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Why Africa leads the world in COVID-19 performance

Why Africa leads the world in COVID-19 performance
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This April, as the novel coronavirus accelerated its global sweep of devastation, pandemic modelers in Addis Ababa and London had dire predictions for the continent of Africa. They foresaw a best-case scenario of 300 thousand COVID deaths and a worst-case of 3.3 million deaths and 1.2 billion infections without mitigation measures. The World Economic Forum substantiated this by declaring that “in Africa, deaths from COVID-19 might far exceed what the world is seeing.” 

Now, seven months later, Africa has recorded 1.2 million cases and 36 thousand deaths. That’s one-tenth of the best-case and one-hundredth of the predicted worst-case scenarios for the continent.

Let’s put this into a global perspective. The global share of COVID deaths to share of the global population is 5 for the US, 2.3 for Europe and 0.26 for Africa. 

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Scientists, health experts and policymakers within and outside the African continent have struggled to find answers for this stunning observation of an exponentially lower than expected Africa virus toll. Finding solutions to this puzzle will have dramatic implications — not only for Africa but also for the rest of the world. 

From presidents to scientists, the continent has taken justifiable pride in these observations. A continent long-inured to being underestimated, misunderstood and subject to colonial stereotyping, has found a resounding public health success to celebrate and rally around.

How can the earth’s poorest continent by almost any health, income, or education measure, including the UN’s Human Development Index, lead the world? How can a continent where 56 percent of its urban population is concentrated in non-social distanced slums, and where only 34 percent of households have access to basic handwashing facilities, largely avoid this viral scourge? These conditions have resulted in Africa having the highest rates of malaria, tuberculosis, AIDS and measles deaths in the world. Not only does COVID not follow this dismal trend, but it has reversed it — demonstrating a dramatically lower toll than any other continent.

This is explained by significant under-diagnosis and underreporting of cases because of a lack of testing capacity and low-quality reporting systems. To date, Africa has conducted only 13 million tests, covering about 1 percent of the population. Massive undercounting is certainly true for infections, but much less evident for deaths, a more reliable indicator of disease burden. It is estimated that official systems capture only one in three deaths in Africa. But even when this is factored in, a dramatically lower African mortality rate persists.

The few antibody surveys that have been conducted in Africa revealed a 5 percent infection rate in Kenya blood donors and a 12 percent infection rate in Malawi health care workers. Kenya’s infection rate is similar to Spain’s in mid-May when Spain had 27,000 deaths. Kenya’s toll was only about 100 at the same time. 

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Experts within and outside Africa have offered many explanatory hypotheses for Africa’s outperformance. Is there some genetic or pre-existing immune protection? A different and weaker virus strain? An immune boost from other communicable diseases? Cross-immunity from previous coronavirus infections? Cultural factors such as outdoor village life with natural physical distancing? Higher temperatures and humidity? 

Africans have highlighted the predominant role of regional policy successes such as tight lockdowns, border controls, and unprecedented continent-wide cooperation, to explain why Sub-Saharan Africa has dodged a deadly wave. Mo Ibrahim, a Sudanese businessman, noted that “African governments responded better than governments in the UK or U.S. The virus doesn’t seem to like us.” 

Africa has the world’s youngest population by a wide margin. Its median age is 18. Europe’s is 42 and North America’s is 35. COVID’s global toll is skewed exponentially by increasing age. Those over age 65 experience 80 percent of the mortality and those under 15 an extremely low 0.08 percent. That’s a 1000-fold difference.

Does the age-structure of Africa explain most of the continent’s amazing performance? Only 3 percent of Africa’s population is over age 65. The comparable number for North America is 15 percent and 18 percent for Europe. On the younger side of the age spectrum, 41 percent of Africans are under 15, whereas only 19 percent of North Americans and 16 percent of Europeans are in this age group.

The continent’s dramatically young demographic is sufficient to explain it as the main driver of the African COVID experience. Accelerating population immunity will also be a major contributor to putting brakes on the pandemic. So is the age-related observation that 80 percent of Africa's infections are asymptomatic, double the proportion in the rest of the world. Other demographic, genetic, immunologic, environmental and policy factors may certainly contribute and merit intensive study. Epidemiologic puzzles are multifaceted, especially COVID. But for now, this important observation, no longer hypothetical, should frame the approach to sharing transportable science and policy benefits.

Africa’s low illness and the death toll has allowed earlier reopening of societies and revitalizing hard-hit economies and jobs. 

The continent’s spectacular success has kindled optimism, determination and cohesion among frequently fragmented regions and countries. It has also spurred extensive scientific collaboration to reap both critical knowledge and vital capacity-building for Africa’s future. Gloriously, Africa is the first in the world to see the light at the end of the pandemic tunnel. 

Steven Phillips. M.D., MPH is a medical epidemiologist and pandemic preparedness practitioner formerly with the Centers for Disease Control and Prevention.