The COVID-19 Riddle, Africa and the Anikulapo Factor, By Simbo Olorunfemi
Experts are looking at all sorts – genetics, climate, culture, public policy and all that for answers… The answer to the riddle is perhaps in the riddle. Africa is perhaps the proverbial Anikulapo, with death in her pouch, dodging the bullets of projections directed at her fragile belly. Just as she has defied death in the face of serial pillaging and multiple violations by friends and foes.
This global pandemic was foretold. That it could come had been long predicted, its fierceness even foretold. Sometime in 2018, scientists in Canada were reported to have successfully synthesised horsepox – “a virus related to smallpox, one of the greatest scourges the world has ever faced — demonstrating how viral synthesis could threaten global disease eradication efforts.” The problem that the experiment presented was that there was “no globally accepted mechanisms…for identifying risks associated with experiments that synthesise new, dangerous, engineered, or eradicated agents – or those that could enhance transmissibility and virulence of pathogens with pandemic potential, like influenza.”
That was not the first time the alarm-bell rang. A global pandemic that could catch the world napping had been predicted by others. What was not foretold is its randomness and the arbitrariness it could carry in its pouch. It was not envisaged that it would come, picking on who it likes, and letting go of those who were assumed to be most vulnerable. It was not thought that it would show up, sneaking into palaces, leaving some exposed to the elements unscathed, making a mess of the best healthcare systems in the world, and ironically revealing the resilience of some struggling ones.
A global pandemic was foretold. What was not foretold is the resilience of the poorest continent in the face of a pandemic of such devastating proportion. Rand Corporation, a research organisation, had, in a bid to help the U.S. government and international agencies, come up with an “Infectious Diseases Vulnerability Index”. Its 2016 report found that of the 25 countries most vulnerable to infectious outbreaks, 22 are in Africa, the other three being Afghanistan, Haiti and Yemen.
In 2019, Johns Hopkins University Centre for Health Security published the Global Health Security Index, a comprehensive assessment of global health security capabilities in dealing with possible epidemic in 195 countries. There were six categories for the assessment: prevention of the emergence or release of pathogens; early detection and reporting of epidemics of potential international concern; rapid response to and mitigation of the spread of an epidemic; sufficient and robust health systems to treat the sick and protect health workers; commitments to improving national capacity, financing and adherence to norms; and the overall risk environment and country vulnerability.
The United States of America was ranked first, with an overall index score of 83.5 out of a possible 100, coming first in four of the six categories, while Nigeria was ranked 96th (categorised as ‘more prepared’), South Africa (34th) and Ghana (105th). China was ranked 51st, instructively, and 101st with respect to preparedness to prevent zoonotic diseases. But in spite of its low ranking, China was first in four sub-categories: risk communication; trade and travel restrictions; cross-border agreements on public health emergency and infection control practicing and availability of equipment.
While the Index shows that, as a collective, international preparedness for epidemics and pandemics were very weak, with the average overall GHS Index score of 40.2, high-income countries had an average score of 51.9. Most of the African countries scored below the average index score, with Nigeria mustering 37.8. These reports must have influenced the panic in informed quarters about Africa, when the pandemic became truly global, making a landfall in the continent on February 14. Even as late as mid-April, the World Health Organisation projected that the coronavirus cases in the continent could surge from less than 20,000 confirmed cases then to 10 million in six months. A model by the Imperial College, London projected 300,000 deaths in the best-case scenario, while the UN Economic Commission for Africa projected 1.2 billion infections and 3.3 million deaths.
It is early days yet, but if morning truly shows the day, indications are more positive now that these projections will thankfully fall short by a long shot. As at May 23, Africa had about 100,000 confirmed cases of infection and 3,000 deaths. Even the World Health Organisation, in an estimate made early in May, now projects 83,000-190,000 deaths and 29-44 million infections in the first year of the pandemic, a drastic cut-back from the early figures.
But even as experts are scaling back on the doomsday predictions about Africa, there is a lingering air of disbelief and shock at what is going on. Whereas one would have thought that the low numbers coming out of Africa would be an oasis of comfort for the parched throats, overwhelmed by the aridity of mind-numbing numbers tumbling out of other parts of the world daily, it would appear that the world has become so numbed that it has chosen to receive this with scepticism, in resignation to the fact that nothing good can come from Africa. Such is the case that even some Africans appear too eager to explain away what might be playing out before a proper interrogation of the phenomenon.
The argument that seeks premise for the relatively low figures in parts of Africa on its malaria-endemic nature does not yet rest on the back of any study. It comes across as mere conjecture, with the possibility of a correlation fallacy playing out. Again, Brazil, with the second highest number of COVID-19 infections, is regarded as a malaria-endemic country. As a matter of fact, the worry for experts is the impact of malaria on COVID-19.
