COVID-19: A Briefing Note for African Contexts

Current extent of spread

As of mid of April, most Sub-Saharan African countries had reported that they are facing COVID-19, totalling over some 10,000 cases, including around 500 deaths. These figures are constantly changing as the pandemic progresses, and cases reported do not necessarily reflect the total magnitude of infection because the amount of testing being done is still very restricted. Thus, reported cases are a considerable under-estimate. Modellers suggest that for every death from community transmission, there are 500-1500 infections. On that basis, sub-Saharan African may already have a pool that is fast approaching 1 million infected people. The early days of the epidemic in Africa appears to be mirroring the early days of the epidemic as experienced in Europe, a few weeks ago.

Based on the current partial data, there appear to be three regional epicentres in Africa: in the south around South Africa, in the west around Cameroon and Senegal and, in the east around Rwanda and Kenya. COVID-19 appears to be following a relentless trajectory on the continent:

In the first phase, with strong trade and education links between Africa and China, travel brought the first few cases. Subsequently, cases were also imported by travellers from Europe.
In the second phase, the initial cases passed on the virus to others and small clusters of cases emerged.
In the third phase, the clusters are coalescing, and the virus spread is becoming more generalized, as community transmission gets established.

Massive testing and contact tracing with isolation of positive cases can slow spread if done meticulously, but it is already too late to completely eliminate the spread in many places. Thus, it is highly likely that community transmission is now progressing in large swathes of the continent. As disease testing, surveillance, and reporting systems become more comprehensive, the availability of more data is likely to show that COVID-19 has become established Africa-wide.

The potential behaviour of the virus in Africa is cause for concern. In favour of a lesser impact is the continent’s youthful demography: only 3% of Africans are aged over 65 years compared to 23% Italians and 11% Chinese. However, younger virus carriers in Africa, even if mildly sick, can still transmit the virus as efficiently as their counterparts in other continents. And conversely, older more vulnerable Africans are more likely to be living in crowded households rather than alone as in Europe. Thus, they have higher inter-personal contact rates, especially in congested urban locations. Note that at least 40% of Sub Saharan African is already urbanised.

Africans have generally less adequate access to water, sanitation and hygiene (WASH). 20% of African families have not reliable access to soap and, in many places, a significant part of household income may be needed to buy water for living purposes. So, water for handwashing may not be prioritised and costs are higher.

African populations have a higher proportion of uncontrolled non-communicable diseases (NCDs), such as hypertension and diabetes, as well as higher levels of tuberculosis (TB), which is now recognised as a risk factor. The higher prevalence of HIV, as well as greater under-nutrition may also have impact on immunity and increase vulnerability to COVID-19.

Finally, the capacities of African hospital facilities are very limited. For example, low and lower middle-income countries have an average of 1-2 beds per 1000 population, compared to around 5 in high-income countries. The same order of differential applies to intensive care beds, and even more scarce are ventilators and staff to operate them. There are only 0.25 doctors for every 1,000 people in Africa, compared to 3 in OECD countries. Therefore, case-fatality ratios may be expected to be much higher in Africa.

Modelling estimates suggest that if the pandemic is not mitigated (i.e. if there is “business as usual”), Africa may expect up to approx. 2.5 million deaths. This approximates, if annualised, to an additional crude death rate of 2.3 deaths per 1000 population, on top of the base death rate of 8.8/1000 i.e. a mortality increase of 25%.

To this excess COVID-related mortality could be added the additional mortality from other treat-able conditions, such as cancers, cardiovascular, and so on, which would be neglected because available health capacities are overwhelmed by the emergency requirements of COVID-19 patients. Comparisons with the Ebola epidemic in West Africa in 2014-2016, and the early years of HIV and AIDS, are pertinent in terms of excess mortality experienced from the neglect of other causes of deaths.

