World View: Africa’s low Covid-19 toll shatters perception bias

Coronavirus disaster for continent avoided for range of social and experiential reasons

An ice cream seller walks through Gandhi Square in Johannesburg. While South Africa has been hard hit, the continent is doing much better than many expected. Photograph: Kim Ludbrook

Early in the spring, as Covid-19 swept across Europe and the United States and pushed some of the world's most advanced health systems to the brink of collapse, epidemiologists and public health officials were preoccupied with fear of the harm the disease could inflict once it reached poorer parts of the world.

With its creaking public health systems, overcrowded slums and limited testing capacity, Africa was a particular concern. Uganda had a total of 55 intensive-care beds; in Malawi the figure was 25.

Ventilators were even more scarce: Mozambique had one for every one million inhabitants. It was widely feared that pressure on healthcare systems from the new coronavirus could also impede treatment of other diseases.

Scientists are grasping for reasons for Covid-19's apparently atypical behaviour in Africa

In February, the World Health Organisation estimated that without containment measures up to 190,000 people in Africa would be dead within 12 months. The United Nations Economic Commission for Africa had a much higher estimate, saying in April that "anywhere between 300,000 and 3.3 million African people could lose their lives as a direct result of Covid-19, depending on the intervention measures taken to stop the spread".


Five months on, those worst-case scenarios have not come to pass. As the world marks one million Covid-19 deaths, Africa is doing much better than many expected. The continent's case fatality rate is at 2.4 per cent, according to Reuters data, with about 35,000 deaths and more than 1.4 million confirmed infections. In North America, the case fatality rate is 2.9 per cent and in Europe 4.5 per cent.

Some of the difference may be down to lower testing rates, but there have been few reports of mass deaths anywhere on the continent and the WHO’s Africa office says that while many asymptomatic cases are being missed – its own analysis suggests Africans may be twice as likely to experience Covid-19 without any illness – there is no evidence of miscalculation of death figures, which are more difficult to miss.

Even when excess deaths are included, the death toll is substantially lower than most predictions. And while infection rates are increasing in some African states, overall the number of new cases has been in decline for more than six weeks.

Prior exposure

Scientists are grasping for reasons for Covid-19’s apparently atypical behaviour in Africa. The continent’s lower age profile (the median age is below 20), its low population density and a humid climate are all likely to be working in its favour.

Some scientists hypothesise that the BCG vaccine for tuberculosis might be helping reduce Covid deaths, or that prior exposure to other coronaviruses has provided some resistance. Matshidiso Moeti, the WHO regional director for Africa, told a briefing last week that an important factor was Africa’s relatively poor road networks and limited access to international flights, which slow transmission of the virus.

“Africa is less connected than other regions,” she said. “So we had some protection when the virus first arrived.”

But perhaps just as important as social and environmental factors has been the aggressive action by governments with more experience than their western counterparts of battling infectious diseases. With more time to prepare than Europe and the US, many African states were quick to close their borders, restrict travel and ban large gatherings.

In a continent where 400 million people live on less than $1.90 a day, the freezing of economies and pressure on national budgets has had a devastating effect on livelihoods

The head-start also gave medics time to set up field hospitals, source oxygen and learn from treatments used elsewhere.

While the authorities’ ability to enforce public health restrictions may have been weaker in some places, recent disease outbreaks such as the Ebola crisis in west Africa in 2014-2016 or in eastern Democratic Republic of the Congo over the past two years taught policymakers and citizens vital lessons.

South Africa imposed one of the world's toughest lockdowns in late March, when it had just 400 confirmed cases. Rwanda locked down around the same. Nigeria, the continent's most populous country, banned interstate travel and imposed a curfew.

Collateral damage

None of this is to suggest that Africa has got off lightly. Some countries have been hit hard: South Africa, for example, has had more than 16,000 official deaths. Fatality rates have also been higher-than-average in Algeria, where, like South Africa, a larger percentage of the population is over the age of 65.

Across the continent, the collateral damage on public health, through untreated HIV or malaria, for example, is likely to be significant. Even more severe will be the economic hit.

Early lockdowns came at a huge cost. In a continent where 400 million people live on less than $1.90 a day, the freezing of economies and pressure on national budgets has had a devastating effect on livelihoods. And that is before the arrival of a second wave, a prospect that preoccupies African leaders.

Nonetheless, the continent's experience to date raises questions about the limits of conventional infectious disease modelling. As Sam Agatre Okuonzi from the Arua Regional Referral Hospital in Uganda told the WHO briefing, those models are based on European populations. "They are also informed by very well-entrenched biases about Africa – that, for example, Africa is prone to disease," he said. "Covid-19 has shattered a lot of biases about the disease in general but also about Africa."