SARS-CoV-2 has arrived in Africa and, progressively, almost all African countries have closed their borders and imposed various levels of “lockdowns” in the hope of limiting the spread of the pandemic, taking measures similar to those taken elsewhere in the world. The pandemic is producing shocking statistics and tragic consequences in developed regions of the world, such as in Europe and North America. What could be the impact in the more fragile context of the African continent? It is mostly in Sub-Saharan Africa that the pandemic gives greatest concern.
This article elaborates on the conditions in which Africa is facing the COVID-19 pandemic. It presents a series of “weaknesses” of the African health systems, but also at the social-economic level, which could facilitate the spread of the infection. Protecting factors specific to the African continent with respect to the spread of coronavirus are also explored.
The article concludes with a series of considerations, namely: the risk, in health emergencies, of the suspension of essential prevention and treatment health services; the difficulties of analysing current pandemic trajectories, since available data in a number of African countries are scarce and uncertain; and the need to prioritise triage based on clinical case definition and presumptive diagnosis as a consequence of the paucity of large-scale diagnostics. The analysis is aimed in particular at the Sub-Saharan region.
Weakness of the Health Systems
Africa, despite having the greatest infectious disease burden in the world, has a weak epidemiological surveillance system. Disease surveillance programmes in Africa often involve too much paperwork, too many dissimilar instructions and terminologies, conflicting priorities, etc. In its recently launched Investment Case for Vaccine-Preventable Disease Surveillance in the African Region 2020-2030, the World Health Organisation (WHO) highlights the drastic consequences that could be in store for the region if countries do not invest in disease surveillance efforts, including a US$22.4 billion economic burden over the next decade. This estimate was conducted before the advent of the SARS-CoV-2 pandemic.
Africa’s health systems have been badly damaged by the emigration of their health professionals, with extremely low doctor-to-patient ratios in comparison to more developed countries. For example, in 2015 there were 0.22 physicians per 1,000 people in Sub-Saharan Africa, while in the EU there were 3.6.
The weakness of the infrastructure system results in a paucity of diagnostic and laboratory centres, which are present almost exclusively in urban areas and mostly cater to a private clientele. These labs have the ability to process a limited number of tests per day. Testing for COVID-19 is hugely important for the containment of the pandemic: it needs viral genome detection, which requires advanced facilities, expensive equipment and well-trained staff. Even some industrialised countries struggle. Despite the fact that Africa CDC drives to help countries in setting up COVID-19 diagnostic testing, and the WHO supports them through supply flights for essential equipment, the situation remains critical. Furthermore, the required kits and reagents are produced for a global market and so Africa is competing with many far more affluent countries for scarce supplies; the severing of most aerial transport links aggravates the situation further.
Another infrastructure limit is the reduced intensive care unit beds capacity. For example, the three most populated Sub-Saharan African countries, Nigeria, Ethiopia and the Democratic Republic of the Congo, have respectively 0.2, <1.0, and <1.0 intensive care unit beds per 100 000 population (in France by comparison, there are 11.6 intensive care unit beds per 100 000 population).
It is important to note that the mere presence of an intensive care unit does not guarantee the ability to effectively care for critically ill patients. Indeed, the ability to comply with sepsis guidelines is minimal in most of Sub-Saharan Africa, despite the presence of an intensive care unit, because highly trained medical staff needed for intensive care units are also extremely scarce. The paucity of ventilators is much lamented, but also supplementary oxygen – a comparatively simple yet life-saving intervention – is often not available in many parts of Africa.
The shortage of personal protective equipment for health personnel is another problem, one which has also hit many European countries hard in the last few weeks. Should the pandemic expand in Africa, this raises concerns about potentially high morbidity and mortality rates among health care workers.
Pre-existing comorbidities, above all HIV/AIDS, tuberculosis and malaria, could increase the susceptibility to COVID-19 or increase the risk of severe disease. Additional factors are related to the lack of treatment. For example, 25.7 million HIV positive people live in Africa: 64% of them – 16.3 million – take antiretroviral treatment. However, the remnants – 9.4 million – are not taking medication. This means a large population with weakened immune systems, which is likely to increase the risk of severe COVID-19.
Socio-economic Factors That Could Further Worsen the Pandemic
A number of socio-economic factors, which influence health conditions, can further aggravate the general picture. 319 million people in Sub-Saharan Africa are without access to reliable drinking water sources, which raises concern of the risk of coronavirus transmission via the faecal-oral route. In addition, hand-washing and good hygiene, major measures for preventing COVID-19, are impossible when people lack access to clean water.
