Dr.Essa Abdi Djama

Covid-19 and Sub-Saharan disease response and readiness?

  • Malnutrition and disease means COVID-19 could be more deadly in Africa than elsewhere in the world.
  • Health systems in Africa have limited capacity to absorb the pandemic.
  • The strategic approach should focus on containment and aggressive preventive measures.
  • Continents case detection, case management disease surveillance systems is too low and most areas none existing.

Growth in Sub-Saharan Africa has been significantly impacted by the ongoing corona virus outbreak and is forecast to fall sharply from 2.4% in 2019 to -2.1 to -5.1% in 2020, the first recession in the region over the past 25 years, according to the latest Africa’s Pulse, the World Bank’s twice-yearly economic update for the region.

Uniqueness of Africa in general- 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 populations 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.

Challenges in Africa at the moment.

Clean running water and soap are in such short supply that only 15 percent of sub-Saharan Africans had access to basic hand-washing facilities in 2015, according to the United Nations. In Liberia, it is even worse — 97 percent of homes did not have clean water and soap in 2017, the U.N. says

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

 Health systems Factors.

Double disease Burden and lacking the capacity for treating the critically ill care.

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.

Less than 1,000 a thousand Ventilator machines in 1.3 billion African population.

A Low-Cost Ventilator Could Be Available Next Year. But Will It ...

Report by the International Rescue Committee (IRC) finds that fragile and conflict-affected countries face a double emergency: the arrival and impact of COVID-19, and the secondary humanitarian, economic and political havoc this outbreak will wreak While there is so many African countries are dealing with civil wars at the moment.

10 African Countries Have No Ventilators

Report shows South Sudan only has four ventilators for the entire country; Northeast Syria has 11; Sierra Leone has 13; in Venezuela, 90% of hospitals lack critical supplies. 

In South Sudan, where less than half the country’s health facilities are functioning, there are 24 ICU beds and four ventilators. With life-saving humanitarian programs globally facing unprecedented disruption and suspension, countries like South Sudan which are already gripped by high levels of malnutrition may face famine.

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 populations.

The analysis shows that COVID-19 will cost the region between $37 billion and $79 billion in output losses for 2020 due to a combination of effects. They include trade and value chain disruption, which impacts commodity exporters and countries with strong value chain participation; reduced foreign financing flows from remittances, tourism, foreign direct investment, foreign aid, combined with capital flight; and through direct impacts on health systems, and disruptions caused by containment measures and the public response.

While most countries in the region have been affected to different degrees by the pandemic, real gross domestic product growth is projected to fall sharply particularly in the region’s three largest economies – Nigeria, Angola, and South Africa— as a result of persistently weak growth and investment. In general, oil exporting-countries will also be hard-hit; while growth is also expected to weaken substantially in the two fastest growing areas—the West African Economic and Monetary Union and the East African Community—due to weak external demand, disruptions to supply chains and domestic production. The region’s tourism sector is expected to contract sharply due to severe disruption to travel.

The COVID-19 crisis also has the potential to spark a food security crisis in Africa, with agricultural production potentially contracting between 2.6% in an optimistic scenario and up to 7% if there are trade blockages. Food imports would decline substantially (as much as 25% or as little as 13%) due to a combination of higher transaction costs and reduced domestic demand.

Several African countries have reacted quickly and decisively to curb the potential influx and spread of the corona virus, very much in line with international guidelines. However, the report points out several factors that pose challenges to the containment and mitigation measures, in particular the large and densely populated urban informal settlements, poor access to safe water and sanitation facilities, and fragile health systems. Ultimately, the magnitude of the impact will depend on the public’s reaction within respective countries, the spread of the disease, and the policy response. And these factors together could lead to reduced labor market participation, capital under utilization, lower human capital accumulation, and long-term productivity effects.

Recent study from Yale University-Should Low-Income Countries Impose the Same Social Distancing Guidelines as Europe and North America to Halt the Spread of COVID-19? by Zachary Barnett-Howell, Ahmed Mushfiq Mobarak

  1. The much lower estimated benefits of social distancing and social suppression in low-income countries are driven by three critical factors:

(a) Developing countries have smaller proportions of elderly people to save via social distancing compared to low-fertility rich nations.

(b) Social distancing saves lives in rich countries by flattening the curve of infections, to reduce pressure on health systems. Delaying infections is not as useful in countries where the limited number of hospital beds and ventilators are already overwhelmed and not accessible to most.

(c) Social distancing lowers disease risk by limiting people’s economic opportunities. Poorer people are naturally less willing to make those economic sacrifices. They place relatively greater value on their livelihood concerns compared to concerns about contracting coronavirus.

Not only are the epidemiological and economic benefits of social distancing much smaller in poorer countries, such policies may also exact a heavy toll on the poorest and most vulnerable

In Africa, social distancing is a privilege few can afford?

The myth of self-isolation

Knowing the realities on the ground, it is curious that the WHO and ministries of health in different African countries are recommending that people self-quarantine if they could have been exposed to the coronavirus. In Rwanda, for example, a man travelling from the US has potentially infected his wife and brother, accounting for three of the seven cases. Which raises the question: how are people in shared accommodation expected to self isolate?

Coronavirus in Africa: Whipping, shooting and snooping - BBC News
Ugandan police hit vendors who refused to clear the streets

Slums and informal settlements are also part of the physical infrastructures of many African cities. All of them were overcrowded and lacked services even before the threat of a global health crisis emerged.

