Uganda’s lockdown may kill more people than it saves.

Uganda’s lockdown is killing people. That’s not a guess, or an opinion – It’s a fact. Every lockdown kills some people, whether in England, America or Uganda. People die through lack of access to medical services, through increased poverty. Through suicide and violence. In England, lockdown may have contributed do a doubling in deaths due to domestic violence. In Nigeria, security forces have killed more people enforcing the lockdown than the virus has killed to date.

Obviously lockdown SAVES many people as well through preventing virus spread. The best question to ask is not whether  lockdown is saving people OR killing people, because the answer is always both. A far better question is.

Will our lockdown save more people than it will kill?

This question should be asked by the public. It should be asked by analysts. Most importantly this question should be asked by policy makers – those implementing the lockdown. There’s no way to answer this question accurately, as we are forced to make many guesses with little data. Which extra deaths were really caused by the lockdown? What would the future have been like without the lockdown? How many cases of coronavirus would there have been? But we must try.

Will our lockdown save more people than it will kill?

In richer developed countries the answer is a resounding YES. Early comprehensive lockdowns have saved thousands of lives, while there is no indication that large numbers of lives have been lost through health service delays or increased poverty. Sweden did not lock down, and coronavirus has killed over 2000 people. The similar sized country New Zealand locked down hard and only 17 people have died. It’s inconceivable that the consequences New Zealand’s lockdown has led to the death of 2000 people, so New Zealand’s strategy of lockdown is to date a winner.

Will our lockdown save more people than it will kill?

In high income countries lockdown kills few people, because governments have enough resources to look after their citizens in a crisis. Health systems have the capacity to continue regular services while also dealing with a surge of coronavirus cases. Governments avoid severe poverty by handing out money or food to those who can’t work. The economic consequences of lockdown might be severe, but the immediate medical consequences are not devastating and few extra people die.

In Uganda on the other hand…

In Uganda, the situation is far more complicated. Lockdown kills people for many reasons, but these two are super important. Both affect people’s ability to access healthcare when they get sick. Lockdown reduces access to health services is by making transport to healthcare facilities difficult, and by squeezing the poor financially.

1) Reaching hospital is now VERY difficult. This is the biggest tragedy of Uganda’s lockdown. Usually when people get very sick in the village, most people will hop on a motorbike taxi to reach the hospital. Right now however in many areas the army and “local defence units” prevent any movement on motorbikes. Motorbikes refuse to carry people even if the situation is desperate, so if you get sick you are in big trouble. There is more and more flexibility compared to a few weeks ago, but this remains a major problem.

 2) Already poor people become destitute. When you have a dollar in your pocket, if your kid get’s a fever you might to your local clinic and pay for a malaria test. If you don’t have a dollar you might stay at home and just hope your kid improves. Sometimes they don’t.

But how many people is lockdown killing?

That question is the big problem. It’s relatively easy to quantify coronavirus deaths, but it’s extremely difficult to estimate how many people a lockdown is killing. Uganda doesn’t keep meaningful death statistics so it’s impossible to know for sure if more people are dying during this time.

So I’m going to do something a bit outrageous.

I’m going to guesstimate how many people the lockdown might kill every month. This is unscientific, flawed and I may even make mathematical errors, but I’m going to do it anyway to illustrate just how many people lockdown might be killing. How will I do it? I’ll use a baseline estimate of the number of deaths that would have happened anyway, and then add a small percentage which might be caused by the lockdown. I’ll include only 4 causes of death which are likely to have increased under lockdown. Infectious diseases, maternal and neonatal mortality, chronic disease and physical violence. 

I‘ll be super conservative and assume that mortality for each cause of death won’t increase by much. I’m going to assume that mortality will only increase by between 2% and 10% for each of these causes of death, with a best guess of 5%. For the baseline mortality figures, I use estimates for Uganda in 2017 generated in the peer reviewed Global Burden of Disease study.

Infectious diseases (Malaria, pneumonia and diarrhea)
Two weeks ago, I received a call from a nurse in a remote OneDay health center we operate. Our amazing nurse had identified that a 12 year old kid had severe malaria with anemia. He desperately needed blood. Motorbikes refused to carry him to hospital as they feared beatings, or the army confiscating their motorbike. After 8 hours an ambulance finally came, but it was too late. Rubanga-Kwo died soon after reaching hospital.

Besides deadly transport delays, mosquito net distribution has been cancelled this year due to coronavirus, and there is no insecticide spraying planned. It’s likely to be a horrible malaria season. Under a worst case scenario, WHO modeling has raised the possibility of a 100% increase in malaria deaths this year mainly due to lockdown consequences. 