Additional risks and vulnerabilities attach to populations of humanitarian concern, i.e. refugees and IDPs. Forced migration in Africa is common, as a consequence of conflict and violence, climate and environmental disasters, as well as poverty-related, livelihood-seeking migration, often from rural to urban areas. In aggregate, in Sub-Saharan Africa:

The region hosts over 18 million refugees (26% of world total) with large numbers in Uganda, Sudan, Ethiopia, DRC, Kenya.
There are at least 10 million internally-displaced (25% of world total) with the greatest numbers in DRC, Somalia, Nigeria, Sudan, Ethiopia, Sudan, CAR, and Cameroon.

Forced migrants are more at risk from COVID-19 because they are likely to live in congested formal and informal settlements including camps and slums, and to be poorer, more exposed in riskier livelihood-seeking environments, of less legal status and thus less able to access key health and social services, less protected, and less well placed to receive and utilise life-preserving information and advice.

Economic impacts in Africa

African GDP was projected to grow by 3.9% in 2020, but COVID-19 is expected to cut this to +0.3% in an optimistic scenario, or to even shrink it by -3% to -8% on more pessimistic, but realistic scenarios. That translates to a loss of between $90 billion and $200 billion in 2020, including from a 35% drop in imports and exports.

Africa is scheduled to suffer disproportionately in economic terms from COVID-19 compared to a projected 0.5% global growth reduction in 2020. The top two Sub-Saharan economies are Nigeria and South Africa – and the latter, which is also a regional economy driver, is now the African nation that is worst-affected by COVID-19.

This analysis is the base case, assuming that there will be no mitigation from fiscal stimulation packages. The pan-economy impacts on Africa come from disruption to the global economy including lower demand for the continent’s exports, as well as supply chain interruptions, reduced foreign direct investment and remittances, collapsed oil and commodity prices (on which Africa is highly dependent), and tourism decline. Additional impacts come from control measures being taken within Africa such as travel bans, border closures, and lockdowns which affect trade, agriculture, and all types of domestic and regional economic activity, and also lead to lost tax revenues and currency pressures.

Several African governments have announced multi-billion dollar rescue packages, but the challenge is in their trickle- down and targeting, as well as on their productive utilisation, while minimising leakages. Bold actions are needed including new financing instruments, debt rescheduling, and public-private partnerships. Total African external debt is valued at $236 billion and writing that off is a big ask as creditor countries are themselves struggling.

Worst affected are small and medium sized businesses (which cater for 80% of employed Africans). The informal sector is also very important, estimated at 55% of the total sub-Saharan economy. Nearly 20 million jobs are threatened with destruction by COVID-19 impacts. Thus, preserving jobs in informal and formal sectors through governments extending subsidies via employers and social safety nets is crucial not just in the immediate future to maintain resilience but also post-pandemic so that economic activity can re-start speedily when that becomes possible.

The broad economic impacts will put additional pressure on the health sector. There are estimates that African countries will need an additional $10.6 billion health spending on the pandemic. COVID-19 is already creating a shortage of medicines and health equipment everywhere in the world. Africa’s biggest suppliers of health products are Asia and the European Union, and their manufacturers have either reduced or even halted their production or are subject to export controls by governments seeking to ensure adequate domestic availability. So African countries may find it increasingly harder to access or afford healthcare products.

Finally, the direct and indirect consequences of the pandemic are set to deepen inequalities. Africa has been growing well over previous decades and, as it did so, inequalities have been getting worse to the point that its Gini index is the second worst for any continent. While we may expect an infectious disease like COVID-19 to be a “big leveller”, the experience from crises is that risks and vulnerabilities are not equitably distributed and neither are protective measures. As the impacts will be felt disproportionately on more vulnerable and marginalised groups, existing disparities in critical areas such as access to healthcare, food, and shelter would be expected to worsen.

PREVENTION AND CONTROL STRATEGIES IN SUB-SAHARAN AFRICA

Set against the above global context and trends, the scenario that is most likely for sub-Saharan Africa is that of partial or limited containment of the virus in the months ahead. To cope with this requires a nuanced and contextualised approach rather than the wholescale and uncritical application of the policies and practices that have been undertaken in Asia or Europe. Informed by the best scientific advice, but cognisant of the trade-off that are forced by the realities of available resources, capabilities, and infrastructure, Africa is obliged to strike a balance between saving lives now and protecting livelihoods in the longer-term.

