NGS Insight – COVID-19 in Africa

September 4, 2020

The pandemic has been with us for most of the year, and as the seasons begin to change again, there is a potential for the pattern of the transmission to change in some parts of the world, depending on the regional environment. This week, the World Health Organisation made the hopeful statement that it believes the pandemic has probably passed its peak in sub-Saharan Africa, in the wake of an average 17% drop in the number of weekly new cases reported across the area in the last four weeks.




Reassuring Statistics


Case numbers in Africa are remarkable for how low they are, particularly when contrasted with case numbers in Europe, South Asia, and the Americas. Official total cases (for the whole of Africa) currently stand at 1,273,213. This is less than the single worst-affected countries in North America (the United States, with over 6 million), in South America (Brazil, over 4 million) and Asia (India, nearly 4 million). The most cases recorded on the continent have been by a long distance those in South Africa (630k), with Egypt next at just under 100k.


However, clearly Africa has some of the largest countries in the world (Algeria), some of the smallest (Burundi), and some of the largest populations (Nigeria). Inevitably, a more reliable indicator for monitoring the outbreak is the number of cases per million population. Using this metric, South Africa records 10k (per million), more than all major European countries, and much more than India (with its population of 1.38 billion). However, it is still recording much lower case density than the United States, Brazil, and several densely-populated Middle Eastern and South American nations (such as Qatar and Peru).


Looking elsewhere on the continent, most mainland African nations have cases per million that are not just lower than those of South Africa, but are considerably lower. In the north, Egypt has less than 1k (per million); in the east, Ethiopia records 470; and in the west, Nigeria has the remarkably low 260.


The statistics for deaths show a similar trend. The total deaths for the whole African continent are currently 30,370, on a par with those for France. Again, this total is less than the United States (189k deaths), Brazil (124k) and India (67k), which are the worst affected countries on their respective continents. It is even less than the reported deaths in the United Kingdom, 41k. Once again, deaths per million are considerably lower in Africa than they are in most Western and developed countries.




Early Fears


In March, after the global nature of the threat had been established, a group of epidemiologists at Imperial College London suggested that the pandemic could end up taking as many as three million lives in Africa alone. In fact, sub-Saharan Africa was earmarked early on as a potential hotspot for the disease, given a host of factors that appear to work against the population and in favour of the virus.


Firstly, so much of the continent experiences high levels of poverty that it was assumed that social distancing would be impossible, and that adherence to official restrictions would be negligible. When fear of starvation runs just as high on a daily basis as the potential fear of yet another disease, it was expected that working adults would quickly return to their jobs to provide for their families. Malnutrition caused by poverty is widespread, and likely to contribute to a reduced immune system in many parts of the population.


Secondly, healthcare systems across the region are generally seen as depleted, poorly-resourced, and failing. Despite some high-quality medical professionals, there is often a lack of bed spaces, staff and resources per population. An East Africa Medical Journal report from 2015 found that Kenya, with a population much the same size as the UK, had 130 intensive care unit beds, and 200 specialised intensive care nurses (the UK has 5,900 and 3,500 respectively). As it happens, Kenya had more than other sub-Saharan African countries, with the exception of South Africa.


Thirdly, there are already a number of pre-existing health issues across populations in Africa, which might either make people more vulnerable to infection, or could use up badly-needed resources. Only limited research has been done into this topic, but infection rates of conditions such as tuberculosis, malaria and AIDS are high in Africa, and there have been concerns that respiratory infections will be more likely for those already suffering from such illnesses.




Reasons for African Success


However, despite these concerns, the feared explosion of cases in Africa does not appear to have transpired. This can be related to a handful of reasons, including demographics, climate, politics and recent experience.



1. Demographics and Climate


There is a possibility that the reassuring statistics from Africa relate to the demographics of the continent, particularly those in sub-Saharan Africa. The UK NHS states that people at “moderate” risk of COVID-19 infection include over-70s, while those at “high” risk include those with conditions affecting the lungs and heart. Children generally appear less likely to be infected, and most young adults experience only mild symptoms. In sub-Saharan Africa, only 3% of the population is over 65, contrasted with 10% in Brazil, 12% in China, 16% in the United States, and 20% in the United Kingdom. More than 60% of this population is under 25, and 70% are under 20, a factor that is generally believed to improve resistance (by their nature, those affected by cardiac and respiratory conditions are already likely to be older anyway) and decrease mortality rates.


