This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. IN PRACTICE MEDICINE AND THE LAW Comparative strategic approaches to COVID-19 in Africa: Balancing public interest with civil liberties A E Obasa,1 BSc (Med Sci), MSc, PhD (Med Virology); S Singh,1,2 B Oral Health, PG Dip (Health Research Ethics), MSc (Dentium), PhD; E Chivunze,3 BSc, MSc (Physiotherapy); T Burgess,1,3 BSc (Physiotherapy), BSc (Med) Hons (Exercise Science), MHSc (Bioethics), PhD (Exercise Science); F Masiye,1,4 BPhil (Applied Ethics), PG Dip (Health Research Ethics), MSc (Med) (Bioethics); T Mtande,1,5 BSc (Biology and Demography), MSc (Health Research Ethics); J Ochieng,1,6 MB ChB, MSc (Anatomy), MHSc (Bioethics); V Chalwe,1,7 BSc (Human Biology), MB ChB, MSc (Med); B Mokgatla,1,8 BSc (Occupational Therapy), MSc (Research Ethics); S Rennie,1,9 BA, MA (Philosophy), MA (Anthropology), PhD (Philosophy); K Moodley,1 MB ChB, MFamMed, FCFP (SA), MPhil (Applied Ethics), Executive MBA, DPhil 1 Centre for Medical Ethics and Law, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa 2 Discipline of Dentistry, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa 3 Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, South Africa 4 Directorate of Research, Postgraduate Studies and Outreach, Malawi University of Science and Technology, Ndata Farm, Thyolo, Malawi 5 University of North Carolina Project, Tidziwe Centre, Lilongwe, Malawi 6 School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda 7 National Health Research Authority, Ministry of Health, Zambia 8 International AIDS Vaccine Initiative, Botswana 9 Department of Social Medicine, UNC Bioethics Center, University of North Carolina at Chapel Hill, USA Corresponding author: A E Obasa ([email protected]) As COVID-19 spreads rapidly across Africa, causing havoc to economies and disruption to already fragile healthcare systems, it is becoming clear that despite standardised global health strategies, national and local government responses must be tailored to their individual settings. Some African countries have adopted stringent measures such as national lockdown, quarantine or isolation, in combination with good hand hygiene, mandatory wearing of masks and physical distancing, to prevent an impending healthcare crisis. The impact of stringent measures in low- to middle-income African countries has bought time for healthcare facilities to prepare for the onslaught of COVID-19 cases, but some measures have been challenging to implement. In some settings, public health measures have been associated with serious violations of individual rights owing to abuse of power and gaps in implementation of well-intentioned policy. Collateral damage with regard to non-COVID-19 diseases that were suboptimally managed in pre-pandemic times may mean that lives lost from other diseases could exceed those saved from COVID-19. While individuals complying with lockdown regulations have embraced an acceptance of the concept of the common good, at a broad community level many are finding the transition from individualism to collective thinking required during a pandemic difficult to navigate. In this article, we look at government responses to the pandemic in six African countries (Malawi, South Africa, Uganda, Zambia, Zimbabwe and Botswana), and highlight ethical concerns arising in these contexts. S Afr Med J 2020;110(9):858-863. https://doi.org/10.7196/SAMJ.2020.v110i9.14934 Africa is currently in the grip of a global pandemic caused by SARS- healthcare and public health systems render capacities for testing, CoV-2 infection. The resulting condition, COVID-19, has spread isolating, quarantining, treating and contact tracing particularly rapidly and infected over 4 million people globally.[1] The pandemic difficult. In a pandemic, public health containment strategies must has ravaged many nations on a global level, and African countries are be balanced against realities such as lack of income, access to basic no exception. services and food security in different contexts. The World Health Organization (WHO) country and technical Some African countries have implemented national lockdowns guideline for COVID-19 is subdivided into 16 different topics with stringent measures as a containment strategy. During the to inform countries about their preparedness for and response national lockdowns, temporary bans have been placed on both to the global pandemic. While these are important public health international and local travel, and citizens are encouraged to self- measures to contain an outbreak in more egalitarian contexts, some isolate and quarantine at their residences. South Africa (SA) has of the topics addressed in the guideline are tailored to a response enforced compulsory wearing of face masks in public, and the country in resource-rich settings.