Jina Moore | May 15, 2020 | The New Yorker
n early March, Ingrid Gercama left her home in the Netherlands and flew to war-torn South Sudan. An applied-research anthropologist with a special interest in epidemics, she had spent time on the African continent during a public-health emergency before, remaining in Liberia, in 2014, during that country’s Ebola outbreak. When she landed at the frill-free airport in South Sudan’s capital of Juba, she was taken to a separate screening area, the shape and size of a shipping container, where her temperature was recorded by government health workers, along with her hotel address and her local telephone number. Gercama was asked a series of questions about her travel and health, she recalled, including whether she had recently come into contact with a bat. The screening area’s walls were covered with posters about COVID-19 and its symptoms, and she was ushered into the country past a banner explaining the disease and offering a telephone number for a national coronavirus hotline, which she was to call if she developed a fever. She had to wash her hands once to get into the screening area, and again when she left.
Much of what Gercama encountered at the airport had been designed to prevent Ebola. Since 2018, the Democratic Republic of the Congo, South Sudan’s neighbor to the southwest, has been struggling with the disease. But local public-health officials’ quick repurposing of Ebola protocols and infrastructure impressed Gercama, as did the work of rapid-response teams, whom she twice witnessed respond to suspected coronavirus cases during the week she spent in the country. She left South Sudan on March 19th, a few days after the country began quarantining arriving passengers, and a few days before they stopped international flights altogether. From Juba, she flew through Stockholm, where no one asked her where she had been nor recorded her temperature, and landed back in Amsterdam, where, again, she was not questioned about her travel history or health. When she passed through passport control, she found no leaflets, no COVID-19 awareness banners, no hotline. “They didn’t even tell me to self-isolate,” Gercama told me. “I did so because I have common sense.”
African governments, unlike their Western counterparts, aren’t relying on common sense. Judging from the numbers, and interpreting them with the scientific information that’s understood so far, Africa has made the better bet. Although cases on the continent are increasing, many African countries are not seeing the exponential daily growth in confirmed cases, nor in mortality, that has been happening in the United States and Western Europe. There are exceptions, especially above the Sahel: Egypt, Algeria, and Morocco alone account for a third of the continent’s seventy-two thousand cases, and fifty-one per cent of its 2,475 deaths. But in parts of sub-Saharan Africa—the forty-odd countries below the sand belt of the Sahara, the places about which the world is almost always wringing its hands—the picture is more optimistic. “Rwanda, in their first month, went from two cases to a hundred and thirty-four,” Joia Mukherjee, the chief medical officer for Partners in Health, a Boston-based nonprofit organization that works in ten countries, said. “Belgium, which is the same size—twelve million people—and is the former colonizer of Rwanda, grew from two cases to seventy-four hundred.” Uganda has only a hundred and thirty-nine known cases. Ethiopia has two hundred and sixty-three. South Sudan has two hundred and three. Burundi has twenty-seven. Botswana has twenty-four. Each of them saw their first cases later than Europe and the United States—but not that much later. If the virus had followed the same trajectory there that it has in the West, most African countries would have seen explosive transmission rates by now.
Confronted with data patterns that don’t match our own, the impulse among Western observers has been to identify what makes these countries like each other but unlike us—to reach for the science (or its best guesses) that tells a soothing story about why Africa appears to have it so much better than, say, New York City. The most obvious question, to people from countries still lacking a true picture of their disease burdens, is whether Africa has enough tests. (The short answer is, often, yes.) From there, and in no particular order, Western analysts cite climate, demography, and magic. Africa is hot, which is to say sunny, and it is humid. Sunlight, some scientists have argued, degrades the virus, and humidity (maybe?) slows it down. Quite a bit of Africa isn’t actually humid, however, and its sun, like the sun the world over, is seasonal. In fact, in several East African capital cities that are home to the majority of their country’s coronavirus cases, it can get downright cold. Brazil, meanwhile, has nearly two hundred thousand cases of COVID-19 and is quite humid. So is Singapore, where a second wave of infections has sent the country back into lockdown.
