COVID in AFRICA
Why has Africa been
less severely hit?
Africa, a continent of 1.3 billion people, has seen fewer deaths from COVID-19 than the UK, which has a population about a 20th of the size.
Inevitably for such a huge landmass, there are major variations, with South Africa in particular experiencing high rates of infection and death. But, in general, official rates have been perhaps surprisingly low.
Half of the COVID-19 deaths registered in Africa up to the beginning of March occurred in South Africa.
But the continent has one of the lowest death rates, comparable to Asia . Only Oceania has a lower death rate.
These pale into insignificance when compared with Europe and the Americas which have seen proportionately far more people die.
So why is the official death rate in Africa so low?
In the early stages of the pandemic, some modellers suggested that because of the "inadequate healthcare systems and personnel" in a number of African countries, the impact could be "catastrophic".
Others said, even if restrictions were imposed, the number of people infected in many countries could be between two-fifths to a quarter of the population in the first 12 months.
That year is over, and so far the fraction of people testing positive across the continent is much smaller and far fewer have died than expected.
Some of the theories as to why Africa appears to have been less badly affected so far are laid out below:
Early lockdown
A number of theorists have said that early and decisive action in many African countries was a major factor in keeping cases low, not just at the start, but as the months went on.
Numerous states imposed lockdowns of varying degrees, with restrictions such as curfews, bans on gatherings and international flights, border closures and other measures, many tougher than those employed in some countries in the West.
In October, the World Health Organisation praised Africa's COVID response, saying it had created a window of opportunity to keep case numbers low, and it was to some extent why the continent was not "seeing evidence of excess mortality" due to the virus.
Imperial College London's Dr Patrick Walker, who, along with Dr Oliver Watson led a modelling study that predicted tough restrictions would have an impact in low income countries, said the early lockdown made a difference.
He told Sky News: "Speed of the response was something we identified in our early analysis… and will almost certainly have played a major role in reducing the relative size of the first wave in many African countries."
He continued: "We identified 38 African countries that had implemented strategies to suppress the disease (e.g. curfews, movement restrictions etc.) and 34 in Europe and Central Asia.
"At the point these measures were implemented, European and Central Asian countries had… on average, a 150-fold higher reported death toll than those in Africa when adjusted by population-size.
"As we know too well in the UK, reacting rapidly has major benefits.
"It… seems… highly plausible that these efforts not only reduced the impact of the first wave in those countries but also reduced the speed at which new strains… were likely to emerge - with demonstrable benefits for other countries including here in the UK."
Some, however, have questioned whether Africa's stringent measures were the main driver for low infection rates early on. A team of mostly African academics, in the early stages of their careers from a range of worldwide universities, have pointed to the fact that Zambia, which "did not fully implement… interventions... as well as other countries that struggled to put into action… interventions, reported no significant increases in deaths compared to countries with more robust responses".
Age structure
One of the early findings from China, which was later borne out by what happened in the UK and elsewhere, was the extent to which COVID disproportionately affects the elderly.
Africa has a very youthful population compared to many Western countries.
The UK has identified that the vast majority of deaths from COVID occur in the over-70s (83%), which was used as the justification for including older age groups in the earlier rounds of vaccination.
Indeed, researchers from Washington State University, Liverpool University and various institutions in Kenya pointed out early on that the higher case fatality rates around the world were seen in places like Italy and the US – which have median ages of 45 and 38 - yet nations like Nigeria, which by May had seen only a few hundred fatalities, has a median age of 18.
Weather, environment & resistance
The Washington/Liverpool/Kenya study also said Africa's more "favourable weather" was a "compelling" factor as to why the continent has seen lower morbidity and mortality rates than others.
The researchers point out that the average daytime temperature across sub-Saharan Africa is greater than 20C, with 30 of the 46 countries in the region averaging more than 25C.
The impact of higher average temperatures could be contrasted with what has happened in Europe and on other continents.
After arriving in the UK from China in January and February last year – when the UK average maximum temperature in January was just above 8C - the infection spread rapidly across the country and Europe during the remaining colder months before slowing as late spring and then summer arrived.