Think of Alexandra in Johannesburg, where over 700,000 people are estimated to live in less than 5 square kilometres (1.9 square miles), Mbare in Harare with some 800,000 people, Kibera in Nairobi with at least 250,000, and Makoko in Lagos with over 300,000 whose homes are built on stilts in a lagoon.

No choice to ‘work from home’

It is more practical for people who work in offices to “work from home” but if your only means of livelihood is selling tomatoes or second-hand clothes at an informal market in a big city, how do you begin to do this “online”?

The choice before you is often to stay home and fail to provide the evening meal for your family, or to brave it out into the city and try and fend for your family. If I was that person selling at a market, I know what choice I would make. It is not social distancing.

For those concerned about the risk of exposure to the virus, the WHO recommends self-quarantining. This has so far included advice for people not to share bathrooms, living space and even bedrooms, if they can. But what if you live in a house where the bedroom doubles as a kitchen and living space – all shared with your (sometimes extended) family?

Struggling health systems

A lot has been said about the health systems of many African countries and how they would struggle to cope with a fast-spreading virus like the coronavirus. Indeed, after many years of conflict, in countries like South Sudan and Somalia, the health system has almost collapsed.

In some countries around the Sahel – Niger, Burkina Faso and Mali – people continue to be displaced by conflict and live in squalid conditions in displaced peoples’ camps. Even in countries not in conflict, like Uganda and Zimbabwe, structural adjustment programmes proffered by the International Monetary Fund (IMF) and the World Bank have seen a continuous decrease in funding available for healthcare. The Abuja declaration of 2001, requiring each country to set aside at least 15 percent of its national budget for healthcare, is still gathering dust in health authorities’ offices. None of the parties to the declaration has managed to achieve its goals.

It clearly does not require a pandemic to expose the gaps in the health system. If developed systems like in northern Italy can buckle under pressure from COVID-19, one can only imagine the impact this will have on front-line health staff who are without adequate training, protective equipment and even basic drugs.

No one knows how the pandemic will spread across Africa. But we know it is a matter of time. One can not help but wonder if it is not time for African governments, with support from the WHO, to develop recommendations that take all these environmental conditions into account.

Social distancing could probably work in China and in Europe – but in many African countries, it is a privilege only a minority can afford.

The WHO has done well since the onset of the outbreak to provide leadership and access to information about a virus that virtually nothing was known about just several weeks ago. But now, more must be done to reimagine our governance systems, especially because healthcare is intrinsically linked to everything else.

And in Africa – likely the next battlefield for the virus – tackling COVID-19 will need more imagination and alternative solutions from all of us.

Poorer countries such as sub Saharan Africa. also have limited capacity to enforce distancing guidelines, and lock-downs may have counterproductive effects if it forces informal sector workers and migrants to reverse-migrate from densely-populated urban areas and spread the disease to remote rural areas of poor countries. It is imperative that the source code for influential epidemiological models (on which the widely-adopted social distancing guidelines are based) are made publicly accessible, so that social scientists can explore the sensitivity of benefit estimates to changes in assumptions about compliance with distancing guidelines or the baseline prevalence of co-morbidities, chronic illnesses or malnutrition that make COVID-19 infections more deadly.

Recommendations.

1.   Masks and home-made face coverings are comparatively cheap. A universal mask wearing requirement when workers leave their homes is likely feasible for almost all countries to implement.

2.   Targeted social isolation of the elderly and other at-risk groups, while permitting productive individuals with lower risk profiles to continue working. Given the prevalence of multi-generational households, this would likely require us to rely on families to make decisions to protect vulnerable members within each household.

3.   Improving access to clean water, hand-washing and sanitation, and other policies to decrease the viral load.

4.   Widespread social influence and information campaigns to encourage behaviors that slow the spread of disease, but do not undermine economic livelihoods. This could include restrictions on the size of religious and social congregations, or programs to encourage community and religious leaders to endorse safer behaviors and communicate them clearly.

The Questions for the public

Does Covid-19 drives sub-Saharan Africa to 30 years recession?

Is there other methods to flatten the curve beyond lock-down and social distancing forgot about the vaccination?

References/citations

Why Sub-Saharan Africa needs a unique response to COVID-19?
Covid-19 drives sub-Saharan Africa toward first recession in 25 years.
https://som.yale.edu/should-low-income-countries-impose-the-same-social-distancing-guidelines-as-europe-and-north-america-to-halt-the-spread-of-covid-19
https://www.rescue.org/press-release/new-irc-report-exposes-double-emergency-covid-19-humanitarian-crises-reveals-grave?fbclid=IwAR1EV4-EANsg2nVbrcW44oHtNxtcmOcD9bTNBl9Q4gVrJL55fl6NuVsYyB4

About the Author 
Dr Essa Abdi Jama was one of the first medical students ever to graduate as a doctor in Somaliland. He as served in a number of senior civil service roles, including serving as the Somaliland Internship Programme Coordinator, and the Director of Human Resources at the Somaliland Ministry of Health. He is currently based out of Port Moresby, Papua New Guine.

Disclaimer: The viewpoints expressed by the authors do not necessarily reflect the opinions, viewpoints of Somaliland Chronicle and it’s staff. 

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