Two months after it opened, Khayelitsha Field Hospital abruptly closed. The facility, constructed in a sports hall in early July on the outskirts of the South African city of Cape Town, had been constructed in anticipation of a wave of Covid-19 deaths. But the infections and deaths that have overwhelmed healthcare systems across the world never came. Almost a year into the pandemic Africa has mostly been spared from a crisis that has brought much of the world to its knees.
It wasn’t meant to be this way. In April, as Covid-19 shut down country after country, the United Nations issued a stark warning: Africa might be next. Officials said Covid-19 could directly kill at least 300,000 people in Africa and possibly as many as 3.3 million. In May, with infections and deaths still surprisingly low, the World Health Organisation revised that prediction down to between 83,000 and 190,000 deaths. To date, just over 40,000 Africans have lost their lives to Covid-19. “Very few cases were identified,” says Gilles Van Cutsem, a senior HIV and tuberculosis adviser for Médecins Sans Frontières at the Southern African Medical Unit in Cape Town.
There is no single reason for Africa’s seemingly remarkable escape. For one, Africa isn’t a homogenous lump of land. Its 54 countries are ethnically and socially diverse. Yet, across the continent, there are some trends that hint at why deaths from Covid-19 remain so low. The median age in Africa, where more than 60 per cent of people are under the age of 25, is about half of that in Europe. This has played a significant role, says Denis Chopera, a public healthcare expert at the Africa Research Institute in KwaZulu-Natal, South Africa. He also points to Africa’s warm climate and the potential of pre-existing immunity in some communities. “Africa has a high burden of infectious diseases, including coronaviruses, and it is possible that there is some cross-immunity which protects Africans from severe Covid-19,” Chopera says. The WHO has made similar suggestions.
Across the continent, high rates of tuberculosis, HIV, polio and Ebola, have also ensured a wealth of well-trained medical professionals and, crucially, the infrastructure and expertise to handle a pandemic. “The experience has come in handy, especially in countries such as South Africa where contact tracing already existed for tuberculosis,” says Chopera. “These were repurposed to combat Covid-19.”
To date, the continent has recorded 1.7 million infections. The number, as is the case across the world, is likely much higher. One study conducted by researchers at the University of Cape Town collected 2,700 samples during the city’s pandemic peak in late July and early August. A startling 40 per cent of the people tested had Covid-19 antibodies.
That picture varies across Africa. Between the end of April and mid-May, researchers tested the blood samples from more than 3,000 people in Kenya. They found that 5.6 per cent had Covid-19 antibodies. In the popular tourist city of Mombasa nearly ten per cent of donors had antibodies. At the time, official figures in Kenya stood at 2,093 cases and 71 deaths. “This contrasts, by several orders of magnitude, with the numbers of cases and deaths reported in parts of Europe and America when seroprevalence was similar,” the research, which has yet to be peer-reviewed, concludes. Simply put, the official number of Covid-19 deaths and cases remains low, but many more people may actually be infected with mild or non-existent symptoms.
All African countries responded differently to the pandemic – to date, 34 of its 54 nation states have, at some point, introduced lockdowns or curfews. In South Africa, the continent’s worst-hit country, officials declared a state of emergency and imposed a strict lockdown that limited movement, shut borders and banned the sale of alcohol and cigarettes. The army was deployed to enforce the rules. Officials worked to increase testing capacity and stop the country’s healthcare services from being overwhelmed.
Khayelitsha, which literally means ‘new home’ in Xhosa, is a large township in South Africa’s Western Cape. At the start of the pandemic this crowded muddle of informal and formal settlements was seen as an ideal environment for Covid-19 to spread. Worse, South Africa’s high prevalence of tuberculosis (520 cases per 100,000) and HIV (7.7 million cases) means many people live with compromised immune systems.
Despite these challenges, Covid-19 is yet to truly take hold. From the outset, officials in South Africa targeted crowded hotspots with high Covid-19 infection rates, deploying 28,000 healthcare workers to test everyone in sight. Alongside this, the strict and early lockdown gave the country time to increase testing capacity and prepare its hospitals. “We were never overburdened by Covid-19,” Van Cutsem says.
With Covid-19 fatality rates across Africa remaining low, Van Cutsem is more concerned about deaths caused by a healthcare system badly disrupted by the pandemic. As a result, many people were unable to collect treatments for HIV and tuberculosis. Vaccinations for malaria and other chronic diseases were stopped. While much of the world grapples with a second wave of Covid-19 infections, the fear in Africa is that cases of other diseases could surge instead.
