Covid-19: I’d still rather be in Africa, but maybe not next year
- New modelling and data vindicate my prior view that Africa will be less badly impacted by Covid-19 than other regions
- Fewer people will die in the WHO Africa region than in the US this year, but Algeria and South Africa are hotspots
- The virus will drag on for longer in Africa — bad for Ethiopia, South Africa and East Africa, which rely on tourism
At the end of January, I stood beside Murchison Falls with my family, drenched in the spray of the world’s most power waterfall, and I reflected on how much can change in a generation. Central Africa is under tremendous pressure to generate more power, and Uganda, with its many lakes and rivers, is working to meet this demand with hydropower. The combination of plans to dam the Victoria Nile, which would hobble the mighty Murchison Falls, and the certainty of oil exploration in nearby Lake Albert, which will industrialise the most remote of Africa’s Great Lakes, will transform the area fundamentally over the next generation. My children’s children might never have the opportunity to experience the falls as I did that day.
The world can change in a generation, but it can also change in a month. When I passed through Kigali airport two days later, on my way to Cape Town, my biggest concern was whether I would be able to find a bottle of my favourite Rwandan beer, Virunga Mist, named for the great gorilla parks of Central Africa, for my father-in-law. When I passed through Kigali two weeks later, on my way home to London, I was stopped and screened by Rwandan health officials in head-to-toe PPE before being allowed into the terminal. I still managed to pick up a bottle of Virunga, but my biggest concern was Covid-19. It was 7 February.
The world had changed completely in Kigali, but not in London, where Gatwick airport showed little evidence of preparation for virus; indeed, the most interesting change in the signage was spotting whether the British flag had or had not been removed from the lists of EU member states. Reflecting on this, I wrote for Tellimer that, with the threat of Covid-19, I would rather be back in Africa. It’s fair to say that this view encouraged some significant scepticism. Now, with the virus well-underway and much better understood, I want to reflect on why those initial thoughts were correct and what might come next.
Africans are relatively well positioned to survive Covid-19
Modelling released by the WHO regional office for Africa predicts that 150,000 of the c1bn people in the 43 countries of the WHO Africa region could die of Covid-19 over the first year of the virus if containment and Covid-19 spreads out of control. While this sounds like a large number, consider that the US, with only one-third of the population of the WHO Africa region and the virus not yet having spread evenly across that population, has already had 120,000 Covid-19 deaths. Similarly, modelling in the UK predicted half a million deaths without containment, and that in a country of only 67mn people. Comparing the modelled outcome for Africa in 2021 with the current situation in the US is striking, especially bearing in mind that the virus is moving south and west from the initial epicentre in the northeast.
Figure 1: Modelled deaths per 1,000 population (green = more deaths; purple = fewer deaths)
Figure 2: Many US states already have a higher rate of deaths than is expected in many African countries across the entire first year of the epidemic (thresholds for the colour bands are identical in Figures 1 and 2)
This isn’t because fewer people will get the virus. The US’s 120,000 deaths have come from 2.3mn confirmed cases, whereas the WHO’s model predicts 37mn symptomatic cases in the Africa region, 4.6mn of which would be severe enough require hospitalisation were that available. The US’s 120,000 deaths have come from 2.3mn confirmed cases, whereas the WHO’s model predicts 37mn symptomatic cases in the Africa region, 4.6mn of which would be severe enough to require hospitalisation were that available. A comparable estimate of confirmed cases would sit somewhere between these two bounds, at least twice the level as in the US. The modelled data shows a much lower case fatality rate—the number of confirmed cases that result in deaths—in Africa.
Data on the progress of the epidemic so far support this view. As of 24 June, Africa had a case fatality rate of 2.2% compared with 7.5% in Europe and 5.2% globally. Given that limited testing means that Africa is likely only detecting the most serious cases, even at 2.2%, Africa’s case fatality rate is likely to be overstated. The simple fact is that Africa does better because Africans are better positioned to survive Covid-19.
Figure 3: Africa has the lowest Covid-19 case fatality rate of any of the WHO regions (%)
Many of the positive factors that I originally identified seem to have played out as expected:
Africa’s young population has proven to be much less susceptible to Covid-19 than older populations in other regions of the world;
Africans travel very little, limiting the spread of the virus; and
Density is low, with few indoor public spaces, also limiting to the spread of the virus.
