It was expected that the Coronavirus would devastate the continent, but it appears to have affected countries with higher incomes and better preparedness far less than those with lower incomes.
In Kamakowie, Sierra Leone, there are no fears of Covid.
Since the start of the pandemic, the district’s Covid-19 response center has registered just 11 cases and no deaths. The wards of the regional hospital are packed with malaria patients. Covid’s isolation ward door is bolted shut and overgrown with weeds. It’s common to see people without masks at weddings, soccer matches, and concerts.
Sierra Leone, a nation of eight million on the coast of Western Africa, seems inexplicably spared from the plague. The pandemic’s occurrence here and in much of sub-Saharan Africa is a great mystery.
A debate has divided scientists on the continent and beyond over the low rate of Coronavirus infections, hospitalizations, and deaths in West and Central Africa. Have the sick and dead simply not been counted? Why has Covid done less damage here if it has? How could we have missed it if it was just as vicious?
In an interview in Freetown, Sierra Leone’s capital, Austin Demby, Sierra Leone’s health minister, said the answers “have implications not only for us” but also for the greater good.
The assertion that Covid isn’t as big a threat in Africa has sparked debate about whether the African Union’s push to vaccinate 70 percent of Africans against the virus this year is the best use of health care resources, given that the devastation from other pathogens, such as malaria, appears to be much greater.
During the first months of the pandemic, it was feared that Covid would eviscerate Africa, ravaging countries like Sierra Leone, where there are just three doctors for every 100,000 residents, according to the WHO. Malaria, H.I.V., tuberculosis, and malnutrition were seen as kindling for disaster.
So far, that hasn’t happened. This was relatively unaffected by the first iteration of the virus that raced around the world. Despite the fact that the Beta variant devastated South Africa, as did Delta and Omicron, much of the rest of the continent was spared.
As we enter Year Three of the pandemic, new research shows Covid has spread widely in Africa. That’s true.
About two-thirds of the population in most sub-Saharan countries has antibodies against SARS-CoV-2, the virus that causes Covid. Since only 14 percent of the population has received Covid vaccination, the antibodies are mostly from infection.
Africans have been infected at a rate higher than many other parts of the world, according to a new WHO-led analysis, not yet peer-reviewed. Vaccination rates were only 4 percent among Africans when these data were collected.
Africa is the location of the virus. Does it kill fewer people?
The relative youth of Africans has been the subject of some speculation. The median age of their population is 19 years old, compared with 43 years in Europe and 38 years in the United States. Two-thirds of the population in sub-Saharan Africa is under 25, and only three percent is 65 or older. As a result, much fewer people have lived long enough to develop health issues (cardiovascular disease, diabetes, chronic respiratory disease, and cancer) that can increase the risk of severe disease and death from Covid. Coronavirus infection is often asymptomatic in young people, which may explain the low number of reported cases.
There have been plenty of other hypotheses put forward. The fact that most people spend much of their time outside and the high temperatures could prevent the spread of the disease. Or the lack of public transportation infrastructure in many areas, or the low population density. Exposure to other pathogens, such as Coronaviruses and deadly infections such as Lassa fever and Ebola, may have provided some protection.
Covid tore through South and Southeast Asia last year, making these theories harder to accept. India’s population is young, too (with a median age of 28), and temperatures are also relatively high. Researchers have found that the Delta variant caused millions of deaths in India, far more than the 400,000 officially reported. There are also high rates of infection with malaria and other coronaviruses in places, such as India, where Covid fatalities have been high.
Are Covid deaths in Africa simply not recorded?
There are no Covid cases reported in Sierra Leone by most global Covid trackers since testing for the virus is virtually nonexistent. In the absence of testing, there are no cases to report. Researchers at Njala University in Sierra Leone have found that 78 percent of people have antibodies for this coronavirus. In spite of this, Sierra Leone has reported only 125 Covid deaths since the outbreak began.
It is more common for people to die at home, rather than in hospitals, either because they cannot reach a medical facility or because their families take them home to die. There are many deaths that are not registered with civil authorities.
Across sub-Saharan Africa, this pattern is common. According to a recent study by the United Nations Economic Commission for Africa, only one in three deaths are captured by official registration systems.
