Navigating COVID-19's Multi-Sectoral Crisis in Africa

I work with the billion first descendants of Homo sapiens. Much has happened since this continent, notably Ethiopia where I am currently based, first emerged as the birthplace of humanity. Tragically, it has become the home of the bottom billion among some of the world’s poorest countries. Not only has it fallen behind economically, but it has endured countless droughts, conflicts, plagues and deadly communicable diseases.

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Until recently, many believed such scourges could progressively but decisively become a matter of historical record. We believed that the next generation would grow into a new millennium without the shameful realities of exclusion, extreme poverty, hunger, and excessive preventable mortality. We would finally focus on the future. The COVID-19 pandemic is now threatening to reverse these gains. The need for more effective responses couldn’t be more urgent. A collective approach is not just a moral imperative, it is a practical necessity to ensure global security.

A strategy fit to context

Lockdowns, aggressive contact tracing and tertiary health care boosting have been the essence of the fight against COVID-19 across the globe. Families filled their refrigerators or ordered out for pizzas, and shifted to remote working. Or they applied for unemployment benefits, while students sought to finish their year with online schooling. In cities like Madrid, New York, London, and Milano, where confinement was strict, one could hear the birds singing. Without pollution, the sky turned blue again.

At the same time, however, elective surgeries were postponed, and health personnel were reoriented to manage the pandemic. Hospitals filled with Intensive Care Unit (ICU) beds equipped with ventilators, while scientists bundled up in their laboratories to develop new drugs and vaccines. The manufacturing industry focused on mass production of protective equipment and the laboratories on diagnostic tests. Media and politicians bombarded society with speedy TV virology courses and hygiene education. Where these measures were implemented seriously, they worked. All this was achieved at great cost, no doubt. But it was possible.

In Africa, where individual confinement is a luxury only a few can practice, lockdowns are virtually impossible beyond a few days. Movement restrictions and their impact on regional trade not only asphyxiate economies, but leave stomachs empty as food prices skyrocket. For most Africans, the trade-off between the certainty of hunger and the possibility of a debilitating if not deadly sickness leaves them with no choice. Lockdowns have gradually evolved into slowdowns, and then, in many cases, were ignored.

Merkato is the busiest open market in Addis Ababa. It is also one of the biggest in Africa. You must push yourself to navigate amongst crowded alleys of moving people. If you wish to find saffron, pepper, butter, coffee, or spare parts for your car, this is where you go. Merkato did not slowdown. On the contrary, its fast-paced bargaining only increased as certain commodities became rare. Yet no temperature checking, handwashing or distancing options are available. It is now the epicentre of the pandemic, along with the city slums.

In the African context where the informal sector represents 86 per cent of employment and 40 per cent of total economic output, keeping markets open is inevitable. Hence, making them safe should be a vital concern. To prevent imported cases of COVID-19, borders were partially or totally closed. Returning migrants and travellers have been forced to quarantine for at least two weeks. The impact on regional trade caused rapid price rises of basic commodities coupled with food insecurity. Normally limited to the rural areas, the same situation began to happen in urban centres.

School closures in Africa have severely affected children. Numerous pupils have been forced to drop out, some 26 million in Ethiopia alone. This is particularly aggravated in rural areas with little or no access to remote learning; child labour as well as abuses such as early forced marriages are also on the rise. In many parts, where school feeding programmes are no longer available, there is severe malnutrition.

There has been much faith in Africa in applying the same measures of strict lockdowns and aggressive case tracing and isolation adopted by certain (but not all) wealthy countries to slow down viral transmission. Initially, this appeared to work. But with limited ability to confine, test and isolate, the inevitable community transmission is beginning to expand at a speed that the continent’s meagre human, technical and financial resources simply cannot keep pace with. In Ethiopia for example, it took 77 days to reach the first 1,000 cases, but only seven for the second 1,000. With community transmission in logarithmic expansion, the once ‘silent’ epidemic is now raging loud.

What do we need?

A friend and former colleague from New York recently texted me a stark question: “What do we need?” I was halfway through my daily routine, but the weight of his question caused me to drop everything and answer him immediately.

We urgently need medical grade protective supplies for frontline health care personnel. We have far too few healthcare workers. COVID-19 is threatening to make this even worse. Health workers in several countries have gone on strike to protest the lack of Personal Protective Equipment (PPE) and in some places, non-governmental organizations specializing in health have refused to expose their staff to the disease without such protection. And rightly so. As my mother says, we are humanitarians, not “cannon fodder”.

We have already learned tragic lessons from the delayed response to the West Africa Ebola breakout which left Liberia with the lowest number of doctors in the world: 37 per million.

Appropriate protective equipment is vital for COVID-19 contact tracing and case management, but it is also critical for maintaining basic health care services and the delivery of humanitarian relief. The collateral damage of increasing numbers of primary health care centres being abandoned due to a lack of, or inadequate, protection is already causing an usually high toll on morbidity and mortality as other opportunistic epidemics surge. Out of fear of contracting COVID-19, some health care providers are abandoning their posts. Similarly, families have stopped bringing in their children for routine vaccinations against common endemic diseases, which are significantly far more lethal than COVID-19.

With the second wave of coronavirus now threatening much of the planet and increased global competition to access protective commodities, it’s important to revert to local production. If low income countries are attractive to the garment industry, why not re-orient local manufacturing not only to produce “community” masks, but medical grade protective equipment for frontline workers?

One context does not fit all

Reverse transcription polymerase chain reaction, or RT-PCR, is the gold standard for COVID-19 testing that most countries are seeking to achieve. But it is expensive and requires considerable training. It is also a struggle to compete globally for access to the kits. Dramatic improvements in testing capacity have been made, but Africa has still only tested 7.2 million persons. This means that during the first six months of reported cases only half the desirable one per cent minimum testing recommended by the World Health Organization (WHO) has been achieved.