Indeed, Africa is a tough nut to crack for many in the West, starting from the misrepresentation of the continent as a monolith, lumping unlikes as one, to perpetrate preconceived notions. Unfortunately, the COVID-19 story has been largely approached with the same mind-set and methodology, such that the strategic responses and efforts at containment across the continent are not just being downplayed, but there is the rising wave of attempts to find explanation or justification for the scenario playing out in Africa, outside parameters that can attribute credit for the ‘success’, at least, in part, to the tremendous work done by the experts, health workers and even some political leaders.
The eagerness to embrace alternative explanations founded around disproved and unproved theses is apparent. The argument about high temperature/humidity has been largely discredited by the fact that a number of countries within the same belt wwith Africa are experiencing high numbers – Brazil, India and Iran being examples. The virus has defied uniformity in contiguity, demographics and culture in it capricious run. It takes on one neighbour and spares the other. Iran has over 130,000 cases, while Iraq has about 4,000 cases – a disparity that queries the argument about high temperature as a mitigating factor.
Professor Maurice Iwu is reported to have raised the question of humidity as distinct from that of high temperature. But the level of humidity in Brazil and India is equally high as in parts of Africa, yet they have some of the highest numbers of infections in the world. A look at the numbers in South Africa shows that Western Cape, with higher humidity and half the population of Gauteng, has more than four times her number of confirmed COVID-19 cases.
The argument that seeks premise for the relatively low figures in parts of Africa on its malaria-endemic nature does not yet rest on the back of any study. It comes across as mere conjecture, with the possibility of a correlation fallacy playing out. Again, Brazil, with the second highest number of COVID-19 infections, is regarded as a malaria-endemic country. As a matter of fact, the worry for experts is the impact of malaria on COVID-19. Dr. Ngozi Erondu, an associate fellow in the Global Health Programme at Chatham House, expresses her concern: “We are seeing that the virus has a more severe impact on people with underlying health conditions and so it is logical to hypothesise that we may see more severe COVID-19 illness in a population that is malnourished, has malaria as well as a mound of other infections. There’s not enough data at the moment to quantify those risks.”
Yet the search for answers to unlock the African COVID-19 riddle has been relentless. A report in The Economist finds explanation in the fact that “Africans travel less, thanks to sparse road network”, but does the manner in which they travel, especially within the cities, cramped together in mini buses, not count as a possible trigger for a higher number of infections than seen?
Most of the reports in the Western media focus more on possible under-testing and under-reporting of infections and deaths, citing the case of Kano, among others. The Economist estimates a tally eight times higher than reported. Valid as the argument might be with the possible under-reporting of infections and deaths, there is also agreement that there is a limit to which that can be done. Kano is being cited because there were reports form the community about an unusual high number of unexplained deaths within a short period. There is no way that people would be dying in large numbers that this will not lead to the raising of alarm, with the prevalence of social media platforms as means of communication.
The argument about under-testing is an interesting one. The strategy in Nigeria is slightly different from what those looking in through the template adopted by the West were expecting. People were particularly concerned about the numbers – bed spaces, ventilators, medical personnel, test, etc. But, as Dr. Chikwe Iheakweazu, the director general of the Nigeria Centre for Disease Control (NCDC) said, he was not playing the numbers game. “We have a strategy and we will stick with that strategy and make sure we deliberately increase the number of testing, while testing the right people at the right time.”
In as much as testing is important, the NCDC must have realised early in the day where the country’s strengths are. There are only a few molecular laboratories and it would have been disastrous to build its strategy round that. Rather, it opted for early preparation and aggressive application of the basic containment strategy. Perhaps benefiting from insight gained from the DG’s visit to China as a member of the World Health Organisation (WHO) team, the competencies locally gained from previous management of other infectious diseases, the network of contacts and communities built through a robust nationwide immunisation programme, as well as epidemiological knowledge acquired from the containment/management of epidemics, with its newly acquired real-time software package assisting with quality epidemic surveillance.
How Africa has managed to dodge the bullet, as projected, remains largely unclear. But the quality of efforts put in by African countries should not be discountenanced or downplayed on the altar of her notoriety for flailing over many things and failing where it matters most. These factors must be carefully interrogated, along with others that have been thrown up.
The NCDC opted for the simple approach of early preparation. While nations in Europe and America were still laidback with virtually no checks in place at points of entry, Nigeria, as well as many African countries, were already up and running. The NCDC strategy founded around the principle of four concentrations, has largely held firm, as it has continued to tinker with it, gradually ramping up on testing, even as that is not its primary intervention tool. Of course, with increased testing, the figures have been going up, making some argue that figures have been low simply because we have not been testing more. I will argue though that it is only partially true and it might be more of a correlation fallacy. Figures have gone up largely because people have breached the restriction order, thus enabling a greater risk of community transmission.
