Six months after the COVID-19 outbreak first started, Africa accounted for only 1.5% of the documented cases (Bruce-Lockhart, Reference Bruce-Lockhart2020). Some reasons are structural: Only 40% of the population is urbanized – compared with 55% globally and 80% in the OECD. This geographical dispersion makes it harder for the virus to spread. Moreover, the continent is young – only 3% of the population is 65 years of age or older, compared with a 9% global average and 17% in the OECD. Given that the virus disproportionally affects older people, this matters.
The spread of the disease is accelerating, and the World Health Organization (WHO) predicts a prolonged trajectory over several years for Africa (‘New WHO estimates: Up to 190,000 people could die of COVID-19 in Africa if not controlled’, 2020). Still, the continent has been less severely affected than was feared. I suggest three reasons why.
Much as it is disadvantaged by its weak healthcare systems, Africans also benefited from lessons learned in responding to earlier epidemics, e.g., the 2014-2018 Ebola epidemic in West Africa and the ongoing Human Immunodeficiency Virus (HIV) epidemic that spread continent-wide from Kinshasa in the late 1970s. Coordinated continental leadership facilitated the implementation of those learnings. Moreover, the collectivist culture of Africans where the wellbeing of the group tends to take precedence over individual freedoms supported compliance, even when it meant the loss of livelihoods.
LESSONS LEARNED FROM PRIOR HEALTH CRISES
Africa is often inexactly discussed as if it is a single unit rather than a collection of 54 diverse countries. Different countries have pursued somewhat different strategies to deal with COVID-19 (Herman, Maarek, Wilde, Adao, & Abousaada, Reference Herman, Maarek, Wilde, Adao and Abousaada2020; Maseland, Reference Maseland2020). Yet the similarities justify discussing the continent as a unit (Chigudu & Huaini, Reference Chigudu and Huaini2020).
Because it remains largely disconnected from the global economy (Geyer, Reference Geyer, Scholvin, Black, Revilla and Turok2019), the outbreak of the pandemic lagged the rest of the world by weeks and even months. The first reported case in Africa was in Egypt on February 14, 2020, and the last African country to report a COVID-19 case was Lesotho on May 13. This lag meant that Africa could observe what was happening elsewhere. African countries saw the medical facilities of various European countries nearing a state of collapse and realized that they must find ways to respond locally.
Africans have an overall poor prognosis in terms of health. Current World Bank estimates for life expectancy are 73 years worldwide, 80 years in the OECD countries, but 61 years in Africa. The global average child mortality rate (deaths before five years of age) is 39 children per 1000, but 77 in Africa. Of the approximately 295,000 maternal deaths per year worldwide, 200,000 happen in Africa. Table 1 outlines key global disparities.
Source: World Bank
The continent also carries a disproportionate disease load. For example, 70% of all AIDS deaths and 90% of all malaria deaths worldwide occur on the continent. A WHO report (‘Neglected Tropical Diseases (NTD)’, n.d.) suggests that of the more than one billion people suffering from NTDs like leprosy, rabies, river blindness, and others, about 40% live in Africa. NTDs encompass a number of diseases where pharmaceutical companies see little financial returns to developing effective treatment, and the local research capacity is too limited to do so.
Aware of these challenges, used to major diseases not having any effective treatments, to disappointing results after decades of failed HIV vaccine trials (Mastroianni, Reference Mastroianni2020), and to being ‘last in line’ for scarce resources (Ahmed, Reference Ahmed2020), few Africans had confidence in a vaccine providing a significant source of protection from the COVID-19 pandemic. It has also been observed that ‘the conditions that facilitate rapid spread of an infectious disease are also, by and large, those that make it hard for societies to respond’ (Barnett & Whiteside, Reference Barnett and Whiteside2002: 15). Changed behavior would be needed to respond to the pandemic.
The African Union (AU) was founded in 2002, replacing the Organization of African Unity which had been criticized for being ineffective. The AU has seen some progress: Various member states have been expelled for deviating from principles of constitutional rule (and reinstated when correcting course). An African Continental Free Trade Agreement had also been negotiated and should have launched across Africa from July 2020, although the pandemic delayed the planned start until 2021. But progress towards the ambitious AU goals has been slow.
When COVID-19 was declared a pandemic, the rotating position of AU chair was occupied by South Africa's president Cyril Ramaphosa. His role at that point was a fortuitous coincidence. Ramaphosa had been key in negotiating the transition to a democratic South Africa, and is known as an inclusive consensus builder (Ellmann, Reference Ellmann1994). South Africa is the leading economy on the African continent, and is increasingly recognized as an important development partner (Vickers, Reference Vickers2012).
South Africa is also the country globally with the most HIV-positive cases, with about one in seven of the population HIV-positive – a situation that developed because political leadership was absent as the virus started spreading. When HIV was first isolated, South Africa was preoccupied with the violent end-days of Apartheid and then its nascent democracy. Immediately following Mandela (and Ramaphosa's rival), President Thabo Mbeki was an AIDS denialist. Within fifteen years, HIV had ballooned from a rare disease to one affecting millions of South Africans. Having experienced the exponential growth of HIV, South Africans are acutely aware that viruses do not simply disappear without interventions, and that informed leadership matters. Despite lingering divisions in the country, South Africans were largely united in their conviction that the COVID-19 pandemic must be decisively fought (Nordling, Reference Nordling2020).