A similar timeline occurred this winter in the UK with COVID infection rates beginning to increase in September and October and peaking in the coldest months of the year – a phenomenon many epidemiologists were predicting, because of patterns commonly observed in the spread of flu.
However, the lockdowns imposed across many of the worst affected countries make it difficult to determine the extent to which climate has affected infection rates.
Why weather could be a factor is still under debate but the Washington/Liverpool/Kenya study is not alone in linking it to the impact of coronavirus. Factors may include the virus being inactivated by sunlight, people spending more time outdoors in warmer countries and also the impact of sunlight on vitamin D production, resulting in boosted immune responses.
The correlation is not exact however. It has also been pointed out there were places around the world which saw rates rise during their warmer seasons – for example in Brazil - and others where rates didn't rise in colder weather despite older age structures – such as in New Zealand. In both cases, the authors of the above study say it was the speed and effectiveness of restrictions that made the difference.
It has also been pointed out that when swine flu (H1N1) swept across the world in 2009, climate appeared to have little influence on its global spread.
Some have said the environment in which Africans live and grow up may also have contributed to lower rates.
With poor quality housing due to income inequalities in many places, and a larger population working outdoors in jobs like farming, some have said the disease is likely to spread more slowly than it would if people were spending most of their time inside – working in enclosed offices, for example.
Professor Phelix Majiwa, a molecular biologist and zoonotic disease expert from Kenya, told Sky News: "Over 70% of Africans live in areas which cannot be described as cities. They're either in suburban areas, or rural areas, and people spend a lot of time outdoors, either working… or doing something, but most often in the open air… they have a lot of space between one person or another.
"That kind of lifestyle is slightly different from what you find in South Africa. It's very Europeanised, and the majority of Africans there live more or less like how Africans in the diaspora live.
"The other big thing, which I think really contributes to this is, as a child growing up here in Africa… in the process, you get... exposed to things to which the body reacts... some of which can be pathogens. And some of the profiling can be cross reactive."
That theory was in part backed by the Washington/Liverpool/Kenya study which said "the continuous contact between bats, livestock, and humans in rural Africa may have resulted in exposure to... emergent coronaviruses and development of… cross-reactivity".
It led the researchers to conclude "low transmission and reduced disease severity in Africa" was due to a combination of age profile, weather, and acquired resistance.
Rana's story
Rana, a 24-year-old researcher and youth-peer activist from the city of Madani in El Gezira state in Sudan, describes what she has seen and how those around her have reacted to COVID.
"I started volunteering in my home city in the first stages of the COVID epidemic. I was working in one of the isolation centres that were set up quite early on to isolate those with COVID infections, in the kitchen delivering meals to those [who needed it].
"I then joined the research project with the Sudan Research Group and our first study was trying to look at what people understood... and what the barriers were to implementing any preventive measures."
"There's a distinct difference between the first lockdown and the second one.
"In Madani, on 17 March, there were no cases, but they went into a partial lockdown and the Ministry of Health cited cases in Khartoum State. That was from 10pm to 6am with half of the work force being out.
"In April, a lot of the people in my neighbourhood worked in the informal sector and were not able to work. This became quite a strain on their daily lives.
"Many found it very difficult to follow the lockdown rules. That was the first impact - it wasn't the mortality or the health impact necessarily but the economic hardship.
"The most pronounced impact was in my family and friends. It used to be that once a year we would lose one person. But during the peak of the epidemic, we would lose about four or five people in my family and friends per month.
"I lost two friends, my uncle, my grandfather, all of whom have died because of COVID. We're not sure how they got it, but they did and they died. In my immediate circle, there were three people who were quite vocal about not following the rules. They all worked in the informal sector and all three were infected and two have since died."
Under-reporting
The elephant in the room is the accusation that many African countries have not been accurately counting how many people have had the disease and have died from it.
A growing body of evidence – from studies that look at the number of people who have antibodies in their system to show if they have been infected – is revealing the extent to which people in many African countries have been infected but not tested.
Studies in Zambia, Kenya, Mozambique, Malawi, South Africa and a number of other countries have found what are called seroprevalence levels that are wildly at odds with reported infection rates.
Dr Lawrence Mwananyanda, an assistant professor at Boston University who works in Zambia and is an expert in infectious diseases in Africa, carried out a study of deaths recorded at the morgue in one of Lusaka's teaching hospitals.
