(This is a longer post than usual but I thought more useful to keep whole rather than split into different posts. Also, note that figures on infection rates change daily. The figures here reflect the current – at point of writing – position)
As lockdowns, restrictions on movements, queues for getting into supermarkets and empty streets become the new normal for growing numbers of millions across the world, we are all being encouraged to modify our behaviour because we are all in this together. It’s the right message, but we know that it isn’t true: the impact of Covid-19 will hit some groups harder than others, its biological, social and economic impact will be dependent on your gender, your age, your class, where you live, and how you live. It will also hit some global regions harder than others.
We know, for example, that women will be more impacted than men – because this is what almost always happens during an epidemic. During the Ebola epidemic in 2014-15 women were more likely to have their livelihoods negatively affected, were more likely to have to take on additional caring burdens, and were ultimately more likely to be infected and die. The shift of health-funding and care to dealing with the Ebola virus also left vital maternal and child health services under-resourced, contributing to non-virus but very much Ebola-linked deaths from otherwise preventable conditions. The Zika virus also had a gendered impact: women had less access to health care, had little autonomy over their reproductive health needs, and were more likely to be undertaking the vector control activities that placed them at greater risk of infection. Although data so far from China suggests more men have died than women, when full data sets are available, the expectation is that, given gendered norms over care-giving (and therefore who is in closest contact with the virus) this may change, with women more likely to have been infected. [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30526-2/fulltext]
Similarly, the impact of national lockdowns is hitting some groups economically harder than others. Five million people may have lost their jobs in China during January and February (https://www.cnbc.com/2020/03/16/china-economy-millions-lose-their-jobs-as-unemployment-spikes.html). European and US clothes retailers have cancelled around $1.5 billion of orders from Bangladesh factories alone, affecting over 1000 garment factories in the country. With the sector providing around 4 million jobs, and accounting for 13% of the national economy, the impact on already vulnerable garment workers, unlikely to have their incomes protected by the government, could be devastating. Who knows how many millions will have lost their already precarious, low-paid but essential jobs as the weeks and months roll on.
One feature of the Covid-19 epidemic is the way in which global collaboration has been replaced by national action in response. And with that, the focus of attention has tended to be on the main sites of current infection: China (and some neighbouring countries affected in the first wave); the second-wave epicentre of Europe; and the United States with its rapidly growing crisis. Brazil’s President Bolsanaro, seemingly desperate to join the ranks of national leaders historians of the Covid-19 pandemic will not judge well, has also drawn attention to the growing numbers of infected in Latin America. But what of Africa?
Covid-19 in Africa
As Tedros Adhanom Ghebreyesus, Director General of the WHO, said on 16th March, the attention of global health is looking increasingly to the implications of Covid-19 spreading to sub-Saharan Africa and other low-income regions:
As the virus moves to low-income countries, we’re deeply concerned about the impact it could have among populations with high HIV prevalence, or among malnourished children.
As the world’s poorest region, with the weakest health systems, the impact of Covid-19 across the sub-Saharan Africa will be devastating. Governments are trying to respond fast to limit the impact of the disease before it takes hold as it has done in Europe. South Africa imposed a nation-wide three week lockdown on Monday 23rd March. Nigeria has banned flights from the most affected countries, closed schools and places of worship and sought to encourage social distancing. Ethiopia has closed its borders, and tried to limit the use of public transport, amongst other measures. Every country is concerned about what will happen if (when?) the virus begins to spread exponentially, and the toll it will take on health, on the economy, on society, and on life itself.
Confirmed infections are still low, standing at 1,210 officially confirmed cases across 43 African countries as at midday on 24th March (a number we know can shift significantly in a very short space of time, see here for latest updates). But this will mask a much larger number of untested and undetected people living with Covid-19 and so is undoubtedly a significant underreporting of the full extent of the impact.
Sub-Saharan Africa’s demographic health profile
Despite having the youngest population in the world, with around 60% of the continent’s population under the age of 25 and therefore belonging to the group least likely to suffer serious health complications following infection with Covid-19, the health profile of the continent suggests a large-scale epidemic would be indeed be serious.
Covid-19 is entering environments with already existing serious health issues and crises, raising questions of how funding can be diverted without undermining other health initiatives and worsening overall health profiles. Nigeria, for example, is facing its largest spike in Lassa Fever cases as it now has to look to controlling the spread of Covid-19. Sub-Saharan Africa faces a high burden of tuberculosis, with around 2.5 million people newly infected each year; and the world’s highest rates of HIV. Although living with HIV is not in itself linked to higher infection rates of becoming more seriously ill if infected, the presence of other health conditions is likely to lead to complications. And with 15 million people living with HIV still without access to the life-saving antiretroviral treatment (the majority of those living in sub-Saharan Africa), huge numbers are vulnerable to the severest impact of Covid-19. Estimates suggest that almost half of those living with HIV and TB are unaware of having both, and are therefore not receiving the treatment they need, leaving them more vulnerable to Covid-19.
Sub-Saharan Africa also has very high rates of mal- and under-nourishment. Around 22.7 percent of the population are undernourished (in eastern Africa, it is over 30 percent), leaving people vulnerable to Covid-19. The non-communicable disease burden is also significant and growing, with many conditions forming the underlying health conditions that can make Covid-19 infection so serious. Diabetes, chronic respiratory diseases, kidney diseases, cardiovascular diseases, and cancers are all growing health burdens; and research suggests that almost all adults in the region are exposed to at least one risk factor for a non-communicable disease: including smoking, excessive alcohol consumption, poor diet, and high blood pressure.
