In late March an anonymous doctor in a New York hospital told CNN that he was working in “Third World” conditions, with patients coming in so fast, and so gravely incapacited, that he and his colleagues would soon be overwhelmed. “Third World” is strong language, with an antique ring to it—a memory of the 1980s, when late-night TV ads regularly featured pleas for charity accompanied by images of skeletal, fly-bitten African children barefoot in the dirt outside their huts. It was a generation’s cliché of misery. That’s us now—or it will be soon, the New York doctor’s comparison implied, if we don’t control the spread of this disease.
But the comparison invites a question. If America is now Africa, what is Africa? Africa is much better off than it was 30 years ago, but even today, most of the world’s extremely poor live on that continent, and its health-care systems are (with a few exceptions) a wreck. COVID-19 has been slow to arrive in Africa, or at least has been slow to be detected there. But the wave is coming. “Our health systems cannot absorb additional shocks,” Simon Antara, of the African Field Epidemiology Network, told me from his office in Kampala, Uganda. “We are preparing for disaster.”
Right now the numbers may appear manageable. The African countries with the most confirmed COVID-19 cases are South Africa (1,934), Algeria (1,666), Egypt (1,560), and Morocco (1,374). No sub-Saharan country other than South Africa has more than 1,000 cases. The countries hardest hit are those most connected with international travel, especially to France. (Kenya, at 184 cases; Ethiopia, at 56; and Nigeria, at 276, have numbers that remain suspiciously low.) Burkina Faso—not an especially connected country, or one with a huge population—has 414 cases. Every country in Africa has testing kits, many of them due to the largesse of China’s Jack Ma. In some countries, such as Rwanda (110), quarantines and the careful tracing of contacts have kept the numbers down.
We should not be too relieved that these numbers are not as high as, say, those of the United States (457,000). Every country’s numbers started small—and every country with endemic COVID-19 had a period when outbreaks looked contained, until a thousand fires ignited at once, and the caseload started doubling every few days. So far, Africa seems unlikely to be exempted from these iron laws of exponential contagious spread. If the spread seems slow to develop, that may be because no African country has the same volume of international travel as the countries elsewhere that are already suffering.
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Most worrisome is the lack of any possibility of an effective response. Consider the Central African Republic (CAR), at the geographic center of Africa. It has a population of almost 5 million, about the same as Alabama. CAR still has only 10 cases, but the virus is spreading in the community, which means that those numbers will eventually rise very quickly, as they have elsewhere.
Alabama expects to need 340 ventilators at the peak of its outbreak (currently prophesied for April 20). The United States has roughly 172,000 ventilators—and that isn’t enough. Sierra Leone (about the population of Washington State) has 13 ventilators. CAR has three ventilators. Liberia (Louisiana) also has only three; South Sudan (Ohio) has four.
Or take ICU beds. Some African countries have many; South Africa has 3,000. (The United States has 64,000.) But Somalia has 15 ICU beds for the whole country. The largest city in eastern Democratic Republic of Congo has perhaps two dozen ICU beds to serve a province with a population about the same size as Louisiana’s, with endemic malaria, malnutrition, tuberculosis, and other diseases that make COVID-19 especially dangerous. (One comorbidity relatively absent in Africa is obesity.)
The COVID-19 strategy in most of the developed world has been to “flatten the curve”—spread out the infections across the year, so that at any given time, enough ventilators and ICU beds are available to accommodate everyone who is sick. If you flatten the curve enough, the tail end might even get vaccinated and avoid infection altogether.
In much of Africa, this strategy is absurd, because no amount of home quarantine will flatten the curve enough to let everyone have a turn at one of three ventilators. “It’s pointless to try,” says Tom Peyre-Costa of the Norwegian Refugee Council. “Flattening the curve implies having a minimum of health-care capacity.” With few exceptions, African nations’ domestic surge capacity is nonexistent. In the past, when patients in very poor African countries needed intensive care, they effectively had two options: a hospital overseas (an option available to the rich), or the graveyard. Now that other countries (including the wealthier African countries) have closed their borders and maxed out their own hospitals’ resources, the first of these options is gone. The surge capacity for some countries was, in effect, France—which is itself flooded with COVID-19 and unable to help.
At least a few small mercies might make endemic COVID-19 more bearable. Having relatively few international connections has given Africa a window of time to prepare, Antara said, and preparations—subject to the extreme limitations—have been intense. Being in the last continent without widespread outbreaks has given African countries the opportunity to witness how bad those outbreaks can get, and to plan accordingly. Rwanda shut its borders when it still had only a handful of cases. It would not have done so if it hadn’t seen Italy and Iran suffering first. (Peyre-Costa notes that the lack of international connections has serious drawbacks, too. In some countries, the health sector is largely foreign-led and humanitarian, and as long as supply chains and human movement are disrupted, foreign health-care workers will have trouble getting in.)
When community transmission begins, it may move more slowly than it has elsewhere. Most Africans live in cities, but the traffic between those cities is less than in other parts of the world. CAR, for example, has no domestic airline or railway, or even a domestic bus network. People move around much less, almost as if they were practicing social isolation avant la lettre.
Most of all, Africa will enjoy the advantage of youth. COVID-19 kills mostly the old, and Africans are relatively young, with a median age of 18.9. (The median age in the United States and China is 38.) That means, in effect, that about half of Africans who get COVID-19 will have a low risk of death. In an aged population such as Japan’s, 2 percent of those infected might be expected to die. In Africa (following the figures here), only 0.3 percent would die, or about 3.8 million people, if everyone were to be eventually infected.
A further possibility—however remote—is that Africa will be an exception. Already the case numbers are showing some anomalies. In Rwanda, for example, the confirmed COVID-19 cases are all mild. Not one of the 110 patients has required a ventilator. Indeed, none has even been admitted to an ICU. (Here is a video of a Rwandan COVID-19 patient dancing.) The median age of COVID-19 patients there is 36, so age alone does not explain the good luck. The low numbers in Kenya and Ethiopia—both of which have major international airlines that kept flying well into the pandemic—are also puzzles. One possibility, says Jeffrey Griffiths, a physician at Tufts University who works in Africa, is that some level of endemic immunity already exists in Africa, because of similar viruses whose effects are too mild to have warranted notice. (Griffiths thinks the catastrophe is still coming, but holds out immunity as an option that any remaining optimists can cling to.) And COVID-19 may transmit less readily in warm weather, like the common flu. These would all be incredibly lucky breaks. Perhaps the “Third World,” once a net recipient of pity, will begin to export it to Europe and America.
We cannot count on catching a break. Any situation whose most likely bright side is the death of 3.8 million people is a dire situation indeed. The United States will, for the next month at least, be preoccupied with its own miseries. But we should prepare for a second and potentially worse wave of catastrophe in Africa.