By Alex Ezeh* & Sharon Fonn*
Africa remains one of the regions least affected by COVID-19, although evidence suggests it is an evolving and growing pandemic. It is now present in all African countries and territories.
From the start, the responses across many African countries have mirrored those of other countries where the pandemic has been more prevalent. These measures generally include the promotion of social distancing and personal hygiene, lockdown orders, and management of more severe cases in hospitals. Other responses, such as contact tracing, testing, and isolation of suspected cases, have been used less widely.
The implementation of lockdowns has created major challenges for governments and citizens alike. Local realities – such as urban slums – make the spread of the virus more likely and social distancing almost impossible. Lockdowns in these settings pose very high economic risks for the residents.
Given local conditions in many of Africa’s urban areas – including high density slums and informal settlements – lockdown strategies are proving to be unworkable.
Part of the disconnect between the current responses and the current realities of many Africans stems from the limited engagement between policy decision-makers and African institutions generating contextual knowledge. Some examples are the lack of an adequate notice period before lockdowns and the limited consideration given to the situation of slum residents.
The gaps in our current knowledge of the course of COVID-19 in Africa make things even more difficult.
We don’t know what accounts for the very low numbers of cases in most countries. Is it a reflection of very low testing capacity? Or rather, of Africa’s very young demographic profile? Or is it simply that we are in the early phase of the pandemic?
Each of these possible explanations will demand different policy responses.
Now more than ever, African governments need their scientists and their scientific institutions to provide insights and guidance. They are turning to these local institutions for help in managing their responses to the pandemic. Unfortunately, many years of neglect and limited investment have created capacity gaps. Where capacity does exist, it is being used, though it remains inadequate. The extent of this is being documented by a network of academics across the continent.
African scientists are not able to deliver what Africa needs because governments have starved their institutions of crucial funds for many years. The result is that governments are importing wholesale what is being done elsewhere.
Africa’s experiences in managing other recent and ongoing epidemics could be an advantage in responding to COVID-19. These epidemics include cholera, measles and viral haemorrhagic diseases like Ebola virus disease, yellow fever, dengue, Lassa fever, and Rift Valley fever. The potential is there, but strong research institutions and systems are needed to activate this advantage to inform timely local, national and global responses to the COVID-19 pandemic. These, unfortunately, remain underdeveloped. The use being made of the resources that do exist only underlines the need for the science and research systems in Africa to be strengthened.
For example, there has been a glaring lack of ongoing rigorous studies of the pandemic on the continent. Of the 2,032 clinical trials related to COVID-19 registered by 14 May this year, only 35 included study sites in Africa. Of these, 23 were in Egypt and only 12 included a site in a sub-Saharan African country. Seven of the 12 were internationally led multi-country studies. The remaining five were in Nigeria and South Africa.
Additionally, the 12 clinical trials involving a country in sub-Saharan Africa are extremely limited as most are looking at hydroxychloroquine, while another is looking at traditional medicine.
This pattern positions Africa to remain a consumer of knowledge and solutions produced elsewhere.
And, during this period of a global pandemic with critical shortages of life-saving resources, Africa is losing because it lacks the capacity to produce what it needs and what others may need.
What needs to be done
What key actions need to be taken?
The first lesson for Africa is that it cannot continue to depend on international and multinational agencies to determine the path it takes to development. We must reverse the limited investments in local and regional research institutions and universities. Countries must do more to attract their best minds, many of whom have been forced, over the years, to leave Africa.
As we look towards a post-COVID-19 world, investments in strengthening local and regional knowledge-based institutions will be key to enhancing the continent’s global relevance and competitiveness.
And we need to understand where we currently are in the course of the pandemic. This requires clarifying the drivers of current low levels of reported infections and deaths. Achieving this will require coordinated serological antibody surveys across countries with different epidemiological profiles of the pandemic. These surveys would be a game changer.
At the moment countries are only doing antigen tests. These tests are positive if a person is currently sick with the virus. Once the person is better, the test will again be negative. Antibodies, however, last longer in people who have contracted a virus and will be positive in asymptomatic people as well (it is not yet known for how long). An antibody survey would involve selecting a sample of people who are representative of the entire population and testing them. This will show how widespread the infection has been in a given population.
Such antibody surveys will show who has had the virus – and therefore has built antibodies (some kind of immunity) to it. This will be key to formulating appropriate context specific responses to the pandemic. And it would help us understand where a country’s responses to the pandemic have been appropriate.
These surveys could show us, for example, if the lockdown policies have been beneficial, or if there have been very widespread infections but with mild morbidity and very low mortality, perhaps due to the continent’s young age profile. This would mean the quarantines and lockdowns have come at a high price with less than anticipated benefits.
Combining such surveys with community studies that include verbal autopsies – interviewing people who were close to the person who died, and from this deciding the cause of death – could show if the lockdown is leading to increased mortality within communities that are not being captured in our accounting of COVID-19-related deaths.
Understanding the extent of the spread of COVID-19 within urban and rural Africa can also help with the adaptation of policy responses to a specific setting. This is urgently needed as many countries are in the middle of their rainy season when most villagers cultivate their farms. Disruptions in farming activities, coupled with the effects of climate change-related floods and an ongoing locust epidemic in East Africa, could spell an uncertain future for hundreds of millions of people as they begin to face massive food insecurity.
Evidence from such studies can help countries calibrate their national responses to the pandemic.
In the long term, we must be better prepared to deal with future pandemics, and that preparation needs to start with a re-assessment of how we invest in and support local research and service delivery institutions across Africa.
This article draws on contributions to Drexel University’s Webinar on “The Global Impact of Pandemics”; the African Development Bank’s Global Community of Practice Webinar on “Enhancing Resilience in African Economies: Macro-Economic Policy Responses to COVID-19 Pandemic in Africa”; and the Think-20 Engagement Group and Global Solutions Summit Panel on “The Social and Economic Implications of Covid-19 Pandemic and Beyond: Risks and Opportunities for the Global South”.
*Dornsife Professor of Global Health, Drexel University
*Professsor of Public Health; Co-Director Consortium for Advanced Research Training in Africa; Panel Member, Private Healthcare Market Inquiry, University of the Witwatersrand