South Africa is the only sub-Saharan country where almost every death is counted. It’s clear from the data that Covid has killed a significant number of people in that country, far more than reported virus deaths. Excess mortality data indicate that between May 2020 and September 2021, there were some 250,000 more deaths from natural causes than had been predicted based on previous years’ patterns. Covid cases show similar increases in death rates, suggesting the virus was responsible.
Doctor, a Boston University epidemiologist and special adviser to the president of Zambia, said he had no doubt the impact in Zambia had been just as severe as in South Africa, but that Zambian deaths had simply not been captured by the much weaker registration system. More than 4,000 Covid-19 deaths have been reported in Zambia, a country of more than 18 million people.
“If that’s happening in South Africa, why shouldn’t it happen here?” he asked. He added that South Africa has a much stronger health system, which should result in a lower death rate.
During Zambia’s Delta wave, 87 percent of bodies in hospital morgues were infected with Covid, according to a research team he led. There was a lot of body in the morgue. What is different is that we just have very poor data.”
Africa has seen similar rates of death throughout the pandemic, according to The Economist. According to Sondre Solstad, who runs the Africa model, there were between one million and 2.9 million excess deaths during the pandemic.
“If Africans were spared, that would be wonderful, but they aren’t,” he said.
However, many scientists tracking the pandemic on the ground disagree. Covid deaths could not have gone unnoticed by hundreds of thousands or even millions, they claim.
“We have never seen massive burials in Africa. We would have seen them,” said Doctor, who runs the W.H.O.’s Covid emergency response in Africa.
Doctor, an epidemiologist at the African Population and Health Research Center in Nairobi, Kenya, said that no death goes unrecorded in Africa despite our poor record-keeping skills. “There’s a funeral, an announcement: A burial is never held in a week because it’s a major event. We may not have accurate numbers, but the perception is palpable for someone sitting in New York hypothesizing they were unrecorded. If there are deaths in the media, in your social circle, you know about them.”
As an epidemiologist by training, Doctor, the Sierra Leone health minister, agreed. As far as I know, we haven’t had overflowing hospitals. “No, we haven’t,” he said. It is not clear whether excess deaths are occurring.
What could be keeping the death rate low?
While Sierra Leoneans are experiencing weak health surveillance, they have recently experienced Ebola, which killed 4,000 people here in 2014-16. Since then, citizens have been on alert for an infectious agent that may be killing them. He said they wouldn’t continue to pack into events if that were the case.
According to Salim Abdool Karim, a member of the African Centers for Disease Control and Prevention Covid task force who was part of the research team tracking excess deaths in South Africa, the continentwide death rate is probably similar to that of his country. He said Gambians and Ethiopians are no less vulnerable to Covid than South Africans.
However, he added that a large number of people were not showing up at the hospital with respiratory distress. Some older people who die of strokes or other Covid-induced causes are not being identified as Coronavirus deaths, he said. There are many who don’t make it to the hospital at all, and their deaths are not registered. Other people do not fall ill at the same rate as elsewhere, and that is a mystery that needs to be solved.
“It’s relevant to the development of vaccines and treatments,” said Doctor, who heads the Centre for Global Health Research in Toronto and analyzes causes of death in Sierra Leone.
Researchers working with doctor are using novel methods — such as looking for any increase in revenue from obituaries at radio stations in Sierra Leonean towns over the past two years — to see if deaths could have risen undetected, but there had been no wave of desperate sick people, he said.
Vaccination groups working on Covid say lower illness and death rates should lead to policy rethinking. In a year ago, it seemed that vaccines might provide long-term immunity and make it possible to end Covid-19 transmission, said John Johnson, vaccination adviser for Doctors Without Borders. It no longer seems possible to achieve collective immunity now that protection is waning. An immunization strategy that protects just the most vulnerable would arguably be a better use of resources in Sierra Leone.
What is the most important thing to do in countries where malaria, polio, measles, cholera, meningitis, and malnutrition are much bigger problems? Do we want to spend our resources on this in those countries? I asked. At this point, it’s not for those people: It’s to prevent new variants from appearing.
According to him, new variants of Covid pose the greatest risk in areas with older populations and high levels of comorbidities such as obesity.
Experts warned that the virus remained unpredictable, and scaling back vaccination efforts could lead to tragedy.
“Africa can’t be complacent and assume it can’t go the way of India,” doctor said.
Unless vaccination rates increase significantly, a new variant as infectious as Omicron and more lethal than Delta may emerge, he warned.
“I think we should avoid the hubris that all Africa is safe,” he said.