COVID in Africa: A Long-Term Relationship

At this juncture, all findings and projections must be interpreted with caution since our understanding of COVID-19 is evolving, and today’s assumptions may not hold. Nearly six months have passed since this virus has garnered attention and there continue to be numerous key questions immunologists, virologists and epidemiologists have trouble answering. Among them is how COVID-19 will evolve in Africa. As of the time of writing, the number of cases that SARS-Cov-2, the virus that causes COVID-19, officially inflicted in Africa is so low[1] that it has been labeled the silent epidemic. The optimists point to the continent’s natural advantages of youth and weather, and its public health experience and resourcefulness[2] as reasons for such low numbers, while the skeptics point to a lack of infrastructure, including testing capacity.

Meanwhile, the lack of regional data has refrained modelers from making estimations for the continent, although most agree that the overall impact of COVID-19 in Africa is likely to be particularly grim. Africa has a population of 1.3 billion people, almost half of which live in crowded urban centers, half of which are slums[3] where people have limited access to safe water and sanitation facilities[4]. Nearly half a billion people live in extreme poverty[5]. The economy beats very much around the informal sector[6] and daily labor. For most households, a full lockdown is only sustainable for a couple of days. In this context, the suppression strategy, as it has been implemented in Asian and Western contexts, will not only disproportionally affect the poorest but severely impact society in its entirety due to trade, markets and price disruptions. Consequently, the chance of the pandemic being dissipated through extreme confinement, however short, is unrealistic for most Sub-Saharan countries. Mitigation measures, the next best option, focusing on spacing out transmission while shielding off the most susceptible[7] requires individual co-habitation structures that aren’t available in most family living arrangements. Culture matters, and in this context the unavoidable intergenerational transmission will likely quickly overwhelm the fragile health systems. This balance between greater or lesser strict confinements and restrictions, and socio-economic asphyxiation has been the nightmare of policy makers[8] from poorer countries. The South Korean solution of very early and comprehensive contact tracing and rapid isolation has proven difficult to export to Africa due to infrastructure limitations. At the end of April, the region’s ability to test was still between 10 to 200 times lower than in the Western hemisphere and considered Africa’s Achilles heel[9]. Innovations such as the use of drones to deliver test samples in remote areas, the inclusion of less sensitive but much faster and affordable rapid testing tools, and the extraordinary mobilization of health extension workers, volunteers, religious and civil society actors, may prove able to slow the pandemic’s progression. But in view of the near impossibility of implementing sustained lockdowns, it’s necessary to reflect on how long it will take to get through the pandemic and what the final cost could be. Is herd immunization the only option? Will drugs and vaccines be affordable and available before natural immunity does the job? The pessimistic scenario of having to wait to reach enough population immunity for SARS-Cov-2 transmission to eventually stop, assuming a basic reproduction number of 2.4[10], would require having 55 to 82 percent of the population being infected[11]. This represents between 715 million and 1 billion people or using the commonly estimated intermediate value of 60 percent, as many as 780 million people infected.

Another critical unknown is how many of the infected will develop moderate or severe disease. The two factors that seem to most influence COVID-19 morbidity are age and general immunity. As such, the relative youth of Africa’s population could be a significant protective factor against the pandemic. The median age in Africa is 19.7 years—considerably lower than the European median of 43.1 years. However, the high prevalence of immune-depressing co-morbidities could counterbalance the youth effect. It’s unclear how much malnutrition, and endemic diseases like diarrhea, pneumonia, cholera, malaria, measles, HIV, and tuberculosis, contribute to COVID-19 morbidity. Assuming the factors of high youth and co-morbidities neutralize each other, we could expect the same morbidity levels as in developed countries, with roughly 20 percent of COVID-19 cases requiring medical attention. That percentage represents 156 million persons.

The fragility of tertiary health systems in Africa is well known. The continent has 8 times less physicians than the world average, a rate than in some countries like Liberia can be as low as 38 doctors per million persons[12]. This is 75 times fewer than in North America or Europe. A recent article entitled Think 168,000 Ventilators is Too Few? Try Three[13] illustrates the weakness of tertiary healthcare capacity on the continent[14]. The same could be said for the number of Intensive Care Unit beds, or access to expensive therapeutics. More importantly is the fragility of the primary and secondary health systems, which reflects the general low spending on health in the continent[15]. How much COVID-19 mortality can African health systems avoid in these circumstances? Thus far, estimates made in developed countries are calculating an average case fatality rate of between 1 and 2.5 percent of infected persons[16]. Should health care capacity be boosted enough and manage to control the flow of care for this best-case scenario estimate to hold for the continent, we are looking at the loss of nearly eight million lives[17].

In Africa, mortality due to COVID-19 will need to factor two additional elements: the excess deaths of other endemic diseases likely to be left unattended due to limited services provision and less health seeking, and the excess malnutrition mortality; a consequence of the limited supply and high prices of food. Malnutrition and communicable diseases not only risk to increase many times the indirect mortality toll of the pandemic, but also that of COVID-19 itself. The indirect COVID-19 deaths have been modeled but not yet fully accounted for, as the epidemic is still surfacing. It would be however inexcusable to ignore them. The lessons of the West Africa Ebola outbreak, where the excess mortality observed was 2.7 times higher than Ebola itself, serves as a reminder. The food spikes that led to social unrest and culminated with the Arab Spring, or Hunger Revolution, that sparkled through the Middle East and North Africa in 2010 are another alarm bell for monetary policy makers.