[2] In Africa, given substantial inequities in initially scaled up mass testing, community testing and contact health systems and socioeconomic conditions, our challenges vary, as tracing, at the centre of its multifaceted response. In public health under-privileged and vulnerable people are differently affected by the emergencies, both isolation and quarantine are ethically justifiable. [3,4] pandemic compared with those in resource-rich settings. In low- to An intrusion on the autonomy and privacy of individuals through middle-income countries (LMICs), some of the recommended critical contact tracing requires explicit ethical justification. The standard measures for COVID-19 prevention and control could potentially ethical justification is that the public health measures will reduce and paradoxically be harmful, as they threaten survival. Fragile transmission and mortality and preserve healthcare capacity. Zambia 858 September 2020, Vol. 110, No. 9 IN PRACTICE and Uganda have taken a similar approach to SA; however, there is on confirmed positive cases, there has been public disclosure of no evidence of massive community testing and mandatory wearing personal information and the public’s knowledge of the quarantine of face masks. The policy decisions made and implemented by and treatment centres in their localities has made individuals who governments in the region to date have inevitably varied. This article have tested positive to the virus identifiable, leading to stigmatisation looks at these different responses to the COVID-19 pandemic in six of and discrimination against patients by community members.[8,9] African countries and highlights some of the ethical concerns that Health workers have also experienced stigma, to the extent that some have arisen during the response in these countries. were denied access to public transport because it was feared that they would spread the disease to fellow passengers.[8,9] Healthcare workers Malawi’s response to COVID-19 face an ethical dilemma in balancing the principle of duty to care with The President of Malawi formed a Cabinet Taskforce on COVID- their own safety owing to inadequate supplies of personal protective 19 comprising politicians from the ruling party with a mandate equipment (PPE). This conflict has led to industrial action to force of managing the response to the outbreak before any confirmed government to provide PPE. It is recommended that both members positive case was reported in the country. Owing to irregularities, the of the Special Presidential Committee on COVID-19 and healthcare committee was dissolved and a new Special Presidential Committee workers be on high alert for unethical practices. All stakeholders in on COVID-19 comprising public health experts, cabinet ministers, the COVID-19 response must respect patients’ rights to informed civil society representatives, traditional leaders, religious leaders consent, privacy and confidentiality to the fullest extent possible, and opposition party representatives was formed at the end of April provided the rights of others are not infringed, in keeping with the 2020. The first three COVID-19 cases in Malawi were reported on principles of public health ethics. The Special Presidential Committee 3 April. Regional COVID-19 cases for Malawi, SA, Uganda, Zambia, must ensure that there is strong strategic community education Zimbabwe and Botswana (11 August) are shown in Table 1. and engagement to disseminate factual information on COVID-19 Strategies to control the spread of the COVID-19 pandemic have supported by scientific evidence. included the recruitment of 2 000 additional new health workers, establishment of nine laboratories across the country to conduct SA’s response to COVID-19 tests on suspected COVID-19 patients, community sensitisation The first confirmed COVID-19 case in SA was reported in KwaZulu- messaging and surveillance, renovation of some wards in public Natal Province on 5 March 2020. This was characterised as an health facilities to act as treatment centres for confirmed positive imported case (i.e. the infected person had travelled out of the country cases, and suspension of public gatherings of more than 100 people. and contracted the disease). The strategy used by the SA government As the number of cases increased, the Malawi Public Health Act of in response to COVID-19 is described in Box 1. 1948 was updated to include strategies for managing the COVID-19 Cyril Ramaphosa, the South African President, declared a National