Within days of his inauguration in June, Evariste Ndayishimiye, Burundi’s president, ended months of official denial about coronavirus by ordering mass testing in the commercial capital of Bujumbura. Well he might. His predecessor, Pierre Nkurunziza, who had scoffed at the virus and entrusted Burundi’s protection to God, paid a heavy price for his nonchalance. He died, almost certainly of Covid-19 itself.
After months in which Africa escaped the worst of the coronavirus pandemic as the global centre shifted from Asia to Europe and then to the Americas, the number of African infections — and deaths — has begun to increase sharply. At least 14,500 people have now died out of 667,000 confirmed infections. That has raised concern among some experts that the world’s poorest continent may be about to enter a critical phase of the coronavirus outbreak.
“The pandemic is gaining full momentum,” says John Nkengasong, director of the Africa Centers for Disease Control and Prevention, which has mounted an effective continent-wide response. As transmission of the virus gathers pace, he warns, the danger is that “our hospital systems will be overwhelmed”.
That is already happening in South Africa, the worst affected country on the continent, where confirmed cases are doubling every two weeks and intensive care wards in Johannesburg and Cape Town are overflowing. At the current rate, more than 1m people will be infected by early August.
Deaths have topped 5,000, and the number of fatalities is escalating sharply. One health official caused panic by suggesting, erroneously, that Gauteng province was preparing 1.5m graves for the dead. Cyril Ramaphosa, the president, in a speech in which he compared the virus to a storm blowing in with the cold winter winds of the southern hemisphere, warned that few parts of the country would be spared.
Not all of Africa has been severely struck. Some countries, such as Botswana, Namibia and Gambia, have registered few infections and barely any deaths. The island of Mauritius successfully stamped out an early rash of imported infections and has not recorded a single case of local transmission for nearly three months.
“At the beginning, we thought we were going to see a massive disaster,” says Mo Ibrahim, a Sudanese businessman who is the head of an eponymous foundation. “The numbers so far don’t show that,” he says. “African governments probably responded better than governments in the UK or the US. And fortunately, in Africa, the virus doesn’t seem to like us.”
‘A new phase’
However, new spikes of infections in several African countries are clouding such optimism. Of the states that have been harder hit, more than half of recorded cases have been in just five countries — South Africa, Egypt, Algeria, Nigeria and Ghana — although that partly reflects their higher testing capacity.
But the pandemic has spread much further than that. According to the World Health Organization, in 22 of the continent’s 54 countries, cases have more than doubled in a month, with states such as Ethiopia, Kenya, Cameroon and Djibouti showing sharp rises. After a long period in which most infections in Africa were imported, mainly from Europe, two-thirds of countries on the continent are now reporting community transmission, the WHO says.
Malawi, a tea-producing country of 18m people in southern Africa, is a case in point. On the face of it, its numbers look reassuring, with just 51 deaths and around 2,700 infections by mid-July. But healthcare workers say they are starting to see a significant rise in infections.
“Our first case was in early April and since that time we have had this very gradual trickle, trickle, trickle,” says Mina Hosseinipour, professor of medicine at the University of North Carolina’s Malawi project in Lilongwe, the capital. “We were like: when is this thing going to come?”
The lack of deadly infections was all the more remarkable, she says, given a series of blunders that might have been expected to spell disaster. Many of the Malawians who were sent home by the busload from South Africa, where they had been working, returned with Covid-19. Some escaped from ill-equipped quarantine camps, risking spread in their communities. Nor was Malawi’s government able to impose a lockdown after civil society groups, concerned at the dire impact on people’s livelihoods, successfully challenged the measure in court. Like Burundi, Malawi even ran a national election, the incumbent losing power in a rerun of last year’s poll.
Yet, despite these potential superspreader events, deaths from the virus in Malawi remained stubbornly low, says Prof Hosseinipour. Until now. “The last two weeks is changing our perspective,” she says, adding that more deaths are being registered and many more people are coming to hospital seeking emergency respiratory care. “The new government is mandating face masks across the country and recommending more serious isolation and social distancing measures,” she says of the sense of urgency the rise in infection has engendered. “We have entered a new phase.”
Huge gaps in the data
The recent experience of Malawi, and many other African countries like it, has tempered, if not entirely scotched, early hopes that the continent might somehow avoid the worst of the pandemic.
“What we are seeing is just the effect of the delayed timeline,” says Francesco Checchi, professor of epidemiology and international health at the London School of Hygiene and Tropical Medicine, who adds that the disease came late to the continent. “I don’t really see any evidence that we’re seeing a qualitatively different course of the pandemic in Africa.”
Prof Checchi says that countries with good air links to the rest of the world, such as South Africa, Egypt and Morocco, were the first to import “seed cases”, causing the pandemic to spread more quickly. He praises early efforts by many African governments — all too familiar with the threat of infectious diseases such as tuberculosis and Ebola — to contain the virus through screening, public health campaigns, curfews and lockdowns. But in the end, he says, this is just a delaying tactic. “Lockdowns only gain you time.”
Sema Sgaier, executive director of Surgo Foundation, a non-profit organisation, agrees that the pandemic has much further to run in Africa. Her foundation has compiled an index from open source data of regions most vulnerable to the social, economic and health impacts of Covid-19. Among those highlighted are Cameroon, the Democratic Republic of Congo, Madagascar, Malawi, Ethiopia and Uganda — all countries where the pandemic is yet to really take hold.
