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- health policies and all other topics
- health services research
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Summary box
Ethiopia’s social, cultural and economic conditions place significant limitations to the use of lockdown as a public health strategy for containing the spread of COVID-19.
Shielding focuses efforts to prevent vulnerable people from COVID-19 infection.
Shielding empowers communities to stand by each other and harness the power of communal values
Shielding protects against socio-economic and political crises that may result from complete lockdown.
Introduction
‘When spider webs unite’, says an Ethiopian proverb, ‘they can tie up a lion’. It reflects a relational way of thinking about the world that underlies Ethiopia’s public health response to the COVID-19 pandemic. Togetherness is a fundamental value that binds this country of more than 110 million people and is embedded in deep-rooted systems that support communal life. By standing together, we become bigger than ourselves. As health policy stakeholders in Ethiopia, we believe that the only way to contain COVID-19 is to implement strategies embedded in togetherness.1
This notion of connectedness is embodied in the concept of ubuntu, which has been a guiding principle in sub-Saharan Africa for hundreds of years.2 Many great African leaders, including Desmond Tutu and Nelson Mandela, incorporated elements of ubuntu into their work.2 Ubuntu situates individuals within a web of relationships that is born of identifying with others and acting in solidarity. It is by sharing a way of life with others that individuals ‘come into existence’.3 We exist because our social connections remain strong, extending beyond family to embrace our clan, village and entire community.
Although every country has different values that guide public health policies, ubuntu may be a useful concept to integrate into public health responses to COVID-19 across the globe. We describe shielding, a public health response grounded in ubuntu, to further the global discourse about this pandemic.
What is shielding?
We have learnt from our past responses to emergencies and epidemics that a relational approach is crucial to the success of any public health initiative.4 5 Stratified shielding is one such approach that is being used to fight COVID-19.6 It involves protecting high-risk individuals from infection while allowing exposure and immunity to grow among people at lower risk until most of the population is protected. Shielding aligns with the concept of ubuntu by focusing on protecting groups at most risk to safeguard entire communities.
Why use shielding?
Health leaders and decision-makers in Ethiopia are using stratified shielding as a more appropriate strategy than lockdown.7 Lockdown involves closing non-essential businesses, restricting movement and banning public gatherings, and often fining people who do not comply with these measures. But culturally inappropriate responses can have serious unintended consequences. When Nigeria attempted to enforce lockdown, many citizens protested and ignored the measures, for example, continuing to work in order to earn money to survive, leading to arrests and even death.8 Other African countries are also concerned about economic collapse, food insecurity, and disrupted prevention and treatment interventions for HIV, tuberculosis, measles and malaria.9–11 In Ethiopia, where much of the urban population subsists on daily labour and private small businesses, complete lockdown for extended periods is nearly impossible to implement and could exacerbate the existing economic and social crises. While lockdown measures were implemented early during the pandemic, they have deliberately been unenforced. In part, this reflects an understanding of the great risk of vulnerability for those in the informal economic sector and for food insecurity, and of the communal and tactile nature of Ethiopian culture.12 In countries with strong communal relationships, shielding is a more feasible response that has been proposed to be more realistic in low-income settings.13
Who to shield?
The image of a shield resonates with Ethiopians as a symbol of our struggle to protect ourselves from an overpowering enemy. As a pandemic response, the idea of shielding the vulnerable from attack has a stronger emotional appeal than a generic call to socially distance ourselves from others. It protects the most vulnerable individuals and allows others to continue activities.
Our shielding intervention targets the two most vulnerable groups: older adults (60+ years) and people with serious medical conditions.14 In Ethiopia, approximately 10% (11 million people) of the population needs shielding. With an average of five people per household, this translates to one high-risk person in every second household.
Shielding unites communities
Pandemics create fear, frustration and anxiety, which can disintegrate social mechanisms that bind people together and challenge their coping capacities and resilience. Weakened bonds threaten already strained infrastructure and technological and resource capacities to respond to the pandemic. Public engagement increases when prevention focuses on active participation of communities. In ubuntu, there is no ‘I’. ‘I’ can exist only if ‘we’ is nurtured and sustained. In Ethiopia, we expect to be available for one another, particularly for those in greatest need. As a public health response to COVID-19, shielding protects the vulnerable ‘I’ in a way that mobilises and safeguards ‘we’.
Conclusion
In countries like Ethiopia, there is an opportunity to contain COVID-19 and flatten the curve by implementing public health interventions that are culturally appropriate and that address the health and socioeconomic impacts of COVID-19. Ethiopia’s social, cultural and economic state of affairs place significant limitations to the use of lockdown as a public health strategy for containing the spread of COVID-19. By aligning with the Afro-communal philosophy of ubuntu, shielding promotes elements of social distancing among those who are most vulnerable in a way that is practical and appropriate within a culture that values communion, togetherness and cohesion. Adapting practices within communal relationships may be essential to protect a strong and long-standing communal tradition and to mitigate the impact of COVID-19 in the country.1 The African proverb ‘if you want to run fast, run alone; if you want to run far, run together’ captures this important value. Calling on household members, extended family, neighbourhoods and local institutions to share the responsibility reflects the realities and needs of a country deeply rooted in communal values. Thus, shielding empowers communities to stand by each other while protecting against the socioeconomic and political crisis that may result from complete lockdown.
Acknowledgments
We acknowledge Ms Hema Zbogar for her editorial support.
Footnotes
Handling editor Seye Abimbola
Twitter @SSoklaridis
Contributors ASE, GA, SN, DE, YM, AA, YG, HY, AM, DHG, MGK and DW had the idea for the article; ASE, DW, SS, CRW and CC performed the literature search; all cited authors wrote and provided revisions to the article and; DW is the guarantor. The corresponding author, SS, attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No additional data are available.