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The first batch of COVID vaccines touched down in South Africa in February 2021. Health workers were the first to get a jab under the Sisonke study. But even before the country had bought any jabs, our reporters were writing about the logistics and the politics of the project. If you want to know how well the vaccines work, how the different jabs compare or what it takes to create a vaccine from research, to regulation, to rollout, you’re at the right place.

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A confusing COVID caseload: Why Africa’s missing numbers show a different side to the pandemic

  • South Africa’s COVID death toll may only represent a third of the lives lost during the pandemic.
  • Many African countries do not have the capacity to test and track their COVID outbreaks at the same rates as richer countries, leading to undercounts of the COVID cases.
  • This creates a misconception that Africa is not as hard hit by the disease as the rest of the world and should not be prioritised when it comes to vaccine distribution.

Only one in 20 people in Africa have been tested for COVID, one in seven COVID cases are recorded, and resulting deaths are likely vastly under-reported. This is the second in a two-part series on vaccine inequity. Read the first part.


Next time someone tries to argue that low-income countries have not been hit hard by COVID, think about this: only one in seven cases in Africa make it into official statistics

By mid-October, the real number of infections on the continent from SARS-CoV-2 (the virus that causes COVID-19) was estimated to be 59-million, compared with the approximately 8.5-million cases officially reported.

Under-reported statistics like these skew the actual impact of COVID-19, feeding perceptions that the pandemic has not been so bad in Africa. And so starts a tumble down a rabbit hole of numbers, perpetuating the idea that denialism drives apparent vaccine hesitancy in Africa.

In turn, the racist trope of vaccine hesitancy in Africa being “way, way higher than the percentage of hesitancy in Europe or in the US or Japan” becomes fodder for pharmaceutical companies to conveniently justify the trickle of vaccine supplies to African countries.

But the story of “COVID in Africa” is not an easy one to tell.

For one, Africa is not a single, uniform entity. Each country on the continent has its own particular social, political and economic endowments and histories. And barring a few exceptions, we know almost nothing really of the extent to which COVID is ravaging its way through the continent. 

The sketchy statistics behind Africa’s COVID outbreak

Public healthcare in Africa is complex, with the legacy of neo-colonial social and economic policies having left most countries’ systems fragile.

As a result, few are able to confidently detect and report COVID-19 cases and deaths. The (misinformed) interpretation of already sketchy statistics from COVID data aggregators perpetuates the ignorant myth that somehow Africa is “immune” to the disease. 

When we look deeper, past the officially reported numbers, and instead explore the reasons for them, a different picture emerges. Africa is not unaffected by the pandemic; we simply don’t have the data.

Without adequate testing there’s no way of knowing what the real rate of new SARS-CoV-2 infections is in a country. “We’re still flying blind in far too many communities in Africa”, argues Matshidiso Moeti, the World Health Organisation’s (WHO) regional director for Africa. 

Officially reported statistics show that by mid-October 2021, approximately 75-million tests had been performed across Africa – roughly one for every 20 people on the continent.

Compare that with the situation in the United States, where data shows that more tests have been performed than there are peopleapproximately two for every one person in the country. That is 40 times more than in Africa. 

Number crunch: How low are Africa’s COVID numbers really?

But adequate testing is only the first step.

To get the full picture of the extent of the pandemic, testing should ideally be part of a larger epidemiological surveillance plan, also incorporating contact tracing and isolation.

Reliably reporting case numbers and resulting deaths also requires a well-functioning civil registration and vital statistics (CRVS) system, with all deaths being recorded timeously. But according to the UN Statistics Division, the CRVS systems in most developing countries do not work as they should.

In continental sub-Saharan Africa, only a quarter of the countries are considered to collect data on at least half the deaths that occur in that country. In many cases the cause of death is not recorded or information may not be available in near-to-real time.

Not having information on cause of death limits the value of the data from a CRVS system. Consider, for example, the case of Eswatini. As the African country with the fourth most reported COVID-19 deaths per million people, it comes in only at 74th place in the global rankings. Either people are not dying of COVID in Eswatini or, more likely, deaths from COVID are dramatically under-reported in that country. 

To understand why, let’s look at data from Eswatini’s neighbour South Africa.

An excess of deaths: Tracking the true toll of COVID

South Africa has a reasonably comprehensive COVID testing programme, a fairly reliable CRVS system and the expertise to crunch the numbers and address data gaps. This combination is exceptional in sub-Saharan Africa, and has allowed the country to track how excess mortality trends develop almost in real time. 

Excess mortality is the difference between the recorded number of deaths and the number that would have been expected in that period based on past trends in the country. A high number of excess deaths therefore means a country is experiencing a health crisis of some kind, such as an epidemic.