Without external support, it is unimaginable to expect a population that for the large part lives hand-to-mouth to be able to confine for as long as it is necessary for viral transmission to fade away. Equally, it is unlikely that this virus will slow its transmission trajectory when no members of the community are immune, and spreaders are not isolated. Resultantly, COVID-19 in Africa will likely linger and new ways to live with the virus will emerge that will need to be merged with local public health and economic realities.

These scenarios in which inaction determines the course of events, may seem apocalyptic. Similarly, the interpretations of events that point to occasional reductions in daily case numbers as meaning that the peak of the epidemic curve has passed are imprudent. The future may lie somewhere in between. It will be extended over the long-term, largely dependent on how well balanced and adapted to the regional context the containment and response measures enacted are, and ultimately on the readiness of treatments and immunizations as well as Africa’s access to these solutions.

Africa must build a context specific regional strategy that: integrates COVID-19 surveillance and case management into the existing heath systems and structures that are vital for the health needs of the continent; scales up an urban welfare program that puts cash into informal daily workers’ hands; shields not only the elders but the other highly vulnerable communities such as the millions of internally displaced persons and refugees that live in highly congested sites; protect the local markets regional trade; brings hygiene opportunities, as well as risk communication and community engagement to the slums and other high vulnerable congested areas, and; rapidly scales up testing. Meanwhile, Africa and the world must continue to negotiate primacy access to affordable treatments and immunizations and consider the best interest of our collective well-being and security.

Disclaimer: This paper solely contains personal opinions, advice, and statements belonging to the author, and does not represent in any way the opinions of any institutions or organizations, including that of the United Nations. Its potential inaccuracies, errors, or omissions are the sole responsibility of its author.

[1] By mid-May the number of COVID cases per capita was 6 times lower in Africa (2 per million persons) than the world average (12.5 per million) and the case fatality rate less than half of the rest of the world (3 instead of 7 percent). https://ourworldindata.org/coronavirus

[2] Rosenthal P.J. et al., COVID-19: Shining the Light on Africa. Am. J. Trop. Med. Hyg. 00(0), 2020, pp.1-4

[3] Fifty-six percent of Africa’s urban citizens live in slums. UN-Habitat.

[4] Only 34 percent of the population can wash their hands with soap and water in their homes and 40 percent has no access to potable water. United Nations Economic Commission for Africa, COVID-19 Lockdown Exit Strategies for Africa, May 2020. https://www.uneca.org/covid-19-lockdown-exit-strategies

[5] https://www.worldbank.org/en/region/afr/publication/accelerating-poverty-reduction-in-africa-in-five-charts

[6] Nearly eighty six percent of employment is on the informal sector which in case of a lockdown would lose their livelihood (International Labor Organization. The impact of the COVID-19 on the informal economy in Africa and the related policy responses, Informal Economy brief, 14 April 2020); The informal sector contributes to 25 to 65 percent of the national GDPs depending on the economies (see IMF Global Informal Economy, October 2019); World Bank Group, Africa’s Pulse. An Analysis of Issues Shaping Africa’s Economic Pulse. April 2020, vol. 21.

[7] In Africa besides the elderly, vulnerable groups will likely need to include several other groups such as internal displaced people, homelesses and street children.

[8]There is no easy policy decision to be made in these circumstances. Full lockdown may suppress viral transmission but in most African countries it will lead to a massive food insecurity crisis and ultimately an unacceptable human cost.

[9] Nkengasong J., Let Africa into the market for COVID-19 diagnostics, Nature, vol 580, 30 April 2020. By mid May South Africa’s testing capacity was at 6/1,000 persons and Ethiopia at 0.36/1,000 persons whereas in the US it was at 30/1,000 persons.  https://ourworldindata.org/grapher/full-list-cumulative-total-tests-per- thousand/country

[10] SARS-Cov-2 basic reproduction number (Ro) ranges between 1.4 and 3.9.  Li Q, Guan X, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-infected Pneumonia. N Engl J Med, 382 (13):1199-1207. doi:10.1056/NEJMoa2001316. PMC 7121484. PMID 31995857; Riou J. et al. Pattern of early human-to- human transmission of           Wuhan   2019               novel       coronavirus. Eurosurveillance. 25(4). doi:10.2807/1560-7917.ES.2020.25.4.2000058. PMC 7001239. PMID 32019669.

[11] Neil M Ferguson et al., Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Report #9, 16 March 2020 Imperial College COVID-19 Response Team DOI: https://doi.org/10.25561/7748. This Ro estimation may vary, as the Ro varies with the environmental conditions and the behavior of the infected population.

[12] Sub-Saharan Africa average of physicians per 1,000 persons is 8 times lower than the world average (1.565/1,000). https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=ZG-BJ-TD-CD-TZ-SO-SL-LR&m

[13] Graeme Wood, Think 168,000 Ventilators Is Too Few? Try Three. The Atlantic, 10 April, 2020.

[14] As of April, Africa had a total of no more than 2,000 ventilators, and some countries had none. Ruth Maclean and Simon Marks, The New York Times, April 20, 2020.

[15] Only 6.1 % of GDP on average in SSA.

[16] In May 2020, COVID-19 Case Fatality Rate in Africa ranges between 1 to 16% while the estimated worldwide rate is at 7%.

[17] The number of estimated deaths due to COVID-19 if no interventions take place, and based on a Ro of 2.4, was calculated at 40 million worldwide, of which 05. million in the UK and 2.2 million in the US. Estimations for low income countries with more fragile heath systems were proportionally higher due to the outstripping by a factor of 25 of health care demand/supply (Patrick GT Walker et al., The global impact of COVID-19 and strategies for mitigation and suppression. Imperial College of London, Report #12, 26 March 2020).