Thinking Aloud – My Thoughts on Liberia’s Current Fight against Coronavirus

 Introduction

On Wednesday, April 8, 2020, President Gearge M. Weah declared a 21-day State of Emergency (SOE) along with a two-week partial lockdown of Montserrado and Margibi counties effective midnight April 10, 2020. The Legislature would later endorse the SOE and extend it for a period of 60-days. The Legislature also empowered the President to periodically review the SOE and choose whether to lift it or not anytime within the 90-day period. Since then, the two-week partial lockdown that include a de facto curfew from 3 PM to 6 AM and the shutdown of most government offices and business centers (with a very few exceptions) have been extended twice. This is the last week of the latest iteration of the two-week partial lockdown, which is expected to end on Friday, May 22, 2020.

What happens next? Would the lockdown be relaxed to reduce its crushing impact on the economy and the livelihoods of the populace, especially the poor? Or would it be extended to allow for the distribution of the much-trumpeted food aid package that, as some officials of government have hinted, would serve as a palliative to facilitate the imposition of a “total lockdown” expected to be more restrictive than what is obtaining currently?

Let me admit that the choices that the Government faces are difficult and are not as easy as deciding between black and white or good and bad. None of the options or variants of them are entirely perfect and problem-free. Therefore, decision making in such a situation is tantamount to walking a tightrope and balancing the various perspectives to tease out the “least problematic” option. My choice of the phrase “least problematic option” rather than “best option” is deliberate because where all the options available are, to some extent uncomfortable, I don’t’ think it sounds right to label any option “the best”. Now the question becomes, what should Liberians expect on Friday? 

Some Arguments that Could Support the Extension or Tightening of the Lockdown

If one were to put a bet on this, it would be safer to wager that the lockdown may be extended for an additional period, most likely two weeks. And what could be the basis for the extension? The most convenient reason that supporters for an extension could proffer would be the uptick in the numbers of confirmed Coronavirus cases and deaths since the imposition of the SOE and the lockdown. The number of confirmed cases as at April 10, 2020 was 40 and the total number of deaths on that date was 5, As at Monday, May 18, 2020, the number of confirmed cases had risen to 223 while the number of deaths had also risen to 22.  In other words, supporters of lockdown extension could point to these figures to make the case that it may not be appropriate to lift or relax the lockdown when the absolute numbers of confirmed cases and deaths are increasing.

They could also argue thus, “The Government promised about a month ago to distribute food to the population to facilitate a subsequent roll-out of a total or tighter lockdown. The food distribution process has delayed because of technical or other glitches. Still, Commerce Minister Wilson Tarpeh, head of the Government’s Steering Committee on the food distribution, has assured that the distribution will commence once modalities, including enumeration of potential beneficiaries by the Liberia Institute of Statistics and Geo-Information Services (LISGIS), are completed. So until food distribution can commence probably in the next couple of weeks, the Government has no other option than to extend the lockdown. Any lifting of the lockdown before the commencement of food distribution may undermine the central logic behind the food distribution- to prepare the populace for a total or tighter lockdown.”

 Still others in support of lockdown extension could argue that the 6 AM – 3 PM window given to the general public to find food and attend to essential services is undermining the fight against the virus by canceling out the gains achieved during the 3 PM – 6 AM stay-at-home period. Therefore, they could argue that until a total lockdown is imposed that will require residents in the affected counties to stay at home for not less than the two- week incubation period of the virus, we will never be able to defeat the deadly enemy.

Besides what has been delineated above, apologists for lockdown extension may proffer other justifications.

Some Arguments in Favor of Lifting or Relaxation of the Lockdown

At the other extreme, it could be argued that the lockdown is having a devastating impact on the economy and the livelihood of Liberians. Before the Coronavirus crisis, the Government had to recast the budget downward from US$526 million to US$505 million (reflecting a projected revenue shortfall of US$21 million). In his letter to the Legislature justifying the declaration of the SOE, the President announced that the COVID-19 crisis was expected to occasion an additional shortfall in government revenue of US$32 million. Available data on the performance of government revenue is leading me to believe that the COVID-19 impact on government revenue will be far higher than the initial forecast of US$32 million. Already, many business entities have been rendered idle as a result of the crisis and the forced shutdowns. Private school teachers and many others employed in the private sector have been deprived of income for nearly two months now as a result of the mandated shutdowns Few days ago, it was reported that Golden Veroleum Liberia (GVL) would be laying off more than 400 of its workers due to the slump in the price of palm oil caused by a combination of factors, not the least of which has been the current COVID-19 crisis.