But I’ll be conservative and not use the worst case scenario of a 100% increase. If the lockdown caused just a 5% increase in mortality rates of malaria, pneumonia and diarrhea, then in one month lockdown may have killed 203 people with these diseases.

lukeoutside.jpg

Maternal and neonatal mortality
One of our nurses at a different remote OneDay health center delivered 4 babies last week. Before lockdown in the previous 12 months he didn’t deliver one baby. He isn’t properly trained or equipped to deliver babies, but was forced to as women couldn’t travel to the proper maternity centers and arrived to the facility late in the labour process. Fortunately the mothers and the babies are all OK, but the situation was high risk, and a recipe for disaster. We’ve now liaised with the district up a better system for referral, as well as equipping him for emergencies.

Besides the actual delivery process, getting antenatal visits to be checked up and receive iron, folate and malaria prevention has also become more difficult.

If the lockdown caused just a 5% increase in the maternal and neonatal mortality rate, then in one month the lockdown may have killed 118 people with these diseases.

Chronic diseases (Cardiovascular disease, diabetes and kidney disorders)
Last week, 7 people were supposed to come to my hypertension and diabetes clinic at St. Philip health center. Only 3 made it. The rest of course couldn’t get to the health center because they normally arrive on the back of motorbikes. Without their regular medications, those people  are at higher risk of heart attacks and strokes.

If the lockdown caused just a 5% increase in deaths due to these chronic diseases, then in one month the lockdown may have killed 123 people.

Physical violence
Under times of stress, domestic violence and suicide are likely to increase. In addition, in some countries army and police brutality to enforce lockdown is killing some people.

If the lockdown caused just a 5% increase in deaths due to suicide and interpersonal violence, then in one month the lockdown may have killed 38 people.


How many lives will lockdown save in Uganda?

This is just as hard to predict, and is based on estimating how many coronavirus cases lockdown could prevent. Based on Uganda’s young population, I’ve estimated a mortality rate for coronavirus of 0.75%. It’s hard to predict how many coronavirus cases there might be per month under a less extreme lockdown scenario, but given the relatively slow progress of the virus in Sub-Saharan Africa so far, I’ve estimated that in a worst case scenario, Uganda may experience 50,000 cases a month (average of 1600 cases a day), and 375 deaths. To give some context, so far,the most cases reported in a single day Sub-Saharan African country was 318 yesterday in South Africa.

Under a less severe scenario, coronavirus cases may not exceed 10000 monthly even without a severe lockdown

If Uganda suffered from 20000 cases a month (a midrange estimate), coronavirus might kill 150 people a month, which is far less than my dodgy (but conservative) estimate of 482 deaths caused monthly by lockdown.

FINAL extra deaths graph

This graph indicates the number of coronavirus deaths under different scenarios. First assumes the current status quo of lockdown, while the second assumes a far less severe lockdown with spread of coronavirus. The blue bar indicates the “best guess” number of deaths, while the black lines indicate the range of possible numbers of deaths under each scenario.

As you can see from the graph, there are a range of possibilities, most of which estimate that Uganda’s lockdown will kill more people than it will save. This could be the case even if Uganda’s lockdown prevented 50,000 coronavirus cases a month, which might be a surprise to many. Given this situation, it’s worth considering a serious revision of how lockdown works here in Uganda. A couple of changes could make a huge difference in reducing lockdown related mortality.

  1. Allow transport for all sick people, without needing written permission from officials. If sick people could move with only a written note from their medical professional on official facility headed paper, the transport issue could be mostly solved. Of course this would be widely abused, but the deaths safe through prompt treatment of sick people would outweigh the extra risk of coronavirus spread.
  2. Widespread food or cash distribution. If a government closes their country down, they are under obligation to provide for their citizens during the lean time. This is EVEN MORE IMPORTANT in poorer countries like Uganda, where many are struggling to get by at the best of times. Supplying people with food or cash will help relieve stressful social situations, and free up money to access health services. Unfortunately the Ugandan government is prioritizing vehicles, allowances and giving millions of dollars to MPs rather than providing for their citizens.

I want to stress that these calculations are more about raising the issue of balancing lockdown killings vs coronavirus killings, rather than an accurate indication of the current situation. I’ve opened myself up to very reasonable criticism as to whether it’s fair to even try and make these guesstimates, but I think the only way to get people to take this issue seriously is to try and quantify the number of people lockdown might be killing.

I would love corrections and comments on my math and estimates, so together we can improve this hypothetical analysis. If you want to understand my working better, please make a comment, or contact me through the blog.

Stay safe Uganda!

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3 Responses to Uganda’s lockdown may kill more people than it saves.

  1. Peter Hill says:

    Thanks for this Nick. I am sharing this with interested friends

  2. Dean Yarrall says:

    https://www.businesslive.co.za/fm/features/2020-05-05-lockdown-disaster-dwarfs-covid-19-say-sa-actuaries/

    Something similar from SA (the full paper is in the link)

    Lockdown is probably more effective (relatively) if protecting a population that is quite old – ie Italy. May not be analagous for other countries with different age distribution, and higher risk factors for other diseases (ie Uganda) as you observe.

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