Narrow health systems easily overwhelmed
The 2014-15 Ebola epidemics in Guinea, Liberia and Sierra Leone exposed the weak state of African health systems. This despite donors pouring billions into health spending over the past two decades. In 2001, donors spent around $13.5 billion on aid for health. By 2018 that had risen to around $39 billion. But much of this increase has not been invested in strengthening health systems, but in ways that have contributed to the hollowing-out of those national health systems and to reduce the ability of government to respond to epidemics.
Since the 1980s, health funding has shifted from support for general health, to funding for specific diseases and health issues (encapsulated perhaps by the Global Fund’s focus on the big-3: malaria, TB and HIV, as epitomised by the full title of the organisation). Donor funding for the WHO has shifted from general budgetary support (whose spending is controlled by the WHO secretariat) to extra-budgetary contributions, the use of which can be tied by the donor. Direct funding of health in recipient countries has followed similar patterns: focused on single or small numbers of diseases, the priorities set externally (eg through the MDGs and SDGs, or by donor interest), using structures often set up in parallel to existing health services, and often much better resourced. This is what is known as a vertical delivery model. And whilst it may have led to great successes in dealing with specific diseases and health issues, it has contributed to a hollowing-out and weakening of health system infrastructures that would have been able to cope better with, and probably end sooner, an outbreak such as Ebola. And, as we are now seeing, Covid-19.
In the decade before Ebola, Guinea, Liberia and Sierra Leone received around $1.8 billion in funding for health. But the vast majority was tied to specific programmes and diseases, especially the big-3. Not only was it channelled through specific programmes, but often through dedicated single- or limited-purpose structures, skewing health professional expertise, time and commitment to a narrow range of interventions. Support for general health, for monitoring and responding the general health needs or spotting outbreaks, was limited. Only around $20 million was spent on training for doctors and nurses, for example; $24 million for repairing health facilities in increasingly poor condition; $87 million for infectious disease control (despite this being long-recognised as an area of major global threat).
This is a pattern replicated across sub-Saharan Africa, and as a result health systems are underprepared and unable to respond quickly, effectively and at scale to epidemics. The ability to detect cases, although perhaps stronger in post-Ebola Africa, is still weakened by poorly resourced surveillance structures, and underfunded local health facilities already struggling with the burden of care for existing health issues. Within countries, there are vast regional inequalities in quality and number of facilities and health care professionals between urban and richer areas, and more rural and remote ones. In Tanzania in 2006, 80% of doctors were based in urban areas responding to the health needs of just over 25% of the population. A survey in the same country in 2009 suggested over a quarter of young doctors placed in rural settings failed to turn up to their posting; and another study suggested almost half of all medical students would simply refuse a rural posting. One feature of this crisis is likely to be the regional and local inequalities in response and impact.
Despite global commitment to universal health coverage, the reality for most Africans is a reliance on (at best) community-based health insurance, or for most out-of-pocket payments for treatment (a system that drives millions into poverty each year). Even for those with some form of insurance, coverage tends to be limited and basic, and for many will not cover any required treatment. Even in a country with as large health spending as the US we have seen the confusion, panic and fear resulting from reliance on private health insurance and a fragmented health system (and the ways in which this worsens the epidemic). Across sub-Saharan Africa, these consequences are vastly worse.
The impact of Covid-19
The epidemic has not yet swept through sub-Saharan Africa, still (as I write) being in its early phases. But if the efforts of African governments to limit the epidemic taking hold, with far fewer resources than those available to the governments of China and Europe, fail, then the impact is likely to be severe, and for some groups more so than others.
Dealing with large numbers of people requiring treatment will inevitably require diverting funds away from current health spending areas. From the experience of previous epidemics, that would include, almost certainly, maternal and child health services, leading to a spike in non-Covid-19-related deaths. Women, being the primary care givers and making up a large proportion of front-line health workers, would be more likely to be infected. Making up a larger proportion of the informal sector, and especially those areas most likely to be devastated by the required social controls on movement, women are also likely to see their livelihoods more adversely affected, with implications for household incomes and the overall health and wellbeing profile of other vulnerable household members. Rural dwellers, too, are likely to see a sharp disparity in treatment and care compared to urban dwellers (though the more rapid spread through urban areas will quickly overwhelm health facilities).
Dealing with Covid-19 in the midst of humanitarian emergencies creates a whole new set of challenges in protecting and meeting the health rights of already highly vulnerable populations. Humanitarian actors are already warning of the dire consequences for their operations as many international organisations are withdrawing from the field (Sarah Collinson and Mark Duffield’s 2013 piece on risk management and aid culture is worth revisiting in the light of the current crisis). Is this a moment in which the localisation agenda comes of age, as ‘local’ agencies need to formally occupy the space left by international agencies and as donors look for alternative means of supporting vulnerable populations? Or will it highlight the weakness of local actors enmeshed in a global humanitarian architecture, requiring a more root and branch re-modelling to be able to live up to their potential? What of the potential for conflicts between local and displaced populations if donor responses lead to varying levels and quality of health care? Will humanitarian agencies repeat the vertical delivery failure of DAH in humanitarian settings, creating structures that focus solely on Covid-19 and fail to strengthen wider health systems?
A vaccine for Covid-19 will provide the immediate solution for the crisis, albeit only coming after economies, societies and communities have been ravaged by new ways of having to live, by illness (and the economic costs of being ill) and the tragedy of death. But even then, questions remain about the speed with which Africa will benefit. As global responses have retreated into national solutions and national self-interest, with the most powerful countries looking after their own needs first, will enough vaccines be made available to African countries, before we even think about the logistics of delivering them? And will lessons be learnt from this experience, about the need to focus on general health systems rather than disease-specific approaches, in order to build up African resilience to new epidemics, which will surely come.
Covid-19 presents a particular challenge to sub-Saharan Africa. But only global collective action and support can prevent national health crises turning into a global tragedy.