Many countries use the number of excess deaths to get a more realistic idea of the true impact of the COVID pandemic.

And although almost all countries’ official number of COVID deaths is an under-representation, the difference is that where good CRVS systems are in place, such as in the US, Scandinavia and many European countries, the number of excess deaths is generally fairly close to the officially reported COVID deaths.

In South Africa, a country with a well-established CRVS system, researchers estimate that approximately 265 000 excess deaths have occurred since May 2020. Yet the number of officially reported COVID-19 deaths – less than 90 000 –  represents only about a third of those.

What’s more is that this number mostly comes from people who died in hospitals or clinics; people dying from COVID outside health facilities are likely missed. As such, researchers estimate that 85–95% of the excess deaths, perhaps as many as 240 000, are likely due to COVID-19.

Competing with COVID: What’s driving Africa’s outbreak

Data shows that the risk of getting severely ill or dying from COVID is higher among the elderly than younger adults. Africa’s population is predominantly young: approximately 40% of people are between 25 and 64 years old, whereas people older than 65 make up only about 4% of the population.

Yet several African countries have seen a dramatic increase in both COVID cases and deaths since the highly contagious Delta variant emerged. 

The high burden of HIV infections and lifestyle diseases such as hypertension (high blood pressure), diabetes and obesity on the continent does not bode well for COVID numbers here.

Studies have found that people who are HIV positive have a higher risk of getting sick or dying from COVID. Similarly, hypertension, diabetes and obesity are health conditions that increase the risk of falling seriously ill – or dying – of COVID.

Add that to fragile public health systems in many African countries and the outlook becomes increasingly bleak.

Inequity in the time of COVID

A rapid upscale of vaccinations in Africa is needed to help curb the pandemic’s death toll – just as in the rest of the world. But the problem is that people in Africa are not getting vaccinated at nearly the same pace as in western countries.

And it’s not because they don’t want to; it’s because African countries are not getting stock fast enough.

The inequitable distribution of COVID technologies is not limited only to vaccines. Already in April 2020, shortly after COVID-19 was declared a pandemic, John Nkengasong, head of the Africa Centres for Disease Control and Prevention, appealed for global solidarity to let Africa share in diagnostic know-how.

Yet instead of solidarity, he wrote, “global protectionism has prevailed, with more than 70 countries imposing restrictions on the export of medical materials”.

Similarly, hoarding and panic buying of personal protective equipment such as surgical masks in higher-income countries disrupted the supply chain early on in the pandemic, and were cited as a potential risk for managing the disease in low-income countries.

African lives matter: ‘A global crisis that requires global action’

Contrary to a commonly held perception, Africa is not unfamiliar with effectively responding to large disease outbreaks.

Know-how from dealing with Ebola, Lassa fever and the HIV epidemic could therefore be adapted fairly swiftly to fight COVID-19 early on and drawing on networks of community health workers helped to raise awareness about the disease.

For example, in South Africa, the country leveraged its ability to do viral load testing for HIV to quickly build capacity for performing PCR COVID tests. And now again, as models suggest alarming under-detection of COVID cases, efforts are underway to use strategies that have proven effective in vaccinating people against smallpox and Ebola to contain the spread of disease.

But having to rely only on the continent’s own capacity and resources will not be enough to save African lives. Nor should it be. 

African lives matter, just as much as lives in Berlin, Washington, Tel Aviv, Geneva, London, Toronto or Brussels.

COVID-19 is a global crisis that requires global action, in which all countries should be able to share equally.

Indeed, as Ayoade Olatunbosun-Alakija, head of the African Vaccine Delivery Alliance, said at an Access to COVID-19 Tools Accelerator meeting recently, “a few cannot be given ‘godlike’ status and therefore the power to decide within a pandemic who lives or dies”.  

Tian Johnson is the head of the African Alliance, civil society observer at the Robert Carr Fund, co-chair of the African CDC Vaccine Delivery Alliance’s community engagement pillar and founding member of the Vaccine Advocacy Resource Group. They are an Aspen New Voices 2021 fellow.

Tom Moultrie is professor of demography, and director of the Centre for Actuarial Research (CARe) at the University of Cape Town.

Gregg Gonsalves is an associate professor of epidemiology of microbial diseases at Yale school of public health and associate professor (adjunct) of law at Yale Law School. He is the co-director of the Global Health Justice Partnership.

Fatima Hassan is a South African human rights lawyer and heads the Health Justice Initiative in South Africa, after formerly being the executive director of the Open Society Foundation for South Africa.