No Weapons in Hospital. Photo by Peretz Partensky via Flickr (CC BY-NC-ND 2.0)

Most countries around the world have responded to the COVID-19 pandemic with  extreme social distancing measures that are likely to have profound economic consequences. But to what extent are these measures appropriate for low-income countries, particularly those suffering from violent conflict?

A three-week lockdown of Afghanistan’s capital city Kabul was recently extended for another two weeks, leaving thousands of labourers working in the informal economy with no way to earn a living – and no money to feed their families.

And concerns about lockdowns triggering acute poverty and starvation have been echoed throughout the developing world, suggesting that these societies will struggle to maintain extreme social distancing measures for long.

Given these challenges, what should policymakers keep in mind while designing strategies to cope with COVID-19 in low-income conflict-affected states?

Strategies designed to preserve public health service capacity in high-income countries may not be sensible for developing nations

Lockdowns and other extreme social distancing measures in high-income countries are intended to ‘flatten the curve’ of new infections to a point where the number of severe cases requiring treatment at any given time remains below the number of critical care beds. Most high-income countries implementing lockdowns have used the time to ramp up testing and critical care capacity.

Countries that have managed to avoid full lockdowns have typically implemented early and aggressive control measures such as mass testing and contact tracing.

For many low-income countries, these aren’t viable near-term strategies. Global shortages of testing materials and a lack of lab equipment and manpower have left many developing countries struggling to increase testing capacity to sufficient  levels.

In conflict-affected settings, public health systems have been undermined by years of armed conflict. For some citizens, health care is entirely inaccessible. The number of critical care beds and ventilators needed is already extremely limited. The Central African Republic, one of the poorest nations in Africa, has only three ventilators for a population of 5 million.

Keeping the curve of infections under these extremely low levels is unrealistic.  Temporary lockdowns that are not followed by aggressive control measures are unlikely to eliminate the disease, and may forestall a worse wave of infections later.

Lockdowns are often justified as buying time for countries to better prepare for the virus. For the poorest countries, it is not always clear what they are buying time for.

Therefore, governments must turn their focus on coming up with realistic policies to cope with the disease tailored to their particular circumstances.

For some countries, it may be prudent to prioritise relatively low-cost but widespread health interventions, such as public campaigns on hygiene and social distancing, improved sanitation, and life-saving investments in areas such as maternal and child health, as well as more protective kit for healthcare staff.

In crisis zones, these interventions may ultimately save more lives than investments in highly specialised hospital equipment to treat Covid-19, particularly where there are limited numbers of trained staff to operate them.

Social distancing carries higher economic and human costs

The downsides of extreme social distancing in conflict zones are much more severe than in high-income countries, and the costs fall disproportionately on the most vulnerable.

Comparatively large proportions of citizens work in the informal economy, and there is often no social safety net to provide adequate protection during economic downturns.  Many families who cannot work will struggle to survive.

As borders close around the world, migrants and communities whose livelihoods depend on cross-border trade and exports will be particularly hard hit.

Conflict-affected countries tend to have lower aggregate savings rates, and therefore fewer resources to weather economic disruption. Societal norms of larger, multi-generational households make it difficult to isolate older and more vulnerable household members from catching the virus, further underlining the difficulty of halting the spread through social distancing measures.

Every country will need to design flexible strategies according to their own strengths and constraints. These should be developed with inputs from both international and local experts, including civil society groups, NGOs and universities, to ensure that strategies reflect international best practices while remaining locally informed.

Some forms of social distancing and border controls may be appropriate to delay the onset of COVID-19. However, governments and donor agencies recommending these policies should be very clear about their aims, and use any additional time gained from these measures wisely. 

At the same time, wealthier countries should set aside emergency funds to help fragile states grapple with the severe economic and health costs of COVID-19. Failing to act risks exposing these states – and their citizens – to higher rates of poverty, illness and death.

Interventions to suppress COVID-19 may make conflicts worse

Overly zealous or discriminatory policies to suppress COVID-19 may exacerbate existing political and social cleavages. Police deployed to enforce lockdowns in conflict zones are often distrusted by civilians and may be badly overstretched, leading them to resort to increasingly draconian measures to enforce lockdowns.

Unfortunately, excessive violence against civilians by government authorities enforcing social distancing has already been observed in numerous contexts.  And we’ve seen cases where COVID-19 emergency powers  have been used as a pretext to restrict civil liberties or target political dissidents

In conflict zones, such measures threaten to inflame ongoing conflicts and lead to breakdowns in fragile political settlements.  Given that civil society and community-based initiatives to support peacebuilding have likely been put on hold due to social distancing, these settlements are more at risk than ever. In Colombia, there have been reports of armed groups ‘using coronavirus as a cover to kill’. 

Despite the challenges posed by COVID-19, policymakers should consult with and seek the consent of communities with regards to how social distancing and other suppression measures should be applied.  

This approach can help generate solutions appropriate for local contexts and avoid exacerbating already fraught political and social tensions. Experience from past outbreaks of Ebola in West Africa suggest that getting traditional and religious leaders involved in education about social distancing and treatment can help bring the epidemic under control.

Policymakers may reason that, given the speed at which this crisis is unfolding, there isn’t sufficient time for consultations. However, if these tensions aren’t properly managed, the results could be violent – possibly costing more lives in the long run than the COVID-19 itself. 

Governments must move quickly to level with their citizens about the nature of the threat and get them involved in finding solutions. Given what is at stake, there is not a moment to lose.