That may already be happening. From May to August, more than 33,000 excess deaths were recorded in South Africa. Of these, 9,000 were from Covid-19. That leaves 24,000 deaths unaccounted for. Where and when the deaths occurred – as well as the age groups affected – suggest a large number of unrecorded Covid-19 deaths, but other factors may be at play.
Landon Myer, director and head of the School of Public Health and Family Medicine at the University of Cape Town, told Spotlight that while deaths related to HIV, diabetes or other chronic diseases cannot be ruled out, these deaths might take more time to appear. “If you’re living with HIV and are on antiretrovirals and you’re relatively healthy, and you stop taking your antiretrovirals, it could be months to years before you die,” Myer says. “Certainly not weeks.” Such concerns are backed up by historical data. After the Ebola outbreak of 2014, research showed that 11,300 deaths from the virus had coincided with 10,600 excess deaths from other diseases, especially malaria, HIV/AIDS and tuberculosis.
Excess deaths are one thing. But a sudden surge in Covid-19 infections, similar to the current situation in Europe, could be even more catastrophic in Africa. John Nkengasong, director of the Africa Centres for Disease Control and Prevention (Africa CDC) has urged nations to prepare for a second wave on the continent. “The time for the continent to prepare for the second wave is now,” he told reporters, adding that Africa was now far better prepared than it had been ten months ago.
But many scientists remain optimistic. Gerald Mboowa, a bioinformatics expert at the Infectious Diseases Institute at Makerere University in Uganda, argues that the last several months have built up some level of herd immunity in most African countries, meaning that subsequent outbreaks are likely to be less serious. “I am compelled to think the continent may not have a serious next wave of Covid-19,” he says.
There will, of course, be moments when that optimism is tested. In early October, a Cape Town night club faced an investigation by city authorities after 89 new cases of Covid-19 were traced back to students who had been partying on its roof terrace. Over the four weeks to October 28, there was an average six per cent increase in new cases across Africa. This rise was measured across most regions, except in west and central Africa. Cases decreased in Burkina Faso, Eswatini, the Gambia, Ivory Coast, Nigeria and Sierra Leone.
Decreases in case numbers are likely to continue, so long as Covid-19 doesn’t break out into communities and regions that haven’t previously been exposed. “The term ‘wave’ is more of the graphical representation of increased numbers on a chart than a real reflection of what is happening on the ground,” says Moses Alobo, co-chair of the Covid-19 committee at the African Academy of Sciences. He points to a city such as Cape Town where up to 40 per cent of people in some communities are believed to have been infected. In others, that number is lower than five per cent. “The second wave is really an increased exposure of the virus to communities or groups that would otherwise not have been exposed,” says Alobo.
After months of living with economically damaging restrictions, much of Africa is now opening up. On October 5, the Africa CDC launched a travel information hub to help people moving around the continent access and comply with Covid-19 restrictions. But as people start to travel again, so will the virus – and that necessitates a big increase in testing capacity. In June, the Africa CDC said it had distributed more than 2.5 million tests across the continent. By September, the total number of people tested in Africa had reached 12 million. But Van Cutsem says many African countries still have poor testing capacity.
Ramping up testing numbers also means improving the tools available to detect new infections, be they asymptomatic, mild or severe. More research is also needed to understand the level of community spread across Africa, says Alobo. “One of these without the other provides for possibilities of reaching a wrong conclusion as to how the outbreak will progress in the community,” he adds. The hope amongst experts is the last ten months are a sign of what’s to come: Covid-19 will continue to spread in Africa, but not with the same devastating consequences faced in much of Europe and North and South America. For that to happen, continued vigilance will be required from both the general public and healthcare officials.
Despite its remarkable success in the fight against Covid-19, Africa remains vulnerable. Across the continent, there is an average of less than one intensive care bed per 100,000 people. In the United States, that figure is 34.7 beds per 100,000 people. As the virus continues to spread, surges in cases in certain regions could, if not contained, quickly overwhelm local healthcare systems. Countries such as the Czech Republic, which initially handled Covid-19 well and largely returned to normal, only to be hit by a devastating surge in infections, serve as a warning. The pandemic is still raging and Africa may not be spared forever.
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