Africa has also benefitted from some factors that I did not fully appreciate. Most notably, Covid-19’s comorbidities all appear to be diseases of wealth, but not diseases of poverty. When I modelled global Covid-19 vulnerability, I used a standard set of comorbidities including diseases, like tuberculosis and HIV, that are more prevalent in Africa, and those like cardiovascular disease, that are more prevalent in wealthier countries. A more focused comorbidity model that includes obesity produces a result that looks much more favourable for sub-Saharan Africa, but with higher levels of vulnerability in South Africa and across North Africa.
Risks play out as expected: Autocrats take advantage and health systems struggle
Meanwhile, some of the risks that I expected have also played out. Authoritarian leaders have used Covid-19 as an opportunity to assert greater control of society. Less than a week after the Ugandan constitutional court struck down a law making it illegal for more than three people to gather without informing the police, President Museveni banned public gatherings as part of Uganda’s Covid-19 lockdown. Moreover, low capacity health systems, even relatively advanced ones like South Africa’s, have struggled to cope with even a low-level of serious Covid-19 cases. Indeed, the other conditions that fail to be treated while health systems focus on Covid-19 may be one of the greatest impacts of Covid-19 on the health of Africans.
Figure 4: A comorbidity model focusing on the established comorbidities for Covid-19, like obesity, shows a more positive picture for Africa (green = better score; purple = worse score)
Slow burn of Covid-19 could be a disaster for African countries that depend on tourists
Meanwhile, the jury is still out with respect to some aspects of Africa’s Covid-19 experience. Despite my positive experience with the border check in Rwanda in February, which were clearly a reflection of Rwanda’s experience fighting Ebola, there is no aggregate evidence to say whether this has helped to slow the virus. I would argue that the experience of Ebola caused many African countries, including Rwanda, to choose to lock down more strictly and sooner than they might have otherwise done. However, the significant period during which a carrier of the virus is infectious, but asymptomatic, may undermine the value of screening capabilities built to counter Ebola in the fight against Covid-19.
Another of Africa’s health legacies, South Africa’s sophisticated system for tracing tuberculosis and HIV, has similarly proven to be less useful than anticipated. While South Africa has plenty of trained contact tracers, a workforce that developed countries are now trying to build, weaknesses in testing have undermined their usefulness. When tests take 14 days to turn around, contact tracing has little value, as infected people will have spread the disease extensively—much more so than even the greatest philanderer could spread HIV in a fortnight. To get full value from their legacy public health capabilities, African countries will need to adapt them to the specific nature of Covid-19.
Even if a vaccine is developed early next year, Covid-19 will remain an issue for Africa for several years, if not longer. The reality is that vaccine doses will go to wealthier countries first, and the combination of limited availability of the vaccine internationally and patchy health systems to deliver it domestically, means that most Africans will have to wait a long time to get vaccinated, if they are able to at all. Meanwhile, lower transmission rates than in other regions mean that the virus will slowly move around the continent, flaring up and then dying down in rural areas, and persisting in cities. As Dr Matshidiso Moeti, the WHO Regional Director for Africa, has put it:
“While Covid-19 likely won’t spread as exponentially in Africa as it has elsewhere in the world, it likely will smoulder in transmission hotspots. Covid-19 could become a fixture in our lives for the next several years unless a proactive approach is taken by many governments in the region.”
This will be bad for countries that rely on international tourism, like Egypt, Ethiopia, Tanzania and the rest of East Africa, South Africa and Namibia. Many western tourists are delaying international travel until next year. If the Covid-19 epidemic is still simmering in Africa without a clear end in sight in early 2021 when people plan for travel that summer, then they will go elsewhere. International tourists already need a vaccination card as long as their arm to visit most of sub-Saharan Africa, but many tourists will feel that taking a new vaccine for a virus that they are highly likely to encounter is a higher, and unacceptable, level of risk. The supply of tourism may also be limited. Indeed, South Africa’s Department of Tourism has already stated that international tourism won’t resume before February 2021.
Figure 5: A prolonged course for Covid-19 will be particularly damaging for economies in East Africa that rely relatively more on tourism (purple = more vulnerable; green = less vulnerable)
 Cabore JW, Karamagi HC, Kipruto H, et al. The potential effects of widespread community transmission of SARS-CoV-2 infection in the World Health Organization African Region: a predictive model. BMJ Global Health 2020;5:e002647.
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