There remains some cause for cautious optimism, Prof Sgaier says. Even if the virus ends up spreading as widely in Africa as in Europe and the Americas, it is likely to kill fewer people, she says, because of the continent’s more youthful population. Africa has a median age of 19.4 years against 38 in the US and 43 in Europe.
Based on age and gender distribution, the Surgo Foundation estimates Africa’s infection fatality rate — the proportion of deaths among those infected — at 0.1 to 0.15 per cent. Adjusting for the poor quality of health services with a lack of oxygen and ventilators as well as for co-morbidities, such as HIV/Aids, it puts the infection fatality rate at an average 0.55 per cent, with the best countries in Africa at 0.22 and the worst at 0.76 per cent. That compares with 1.3 per cent in the US, meaning that an African infected with Covid-19 is between twice and six times more likely to survive than an American.
Still, even if those lower estimates prove correct, it implies that, if 60 per cent of Africans eventually become infected, more than 4m will die.
Such calculations are guesses at best. Researchers have to take into account estimates for the rate of non-communicable diseases for which data is almost non-existent in many countries. Diseases such as hypertension and diabetes, which raise the probability of death in Covid-19 patients, are almost certainly lower in many African countries than in relatively affluent South Africa, where such co-morbidities help explain the higher number of deaths. With a median age of 28, South Africans are also nearly a decade older than the rest of the continent.
The task of modellers — who must also juggle factors such as malnutrition and HIV — is further impeded by limited records of deaths in many countries. This has forced statisticians researching some countries to turn to satellite imagery of graveyards for clues about the so-called “excess deaths” that may be down to Covid-19. “We’re really fumbling around in the dark here,” says Prof Sgaier.
There is also tentative evidence emerging that African countries may have a high prevalence of asymptomatic cases thanks to its young population. An antibody study conducted by the Mozambican government in the northern city of Nampula with a population of 750,000 found that some two-thirds of people infected had suffered only very mild symptoms or no symptoms at all.
In addition, the study found that 5 per cent of people in the community and 10 per cent of market vendors had been infected with coronavirus. Yet only four Covid-19 deaths have been recorded in Nampula province out of nine in the country as a whole.
Even Mr Nkengasong at the Africa CDC, who has strongly cautioned against complacency, acknowledges that the continent’s young population means the death rate is likely to be lower. “We see these young people running around with Covid, just living their lives normally,” he says. “But we need to back this up with appropriate studies.”
A plea for more testing
This competing evidence makes it difficult for African governments to determine what to do next. But, say researchers, they must persevere with policies to mitigate risk. There is a middle way between full lockdowns — difficult to maintain in poor communities — and letting the pandemic take its course, they say.
Cooper/Smith, a Washington-based professional services organisation that uses data to inform policymakers, has run statistical models indicating that social distancing could stop millions of infections and save 9,000 deaths in Malawi alone. Hannah Cooper, its managing director, says: “African countries don’t need to make a Sophie’s choice” between damaging lockdowns and “letting the epidemic run rampant”. Even in the absence of robust data, she says, there is enough information to tailor responses to specific communities.
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Ibrahima Kassory Fofana, the prime minister of Guinea, says his government has implemented mitigating measures that stop short of full lockdown. Its experience with the 2014-16 Ebola epidemic — which killed more than 11,000 people in west Africa — has stood it in good stead, he says. Guinea has closed its airspace, encouraged hand washing, banned mass gatherings, including in churches and mosques, and sealed off the capital, Conakry, from the rest of its territory. The country of 13m people has recorded 6,200 cases with 38 deaths.
“In terms of managing the pandemic, so far it is under control,” says Mr Kassory Fofana. “We are optimistic because our population is much younger.”
The second lesson is that more testing is urgently required. South Africa is testing around 50,000 people a day and countries such as Djibouti, Ghana and Morocco have made concerted efforts to test widely. Yet, according to an analysis by Reuters, African countries had on average tested 4,200 per 1m people by July 7, compared with 74,255 in Europe.
Strive Masiyiwa, a Zimbabwean businessman appointed as a special envoy of the African Union, says that a pan-African medical supplies digital platform he has helped establish should enable a massive ramp-up in testing capacity. The platform, which went live in July, is backed by a $3.8bn credit line from the African Export-Import Bank. It allows African governments and organisations to pool their orders, making it easier to benefit from bulk pricing.
“There is now no excuse to say we can’t get test kits and therefore we can’t test,” says Mr Masiyiwa, who adds that governments can also use the platform to equip hospitals with oxygen units, protective equipment, medicines and ventilators in preparation for a coming wave of infections.
Armed with greater testing capacity and policies aimed at slowing the spread of the disease, many African governments are gearing up for the next, possibly more serious, phase of the pandemic.
In the coming months, says Prof Checchi of the London School of Hygiene and Tropical Medicine, some countries will have to move from the suppression stage to one where they seek to reduce the impact of the virus.
“There is no shame in saying that we cannot suppress this epidemic for another year and a half until we get a vaccine,” says Prof Checchi. “That we are going to try to mitigate it through social distancing, curtailing unnecessary gatherings and subsidising soap and water,” he says. “A few policies like that can make a significant difference in terms of the ultimate death toll.”
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