Why Sub-Saharan Africa needs a unique response to COVID-19

As of 29 March 2020, there have been more than 680,000 confirmed cases of COVID-19 disease in 203 countries around the world.

On 11 March, the World Health Organization characterized COVID-19 a pandemic. Africa was initially spared, however this is changing rapidly. In the last two weeks, the number of affected African countries increased from 9 to 41. As people continue to travel, it is only a matter of time before COVID-19 spreads to the rest of the 54 countries on the continent. As I write this from Monrovia, Liberia – a country whose health system has suffered enormous challenges due to civil wars and the Ebola epidemic in 2014 – I am compelled to highlight that one size does not fit all, and special considerations need to be taken into account as we develop the COVID-19 response for Africa.

The continent’s population and health systems make it different from other regions that have experienced COVID-19 to date. Three factors are important at the population level.

First, the continent’s demographic structure is different from other regions in the world. The median age of the 1.3 billion population in Africa is 19.7 years. By contrast, the median age in China is: 38.4 years, and the median age in the European Union is: 43.1 years.

Experiences in Asia and Europe showed that people over 60, and those with significant health problems are most vulnerable to severe cases of COVID-19. Although Africa’s youth may be considered a significant protective factor in the pandemic, how the virus will evolve and manifest itself on the continent remains unknown.

The second factor within the population is the high prevalence of malnutrition, anemia, malaria, HIV/AIDs, and tuberculosis. Liberia, for example, has one of the highest rates of stunting in the world: one in three children under five years old are stunted. In recent weeks, we have witnessed an increase in the incidence of malnutrition. Moreover, the rainy season has come early this year, which means that malaria cases will rise rapidly and peak malaria cases in 2020 may coincide with the ongoing COVID-19 pandemic.

We should therefore anticipate that in Africa a higher incidence of severe forms of COVID-19 will occur in younger patients because of the demographics and associated endemic conditions that affect the immune system. Malnutrition, anemia, malaria, HIV/AIDs, and tuberculosis are likely to increase the severity of COVID-19. Africa may not see the same narrative of “most people who get it will be fine” play out.

Third, social cohesion and social gatherings are of great importance in Africa. For example, weekly attendance of a religious service is highest in Africa with rates as high as 82% in Uganda and Ethiopia. As a result, measures to impose social and physical distancing may prove to be more challenging, as demonstrated by the protests that broke out on 20 March 2020 in Senegal after public gatherings, including gatherings at mosques were banned as cases of COVID-19 rose. Earlier this week, Tanzania came under scrutiny when it was announced that the country will not close places of worship.

There are two major health system factors that will make the COVID-19 response in Africa more challenging. First, the continent is experiencing the double burden of diseases: in addition to dealing with these endemic infectious diseases, health systems in Africa are facing non-communicable diseases, including injury, and cancer. As a result, the health systems are stretched thin to begin with, and there is very little room to absorb the COVID-19 pandemic.

Second, the capacity to provide critical care is the lowest in the world. Severe forms of COVID-19 lead to respiratory failure requiring ventilation support. The ability to treat severe forms of COVID-19 will depend on the availability of ventilators, electricity, and oxygen. A recent analysis of countries with the highest numbers of intensive care beds per capita does not include any country from Africa. In Liberia for example, there are no intensive care units (ICU) with ventilators. Uganda has 0.1 ICU bed/100,000 population. In contrast, the United States has 34.7 beds/100,000 population.

Lessons learnt in Italy and China are extremely valuable. However, they cannot be extrapolated directly to Africa because of these differences in demographics and health system constraints.

Because health systems in Africa are strained to begin with and have very limited capacity to absorb the pandemic, the overall strategic approach should focus on containment and aggressive preventive measures.

Early and aggressive physical distancing and frequent handwashing will prevail as the most effective and affordable interventions for the continent, with parallel testing, contact tracing, and isolation of cases. For aggressive preventive measures to work, we will need the full support of populations. Full support of populations can only be achieved with community engagement and strong health leadership.

Furthermore, given the youth of the continent, youth leadership and engagement will be critical for prevention and containment activities. And lastly, given the priority given to religious services, religious leaders will need to participate actively in the COVID-19 response. At the health system level, operating rooms and teams could be reorganized and repurposed to build critical care capacity in district hospitals.

The African context is unique. There are population structure differences, high prevalence of endemic diseases and the double burden of disease, with health systems that are stretched thin with minimal critical care capacity.

A robust COVID-19 response for the continent will need to take these factors into account and include community engagement, health leadership, and involvement of youth and religious leaders to drive containment. At the health system level, temporary repurposing and reorganizing of the surgical system will be key to increasing critical care capacity during the response, focusing on what we have as we move forward.