Primum non nocere: Potential indirect adverse effects of COVID-19 containment strategies in the African region

Dear Editor

With the COVID-19 pandemic spreading in sub-Saharan Africa [1], governments and health authorities are stepping up containment measures. In Sierra Leone, measurements taken include training of healthcare professionals, establishing testing facilities, information campaigns and a partial lockdown. In many ways, there are parallels with the early phase of the West African Ebola outbreak 2013–2016 – including a steep decrease in in- and outpatients across health facilities [2].

In Sierra Leone, which ranks amongst the countries with the highest maternal and child mortality rates worldwide, the rapid decrease of patients presenting to healthcare facilities in this evolving crisis might herald a massive indirect COVID-19-related death toll. There are many well-understood reasons for healthcare avoidance in times of a massive infectious diseases outbreak [3].

Measures aiming to reduce the mortality and morbidity from COVID-19 needs to be weighed against their unintended adverse effects. The future course of the epidemic in Africa remains uncertain, but might differ from those in HIC, as the potential effects of climate, population age pyramid, and co-morbidity pattern differences are currently unknown.

A ‘flattening the curve‘ approach seems not to be a realistic option, because healthcare systems in many LMICs are often overwhelmed with handling caseloads even in ‘normal times’. Additionally, PPE availability is limited, separation of suspect and confirmed cases and non-cases does not necessarily lead to prevention of transmission [4], rt-PCR testing might yield false-negative results [5], and there are essentially no treatment options in view of limited oxygen supplies and almost no facilities for mechanical ventilation.

Regarding the best possible choice of tools to optimize COVID-19 containment in resource-poor settings, the adverse effects of possibly too stringent public health measures and accompanying anxiety and fear should be taken into account. Therefore, a strategy of urging the general population to come to healthcare facilities with acute medical problems should be a top priority of the WHO and other actors, parallel to their efforts to combat COVID-19. Emphasis should be placed on the fact that in most low-income settings, many infectious diseases or surgical and obstetrical emergencies are more deadly if left untreated than COVID-19.

Like with any other health intervention we need to be critical about possible adverse effects of well-intended COVID-19 containment measures, and try to carefully strike the balance between what might be useful and what might be counter-productive, by upholding the first principle in medicine: Primum non nocere - First do no harm.

Funding

None received.

Author contributions

All authors have contributed to the writing process and have agreed upon the final version.

Declaration of competing interest

None of the authors has any conflict of interest to declare.