On Jan 30, 2020, WHO declared the current novel coronavirus disease 2019 (COVID-19) epidemic a Public Health Emergency of International Concern. On March 11th the WHO raised the alert and declared it a pandemic. It’s the first time the WHO has called an outbreak a pandemic since the H1N1 “swine flu” in 2009. However, all of the mapping initiatives that have arouse as part of the response to coronavirus show few cases in the continent, while the rest of the World is crowded with cases. Sub-Saharan Africa is home to more than a thousand million people. Some scientists believe COVID-19 is circulating silently in Africa, taking advantage of weaker health systems and more crowded cities and homes.

The current situation in Africa

Over the last few days we have seen the first confirmed cases arise in Africa, which was expected considering China is Africa’s largest trading partner. Just today, Sudan declared coronavirus an emergency and Somalia, Liberia and Tanzania confirmed their first cases. So far all confirmed cases trace back to travellers from Europe, and local transmissions are rare or have not been identified.

Why is this a concern?

Weak health systems

Last month, World Health Organization Director-General Tedros Adhanom Ghebreyesus, an Ethiopian, said his “biggest concern” was COVID-19 spreading in countries with weak health systems. A lot of countries in Africa have what you would call weak health systems. I have personally seen clinics and hospitals in a handful of African countries: Liberia, Guinea, DRC, Malawi, Zimbabwe… and I have worked with medical data in some of them. I wouldn’t define any of what I have seen as a part of a strong health system.

Africa accounts for 16 percent of the world’s population but just 1 percent of its health care spending. For comparison take, for example, Italy, under assault from coronavirus. In the country there are 41 medical doctors per 10,000 people; in Africa there are 2 medical doctors per 10,000.

Let’s take a look at three areas where the African healthcare system is facing issues that may affect the report of coronavirus cases:

Health care facilities

African countries have less health facilities and most of them lack the necessary equipment to treat critic coronavirus patients. They are hard to reach facilities, in old buildings with no isolation rooms or equipments. Capital hospitals have little or no intensive care beds and poor isolation. Ebola treatment units were mostly tents and prefabs for this reason.

Even countries like Nigeria () are ill-equipped for an outbreak. According to this report, Clinics in smaller cities and the countryside lack everything from bandages to beds to physicians, and the national Center for Disease Control has a staff of just 250, with five laboratories to test new infections in a country of 200 million. The U.S. Centers for Disease Control and Prevention, by contrast, has 11,000 employees and hundreds of labs.

Health care workers

In Europe, your typical health care worker is a medical doctor or a nurse. When we look at African countries we need to readjust this perception. Healthcare and public health activities, particularly in the rural areas, is usually delivered by community health workers, midwives, and other health professionals. This is easy to observe looking at some of the research studies made in West Africa after the Ebola outbreak.

Health care workers, specially in rural areas where they don’t necessarily have full medical training, aren’t always prepared to properly diagnose and treat diseases. Malaria, which kills 400,000 Africans each year, and coronavirus share many of the same symptoms in the early stages of the disease, complicating diagnoses, especially with a shortage of coronavirus test kits.

Health care workers also carry a lot of stigma and can see their securities affected in these situations: Lack of knowledge about disease in the population and an absence of official communications feeds rumor and can promote panic. During Ebola outbreaks, health workers attacks by local people were not rare, and this may happen again with coronavirus.

Data management

I have seen few to none Medical Records in African clinics. Most of the ones I have seen were paper based, sometime not even on printed out templates but on regular notebooks, donated by NGOs or purchased by health care workers from local stores.

I have written about the importance of data in epidemiology and the bad news is that in my experience data management in African health care systems has room for improvement. Lack of zero reporting, duplicates, outdated templates… and more concerning: reports that can take up to two months to reach the Ministry of Health and the official count.

Compromised resistance

There are other factors that make me worry about coronavirus in the continent: Yes, Africa has a lower median age than a lot of countries, which could be an advantage as coronavirus seems to affect older people mostly. Only 3% of sub-Saharan Africa’s population is over 65 years of age, compared with around 12% in China. However, the African population is also disproportionately affected by HIV, tuberculosis and other infectious diseases, which effectively raises the probability of complications and the risk of death in case a person gets infected with coronavirus.

The Academy of Sciences of South Africa has reported that people living with HIV are eight times more likely to be hospitalized for pneumonia caused by the influenza virus than the general population, and are three times more likely to die from it.

Harder prevention

Besides this, social distancing and isolation are a challenge in many African countries: crowded cities and markets, multiple generations or family lines sharing homes…

Dependance on foreign aid

Africa has traditionally relied of foreign help to tackle disease and outbreaks, but with most first-world countries busy keeping the pandemic controlled at home, how many eyes are looking to Africa, and how many resources are available for them?

The response

The President of South Africa has declared Coronavirus a “national disaster” and called for special measures. Rwanda announced it would close places of worship, schools, and universities after its first case, and has recruited final year medical students to undertake screening at airports. Morocco is closing mosques, eateries, cinemas, theatres, sports, public clubs, baths, and other entertainment venues.

Today Algeria has announced a ban on flights coming from European countries, as well as a repatriation plan for their nationals abroad, and Egypt is following. The focus of African COVID-19 surveillance has been at countries’ points of entry, and testing has targeted people with a recent travel history to outbreak areas abroad. However, screening passengers for fever has shown to be largely ineffective, because it doesn’t catch people still in their incubation phase—up to 14 days for COVID-19.

According to Science magazine, the Global Influenza Surveillance and Response System is showing elevated levels for some African countries, says John Nkengasong, director of the African Centres for Disease Control and Prevention (Africa CDC), which is based in Addis Ababa, Ethiopia. But that might be for reasons other than COVID-19, he says, like improvements in the quality of surveillance data.

Aljazeera reports South Africa will revoke nearly 10,000 visas issued this year to people from China and Iran, and visas will now be required for other high-risk countries that had been visa-free, including Italy and the United States.

Studies indicate countries with the highest importation risk (ie, Egypt, Algeria, and South Africa) have moderate to high capacity to respond to outbreaks. Countries at moderate risk (ie, Nigeria, Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya) have variable capacity and high vulnerability. The International Monetary Fund has pledged $10 billion at no interest for poor countries.

In Ebola times, call centers, community healthcare worker trainings, contact tracing applications and SMS workflows helped spread public health information, report cases and ultimately control an epidemic that, at its peak, seemed uncontrollable. Revamping and maintaining these tools could be useful for the coronavirus response. Resources, more intense surveillance, and capacity building should be urgently prioritised in countries with moderate risk that may not be well prepared to detect cases and to limit transmission. The curve doesn’t flatten unless its flattened everywhere.