The argument by The Economist in support of the claim that the tally can be eight times higher than the official figures, is anchored around the high test-positivity rate, put at between 5 and 10 per cent, which it says suggests many uncounted cases. But what it has not taken into account is that the testing protocol adopted in Nigeria, for instance, was not a mass-testing model. Rather, those who qualified for testing were mainly those who had either been directly exposed to those who had been established as infected or those who were symptomatic. That would definitely present a higher test-positivity rate than where the testing is random and mass. Perhaps, that is why the report itself says that “despite under-counting, official data are still a rough reflection of reality in many countries.”
As important as testing is, it only tells one side of the story, even though it looks as good optics and politics. Perhaps that might explain why some countries, as allegedly done by U.K., have fiddled with figures by double-counting the number of tests. Yet, Nicola Stonehouse, a professor of Molecular Virology at the University of Leeds, said: “I don’t think it’s helpful to be simply focused on the numbers of tests. We should concentrate on using our testing intelligently and combining testing with contact tracing.” Devi Sridhar, professor of Global Public Health at the University of Edinburgh, said: “Instead of fixating on the exact number of tests, we should be looking at the ratio of confirmed cases to total number of people tested (and bringing this percentage down), the speed of tests and getting results to individuals.” Well, Nigeria is already moving into a different phase of testing, with the adoption of the rapid testing model, which would make validated rapid test kits readily available, speed up the process and massively ramp up the numbers.
Some had criticised African countries for adopting the lockdown measure, flagging it as a copycat policy patterned after the West. Yet, there is nothing Western, with respect to the management of COVID-19, about the idea. Rather, it was adopted by China and successfully too. The WHO joint mission, which saw it work there, recommended it and countries like Vietnam, which adopted it well, have had beneficial outcomes. The mission found that non-pharmaceutical measures were particularly effective, thereby recommending large scale isolation and rigorous contact-tracing, among others, to countries across the world. It is interesting that while some ‘advanced’ countries have struggled with contact-tracing, Nigeria has done remarkably well. That is a more important figure to look at than the number of those tested. For indeed, that someone tests negative today does not guarantee that he might not yet be infected tomorrow, if the more important measures that can limit community transmission are not adhered to. Nigeria adopted the lockdown as part of a larger strategy to slow down the rate of transmission and buy valuable time for response. Data available indicate that the ‘doubling-time’ of transmission slowed down in West Africa from 4.1 days before lockdown to 10.6 days after April 1, thus establishing the efficacy of the lockdown measure.
As such, the argument must be made that beyond the factors being touted, which deliberately or inadvertently take away from the efforts that have been invested in the containment process in Africa, some of the factors that have made positive impact are founded around the implementation of best practices by African Experts. Staying ahead of the curve, the strategic use of lockdown, early preparation, adoption of the recommendations of the Joint WHO commission, integrated strategy on surveillance and response across each country and the continent, and community-based surveillance built from Ebola, other epidemics as well as the national immunisation programmes. These have invested the African response with unique competencies and experience that have positively impacted the response to COVID-19.
No doubt, COVID-19 is a riddle. There is so much yet unknown about it. Even if the coronavirus is largely accepted as zoonotic, still there is a controversy about its origin, perhaps more to do with politics than science. Even then, the intermediate host is yet unknown. Many of the questions surrounding it are yet to be definitely answered. How Africa has managed to dodge the bullet, as projected, remains largely unclear. But the quality of efforts put in by African countries should not be discountenanced or downplayed on the altar of her notoriety for flailing over many things and failing where it matters most. These factors must be carefully interrogated, along with others that have been thrown up.
Experts are looking at all sorts – genetics, climate, culture, public policy and all that for answers. But it would appear that there is not one answer or possibly, there is a combination of answers wrapped as one. But what must not be left out is the industry on the part of the African men and women who woke up to the reality of the threat earlier than many of the countries in the West, followed through with the recommendations by WHO Mission to China, tinkered with them for local factor, in coming up with a strategy that accommodated their weaknesses and played to their strengths. One lesson in the African story is that there are strengths that can only be forged in the crucible of adversity. Perhaps, therein lies the key to unlocking the riddle of the African miracle story that has held back the fangs of a virus running from fully unleashing its venom on a continent that had been written off. The answer to the riddle is perhaps in the riddle. Africa is perhaps the proverbial Anikulapo, with death in her pouch, dodging the bullets of projections directed at her fragile belly. Just as she has defied death in the face of serial pillaging and multiple violations by friends and foes.