Proponents of relaxation of the lockdown would could also stress that the lockdowns and shutdowns have also deprived many ordinary persons of the opportunity to eke out a living from plying their normal trades, resulting in their inability to cater for the basic needs of their families. The problem has been compounded by the fact that many persons are afraid to go to the hospitals or clinics when sick for fear that they may contract the virus from health workers, many of whom were reported to have tested positive for the virus. In other words, crushing poverty and the inadequate attention being paid to other normal illnesses in Liberia may well be causing more deaths across the country than have been caused by Coronavirus.

 A Better Way to Look at the Rise in the Number of Confirmed Cases

Indeed, the arguments on all sides of the issue have some merits. However, I want to stress that if the primary criterion for deciding whether to lift, relax or tighten the lockdown is whether or not the absolute numbers of confirmed cases and deaths have increased as compared to what they were when the SOE and lockdown were imposed on April 10, 2020, then we must brace ourselves for a protracted implementation of the lockdown. This outcome becomes apparent because, until a vaccine or other globally accepted solution is found, we can expect the absolute number of confirmed cases and deaths in Liberia to go up. Top scientists and epidemiologists have been quoted lately as saying that it would take between twelve- eighteen months to produce an efficacious vaccine to tackle the virus. But do we have the capacity or the appropriate shock absorbers to endure the deleterious impact of a lockdown that could last for even six months? The obvious answer is a resounding “NO”.

If all factors including the devastating impact of a lockdown on the economy, livelihood and the possible spike in deaths from illnesses and causes other than Coronavirus are considered, there is a tipping point beyond which continued extension of the lockdown would begin to yield what economists call diminishing marginal returns. Diminishing marginal return in this context is the point at which the lockdown, on balance, starts to work against, rather than in favor of, the greater good.

The most appropriate way to look at the Liberian situation is not to be fixated on whether the number of cases has increased from a specific date in the past as compared to the current date or whether new cases are reported daily; rather, the most appropriate way to gauge progress is to ask whether the number of cases are increasing at an increasing rate (exponentially) or increasing at a decreasing rate. 

In relation to active testing, if the data shows a daily exponential increase in the number of new cases, then that may be a serious cause for alarm. Conversely, if the number of cases are increasing at a decreasing rate or the number of new cases reported daily is on a downward trend, then we can begin to heave a sigh of relief as this may reflect the fact that the transmission of the virus is being contained. 

Using the number of confirmed cases as a metric, as of Monday, as at Monday, May 18, 2018, Liberia seems to be performing better than any of the other three Mano River Union (MRU) countries with regard to the number of confirmed cases – Liberia has 229; Sierra Leone, 519, Cote d’Ivoire, 2,119; and Guinea, 2,796. At 22 deaths as at May 18, 2020, Liberia is reporting the second lowest number of deaths among the four MRU countries, although its case fatality rate interestingly is the highest. It is worthy of note that that the number of recoveries in Liberia has risen from just 3 out of 48 total confirmed cases as of April 10, 2020, to 123 out of 223 total confirmed cases as of Monday, May 18, 2020. Liberia. The number of active cases in Liberia as of May 18, 2020 was 84. 

Keeping all other factors constant including differences in testing capacity, Liberia’s relatively low number of confirmed cases seem to suggest that the country is making good progress in its fight against the deadly virus compared with its neighbors. The fact that Liberia registered its first case on March 16, 2020, two weeks earlier than when Sierra Leone did and the number of its confirmed cases is less than half of Sierra Leone’s, is an indication that Liberia is faring comparatively better at the moment in its fight against the virus than its western neighbor. 

Food Distribution and the Imposition of a Total Lockdown – Some Issues to Consider

It is a known fact that the Government began mulling over the possibility of a total lockdown before the declaration of the SOE but pulled away from making any such proclamation most likely because the government might have come across as insensitive had it imposed a total lockdown of a segment of the population without firstly providing those affected the means (food) to mitigate the harsh consequences of staying at home for more than seven days or possibly two weeks. So the plan to distribute food aid to the affected populations has been in the works for more than a month now and is expected not to actualize for additional weeks in order to enable LISGIS enumerate targeted beneficiaries in four targeted counties – Montserrado, Margibi, Nimba, and Grand Kru.

The much rumored plan to impose a total or tighter lockdown to be preceded by food distribution may be good-intentioned but it is fraught with a lot of practical challenges. Firstly, given the depth and breadth of poverty in the land, a total lockdown of the population is virtually impossible. It is apparent that whatever food distribution being contemplated may not be sufficient to cover the first four counties targeted in the President’s letter to the Legislature (Montserrado, Margibi, Nimba and Grand Kru), let alone all the fifteen counties as contained in the Legislature’s resolution endorsing the SOE.

The administration is reportedly planning to target the “vulnerable” population in the original four counties, prompting concerns about what will determine vulnerability. It is not difficult to foresee that any group of people left out of the food distribution program may feel less obligated to respect the restrictions to be imposed during a possible total lockdown on grounds that they “have to go out to hustle for food”.