Out of the deaths which were subsequently found to have been linked to COVID between June and September last year, only about 10% were in people diagnosed with COVID before they died.
He told Sky News: "They have on average 21 to 24 deaths per day. And then, during the study, this started increasing. We started going to 30 deaths per day, 35, 45, until we peaked somewhere around 58 deaths a day. So, something definitely was happening in the community that these deaths suddenly more than doubled.
"The surveillance data across the continent is very poor. The only place where you find credible data, South Africa - because they have fairly sophisticated surveillance systems - they have done an excess mortality calculation from May to December (and) they had over 132,000 more deaths than in the previous years. The question would be why would South Africa, which is our neighbour, be different from us?
"At that time, in Zambia, it was not standard practice for doctors to use nasopharyngeal swabs for their patients. We did not even have enough PCR machines to do the tests. So I have no doubt in my mind that this is just a question of data and their inability to collect the data."
His position is backed up by Drs Walker and Watson, who have been working with African and other developing world researchers to aid the modelling done by Imperial College.
Dr Walker said in "most countries around the world, reported deaths do not reflect the true toll of the virus. In many places around the world the impact is better visualised through measures of excess deaths".
He added: "Few other countries on the continent have a COVID-19 testing or death registration system as reliable as South Africa's so it is difficult to quantify… the precise toll of the virus."
Dr Maysoon Dahab, an assistant professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine who has been working with people on the ground in Sudan, said the study she worked on estimated about 97% of deaths in Khartoum state were under-reported or unreported.
She said a combination of factors prevent the recording of deaths linked to COVID - despite high levels of infection being in the community, as indicated by antibody studies.
She told Sky News: "When those guys get sick, there's often two pathways.
"Often you say to yourself, I'm not going to seek care because this is something I've seen before, or you can't afford it, or you're afraid... somebody is going to treat you badly, or a loved one is going to be withheld in hospital. So you don't seek care, you die... and you're not counted.
"The second is that you do seek care, but actually there are no services and you end up dying on the way to hospital or… people can't access care even though they want access to care."
She said even those who can access treatment but die are rarely properly registered.
"There's no simple registration, nowhere that says that you have to be registered before you are buried, there's quick burials and then, even if people know these guys have died of COVID, they won't write it... because of the stigma associated with it.
"So, when you put all those things together, it's unsurprising the map looks the way it does. It is a symptom of a broken health structure, high rates of poverty, and also just the lack of a simple registration system. You've got yourself a perfect storm of under-reporting."
Rana continues...
"In the second wave, people are not at all paying attention to the public figures, not least because they clearly don't reflect what's happening in their communities. They're seeing a lot more deaths than are being reported - these reports cannot be accurate and they certainly do not reflect the level of death they're seeing in their communities.
"There's a complete lack of credibility and if the government puts out reports that say 'absolutely, hand on heart, 100% the truth', they will not be believed. It's so clear, because in my small square we see about three deaths per day. This is much higher than before. And when I ask people around me 'who has had symptoms?', whether they have been tested or not, most will say, 'no, we didn't go forward for testing'. People would have died naturally and at home - although the symptoms speak quite clearly of a probable COVID infection, they were never counted. There's just a complete breakdown between the official figures and what I see on a daily basis."
"This has an effect because if you don't have credibility in the Ministry of Health, then the contract between them and the community is broken, there's no trust.
"The public face of the response is the ability to detect the level of deaths occurring. And that's not happening. There has to be ways for the level of death to be better counted in order that those reports reflect reality more in order that the people can regain trust in the government's ability to track what's going on, let alone respond.
"But there is really a big difference [in people's behaviour] between the first and the second wave. While it's true that, in November, people reacted very angrily to the imposition of a second lockdown and broke it themselves, simultaneously there was a lot more awareness and a lot more willingness to hear the message.
"There were a lot more groups going out and talking about coronavirus, whether it's religious leaders, etc. and it became a lot more acceptable to speak about it. So much so that today, when I go out in the market, 75% of people are actually wearing masks. And this is a huge, huge difference. And in fact, when you see someone not wearing a mask, unlike in the first wave, it's actually OK to go up to them and say 'what's going on? Can we help you wear a mask?'.
