At the beginning of the COVID-19 outbreak, there were dire predictions about the spread of the virus through Africa. The continent was deemed a high-risk area for the spread of this deadly new disease.
However, six months into the pandemic and Africa has largely bucked the trend. While European and American countries have seen deaths in the tens of thousands – and healthcare systems straining to cope – we are yet to see the same scenes play out in African countries.
As St George’s University of London, in partnership with Ilara Health – a Nairobi-based health-tech company – launch a new course exploring how African primary care workers can manage the outbreak, we spoke to Mohammed Razai – Academic Clinical Fellow in Primary Care at St George’s, University of London – and Maximilian Mancini – Chief Strategy Officer at Ilara Health – about what COVID-19 looks like on the ground in Africa.
How has Africa fared so far?
According to Mohammed Razai, “the apocalyptic predictions that COVID-19 would unleash catastrophe in the African continent, thankfully, has not yet come true. According to the WHO, Africa is the least affected part of the world with only 1.5% of the global COVID-19 cases and 0.1% reported deaths.”
This goes against initial predictions, which were, he says “rightly gloomy”. After all:
Most African countries are low or middle income with very fragile, resource-poor health systems both in terms of health infrastructure – Burkina Faso has nine intensive care unit beds – and scarcity of human resources such as frontline caregivers – most West African countries have less than two doctors per 10,000 population, compared to, for example, Italy with 41 doctors per 10,000 people. There are also significant problems around access to water, sanitation, and hygiene.
In spite of this, while Western countries have struggled to contain coronavirus, African nations have, by-and-large, coped relatively well. South Africa has seen the highest number of deaths from COVID-19 on the continent, with almost 1,000.
How has Africa controlled COVID-19?
Maximilian Mancini at Ilara Health argues that this is the result of a mixture of factors. Governments in many African countries were “fairly quick with their internal responses”, with South Africa fully shutting the country down, and Nigeria and Kenya enacting “curfews, suspension of international flights, and restricted local movement”.
Mancini also points to Africa’s youthful demographic as key in keeping death rates low. It has been established that COVID-19 is most dangerous to people over 75 – the median age in Africa is 19.7. He also argues that “previous immunization campaigns across the continent such as the BCG vaccines against TB could be playing some role as well.”
Razai says that African countries had an advantage that many ‘developed’ nations lacked – an existing healthcare response network to outbreaks of infectious diseases, particularly in relation to the Ebola virus.
“Although Ebola is a completely different disease,” he explains, “the containment measures are essentially the same: self-isolation, contact tracing, and behaviour change such as physical distancing and hand hygiene. Many countries with recent Ebola outbreaks are repurposing their isolation facilities and have mobilised effective contact tracing in their communities.”
Ebola responders are traveling to Bikoro, Equateur in western #DRCongo to talk with people, roll out contact-tracing & vaccinate. I can say from experience, it’s physically painful to travel roads like this for 10+ hours. And that’s why I admire the work. pic.twitter.com/IhPoOWefKy
— Amy Maxmen (@amymaxmen) June 9, 2020
What challenges does COVID-19 still pose for Africa?
While the pandemic is so far yet to explode across the continent, both Razai and Mancini are keen to stress we are still in the foothills of the outbreak, and African healthcare systems face multiple challenges in the months ahead.
Access to testing for the virus – crucial to gauging its spread – is often limited at best. According to Mancini:
This is a function of a limited number of labs able to run PCR testing, weak and fragmented private healthcare systems that hinder point-of-care rapid testing, and an equally weak supply chain hindering the uptake of testing capacity. All of this is also exacerbated when taking into account the global competition for various testing supplies, where African countries struggle to compete with Western countries in securing scarce supplies.
Nevertheless, Razai points out that, “the African Centres for Disease Control and Prevention (CDC), which was established in 2016, has been very effective in coordinating a continental response in conjunction with the WHO. It expanded testing capacity as far back as February and has acted swiftly in containment strategies”.
Mancini agrees that “testing capacity has been increasing, with countries such as Kenya receiving donated mobile labs and local supply efforts”.
Do African primary care workers have access to PPE?
Testing is just one part of the picture regarding how primary care workers can manage COVID-19. The (limited) supply of personal protective equipment for doctors and nurses has been a big issue in the West. So far, this has been less of a problem for Africa.