At the same time, although the region may be affected by a large variety of other outbreaks, the population experiences significantly fewer health problems that are common in wealthier countries, such as type-2 diabetes and obesity (with the associated heart conditions), which may also go some way to reducing the likelihood of infection.


Another possible explanation for the low instances of infection in Africa relates to the climate. The medical community that supports this theory has observed that similar coronavirus infections (such as influenza) are more commonly transmitted during colder seasons. For instance, the flu season in South Africa does not start until April, when temperatures fall. This would go some way to explaining the higher infections in Europe and the United States, but not enough research has been conducted on this issue, and it certainly would not account for the high transmission rates in Brazil and India.


2. Political Experience


Of much greater influence over the statistics in Africa has been the quick decision-making by governments across the continent, born out of the experiences that many of them have had with other epidemics in recent years. Those countries that lived through the West Africa Ebola outbreak of 2014-16 have been galvanised by those experiences and acted much more quickly than many countries in the developed world.


By mid-April, most African governments had closed their international borders, imposed social distancing measures and suspended schools. By the end of April, governments such as Abuja had also imposed night-time curfews and partial lockdowns, with some having introduced contact-tracing strategies and requirements to wear facemasks in public. These governments were already aware how best to access their populations, and used social media to link up the public to WHO guidelines on hand and respiratory hygiene. Some governments, such as those of Kenya and Rwanda, identified high-risk public areas, and installed handwashing stations and hand sanitisation equipment in transport hubs and restaurants. Following advice from the Africa CDC (Centre for Disease Control), governments increased the short-term training of healthcare workers and lab technicians in diagnosis and treatment of respiratory infections.


The experience of the Ebola outbreak is a reflection that correct strategies, good planning and (ultimately) strong leadership are of greater value than finances. These governments are aware of the shortcomings of their respective health services, and had no other option than to implement the correct strategies in order to save money as much as to save lives.



3. Public Engagement


It was more than just the governments of sub-Saharan Africa that learned hard lessons from the Ebola outbreak: it is also likely that the positive responsibility taken by the public had a positive influence in keeping infection rates low. Many communities appear to have adopted the wearing of facemasks without complaint, fully understanding the potential consequences of a failure to do so. Civil society organisations, including rural figures such as village chieftains, have been engaged in the process to ensure that communities everywhere are responsive to instructions.


This is in marked contrast to European populations, who view these guidelines as an affront to their civil liberties. These are epitomised by the anti-lockdown protests seen in Germany and Serbia (among many others, such as Paraguay in South America) during the summer, as well as the general half-heartedness towards healthcare guidelines offered by many Western populations. It seems that, in many developed countries, the public is largely at odds with their governments.




Reconsidering the Statistics


However, there is inevitably much more to this apparent remarkable performance than the impression that can be gleaned from WHO statistics. In fact, so many questions need to be raised that most of the above reasons for Africa’s success could be negated, to the extent that the statistics effectively become meaningless. A number of international aid agencies believe that the true number of COVID-19 cases is far higher than the official statistics have so far suggested. Regardless of how few cases may have been recorded, there is still an opportunity for the virus to spread among populations that have become detached from their healthcare systems.


The WHO itself has already said repeatedly that its figures need to be treated with caution, given the potential for confusion when different healthcare systems use different metrics to make diagnoses, different governments have varied approaches towards testing, and given the likelihood that reporting standards are going to be different across a continent as large and diverse as Africa.



1.  Processes


Ultimately, regional statistics can only be provided for those patients who are prepared to travel to a clinic for treatment, who are tested with reliable equipment, and whose data is recorded accurately and reliably by staff who then collate it and forward it to the WHO. Without any of those stages being complete, discussions based upon WHO statistics are invalid. As mentioned earlier, much of African healthcare is of poor quality, and may be prone to any number of issues that would affect statistics. Incorrect diagnoses for respiratory conditions may be made by inexperienced or poorly-trained staff; testing equipment may be inadequate or faulty; local statistics may simply not be passed up to the appropriate managers in good time.



2. Communities


In many African communities, a fear of hospitals is widespread, as places that have come to be associated with death. As a result, many sick people, particularly those in rural communities, would prefer to be treated, and ultimately to die, at home rather than in a hospital environment. These cases all end up bypassing national statistics. An investigation by the BBC last week demonstrated that despite an official death toll in Somalia of 98, there have been thousands more deaths in Mogadishu alone over the last few months, the suggestion being that they were victims of the pandemic whose deaths had not been officially recorded.