As chair of the AU when the COVID-19 pandemic broke out, Ramaphosa also had a platform to encourage an Africa-wide response. The specter of another pandemic, while already battling diseases like malaria, HIV, tuberculosis, Ebola, and others, led other African countries to readily follow (Bruce-Lockhart, Reference Bruce-Lockhart2020)
Since February, the AU has played a central role in the continental COVID-19 response, ‘providing coordination, expertise and technical support to its member states, engaging in advocacy, and mobilizing resources’ (Witt, Reference Witt2020). Ministers of Health, Finance, Education, and others were involved in crafting responses, allowing for continent-wide learnings.
The African response was guided by a number of principles. A first is that science should inform decisions. COVID-19 has resulted in policymakers strengthening continental research-based institutions dealing with the disease, e.g., the African Academy of Sciences and the Africa Centre for Disease Control (Bekker & Mizrahi, Reference Bekker and Mizrahi2020). The guidance of those institutions is widely accepted.
A second principle is that rapid action is essential. In the words of epidemiologist Prof Salim Abdool Karim, chair of the COVID-19 ministerial advisory committee in South Africa, small flames must be prevented from turning into raging fires (Bright, Reference Bright2020). In crafting a proactive response, African countries took advantage of the delay between when the virus first broke out and when it arrived on the continent.
A third is more technical, and relates to contact tracing. Capabilities in contact tracing have been developed in response to outbreaks of diseases like Ebola (e.g., Greiner et al, Reference Greiner, Angelo, McCollum, Mirkovic, Arthur and Angulo2015) and tuberculosis (e.g., Ekwueme, Omotowo, & Agwuna, Reference Ekwueme, Omotowo and Agwuna2014; Shapiro et al., Reference Shapiro, Variava, Rakgokong, Moodley, Luke, Salimi, Chaisson, Golub and Martinson2012). Contact tracing in Africa is typically done using community health workers (CHWs). As laypeople who have received basic training, CHWs have been found to be effective supplements to the scarce skills in the health arena (Hermann et al., Reference Hermann, Van Damme, Pariyo, Schouten, Assefa, Cirera and Massavon2009; Mwai et al., Reference Mwai, Mburu, Torpey, Frost, Ford and Seeley2013). Going household to household, these individuals screen and refer for testing people who may be at risk of the disease. The joint continental COVID-19 strategy includes the deployment of one million CHWs.
To deal with prior experiences of being ‘last in line’, the AU, representing more than one billion members, also pursued a pooled procurement strategy. It negotiated several hundred tons of personal protective equipment from the Jack Ma foundation, established an Africa Medical Supplies Platform to realize economies of scale in procuring essential medical supplies, and guided the formation of partnerships between diagnostic labs across the continent.
A final principle was that the response to a pandemic cannot only be medical. Medical crises disrupt society generally. Many African countries closed borders, and especially cities engaged in strict lockdowns (Giles & Mwai, Reference Giles and Mwai2020). Given the economic setbacks to a continent already suffering from poverty and hunger, the AU set up a continental COVID-19 response fund and initiated several initiatives around nutrition and food security. Hunger presented a massive challenge on a continent where poverty predominates.
A COLLECTIVE RESPONSE
Most Africans work in the informal economy and rely on face-to-face contact to earn a living. Lockdowns resulted in the loss of livelihoods and widespread food insecurity, and many commentators have highlighted the economic devastation and especially severe hunger resulting from the lockdowns in Africa (Mwangi, Reference Mwangi2020; Olukoya & Kamara, Reference Olukoya and Kamara2020). Breaches to the strict requirements have been observed (Maclean, Reference Maclean2020) and a constant message from leaders is around continued compliance (Kamau, Reference Kamau2020).
The African response has been underpinned by the values of ‘ubuntu’ and collectivism. ‘Ubuntu’ is a cross-national African concept that emphasizes interconnectedness and compassion, and theorizes the individual as necessarily situated within society (Migheli, Reference Migheli2017). It is conceptually close to collectivism, and indeed, studies confirm that Africans are collectivists (House, Hanges, Javidan, Dorfman, & Gupta, Reference House, Hanges, Javidan, Dorfman and Gupta2004; Wanasika, Howell, Littrell, & Dorfman, Reference Wanasika, Howell, Littrell and Dorfman2011).
From a purely economic perspective, collectivism is a drawback: The personal achievement, efficiency, and good governance associated with individualism promote economic development (Kyriacou, Reference Kyriacou2016). But from the perspective of healthcare, the sense of collective belonging and in-group obligations has been argued to be beneficial to people's health and well-being (Modesti & Becucci, Reference Modesti and Becucci2019). In contrast to countries like the US and UK where personal freedoms are valued even in the midst of rising mortality, Africans are more likely to accept the value of personal sacrifices like increased hunger for the public good.
It has been argued that an unstated assumption underpinned much reporting about COVID-19: That the suffering caused by the pandemic was ‘unthinkable in one place and inevitable in another’ (Chigudu & Huaini, Reference Chigudu and Huaini2020). Although the fragile healthcare systems and already-impoverished population present massive challenges to Africa as the disease progresses, the early African response has challenged the assumption of an inevitably disastrous outcome.
South Africa played an important and not entirely disinterested role in galvanizing an Africa-wide response. For example, the Africa Medical Supplies Platform prioritizes purchases from African providers. As the leading economy on the continent, this provision stands to benefit South Africa more than others. However, in an era of increasing anti- and de-globalization, Africa has been a noteworthy exception, an ‘island of internationalism’ (Witt, Reference Witt2020). By pooling insights, efforts, and resources, Africans collectively achieved a substantial flattening of the curve of the spread of COVID-19.