Mancini believes there are three reasons for this. The current low number of cases is yet to strain the centralised healthcare systems that provide protective equipment. Social stigma around COVID-19 means many with symptoms might be staying home, rather than seeking care.
And, if “caseloads could dramatically increase in the coming months (as is still the general consensus), limited adherence to standard of practice around infection prevention control (IPC) and PPE management might result in significant material recycling, thereby lowering the need for PPE.”
For Razai, Africa’s response to the limitations of its healthcare systems – preferring preventative measures such as self-isolation and nationwide lockdowns – brings with it its own issues:
“Self-isolation of the vulnerable groups such as the elderly and those with underlying health conditions is more difficult [in Africa] as families are on average larger and several generations live in the same household, hence the risk of viral transmission within families is high.”
Meanwhile, the lack of PPE has also provoked strong local responses and shown the ingenuity of African entrepreneurship. In Kenya, “local entrepreneurs have been re-purposing their 3D printers to print face shields”, while in Nigeria “local tailors have begun creating cloth masks.”
In preparation for a rise in #coronavirus cases in #Kenya, local #3D printing companies are designing printing personal protective equipment and parts for medical devices to address the expected medical equipment deficit in the country. https://t.co/UtfFYG2LOz
— Afrika-Verein (AV) (@afrikaverein) April 20, 2020
It’s also important to remember that the African response hasn’t been homogenous – each country has reacted to the pandemic in its own way. While countries like South Africa, Nigeria, Kenya, and Uganda opted for strict early lockdowns, Ghana and Malawi have had limited or no lockdown measures.
As Razai argues, “For many low- and middle-income countries in the region, the challenge is a trade-off between saving lives from COVID-19 and the potential loss of more lives from poverty and malnutrition, social unrest, and economic collapse.”
What challenges does Africa face against coronavirus?
Moving forward, the continent’s ability to test for the virus remains limited, a fact that Mancini says, “hinders primary care health workers from being able to identify those with the virus.”
The region also faces challenges around “education and information sharing, with the primary care infrastructure across the continent rarely receiving the same level of educational support and training experienced in the more developed parts of the world”. And, finally, he says, the stigma around coronavirus means “patients suffering from COVID-like symptoms are less likely to seek diagnosis and, eventually, care.”
There is also a danger that the focus on COVID-19 takes attention and resources away from other infectious diseases that haven’t gone away. Only recently, a new outbreak of Ebola was confirmed to have taken place in the Democratic Republic of Congo.
Five people, including a 15-year-old girl, have died of Ebola in a fresh outbreak of the virus in the Democratic Republic of Congo, UNICEF says. Nine cases total have been reported, according to the organization. https://t.co/ieHdTS5xol
— CNN (@CNN) June 2, 2020
Mancini points to worrying drops in visits to care clinics, saying that, “this is rapidly becoming a central issue across the continent”.
Razai similarly argues that, “COVID-19 can divert resources away from routine primary and community care such as childhood immunisations. UNICEF estimates at least 80 million children under the age of one will be at risk of preventable diseases due to disruptions caused by COVID-19, including on the African continent.”
Nevertheless, how Africa has managed the pandemic so far has given cause for hope – and shown how preconceptions of disease management in the West were skewed.
Many assumed that Europe and America would cope, while Africa would be swamped – instead, the opposite has occurred. Africa has so far used its prior expertise in disease management to keep the virus at bay.
How confident should we be about Africa’s continued response?
Mancini says he is “cautiously optimistic” about the future of the pandemic in Africa. “We are talking about a continent with…possible demographic traits, local ingenuity, and a long history of having to respond to widespread disease outbreaks”. This gives him “some comfort that the continent might be spared the worst”.
For Razai, “the African continent is particularly vulnerable and its initial success in containing the virus does not mean it is out of the woods.” He believes that “developed countries should step up and respond generously to the UN Humanitarian response plan to fund PPEs, testing kits, medical equipment, immunisations campaigns, and procurement of essential food and sanitation supplies.”
Only international collaboration and sharing of data and expertise can stop the virus in the long term. As Mancini puts it:
“A complete understanding of the virus and its various manifestations will be key in the approach the world takes to manage future outbreaks.”
To learn more about Africa’s response to COVID-19, and how primary care workers can help patients in low-resource environments, sign up to COVID-19 in Africa: Managing the Outbreak in Primary Care Settings from St George’s, University of London.