Is Africa winning the war against COVID? We don’t know yet and here’s why.

A perspective from our epidemiologist, Dylan Green.

In recent weeks, several media outlets have covered the COVID-19 epidemic and response in Africa through an optimistic lens. These articles suggest that there are lessons that North America and Europe could learn from Africa during the global pandemic.

Coverage has focused on public health response, resilience, community health workers, community engagement, and even that African countries are ahead or beating the coronavirus pandemic. This is in contrast to evidence of super spreading events in Ghana, overwhelmed hospitals in Tanzania, a tripling of burials in Somalia, and extensive infections among health care workers in Nigeria.

We agree that there are indeed important features for the COVID-19 response in Africa which are terrific, innovative and world class. There are also valid reasons to believe that COVID-19 could have an attenuated effect in Africa, such as its young population. However, it is our view that there is far more to be concerned about on the horizon. We fear that articles such as these declare that African nations have successfully contained and prevented COVID-19 from taking hold. This communicates to both individuals and governments that COVID-19 may not be a serious issue and that control measures may not be required now or into the future.

The sense that the pandemic is severe elsewhere but “not in my country” has been a mistake of many nations, which later paid a terrible consequence of excess morbidity and mortality due to delayed and insufficient public health response. The delayed response in high income settings has pushed even the most developed health systems to their limits. In much of Africa, fragile health systems cannot risk the strain of a severe COVID-19 outbreak. Indeed, extensive modeling exercises have shown that COVID-19 could cause tremendous negative spillover effects to other important diseases like HIV, tuberculosis, malaria, and maternal and child health. Additionally, recent data have suggested that people living with HIV or tuberculosis may have double the risk of death from COVID-19 — each of which are highly endemic in Africa.

The paramount issue which has not received sufficient coverage (or in many cases, is simply overlooked), is the critically limited amount of COVID-19 testing. Nearly every major news outlet, public health agency, and epidemiologist has hammered home the importance of widespread and extensive COVID-19 testing. In the case of those best performing countries such as South Korea, Iceland, and New Zealand, high levels of testing have been cited as a requirement — not optional — to mounting a successful response.

Before discussing testing, let us first evaluate how the African continent is doing in terms of reported cases and deaths. Using publicly available data, we find the continent to be doing quite well. Compared to high-income countries in Europe, North America, and Oceania, sub-Saharan Africa has a lower number of cases and deaths per capita (Figure 1). Only Japan, New Zealand, and Australia approach the apparent low burden in Africa as whole. At the country level, the pattern still holds as nearly 80% of African nations have case and death rates lesser than high-income nations (Figure 2). Globally among the 20 countries with the fewest reported COVID deaths (excluding zeroes), 14 countries are in sub-Saharan Africa. For cases, Lesotho stands out with the second lowest case rate out of 211 reporting countries.

Figure 1: COVID-19 Cases and Deaths per Capita by Country and Region

Figure 2: COVID-19 Cases and Deaths by Country

A natural follow-up question is: “How much is Africa testing?”

The initial answer is we don’t know.

Using Our World in Data as an initial resource, we find only 9 out of 49 countries in sub-Saharan Africa have testing data available. We sought to fill the data gap and searched ministry of health websites, Twitter feeds, Facebook, and media to find testing data for an additional 16 countries, for a total of 25 countries which represent 750 million people, or 65% of Africa’s population.

As of June 10, 2020, we find that just over 1.65 million COVID-19 tests have been reported in Africa (units unknown). For reporting countries, this comes to approximately 2.5 tests per 1,000 population. Compare this to 20.2 tests per 1,000 in South Korea, 61.4 per 1,000 in New Zealand, or a whopping 184.1 tests per 1,000 in Iceland. Even compare Africa to the United Kingdom or United States — both criticized for limited testing — and find that the continent trails by 15- to 30-fold. Indeed, at its current rate of testing the United States has tested the same number of people in four days as has been reported in Africa in four months.

