COVID-19 in Africa: no room for complacency.

Despite over 100 000 confirmed cases and infections in every country, the passage of COVID-19 through the African continent remains somewhat enigmatic. High numbers of deaths were expected in the region due to fragile health systems, lack of access to preventive measures, barriers to testing, and potentially vulnerable populations. But, according to WHO, Africa is the least affected region globally, with 1·5% of the world's reported COVID-19 cases and 0·1% of the world's deaths. Although comparisons are inaccurate, mortality rates have been lower compared with outbreaks of similar size elsewhere. Many hypotheses have been suggested for this paradox, including sensitivity of the virus to ambient temperature, Africa's comparatively young population, lower rates of obesity, and familiarity with infectious disease outbreaks. Low levels of testing might be artificially lowering apparent infection rates. The situation in the continent is highly heterogeneous and progress varies considerably.

In February, 2020, while many other countries were still dismissing the emerging outbreak, the African Union acted swiftly, endorsing a joint continental strategy in conjunction with WHO. The Africa Centres for Disease Control and Prevention had considerably expanded COVID-19 testing capabilities by the end of the month. Many African countries acted early, enforcing a lockdown and border closure. But these strict restrictions have not been without difficulty. Human rights organisations have voiced concerns about abusive implementation of lockdowns by police and military, including in South Africa. 71% of Africans work in the informal sector and many have no financial reserves. Ghana, Uganda, Kenya, and other countries have initiated emergency programmes for distribution of goods and Nigeria is also providing financial support to the most vulnerable people. Balancing the potential for food shortages, social unrest, and economic collapse, other countries, including Malawi and Ghana, have opted for no or only partial lockdowns. It is too early to fully understand the implications of these differing strategies, but the response of Tanzania has raised near universal concern, with no case numbers released for weeks and the endorsement of unproven herbal remedies by President John Magufuli.

There is no room for complacency. Medical capacity within Africa will be rapidly overwhelmed if containment fails, but vertical efforts concentrated on this outbreak threaten other hard-won gains. As a result of this pandemic, 80 million children under the age of 1 year worldwide may be at risk of vaccine-preventable diseases, as routine immunisations have been disrupted in many countries, including Chad, Ethiopia, Nigeria, and South Sudan. The focus on COVID-19 must not detract from continued action in other areas of health. Interrupted vaccination campaigns in DR Congo might have cost more lives than Ebola infection. Repeating this scenario with COVID-19 on a continental scale must be avoided. This pandemic should underline the importance of universal health coverage over narrow responses.

Despite a strong regional response, the repercussions of the global COVID-19 pandemic could hinder Africa's capacity to minimise deaths and economic disruption. The closure of international borders, disruption of flights and supply chains, and export bans restrict the ability of African countries to procure personal protective equipment, diagnostics, and essential food items, risking disease spread and famine. Many countries have responded with local solutions, such as development of cheap diagnostic tests in Senegal and establishing local supplies of masks in Ghana. Actions including suspension of tariffs on health-care products, establishment of supply corridors, and the easing of restrictions on food exports recommended by the UN must be adopted quickly. The World Bank estimates that up to 60 million people will be pushed into extreme poverty by the end of the year. Global market changes will affect exports, including oil and tourism, with a substantial impact in Africa. The UN Secretary-General has called for a comprehensive global response package, including across the board debt standstill and restructuring to support Africa's economic resilience.

There is still potential for disaster in Africa, especially as countries begin to ease the strictest lockdowns. The COVID-19 pandemic enforces global power structures. The rest of the world has a role in supporting and enabling an effective and safe response, but as much as Africa faces unique difficulties, it also has unique strengths. There have been many national successes and an effective regional response. Future action needs to be Africa-led and the rest of the world should look to see what can be learned.