A few years ago, I was being driven south to the coast from a hospital in the town of Makeni in Sierra Leone, when I suddenly noticed a brand-new railway line paralleling the road. I asked the driver where it was going. “Beijing” he replied. It is a puzzle why Africa, dotted with Chinese construction sites and Chinese investors of one sort or another, was late in catching COVID-19. More likely that China shut down travel early so that Africa’s relatively few diagnosed infections came first from Europe.
Some optimists suggested that COVID-19 doesn’t like a temperature of 31C. But what about Philippines, Australia, India? In Africa the rainy season ushers in the onset of malaria and its high fevers. More likely the onset wasn’t that late - weak health services have been poor at identifying the presence of the disease in amongst other respiratory infections. Senegal has 1 doctor for 10,000 people, Italy 41.
It is right to fear for Africa during the coronavirus pandemic though Sierra Leone has some advantages over other countries. When I visited Freetown’s main medical centre, the Connaught Hospital, I was impressed by its cleanliness and clinical professionalism compared to many African hospitals, but also by the relative absence of medical equipment. On the plus side Sierra Leone has some outstanding doctors, nurses and a battle-hardened Ministry of Health.
Sierra Leone’s government health record is good. It has managed to bring in free maternal and child health care, and to reduce malaria deaths, working with religious leaders to educate people on the causes of malaria and how to prevent it. Of course, it also experienced an Ebola outbreak, another even more terrifying invisible killer, and during the civil war, the visible lethal armed variety. So the people of Sierra Leone have already faced the agony of being deprived of the normal way of caring for the sick and burying their dead. They may be better prepared culturally for responding to the pandemic than some Londoners.
Malaria may seem to be an irrelevance in the face of an Ebola or COVID-19 assault on a population. Not so. Researchers have found that levels of HIV rise in patients suffering from malaria. It is as if the immune system has been diverted or weakened by centuries of combating the malaria parasite. This finding matters particularly in pregnant women because the presence of malaria increases placental transmission of HIV to the baby in the womb.
A further danger of malaria emerged in the Ebola crisis. Until rapid diagnostic kits were more widely distributed by the WHO, patients with malaria were sometimes sent off to Ebola centres for triage and dying as result of the initial misdiagnosis. Widely available and rapid testing for COVID-19 is going to be vital. Although deaths from malaria worldwide have reduced from a million in the last two decades to an estimated 425,000, 92% of malaria infections still occur in Africa.
On Africa’s side is its youth. The median age is 19.4 years. Resilient youth may not be badly affected. But malnutrition and overcrowding in the poorest countries will reduce the effectiveness of even young people’s immune system. Some African countries have been quick to take preventative measures against COVID-19 while infections were still low: the better developed such as Rwanda, Kenya and Ghana. South Africa quickly tried to move into shut-down. Measures have included school closures, checking for raised temperature, restrictions on travel and social gatherings. But once infection enters crowded and poor townships and ‘informal settlements’, spread will be very difficult to contain and treat. Some 400,000 young children die annually of ‘ordinary’ pneumonia in Africa already. Oxygen for medical use is in chronic short supply. Will poor African children with the coronavirus induced variety get off as lightly as young children in Europe?
Coronavirus has shed an extraordinary spotlight on the importance of good governance, and the impact of inequality and poverty on people, both around the world and within nations. Governments that can, and energetically strive to turn well-formulated health policies into reality within their health systems, provide the gold standard. Governments that sustain endemic corruption sacrifice the lives of their citizens. Ways of putting pressure on governments depend on democracy. We in Britain count the number of ventilators in thousands and lament how few. But African doctors treasure the medical equipment sent by a parish in Europe, an x-ray machine donated by Rotary, HAZMAT clothing brought by WHO and international medical charities.
Inequality and poverty cause poor health outcomes wherever you live. Pandemics accentuate dramatically pre-existing inequalities and poverty. Poor Africa has not yet suffered the most from the current outbreak. But this is just a matter of timing. The continent faces a catastrophe once the virus takes hold. Immediate international assistance is needed.
There can be no better target for DfID’s £14.3 billion budget than strengthening Africa’s health systems and helping its population get rid of corrupt leaders. Their commitment to an international response to this global crisis should be championed around the world by wealthier countries and their NGOs.