aspects. How do we expect the poor, the residents of squatter camps, the old age homes, orphanages, prisons, etc., to maintain social distancing? Our communities are being educated on the benefits of handwashing and on general good hygiene habits, but do we have the running water and other facilities for these?
On the more positive side, hospitals are being upgraded to better handle infectious diseases which will be to the long-term benefit of us all. Healthcare workers are being appreciated and held in higher regard. Perhaps designated hospitals to specialize in COVID-19 care are possible. The use of technology, such as telemedicine, is an opportunity that could be harnessed to sustain routine care and avoid death from non-COVID-19 conditions.
The question to ask ourselves: Is the pandemic being handled correctly? Social distancing, avoiding coughing in public, and public mixing when in an infectious state are good practices and should be encouraged. Although lockdowns can be expected to flatten the curve, are we ignoring the unexpected consequences of the pandemic? Are there other ways of fighting the pandemic?
Finally, to avoid unintended human life loss, each country should have guidelines on how to manage non-COVID emergencies and the chronic medical diseases during the crisis.
Declaration of patient consentPatient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorshipNil.
Conflicts of interestThere are no conflicts of interest.
- Ebola Situation Report. In: Weekly Data Report.. Geneva: World Health Organization; 2016.
- Assessing the Socio-Economic Impacts of Ebola Virus Disease in Guinea, Liberia, and Sierra Leone: The Road to Recovery. In: Synthesis Report.. New York: United Nations Development Programme; 2014.
- Working Paper, No. 47417.. Washington, DC: World Bank; 2006.Evaluating the Economic Consequences of Avian Influenza. In:
- The Washington Post.Why the Brutal Murder of Several Ebola Workers May Hint at More Violence to Come.