Some experts point to the continent’s comparative youth: the median age in Africa is barely twenty, and studies (still) suggest that the disease is less severe in young people. Being young may help reduce mortality, but youth is a less satisfying explanation for the raw number of COVID-19 cases, the majority of which have been occurring in people in their twenties and thirties. Finally, some experts speculate about the existence of a special African immunology, suggesting that diseases like malaria (or their treatments) act as biological talismans against the new disease. This coronavirus may be novel, but essentialist Western tropes about magical dark-skinned Africans date back centuries.
Meanwhile, a rather obvious possibility stares us in the face: What if some African governments are doing a better job than our own of managing the coronavirus? “One reason why we may be seeing what we are seeing is that the continent of Africa reacted aggressively,” John Nkengasong, the director of the Africa Centres for Disease Control and Prevention, told me. “Countries were shutting down and declaring states of emergency when no or single cases were reported. We have evidence to show that that helped a lot.”
Rwandan officials responded to their first coronavirus cases by tracing, isolating, and testing “contacts,” people whom confirmed or suspected carriers might have encountered before realizing they were, in fact, COVID-19 patients. Five days after the first cases were confirmed, commercial flights were halted, and two days later, the country was locked down, both to limit the spread of the disease and to ease the tedious work of contact tracing. By the end of April, health workers had tested more than twenty thousand people and conducted two random community surveys, a method for guarding against the bias of testing too narrowly, which might artificially deflate case figures. “We did not find any community transmission of COVID-19 in Rwanda, which was quite good news for us,” Sabin Nsanzimana, an epidemiologist who heads the Rwanda Biomedical Center, which also houses the national reference laboratory that processes COVID-19 tests, said. “So far, we are at the phase of containing the epidemic in Rwanda, which means that we know who has the disease.”
Uganda and Ethiopia also responded to their first cases with aggressive contact tracing and isolation, and they’ve put considerable resources into checking their work. In early May, Uganda completed its first rapid-assessment survey, a randomized sampling of twenty thousand people; it uncovered only two new local cases. Ethiopia completed a door-to-door survey of its capital, Addis Ababa, in just three weeks, documenting symptoms and travel history for its five million residents, and testing anyone who was found to be at risk for the disease or symptomatic. South Africa, where health officials say early intervention staved off exponential transmission, sent thirty thousand community-health workers to survey roughly fifteen per cent of its population in less than a month; it uncovered only two positive cases for every thousand people. The remarkably low number of cases uncovered by community surveys, experts told me, suggest that contact tracing and isolation are working the way they’re supposed to. “Think of it as a web of transmission, not so much a chain,” Tom Frieden, who directed the U.S. Centers for Disease Control and Prevention during the 2014 Ebola outbreak and now spearheads Resolve to Save Lives, a health initiative focussed on global pandemic response, said. “With every filament in that web that you break, you reduce the burden of disease.”
Moses Massaquoi, who directed Liberia’s case-management system during the Ebola outbreak and today is the senior adviser for management system for COVID-19, told me, “I think we are better off because we went through Ebola. This disease is different, of course, but the structure is there—the incident-management system, the protocols, the guidelines. I imagine countries in Africa that didn’t have that experience are going through difficult times.” The East African countries that are, so far, outperforming the global West benefitted from Ebola preparations as well. Rwanda, Burundi, South Sudan, and Uganda all border the Democratic Republic of the Congo, and were forced to respond to its Ebola outbreak in 2018. Each country already has rapid-response teams, trained contact tracers, logistics routes, and other public-health tools and protocols in place, which they have adapted to respond to the coronavirus. That level of cöordination—indeed, of practice—also makes a difference. “We’ve seen that in an epidemic, one day can mean a lot,” Nsanzimana, of the Rwanda Biomedical Center, told me.