Furthermore, it is nearly impossible to conceive of a lockdown scenario where some accommodation is not made for those under lockdown to purchase food in the markets. But unfortunately, any such accommodation for the operation of markets has a huge potential for abuse as it may give the necessary alibi to a significant number of persons who may want to go out for reasons other than the purchase of food, thus ultimately limiting whatever public health gains previously anticipated from the lockdown.

The value of a total lockdown is maximized during the beginning stages of a public health challenge as there appears to be a time value for the imposition of total lockdowns - the sooner they are implemented, the higher the public health dividends to be accrued. Liberia may appear very odd indeed to be seen bulking the global trend by imposing a total lockdown more than two months after its first confirmed case and at a time when nearly the entire world, including many West African countries (Ghana, Nigeria, Senegal, etc) are relaxing their own lockdowns. The imposition of a total lockdown will certainly not jive with the Government’s recent decision to allow for a restricted opening of churches and mosques. The Government runs the risk of coming across as whimsical and inconsistent were it to be seen ordering the ban of worship services at churches and mosques as part of a total lockdown just few weeks after it had given the all clear for religious services to go ahead.

 Recommendations

Given all the above, I would want to recommend the following to the Government:

1)    Develop clear, measurable, and easy-to-communicate indicators for evaluating progress made in the fight against the virus, which would serve as the basis for determining what to do with lockdowns. When President Weah extended the lockdown on May 8, 2020, he stated, “Health authorities have advised that in the wake of the unresolved crisis, the need for the measures to remain in place still is pertinent.” When the lockdown was first extended on April 24, 2020, the President also premised his decision on the advice of health authorities pointing to the “unresolved crisis.”  Relying more on the advice of health authorities during a health crisis is the prudent thing to do. However, the Liberian people deserve more concrete and detailed indicators to justify the extension of a lockdown than the nebulous “unresolved crisis”. As far as we know, the Coronavirus crisis will remain unresolved for the next year or so until the global community develops a solution through an efficacious vaccine or drug. Therefore, the Government may not want to continue to press the pause button on the economy and the livelihood of its people for months only on account of the “unresolved crisis.” Almost all the countries around the world that have lifted or relaxed lockdowns still have “unresolved crisis”. 

I don’t doubt the brilliance of the current health team of government – Dr. Mosoka Fallah, the Director General of NPHIL, was a classmate of mine at the University of Liberia in the early 1990’s and Dr. Francis Kateh, Liberia’s Chief Medical Officer, is a big brother whose medical credentials and professional astuteness are stellar. Health Minister Wilhemina Jallah, JFK Administrator Jerry Brown and the rest of the health folks are all top-notch professionals. I encourage them to deconstruct the “unresolved crisis” and tell us more about the epidemiological curve of Coronavirus cases in Liberia, as such a curve will show, even on a rough basis, how the numbers of confirmed Coronavirus cases and deaths are expected to evolve in Liberia over time, under various scenarios, including 1) a no lockdown, business as usual scenario, 2) a more relaxed lockdown scenario affecting some of the measures, possibly the relaxation of the curfew and the opening of more businesses and government institutions, 3) a partial lockdown scenario (as exists presently) and 4) a total lockdown scenario as has been hinted by government officials. 

 Knowing beforehand precisely what the execution of any one of the scenarios is expected to yield in terms of confirmed cases and deaths will give us the necessary metrics to gauge whether or not we are making progress in our fight. Also, would we be asking for too much were we to request our health folks to develop, or share with the general public if they have already done so, a rough checklist or guidelines on what concrete trends or indicators will inform our decision on whether to entirely lift, partially lift, or significantly tighten the current lockdown?

 2)    Don’t link, at all costs, the distribution of food to the imposition of a total lockdown. As stated earlier, the Government’s decision to distribute food might have been driven largely by a good-faith intention to assuage the impact of a potential total lockdown on the populace. Two months down the road since it made its food distribution intention public, the Government needs to step back and ask whether or not food distribution should necessarily be married to the imposition of a total lockdown. As it appears, the ship might have already left the harbor on total lockdown; therefore, imposing it only because the original thought, two months ago, was that it was inextricably linked to food distribution, may not be the most appropriate thing to do. In strategic decision making, the circumstances, factors, or variables of the present and their potential impacts on the future are more relevant in informing a proper course of action than those of two months ago.

 The Government can still distribute food without necessarily upgrading to a total lockdown. After all, the harsh realities of living under a lockdown, albeit partial, for more than a month can justify the distribution of food. Delinking food distribution from total lockdown comes with the added benefit of averting the likelihood of confusion and push-back during a complete or total lockdown by some disgruntled persons denied food rations on account of not being considered “vulnerable”. Denying a segment of the population food even during the partial lockdown may be problematic; but denying them food and at the same subjecting them to the harsh realities of a total lockdown may be seriously problematic.