Saving lives

Morally and politically, the pressure to save as many lives as possible without undue delay is the imperative pressure on African governments and institutions. They need to:

Expand provision and accessibility to effective hand washing which, in turn, requires wide scale access to soap and water (and alcohol-based sanitiser)
Expand provision of face masks and encourage appropriate use in line with WHO advice
Expand provision of PPE for healthcare workers and other carers of sick people with utilisation according to WHO guidance
Promote physical distancing in daily living, working, and travelling
Make efforts to reduce occupational risks in subsectors of the informal economy such as street hawking, construction, sex work, waste management) through targeted provision of specific advice and self-hygiene promotion materials.
Expand COVID19 testing (antigen, and when available, antibody tests), contact tracing, and isolation of positive cases.
Strengthen public health surveillance and disease tracking, utilising mobile phone and internet technologies, while respecting confidentiality and human rights considerations
Maintain access to preventive and curative healthcare for all other existing conditions while ensuring that general healthcare provision is done safely
Create safe community spaces for self-isolation of contacts, and separately, for the care of sick people if they cannot be isolated at home
Invest in critical intensive-care hospital facilities including medicines, ventilators, oxygen and other supplies and staff for the treatment of seriously ill people who need to go there.

Protecting livelihoods

To protect livelihoods, necessary for resilience against the immediate economic and social impacts of the pandemic, as well as for eventual recovery, government policies and interventions are needed to:

Review the effectiveness of lockdown measures to the minimum period essential for optimal disease control, so that the economy can resume as soon as feasible
In the interim, enable employment to be maintained by subsidising formal sector employers to keep their staff
Consider providing cash transfers as income support for vulnerable families or/and emergency access to food and water (or else people who must work to live may put themselves and others at even greater risk)
Design schemes for subsidies that maintain the small business and informal sector
Give priority attention to food production and distribution and guard against price inflation
Seek private sector partnerships to mobilise additional resources, skills, and capacities
Conduct dialogue with international financial institutions and development partners for concessional finance
Make plans for rapid recovery and be ready to implement them swiftly when feasible, so as to minimise longer-term damage.

A whole-of-society effort

This is an unprecedented crisis and success requires the mobilisation of all elements of society. As learnt from previous health crises such Ebola and HIV/AIDS, that means proactive efforts to build trust with the public through strong community and media engagement to:

Develop and disseminate appropriate messages.
Challenge myths and misinformation, and counter stigma and discrimination.
Maintain essential services that allow the public to access goods and services necessary to meet their basic needs.
Encourage and mobilise large-scale volunteering to meet key gaps among essential service providers who may become sick, or are otherwise needed to expand capacity to meet the needs of isolating and other populations of humanitarian concern, especially in informal crowded settlements and refugee/displaced camps.

What not to do

Of equal importance are negative approaches that include, in particular:

Politicising prevention and control efforts or generating divisions founded on social, economic or religious factors.
Instrumentalising the emergency to make fundamental alterations that may be seen as eroding the principles of good governance and rule of law.
Sending contradictory messages or downplaying the threat or conversely, using alarmist and demoralising messages.
Using penal enforcement methods that infringe on fundamental human rights, and which can cause panic, backfire, or stigmatise.
Closing down all essential services such as food outlets and imposing extremely harsh quarantine restrictions thereby forcing people to take even greater risks to obtain their critical daily survival needs.
Blindly replicating practices from elsewhere – however apparently good – without assessing their appropriateness, feasibility, and acceptability in specific national and local contexts.

The nature of the spread of COVID-19 is such that although it may have generated a global pandemic, durable solutions are ultimately local ones. They depend on the empowerment and willing participation of people and communities who are required to take personal responsibility including by making considerable sacrifices aimed at keeping themselves and others safe.

Prof. Kapila has extensive experience in global and public health, international development, humanitarian affairs, conflict and security issues, human rights and diplomacy, and social entrepreneurship, with substantive leadership roles in government, United Nations system and multilateral agencies, International Red Cross and Red Crescent, civil society, and academia.