Of course, there are still many unknowns, regarding both the data and the virus itself. One ongoing concern is the availability of tests across the continent. Health officials in Rwanda and Liberia contend that they don’t have as large a testing gap as the United States, where the disease, unchecked and untracked, spread so widely in February and March that the need for diagnostic tests alone outpaces the country’s ability to conduct them. At this stage, a true sense of the extent of the virus’ spread would require many more tests, in randomized samples across the country. In countries such as Rwanda, which used isolation and contact tracing efficiently, it’s been much easier to use tests to gain a clear picture of how much disease there actually is in the country. Mukherjee, of Partners in Health, told me that even with limited data, “you can make some estimations.” When public-health practices like contact tracing and isolation are robust, the ratio of positive tests is more telling than the raw number of tests being done, she said. “In South Korea, where really, really aggressive testing seems to have controlled the epidemic, the percentage of positive tests among all tests done is about two per cent. In the United States and many other countries, it has been as high as thirty per cent. That ratio says the bottom of the iceberg in those countries is likely much larger.”
Only now, in the fourth month of their outbreaks, are places like the United States and France beginning to organize contact tracing. The irony, of course, is that some of the nations that are most burdened by COVID-19 taught their African counterparts how to do that work. The U.S. C.D.C. sent disease-surveillance experts to West Africa to train local health workers during the 2014 Ebola outbreak. When the coronavirus struck, the U.S. neglected those same basic public-health protocols. “One of the reasons things got so out of control in the U.S. and Europe is that for us, epidemics are something that happen elsewhere. Africa and Asia, by contrast, know that epidemics can hit home and hit hard.” Jeffrey Sachs, a professor at Columbia University and an adviser on global health and poverty to dozens of governments, told me.
Much has also been made of how few things Africa has with which to fight the virus. Intensive-care and ventilator capacity, for example, are low, and retaining health-care workers has long been a challenge—in part because doctors and nurses can make more money by working in the West. These supply and personnel shortages are dire during a pandemic, but they don’t exist in a vacuum.They exist in relationship with the demands of the West, which drained the continent of skilled medical workers and conditioned aid on a model that demanded users, many of them living in poverty, pay fees for health service. The requirement de facto privatized much health care and effectively starved many health systems of resources. “Years of neoliberalism has basically made it impossible for African countries to build a treatment infrastructure that would include I.C.U. beds and oxygen,” Mukherjee said.
Still, countries on the continent have struggled. Massaquoi said that Liberia has only recently scaled up its testing capacity, and he predicted that broader testing would uncover new cases. Ghana’s contact tracing and lockdown did not catch the virus before it jumped into the community, but its community health workers—a pillar of public-health systems outside the United States and Europe, and key in Ghana—have helped the country identify its outbreak. “We have a good picture of where it exists,” Patrick Aboagye, who directs Ghana Health Services, the country’s national public-health infrastructure, said. “We have a spread in the capital and also in heavily-populated areas, and so our interventions are targeted.” He cited another promising sign: even as the cases go up, the infection rate has remained relatively stable, at around two per cent.
No one is claiming that the continent has beaten the virus. “I think one of the things COVID-19 is really teaching us right now is scientific humility,” Joel Mubiligi, the executive director of Partners in Health in Rwanda, said. Lockdown measures have also brought human-rights abuses: Nigerian, Kenyan, and Ugandan police officers have been accused of beating or killing people to enforce COVID-19 restrictions, and five Rwandan soldiers are facing court-martial on charges of assault, robbery, and rape during nighttime patrols.
Some leaders still display a worrying indifference toward the disease. Madagascar’s President has been peddling a cold herbal tea as a “cure,” eliciting early interest from Congo-Brazzaville and Tanzania, whose President recently claimed that even papayas can test positive for the coronavirus. “We are dealing with a very treacherous, dangerous virus that tends to lure you into a false sense of complacency and then overwhelm you,” Nkengasong, of African C.D.C. said. He worries that, although some countries are faring better than others, the continent-wide caseload continues to increase.
While the worst-performing countries anticipate a disease curve that looks like those in Europe or the United States, the African countries where the response has been better, faster, and smarter may manage to stay ahead of it. At least, that’s what everyone hopes. “As we know, the transmission of the virus is not a single time point. It can evolve; it can change,” Nsanzimana said. “That is why, when we say there is some good news for us, we say it with caution.” Nkengasong, meanwhile, is scouring history for lessons that reveal the dangers of overconfidence. He found one in the West. “In 1720, the so-called Marseilles plague gave people a sense of calm,” he told me, his voice weary with worry. “Then they made a few mistakes, and very quickly it killed almost half of the city.”