Low infection and death rates perplex scientists
Wednesday January 27 2021
The World Health Organisation’s Africa regional office was predicting up to 190,000 deaths and between 29 million and 44 million infections in the first year of the pandemic alone. However, this was not to be. What were these assumptions based on, and what has made Africa different?
When Covid-19 began to spread globally at an alarming rate, many institutions and scientists felt a sense of apprehension and fear for the African continent. Their fear was rooted in the belief that most African countries had overstretched and underfunded health systems, combined with the large numbers of people with infectious and non-infectious diseases that the continent was already grappling with. So the predicted figures came as no surprise.
However, whilst Africa accounts for 17 per cent of the global population, it only has 3.4 per cent of the reported global Covid-19 cases and a similar margin of deaths. This has come as a shock to the world, especially when it became clear that the numbers in Africa were much lower than any other continent. In hindsight, many were quick to forget the experience the continent has had managing previous outbreaks including HIV/Aids, Ebola, cholera, malaria, and even polio and measles for the younger population.
Several African countries have experienced Ebola outbreaks, the largest having occurred in 2014 in Liberia, Sierra Leone, and a couple of neighbouring countries. The approach of hygiene, testing, and isolating cases and tracing contacts that has been successfully used during Ebola outbreaks came in handy when Covid-19 came to the continent. Many countries already had the necessary experience and infrastructure to be quickly mobilised and deployed.
Additionally, Africa reacted faster in efforts to curb the disease than any European country or the US. The fact that the virus spread to the African continent later than other regions gave us the time “to learn and unlearn” before it was too late. We had the benefit of time, which allowed us to see the consequences of late action. We saw the devastating consequences the outbreak had on health care systems in Italy and Spain. More importantly, we could also see that a different outcome was possible with quick action. South Korea and Vietnam were already posting much better results than Italy and Spain. This was definitely an added advantage in fighting the pandemic. The rate of the spread and the level of impact of the outbreak was recognised early, and preventative measures could be put in place at an early stage. Countries that quickly deployed surveillance measures were those that were still doing Ebola surveillance at points of entry due to the outbreak that was still ongoing in DRC.
Many believe that African countries are reporting low rates of infection due to their limited testing capacity. Could this be the reason the figures from the continent seem exceptionally low, in comparison to the global North?
It is not a secret that several African countries have been facing a shortage of testing kits, thus raising concerns that the continent’s relatively low number of reported Covid-19 cases was and is still due to lack of testing. The lack of adequate testing is however not just an African phenomenon. With the exception of a handful of countries in Asia, many countries are grappling with this. Ideally anyone who needs a test should get it, but this is not the case.
Without mass testing in countries like Italy, Spain, UK, and USA the number of cases have overwhelmed health care systems. One could argue that if there were tens of thousands of undetected cases in African countries, the severe cases would have already overrun the health facilities. This is not the case so far.
So can we really trust the statistics from African governments? In reality, this will vary from country to country based on their ability and method of testing large numbers and the phase of the outbreak they are in. One can never tell whether all cases are being detected, however the numbers are more likely to be closer to what is being reported than the millions predicted. Countries are doing surveillance and testing cases of acute respiratory illnesses, targeted testing in high-risk groups such as frontline healthcare workers, truck drivers, and law enforcement. Additional testing is done for contacts of cases. Test positivity rates (the percentage of cases out of the number of tests conducted) vary widely across the region. Rates above 5 per cent are of concern because they indicate widespread transmission.
How did African countries’ public health response to the pandemic differ from the larger global response? And did this play a role in curbing the spread of the virus?
The continent’s response preceded the reporting of cases by many weeks. Countries instituted checks at ports of entry, started tracking travellers from high-risk countries and public education campaigns as early as late January/early February. Most African countries had already established Ebola national task forces; a few in East Africa were still doing Ebola surveillance, so it was easy to repurpose their disease surveillance systems. In Sierra Leone, which was ravaged by the Ebola virus, lessons from the Ebola pandemic were implemented to curb the spread of Covid-19. One of these was the declaration of a state of emergency throughout the country starting from March 25, 2020, even before the first case of Covid-19 was reported in the country. Several countries banned large gatherings and closed schools before even the first case was detected.
This means that countries were already in response mode when the first cases were reported and not caught flat-footed, as has been seen in the worst hit countries in the North. The Africa CDC and WHO have also been instrumental in quickly developing tools and protocols that countries could use to make choices on the most suitable interventions based on the stage of the outbreak in each country. One key feature of the response of Africa is the strength of regional institutions like Africa CDC and WHO Afro – the coordinated approach and the fact that African countries actually took their advice.
Some scientists believe that Africa has been spared the brunt of the virus due to reasons that include a larger youth population, regular exposure to other infectious diseases, and even genetics. What’s your take on these assumptions?
While they might be true, such assumptions are also grounded in the belief that Africans have no agency and things happen to us because of factors outside our control. There have been several other hypotheses floated around, including the hot weather, BCG vaccination, and cross-immunity from other coronaviruses. There are many factors that could explain why Africa has been spared the worst of the pandemic. First and foremost, we must give credit where it is due: That our governments acted first (or fast??) and prevented the virus from spreading uncontrolled before taking serious measures. Second, we must give credit to our regional bodies for reacting quickly and providing advice and guidance to our governments. Third, we must give credit to the African scientists who have been advising governments and customising the response to local contexts. Fourth, we must give credit to the Africans who have taken measures to slow down the spread – hand hygiene, respiratory hygiene, and social distancing. This has come at a great cost to people’s social, economic, and mental wellbeing. We should never minimise that.
Now back to the other theories: Of course the youthful population may mean that most Covid-19 cases have no symptoms or are mild and hence are out there in the community undetected. The hot weather may slow down the spread since the virus may not survive as along in hot as in cold weather. The social interactions in majority of African communities are different. Work in rural areas means walking to the field with one’s family and spending the day outdoors – not taking a crowded commuter train to work in a closed space with strangers. Another plausible theory is that Africans may have what is called cross-immunity, where previous exposure to other coronaviruses has made our bodies resistant to this particular one. The jury is still out there on some of these theories.
For now, I want to go with the agency and ingenuity of Africans – it’s what has brought us this far and it is what will see us through the worst of this pandemic.
Catherine Kyobutungi is the Executive Director, Africa Population and Health Research Centre
This article was first published in a pullout in The EastAfrican on December 5, 2020.