"Practically everyone has seen, in every household - if not in their own homes, then friends and family - someone who has died. Every single person in every household in Sudan has a story about loss and a story of trying to seek care. And that has changed the narrative from one of coronavirus being a conspiracy theory to it being a reality in our communities and our homes.
"It's important to measure the impact of COVID. But, if you're going to try to put that in place, you need resources. We need the international community to both recognise the toll this epidemic is having on us and put... light on it... perhaps they can deliver that message and be listened to more than me and my colleagues."
What it means for Africa in the future and the West
Many researchers say that a failure to understand the depth of the pandemic in Africa has profound consequences, not just for Africa but for the rest of the world as well, including the UK.
While official case and death figures are clearly much lower than those in Europe and America, they are masking the true scale of the problem and possibly the "catastrophe" that was predicted.
Dr Dahab told Sky News: "If you don't know the true impact it has on your community, it does hamper the response, on the local as well as on a national level.
"You have to understand that this is happening against the background of a lot of economic problems… existing disasters, like the floods (in Sudan) that just occurred, other infectious disease epidemics.
"And so allocating resources becomes really difficult at the best of times - nearly impossible when you don't know the levels that you're actually fighting."
But, even if conditions mean it has spread slower in some African countries than on other continents, virtually all agree that COVID will reach the scale it has elsewhere – illustrating why vaccines are needed as badly in Africa as anywhere else and why those in developed countries need to be concerned.
Dr Mwananyanda said: "It is not necessarily the geography, but just socioeconomic status. We are not as mobile as you guys are. It takes a while for the disease to spread from person to person. But, after it gets a foothold, it just becomes the same as it is in the West."
There are signs this is happening, with the World Health Organisation reporting in late January that infections rose by 50% on the continent between 29 December 2020 and 25 January 2021 when compared with the previous four weeks – a phenomenon some are saying is Africa's second wave.
And that could rebound on more developed nations, as places with high levels of infection – particularly hidden infection – could become cradles for future dangerous variants, as has already happened with the South Africa variant.
Dr Walker added: "The suggestion that Africa has been 'spared'… has become a particularly dangerous narrative. COVID-19 trajectories have been highly variable, even between neighbouring countries and in some countries in Africa some of our less optimistic projections are now rapidly becoming a reality.
"It's clear that the threat in Africa is much higher than if we take reported deaths as a measure of total impact and is far from being over… with upwards trends in many countries… continuing into early 2021.
"As with any part of the world where COVID is on the rise, these threats are global as well as local… the success of control in the UK and that in Africa, as with the rest of the world, are inextricably linked."
Credits:
Reporting and digital production: Philip Whiteside, international news reporter
Graphics and digital production: Pippa Oakley, designer
Data journalism and digital production: Carmen Aguilar Garcia, senior data journalist
Sources and references
Global deaths and cases comes from ; world population data from ; the Stringency Index was developed by the University of Oxford and can be found ; England COVID-19 deaths by age groups are published by gov.uk coronavirus dashboard; excess of mortality calculated using data from the ONS, NISRA, NRScotland and South African Medical Research Council.
Modelling study that predicted infections rates in African countries of between 23% in Niger and 42% in Mauritius within the first 12 months can be found .
Modelling study that said the impact of COVID in West Africa could be "catastrophic" can be found .
Patrick Walker and Oliver Watson's study on COVID in countries with different incomes can be found .
Study on the spread of COVID by African researchers in the early stages of their careers can be found .
Mean temperatures in Africa/UK - Sky News analysis based on 2016 yearly averaging of mean monthly temperature as listed on the World Bank's Climate Knowledge Portal. The portal can be found .
Another study linking weather to mortality in Africa can be found .
The Washington/Liverpool/Kenya study can be found .
Lawrence Mwananyanda's study on post mortem surveillance can be found .
Maysoon Dahab's study, in collaboration with other Imperial College researchers, can be found .
The Zambia seroprevalence study results are detailed .
The Kenya seroprevalence study results are detailed .
The Mozambique seroprevalance study results (in Portuguese) are detailed .
The Malawi seroprevalance study results are .