Of course, there is considerable heterogeneity by country (Figure 3). The small nation of Djibouti is leading the continent with 26.7 tests per 1,000 — still considerably behind other high-income countries. South Africa, Botswana, Ghana, and Rwanda, although applauded for their response, have only done 11.8, 7.7, 6.6, and 5.1 tests per 1,000 people, respectively. Africa’s most populous countries — Nigeria and Ethiopia — are faring particularly poorly with just 0.3 and 0.9 tests per 1,000 each. Worse yet is the unknown. Testing coverage is unknown for countries which nearly 500 million Africans call home. With data apparently lacking, it does not seem unreasonable to presume a similar (or even more pessimistic view) for these countries.

Figure 3: COVID-19 Tests per Capita for Reporting Countries in Africa

Now let us return to the question of how severe COVID-19 has been in Africa, and whether or not the disease has been effectively contained. The naïve analysis of case and death numbers per capita could easily lead us to conclude that Africa is performing quite well. However, the testing data show a completely different story. Lesotho, which ranked 2nd lowest in the world in terms of cases ranks similarly low in terms of tests per capita. Indeed, the nation lacks local capacity to conduct tests and are instead sending samples to surrounding South Africa for analysis — a solution which is neither sustainable nor adequate in scale for its needs. Ethiopia, which was reported as potentially beating COVID-19, is in the bottom half of the testing distribution for Africa — which we’ve already demonstrated lags behind other nations by up to two orders of magnitude.

Unfortunately, trend data for countries in Africa indicate a mixed picture of testing scale-up in the past 30 days (Figure 4). Few countries, such as Ethiopia, Kenya, and Nigeria have seen some increase in the rate of new tests over May at a rate of a 2% to 3% per day. This might be considered slow, especially compared to the increase in test scale-up seen in the US and elsewhere of 50% or higher each day during peak scale-up. Meanwhile other countries see no appreciable upward trend or even downward (although potentially an artifact of reporting).

Figure 4: Trend in New COVID-19 Tests in May 2020 for African Countries with Available Data

The reasons for slow scale-up of testing have not be empirically described, although one could easily speculate. African nations face critical challenges in the health sector with highly limited healthcare workforce, low levels of laboratory capacity, and difficulty in supply chain and logistics. Still, there is evidence that capacity, including necessary resources for procurement, are not being fully realized, and that Africa needs greater access into the global marketplace for COVID-19 testing supplies. Lessons and progress from the past two decades into strengthening laboratory and supply chain systems in Africa for HIV, TB, and malaria can still be further leveraged to meet the needs of this new pandemic.

Ultimately, absence of evidence is not evidence of absence. Failure to test more widely is a self-fulfilling prophecy for those who are wishful that COVID-19 will spare Africa. This is of course unacceptable for any other communicable disease — so why then could coronavirus be an exception? If high levels of COVID-19 testing are a necessity for the global north to minimize harm and return to normalcy, then it should also be so for the rest of the world. Lack of capacity and access to COVID-19 testing must not be accepted as a foregone conclusion. It is the duty of the global health community and the media to highlight the global inequalities and advocate and implement solutions to close these gaps.

With severely limited testing (and limited testing data), it is difficult to conclude there is minimal spread or containment of COVID-19 in Africa. It is furthermore even more difficult to mount a successful response consisting of contact tracing and behavioral change. We do not rule it out as a possibility, and it is not our intention to be fear mongers who envision only doom and dread for Africa. We acknowledge the many things which could make COVID-19 less severe in Africa, including the younger demographic, lesser international connectivity and strong community health systems.

In our next piece, we will discuss another key missing metric in Africa — total mortality — and implications for decision making during a pandemic. We look forward to seeing more incredible innovation and creativity in public health from Africa. Still, we simply prefer stronger evidence, in the form of greatly expanded testing, to confirm such a strong conclusion that there is either minimal or no community spread of COVID-19 in Africa.

How do you think African countries and the global community are handling the COVID-19 response? Email us (contact@coopersmith.org) or leave a comment below.