 3)    Direct Government’s scarce resources more on activities and expenditure directly linked to the Coronavirus fight and the health sector in general. Although the World Bank has committed to providing a little upwards of US$15 million to directly assist with our fight against the virus, that amount pales in comparison to the gargantuan resource requirement for a more effective response against the virus. To flatten the curve or raise the line, we need to improve health care capacity and our mitigation efforts by spending more money on the recruitment and proper remuneration and incentivization of more contact tracers, case investigators, Community Health Volunteers (CHVs), Community Engagement Volunteers (CEVs). We need to direct more money to improve our testing capacity across the country by establishing some county or regional testing centers with the proper testing machines and adequate cartridges for such machines as well as fuel to power the required generators. We also need to recruit and train more laboratory technicians to man our testing labs. Of course, we need to purchase enough Personal Protective Equipment (PPEs) for our health workers across the country; procure more beds for treatment centers and other regular hospitals and health centers as well as additional ambulances to be stationed in the counties. There is also a need to ramp up spending on Coronavirus awareness and sensitization campaigns, using multiple modes of communication including the radio and the social media. 

Before the onset of the Coronavirus crisis, news of the lack, or inadequacy, of fuel, drugs and other critical supplies at some hospitals and health centers was common. Directing more of government’s own resources to the Coronavirus fight and the health sector in general is akin to robustly fighting the enemy at the frontlines. This will also greatly improve confidence in the society that whatever progress we are making is sustainable, and not just a fluke. This leads me to my fourth recommendation. 

4)    Considering the crying need for more cash for the coronavirus fight and the health sector in general, step-back and re-assess whether it serves the greater good to dedicate a whopping US$35 million on the food-aid program. In the Liberian context, critical conversation concerning rice or food in general is always sensitive and an area “where even angels fear to tread”. But love for country would compel us to confront this elephant in the room and ask some hard questions. To be sure, I support food aid to the populace during such a crisis, as it helps complement the fight against the virus. And if resources are abundant, I will jump for joy if we dedicated significant sums on activities that complement our fight against the virus. My joy will, however, be dampened when I realize that spending on core activities in the Coronavirus fight may likely play second fiddle to spending on a complementary or tangential activity. My joy will also be dampened when I realize that the US$35 million that is expected to be dedicated on the complementary activity (food distribution) is being sourced from a loan to be provided by the International Monetary Fund (IMF), the payment of which will take up a significant fiscal space in ensuing budgets.

 Also, let’s imagine if we were to find similar US$35 million and pump it directly towards the core components of the Conovarius fight (testing, contact tracing, isolation, PPE’s, etc) and the health sector in general. We will definitely achieve tremendous bang for our buck. Where spending US$35 million on a non-sustainable, low long-term return food-aid program will leave us with less money to spend on health, we must reconsider and reorder our priorities by slicing the food aid budget downward somewhat and upping the budget for core activities in the fight against the virus and to health in general, knowing fully well that adequately funding health will not only help us make quick gains in our battle against the virus but will also help improve the robustness of the health sector and benefit our populace even after the present crisis. 

5)    The President should consider, as part of whatever decision he is contemplating on making with regard to the lockdown, the relaxation of the mandatory stay- at- home period (the defacto curfew) by revising it from 3 PM – 6 AM to 6 PM to 6 AM. As paradoxical as it may seem, the extra three hours that this relaxation will give the public to attend to their basic food, banking and other needs will enhance social distancing, instead of undermine it. A close observation of what happens between 6 AM and 3 PM in Monrovia and other parts of the country under partial lockdown will reveal that because of the short time window provided for people to go out, those businesses and institutions allowed to operate have adopted very limited operation hours, thus prompting a rush for their services by the general public who cluster and clamor in droves outside such premises to be served. This situation is particularly grave at business centers and at commercial banks and their ATMs. This clustering of a huge number of persons actually undermines social distancing. The extra three hours will enable businesses and institutions allowed to operate to extend their period of operations, thereby making it more practical for them to enforce social distancing at their premises.

 Conclusion

I have attempted in this piece to distill some of the issues attending our fight against the deadly Coronavirus by putting them on the scaffold of critical thinking and analysis.  My decision to make my thoughts public springs from my conviction that the thoughts I have proffered herein are not “absolute truths” or “The Ten Commandments” received by Moses on Mt. Sinai. My thoughts can certainly be enriched, refined, or amended by wise contributions and perspectives of other well-meaning persons in our society. I strongly espouse the belief that the best possible outcome is ultimately derived when we as a country and a people subject issues of national significance to healthy national debates. No doubt, the decisions and choices to be made by the President and the Government in the coming days and weeks will be difficult and complex, reminding us of the truism of the biblical statement, “Uneasy lies the head that wears the crown”. I hope by this article I have helped in a little way to lessen that uneasiness.