Large parts of Africa consist of dispersed, rural communities, considered “off-grid” by many. These communities may invariably have no access to clinics, testing or treatment, and their cases, regardless of the outcome, will simply go unrecorded. Unlike Ebola, where symptoms are immediate and severe, COVID-19 has an incubation period of 14 days, so many people in rural communities are likely to be carrying and spreading it without knowing the seriousness of the condition they are experiencing, until testing can reach more dispersed settlements. Tracking and tracing in these environments can be particularly difficult without external support.



3. Testing


The United States government has come in for a lot of criticism for its handling of the pandemic, which has certainly been considerably worse than many other nations. However, one of the mantras that the US president has often repeated is that confirmed cases are much higher in the United States because testing is so much more than elsewhere. Indeed, the country has conducted more than 84 million tests, second only to China’s (reported) 160 million, and nearly twice as many as the next in line, India (45 million). Perhaps, then, it should be no surprise to international observers that the US also happens to have recorded the highest number of cases – it is surely one inevitable result of having conducted more testing.


In contrast it seems that, in much of Africa, not enough testing is being conducted to monitor the spread of the pandemic effectively, or ultimately to provide accurate statistics to the WHO. South Africa has conducted 3.7 million tests, and accordingly recorded the highest number of cases, 630k. Sudan, by contrast, has reportedly conducted 401 tests, and yet has still recorded 13,189 cases, a statistic that goes to show how either figures are being manipulated or blundered, or that reflects a healthcare system that is failing to use testing correctly and failing to conduct correct diagnoses. As discussed above, the continent does not have the best healthcare structures, so in many areas it has proven impossible to conduct any testing at all, without external assistance. Some countries (including Kenya, where numbers have been falling since their peak in July) have reportedly abandoned the practice of random testing, and are testing only in specific communities; it is this failure to acknowledge that a negative test result is just as important as a positive one, that helps to skew the figures.


Perhaps the best metric to measure the practical medical responsiveness of a government is the number of tests per million population. This is a reflection on the importance that a national government has put towards widespread testing, and its determination to trace and treat the outbreak as it spreads. Globally, the countries with the highest tests per million are smaller ones, but notably high on the list are the United States and Russia, both of which have reportedly conducted slightly more than 250k tests per million population, with Australia and the UK not far behind. In contrast, African countries have provided very poor rates of testing per population, suggesting that despite the collective knowledge derived from the Ebola outbreak, governments had not actually put together the funds and the plans necessary to conduct testing on a national scale. South Africa is by far the highest, with 63k tests per million, but further down the list are Botswana (49k), Rwanda (32k), Namibia (25k), and at least 20 other governments beneath 10k. The fact that testing numbers do not even exist for Algeria, DR Congo, Congo-Brazzaville, Somalia, Sierra Leone, Burkina Faso, Liberia, Chad, Tanzania and Eritrea is a reflection of how poorly organised the response has actually been.


4. Nationalism


At this stage, some consideration should be given to the possibility that governments are prepared to manipulate statistics for the sake of their reputations. For instance, it would not be too unreasonable for a casual observer of WHO statistics to question the 85k cases reported in China, the original hub of the outbreak, regardless of how efficient Beijing’s response has been; at the same time, one might think that the 160 million tests conducted in China is unlikely.


With this in mind, the cynical observer of Africa might consider whether statistics in some countries might have been manipulated by central government. In the long run, the only way for some governments to rebuild shattered economies in the wake of the pandemic will be by attracting foreign direct investment, and that FDI is much more likely to be offered to a community that can demonstrate that the spread of the pandemic was not as great as elsewhere.






With the seasons approaching a change in Africa, it is possible that the continent is reaching a moment of change in the course of the pandemic. It will be a long time before the true statistical impact of the pandemic on African nations becomes clear, and will be reflected in how long the outbreak lasts rather than what the actual figures are.


Financially, there is no cheap way of managing this pandemic, as it will be many months before a vaccine becomes available. Most African nations have low capacity in their healthcare systems, and will need to focus on limiting the spread of the disease through testing and tracking.


Of less obvious (but potentially more important) long-term impact in Africa will be the effect that lockdowns will have on the young and the urban poor. A high number of citizens are dependent upon casual labour, and aid agencies are warning that many millions of people are being pushed to the edge of starvation without government or international support. At the same time, children have had no access to school without the online capability of the developed world, and have lost many months of education. Finally, with a healthcare already under unprecedented pressure, there is likely to be a high increase in cases of diseases that are already at epidemic levels, such as tuberculosis, HIV and malaria.







Author: Jamie Thomson, Senior Risk Analyst





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