Given where we stand today, it is crucial that we bring in a more agile, affordable, and easy to read method such as the Rapid Diagnostic Tests (RDTs). They cost 50 times less, are 12 times faster, readable to the naked eye and require minimal training. They are not as sensitive as the RT-PCR but are just as specific. They can be used at border crossings to facilitate regional trade, and in mass surveillance to re-open schools in rural areas where transmission is significantly lower. They can also help keep markets and slums safe in urban areas, to protect highly vulnerable persons living in displacement and refugee camps, and to sustain essential services in primary health care centres, while allowing RT-PCR to remain the standard test for treatment centres. Antigen RDTs could become a game changer for the continent.

We need a regionally crafted strategy

The harsh reality is that what works in the East and West does not necessarily work in the South, where the markets cannot close, and half the urban population live in slums. A regionally-crafted strategy is vital. Proportionally, Africa has the largest rural population in the world. In Ethiopia, 80 per cent of people live in the countryside. Nonetheless, such “rurality” coupled with a younger population represents a critical advantage. People from the countryside trade in the cities, where street markets are a hazard. They return at the end of the day to intergenerational households where social dynamics do not lend to individual or family physical distancing. Protecting this back and forth between urban epicentres and the lower risk rural areas offers a natural geographic advantage to which specific solutions could be tailored.

Reversing development gains

The diversion of existing resources to bolster response to COVID-19 is not only threatening to collapse health systems but also risks dismantling those already in place. Albeit fragile, they are unique and vital to the region. These systems are crucial to treating endemic diseases such as malaria, cholera, HIV, measles and many other preventable diseases. A recent study estimated that for every avoidable COVID-19 death attributable to an infection acquired during a routine vaccination visit, there could be 140 more deaths of children who would miss their routine childhood immunizations.

Restrictions on movement and social gatherings imposed to contain COVID-19 are already leading to surges in lethal outbreaks of measles, cholera, malaria and tuberculosis. Among the most serious concerns is the potential for a resurgence of polio, which has already cost the world $15 billion in eradication efforts.

Primary health services are similarly essential for women and children. Any increase in corelated morbidities will accentuate their vulnerability to COVID-19, completing a deadly vicious cycle. These systems must not be dismantled. We need to do everything possible to prevent such health care centres from being deserted out of fear. This will only reverse the progress of control regional epidemics that has been achieved in the past decades.

A combination of co-pandemics

Women and youth in Ethiopia are particularly hard hit. With little formal education, they are disproportionally concentrated in the hardest-hit sectors of the economy and are the first to lose their jobs. Women also carry the added responsibility of childcare, and when schools close, they are the ones who stay behind. Forced to remain at home with diminishing incomes is reversing advances made in gender equality, exposing them to domestic violence.

Historically, rising rates of indebtedness and poverty have tended to lead to unrest and conflict. As a result of past experiences, however, Ethiopia has developed one of the largest economic safety nets in Africa, with some fifteen million mainly rural people receiving cash transfers or food aid relief. But the country is struggling to extend such coverage to its poorest urban citizens, a reservoir for the virus. Cash transfers and other social protection measures have never been more urgent to mitigate the human cost and eventually bring the pandemic under control.

At present, the bulk of humanitarian assistance is being consumed by needs arising from food shortages, conflicts, droughts and floods, cholera outbreaks and other crises such as locust invasions. Much of this is sustained by international aid and needs to continue if people are to survive.

A strong case must also be made for greater regional solidarity given that so much economic activity is dependent on the import and export of labour. Yet host countries have been deporting undocumented migrants and daily labourers leaving people without means of support. Over the past two months alone, some 20,000 Ethiopians have been deported from the Arab Gulf and neighbouring countries. These returnees often end up in quarantine centres, which can barely cope, further overstretching essential health capabilities.

Today, more than ever, we need a multi-sectoral approach to address this combination of crises, notably the boosting of both health and humanitarian work forces. In Ethiopia, where the number of doctors per 10,000 people is one, 30 percent of health workers are employed abroad, a migratory brain drain that starts early in medical schools. In times of emergency, the continuous brain drain of local expertise to wealthier countries that never reimburse the cost of their professional training. Instead, they offer graduates enticing opportunities to leave their countries. This is happening in other countries ranging from Swaziland to Ghana.

There needs to be a temporary moratorium with compensatory arrangements made to ensure that both the individuals and their originating countries benefit mutually from their investments and assets. We need to draw on our cumulative global wisdom to beat COVID-19. No country can manage this crisis alone. The risk of an-all out-health crisis engulfing Africa and rebounding to impact the privileged West is, let’s face it, inescapable. The day after his first message to me, my friend asked what people like him could do to help. This is a letter to those out there who want to help.

Alexandra de Sousa is a medical doctor and anthropologist working with the United Nations in Addis Ababa. She is writing in her personal capacity.

Links

Key insights into land degradation from seven African countries. 4 October 2020. The Conversation (LINK)

Puzzled scientists seek reasons behind Africa’s low fatality rates from pandemic. 29 September 2020 — Reuters. (LINK)

Africa’s low COVID-19 death rate has multiple causes, WHO says — 25 September 2020. Africans may be twice as likely to experience COVID-19 without any illness, compared with people in the rest of the world, according to preliminary analysis by the African branch of the World Health Organization. Toronto Globe and Mail. (LINK)

G20 debt relief for Africa may be too little too late as coronavirus pandemic takes toll — 30 August 2020. South China Morning Post. Economic Commission for Africa negotiator says she is not aware of any African countries gaining from China debt relief under G20 deal. Eligible countries spend US$92 million a day on debt payments when they could be tackling pandemic-related crises: campaigner (LINK)

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