According to FAO, 20% of Africa’s population is undernourished, a condition that makes it more vulnerable to infections. About 43% of the African population (587 million people in 2019) live in urban areas. There are cities with more than 10 million people (Cairo, Kinshasa and Lagos) and several others with a population between 5 and 10 million. About half of the urban population in Africa lives in overcrowded suburbs, with poor access to running water and decent latrines where confinement is unrealistic.
Other complications are related to the lack of a welfare system, which necessitates daily work in order to survive. In Sub-Saharan Africa, the labour market is characterized by widespread informal employment (which represent 89% of total employment), and a huge presence of small and medium-sized enterprises (90% of business units), which are the drivers of growth in the region. Finally, conflicts and violence make the management of a pandemic even more complicated. At least twenty African countries suffer from armed conflict or strong social tensions. As a result, 6.3 million refugees and 17.7 million displaced people in Africa live in overcrowded camps with poor sanitation and hygiene conditions.
Potential Factors of Optimism
The list of negative factors could be – at least partially – counterbalanced by a series of other factors that are potentially useful in containing the epidemic.
Firstly, COVID-19 affects younger people less frequently and severely. The median age of the African population is 19.7 years, and 60% of the population is under 25 years of age.
Secondly, the warm climate promotes more time outdoors than indoors, which could limit the spread of the infection.
Thirdly, the SARS-CoV and MERS-CoV global outbreaks did not affect Africa on a large scale. The contribution of factors such as the effect of UV light on the survival of the viruses on surfaces, immunological differences of populations and pre-exposure to other coronaviruses is unclear.
Fourthly, the closing of national borders in most African countries, which took place early on, in some cases even prior to the reporting of any COVID-19 cases, may have reduced the spread of the virus significantly. In addition, in rural areas, the reduced mobility of populations might keep specific parts of countries from becoming infected.
Fifthly, previous epidemics – for example the Ebola outbreak – could provide valuable lessons in how to handle the current pandemic, at least in some countries.
Finally, the enormous improvement in antiretroviral treatment coverage including lab support over the past decade may also benefit the COVID-19 response. Platforms such as the Genexpert for tuberculosis testing can also be used for COVID-19 tests, provided affordable test devices become available in sufficient numbers.
Additional Reflections and Conclusions
The economic implications of the pandemic in Africa have only been briefly mentioned here. But the role of the state, international agencies and the international community in conditions such as the present one is beyond question. Africa will need indirect help in the form of debt cancellation, new international trade regulations, which will protect its production and export capacity, and the reorientation of international aid to health.
In health emergencies, especially in epidemic emergencies, one of the most frequent risks is that the new emergency absorbs resources destined for other disease conditions, which – unlike COVID-19 – are more easily preventable and have known therapeutic interventions: common infectious diseases in paediatrics, obstetric complications, vaccinations campaigns, etc. The burden of avoidable morbidity and mortality of common diseases could therefore inflict more damage and claim more victims than the epidemic itself. Indeed, such a burden was seen in the recent Ebola epidemic in Africa. Therefore, the aid and, more importantly, other forms of sustainable assistance that would change the socioeconomic trajectory of African countries – if and when it will be sent in the difficult times we are facing – will have to keep the health system in great consideration.
The data currently available on the pandemic trajectory in a number of African countries are scarce and uncertain due to the limited testing currently performed. They do not allow for an objective analysis to reflect the actual trend . In consideration of the factors discussed above, the trend of the pandemic in Africa should be interpreted by taking into account the following factors: the under-notification of cases, the slower development of the epidemic, a lower incidence compared to other continents.
European experience shows that even with tested information systems, official data are controversial due to poor standardization. Data governance in emergency contexts in Africa is historically difficult. Some evidence also shows that several African countries exert a tight control over public data and information. For example, recently the WHO rebuked the government of Tanzania for its refusal to pass on information on some alleged cases of Ebola, the country denying that it had any such cases. In addition, it is not uncommon for journalists to be subject to intimidation by public authorities for the disclosure of information regarding COVID-19.
Catastrophic predictions were made during previous epidemics (e.g. the AIDS epidemic in the 1980s-90s, the more recent Ebola epidemic, etc.) which, despite the dramatic situation, did not occur. They benefited from massive, albeit often delayed, investments into infection prevention and control, testing, and treatment. Therefore, caution should be applied on the extremely negative predictions of the present pandemic.
Finally, in Africa, particularly in the Sub-Saharan region, there is no nation-wide health system capable of coping with a wave of patients suffering from acute respiratory failure. Provision of intensive care for massive numbers of patients requiring assisted breathing and other organ-failure-support would be very challenging and likely impossible. As in Europe, and likely on a greater scale, any epidemic pressure will have to be addressed with home care under supervised self-medication. And because large-scale diagnostics will not be affordable, it will be necessary to prioritise triage based on clinical case definition or presumptive diagnosis.
• The challenges of tackling Covid-19 in Africa